Thursday, October 27, 2005

Assisted hatching

After the embryos are trasferred into the uterus pregnancy will occur only if the embryo can escape or "hatch" from its shell (called zona pellucida). In some cases the embryos have a very thick zona which may lead to th cause of implantation failure. Making a small hole in the zona, called assisted hatching, before embryo transfer will benefit those cases.

Assisted hatching video

Assisted Hatching

Sunday, October 23, 2005

Blastocyst culture

Normally in standard IVF embryos with six to eight cells will be transferred to the uterus on day three after egg collection. Recently there has been a new development in the culture system and the embryos can be extended in culture until day five or six at the blastocyst stage. Mostly only healthy embryos reach this development stage, about 40% to 50% of fertilized oocytes. There is some patient variation. Embryos can be evaluated for their development potential on day three before blastocyst culture is continued.

Saturday, October 22, 2005

IVF Info interviews patient of IVF clinic in Thailand

IVF Info (II) interviewed the husband of a woman undergoing fertility treatment at a clinic in Thailand and learned about why they chose this particular clinic and what their experience has been like. Note that he asked we not give is full name so we will just refer to him by the intial R.

II: So, Mr. R., the big question really is why Thailand for fertility treatment? Can you tell us what led up to your decision to choose an IVF clinic in Thailand?

R: Well, let me first say that it wasn't so much that we chose Thailand as the place to undergo the treatment. It was more that other circumstances led us to be there and then we happened upon the option that we chose.

II: So you were in Thailand already and then decided to undergo treatment?

R: Yes, that's right. We moved from the U.S. to Thailand about three years ago. We wanted to start a family but with my wife a tad beyond prime child-bearing years we didn't get pregnant as we had hoped.

II: So that's when you decided to try IVF?

R: Not right away. First we went to a regular hospital a got us both checked out. We had some concerns because my wife had surgery to remove an ovarian cyst shortly after we moved to Thailand and we thought that may have resulted in ovary failure or fallopian tube damage. But the checkup showed the tubes were open and ovaries functioning. And the sperm count and motility were in normal range. So the doctor at the hospital said to just keep trying.

II: And you did, with no luck, right?

R: That's right. We gave it another six months and then decided to go to a fertility clinic.

II: How did you choose one?

R: There are two well-known fertility clinics in Thailand. The one we ended up going to, Jetanin, was featured on a television show on Thai TV. It looked very modern and the doctors had good credentials so we decided to visit and check them out.

II: What was your initial impression?

R: On our first visit we were interviewed and counseled by one of the nursing staff. They covered all the basics of what treatment would most likely be appropriate for us and they also itemized the costs at each stage. There was some variability in the cost estimate because it depended on how much of the hormone would be needed to stimulate egg production. The hormones come from the U.S. pharmaceutical companies and are very expensive. When you add it all up the hormone costs are the largest single item, at least for treatment in Thailand since the doctor and clinic fees are quite reasonable.

II: Did you do any independent research about IVF on your own?

R: Some. I did some searching on the internet and read some background articles on the steps in the treatment. So I had a pretty good idea of the procedures and options. I also tried to get an idea of what typical costs are, but that was difficult to find. Lots of fertility clinics have websites but they are very vague about costs. I had the impression they were purposefully vague. Eventually I found some numbers that said it would be between $12,000 and $20,000 per complete cycle in the U.S.

II: For our readers, can you tell us what you mean by "complete cycle".

R: Sure. That would be the initial hormone assay as they call it, basically a blood test, followed by injection of the follicle stimulating hormone for 7 to 10 days, then ovulation induction and egg harvesting, culturing the eggs and sperm, injection of hormones to prepare the uterus for implantation, implantation of embryos, and post implantation followup and pregnancy test.

II: You really sound technically astute!

R: After reading about this stuff long enough those medical terms just roll off the tongue.

II: How did the costs compare to the treatment in Thailand.

R: Two things were apparent right away. The first was that they didn't try to hide the costs. They gave me a handbook that had all fees listed. Where there was a range they showed it, like for the follicle stimulating phase they gave a lower and upper bound which depended on how much hormone was required. And the second thing was that costs were really low, at least for the doctor and clinic fees. Like the charge for the nurse to give an injection is itemized on one of the bills. It's 80 baht, $2 U.S.! Can you imagine any service of any kind at a U.S. hospital costing only $2?

II: What about the total cost, how did that compare to treatment in the U.S.?

R: It looks like the total cost is about one-third. If a lot of hormone is required the cost goes up a lot, and I'm guessing that is what the $20,000 estimate for U.S. based treatment reflects. The older the woman is the more hormone is required. So that's the case I am considering since it seems like that is what my wife and I will require.

II: What about your expectations for quality of medical care at this facility? Many westerners can't imagine seeking medical treatment overseas.

R: I went into it expecting world class quality. That's because of our previous experience with medical care in Thailand. I mentioned my wife's surgery. That was done at a rather famous hospital called Bumrungrad in Bangkok. I knew a little about it before we went there. They are well known internationally as a medical destination for all sorts of treatment. But I was amazed at how great the care was when my wife had surgery there. Top quality medical care and great Thai hospitality. It was so different than any prior experience I had in the U.S. Four nights in a private room with an extra bed for me, doctor's fee, operating theater fee, smiling pampering nurses - total cost less than $2,000 U.S. I have also had medical exams and dental treatment at other private facilities in Bangkok. Each time quality and care exceeded my expectations.

II: That' amazing. The insurance deductible would probably be more than that if the surgery was done in the U.S.

