By Sujatha Rajagopal

IVF, ICSI, GIFT, IUI…
Abbreviation overkill? Here’s a laywoman’s guide to artificial conception.

If you’ve been trying for over a year to conceive without success, it could be time to have a talk with your doctor. There could be a medical reason why you are unable to have a child, such as endometriosis or blocked fallopian tubes. If the doctor diagnoses infertility in one or both partners, don’t lose hope! Infertility only means that becoming pregnant is a challenge. Not an impossibility.

Each year, medical advances enable thousands of infertile couples to have their own biological child. Many of these advances are grouped under an umbrella term called assisted reproduction technology (ART).

If you love two-for-one promotions, you will like this piece of news: according to the US Centers for Disease Control, 28.6% of ART pregnancies produced twins and 4.9% produced triplets or more (2004 US data)!

Here’s a quick look at the key ART procedures in use today.

In Vitro Fertilization (IVF)
If you’ve heard of test-tube babies, you’ve heard of IVF. In IVF, a woman’s eggs are mixed with a man’s sperm and fertilized outside her body, i.e. in a lab dish (in vitro means ‘in an artificial environment’). Within three days, the lab will be able to determine if the eggs have been fertilized and have begun to grow into healthy embryos.

The healthy embryos are then transferred to the woman’s uterus through her cervix via a catheter. Usually, two to four embryos may be placed in the uterus at one time and each attempt is called a cycle. If more than four healthy embryos were cultured, the couple can choose to have the remainder frozen or donated.

After the procedure, the woman will be given hormone medicines for the next two weeks and sent home. If the implantation works (the egg or eggs attach to the uterine wall and begin to grow), the woman will have a positive pregnancy test result.

Do note that a positive test result does not guarantee that a baby can be carried to full-term. According to the Singapore Ministry of Health, the live birth rate per cycle of IVF in 2002 was about 16% to 28% across various hospitals.

A single cycle of IVF can cost a couple at least SGD6,000 depending on the hospital. Researchers are also still trying to determine how safe IVF is exactly.

Despite the challenges, IVF has become a highly recognised method of assisted reproduction and a popular choice for infertile couples since the first test-tube baby was born in England in 1978. IVF has been used in Singapore since 1983—that’s when KK Women’s and Children’s Hospital produced Asia’s first IVF baby. IVF can even be performed on women who have had unsuccessful tubal ligation reversal surgery!

Intracytoplasmic Sperm Injection (ICSI)
OK, you get the sperm and injection parts. What’s intracytoplasmic? The cytoplasm is a jelly-like substance inside a cell. In ICSI, a single sperm is injected into an egg’s cytoplasm using a powerful microscope and special instruments. ICSI is usually the treatment of choice when the male partner keeps producing low-quality sperm samples or when the couple has had numerous failed IVF cycles. ICSI may be used in combination with IVF to increase chances of getting a healthy embryo. Studies show a 70% or higher fertilization rate for ICSI.

Gamete Intrafallopian Transfer (GIFT)
In IVF, fertilization occurs in the lab. In GIFT, fertilization occurs inside the woman’s body, i.e. the egg-sperm combo (gamete) is immediately placed into the woman’s fallopian tube.

However, in GIFT, the transfer involves a surgical procedure called a laparoscopy. An IVF transfer does not require laparoscopy and is as a result, cheaper. Also, while IVF can be used in women with blocked or damaged fallopian tubes, a woman who chooses GIFT must have at least one unblocked, healthy tube. However, GIFT offers an ethical advantage over IVF because you do not have to choose one embryo over another.

Zygote Intrafallopian Transfer (ZIFT)
ZIFT is basically a combination of IVF and GIFT. Fertilization occurs in the lab but the fertilized egg (zygote) is transferred to the fallopian tube (as in GIFT) instead of the uterus (as in IVF). ZIFT may be more effective for couples who have experienced GIFT failure or if the man’s sperm is below optimal fertilization capacity. ZIFT may also be an option for couples who want a lower risk of having twins or triplets.

Intrauterine insemination (IUI)
IUI is used when a woman doesn’t have enough cervical mucous or if there is an incompatibility between her cervical mucous and her husband’s sperm. IUI can also help if a man is impotent, has ejaculation problems or if his sperm count or sperm motility (swimming ability) is low.

In IUI, the sperm is first washed in a special solution and observed for quality. If approved, the sperm is placed directly into the uterus of the ovulating woman, bypassing the cervix and improving sperm delivery to the egg. The procedure is rather quick and often painless. The woman will be able to proceed with normal activities right after it is done.

Keeping expectations in check
If you are considering ART, be sure to thoroughly discuss the options available with your doctor before making your decision. Carefully consider mounting costs should your cycles be unsuccessful. Do remember, although ART has helped countless couples before you, there are plenty of factors that can affect a cycle’s success rate:

• Pregnancy age: women aged 34 years or younger have more success on their first ART cycle than women aged 35 years or older.
• Pregnancy history: women who have already had a live birth enjoy better ART success rates than women who have never given birth.
• Own vs donor eggs: older women or women who have genetic defects may have better success if they use a donor’s eggs. Studies also show that using freshly harvested donor eggs offer better results than using frozen donor eggs.
• Smoking: smokers usually require more ART cycles to become pregnant than non-smokers.
• Genetic defects: even if your ART procedure is successful, there is sufficient data to show that your baby will be at higher risk of low birth weight and birth defects (for causes yet to be understood).
  

Another side to the story is how emotionally and physically draining an ART procedure can be on the female partner. The technique will usually require a battery of tests, injections, monitoring and harvesting of eggs. Although most of these are done on an outpatient basis and you will be able to recover quickly, there will still be cramping, perhaps even queasiness from the hormone medications you are given. You might even be asked to take a few days off work to rest depending on your health condition.

Of course, for a couple who crave a child of their own, these are but small prices to pay. If ART is your definite choice, strap on some mental “seatbelts” and prepare yourself for the ride of your life. It may help to keep those fingers and toes crossed too. Good luck!

Primary sources:
http://www.fertilityjourney.com/therapyoptions/assistedreproduction/
http://www.ivf.com/ivffaq.html
http://www.emedicinehealth.com/script/main/art.asp?articlekey=59058&pf=3&page=1
http://www.cdc.gov/ART/ART2004/sect2_fig5-15.htm#Figure%207
http://www.americanpregnancy.org/infertility/gift.html
See http://www.moh.gov.sg/cmaweb/attachments/publication/281ace193bqB/IVF_paper.pdf for information on ART fees and success rates in Singapore.