R: That's right. And you would probably get the usual cold uncaring treatment by hospital staff. I am so happy we were in Thailand when the need for the surgery came up. If a hospital stay could ever be considered pleasant this was it.

II: That set a pretty high standard. How has Jetanin compared to that?

R: It's not quite the same experience of course since fertility treatment is an out-patient treatment. But I see the same level of quality and hospitality that I saw before so that's what I continue to expect. The other thing that has set my expectations high is the fact that this clinic is used by the very weathiest and powerful Thai people, people who could choose any clinic in the world. If you happen to visit the clinic and see the photo on the wall next to the blood test room you will know what I mean.

II: Can you elaborate on that? What do you mean?

R: Well, I can't really say much since I live in Thailand and must adhere to Thai ways which include avoiding any pubic discussion of private matters of the Thai royal family. You will just need to go there and look at the photo and deduce the obvious.

II: Ok, sounds a bit mysterious. But let's go on. So, you and your wife are in the IVF cycle now, is that right?

R: Yes. We went through one follicle stimulating cycle already and it was unsuccessful. The eggs did not develop sufficiently to harvest. It was disappointing but we will try again.

II: The failure rate of IVF is pretty high; you must know that.

R: Yes, we do. Best case success rates are around 35% and we are not in the prime age range so our expected success rate is lower. But we are not going to fret over it. This gives us a chance so we will try. I read one blog about a couple who were so devasted by the failure to conceive naturally and then failed with IVF that they could not bear to look at each other anymore. It was like they each were a reminder to the other of failure to get something they wanted so much. That's a problem, wanting things so much that it tears you apart when you don't get it. We aren't in that mode. We will be happy either way.

II: That's great. So, for now you will keep trying.

R: Right. We will try another cycle.

II: We would like to get an update and see some of your medical bills if possible.

R: Sure. I'll scan and send some of the bills for your comparison. It's a real eye opener.

II: Any final comments?

R: I know its a giant leap of faith to consider any kind of medical treatment in another country. The fear of the unknown and all that. I can't say for sure I would have done it myself if I wasn't already living in Thailand and somewhat familiar with things that made me comfortable. But now that I know it I would never consider returning to the U.S. for any kind of medical treatment. It's just so much better and more affordable in Thailand. There are a lot of in-the-know people, although I don't know how they got to be in-the-know. But Bumrungrad treats something like 350,000 foreign patients each year for everything from cosmetic surgery to cancer. And I just read about stem cell treatment for untreatable heart disease that is being done in Bangkok. Access to low cost world class medical care is a benefit I didn't anticipate when I moved to Thailand.

Friday, October 21, 2005

In Vitro Fertilization (IVF)

The oocytes are collected in a specially prepared culture medium and are added with highly motile sperm after special preparation. They are cultured overnight and if the eggs have fertilized and are developing normally, the embryo transfer will take place.

Wednesday, October 19, 2005

Gamete Intrafallopian Transfer (GIFT)

IVF versus GIFT

GIFT is an alternative method to IVF. If there is at least one healthy and patent fallopian tube, the eggs and sperm can be placed directly into the fallopian tube where fertilization is most likely to occur. The resulting embryos are nutured in the tube and then move down to the uterus for implantation.

A disadvantage of GIFT is the uncertainty whether fertilization has occurred or not.

Wednesday, October 12, 2005

Sperm collection

Husbands are asked to be present at the clinc during occyte recovery in order to produce a semen sample at that time. It is very important as the egg recovery cannot proceed until the semen sample has been obtained and prepared. The preparation may take one or two hours, with the goal of obtaining the most forward motile sperm from the ejaculate.

If there is the possibility that the husband will not be present during the procedure, or if it is anticipated there will be difficulty in producing a semen sample, special arrangements can be made with couples for the freezing of semen samples.

Monday, October 10, 2005

Oocyte recovery

Oocytes are recovered by one of two techniques:

Ultrasound Oocyte Recovery

This is the technique of choice in the majority of cases since it is a less invasive procedure, the post-operative period is less uncomfortable and excellent results are achieved with it. A vaginal ultrasound probe with an attached needle guide is passed into the vagina under sterile conditions and a needle is passed through the top of the vagina into the ovary. The follicles are then aspirated until oocytes are obtained.

Laparascopy Oocyte Recovery

Prior to the routine use of ultrasound for oocyte recovery, oocytes were usually recovered laparoscopically. At present, on some occasions patients are recommended to have a laparoscopic oocyte recovery, as in the case of the GIFT procedure.

Sunday, October 09, 2005

Ovulation induction and monitoring of treatment cycles

Hormonal medications are administered to stimulate the ovaries in such a way that several follicles develop. Doses my be adjusted during the cycle, depending upon follicle growth. Several methods of ovulation induction are used, depending on which method is suitable for the patient, according to the physician's judement. The combination of GnRH-a and gonadotrophins is currently the most frequently used method for stimulating the ovaries.

Careful monitoring will prevent the development of too many eggs and will thus reduce the chance of multiple pregnancies and the development of ovarian hyperstimulation syndrome.

Monitoring can be performed in two ways:

  • by endocrine assay of the blood levels of estrogen, LH and progesterone.

  • by ultrasound scanning using the modern technique of vaginal ultrasound which does not require the bladder to be full. Using ultrasound, a picture of the ovaries, follicles, and state of the lining of the uterus can be obtained.

When the follicular development has reached the stage when an optimum number of eggs will be produced without untoward effects, hCG will be administered to trigger ovulation. Egg retrieval is normally scheduled 34 to 36 hours after hCG administration.