Introduction

Like graduating from college, getting a job and getting married, parenthood is often considered to be one of the greatest milestones in life. However, it may come as a surprise to learn that approximately one in seven couples worldwide experience difficulty conceiving a child. Though infertility is frequently thought to be a ‘female concern’, any problems a couple faces in conceiving a child together may well lie with the male partner. In fact, about one third of all cases where a couple face challenges in becoming pregnant is the result of male infertility.

Understanding how important the act of creating a child together and nurturing it from infancy to adulthood is, Pantai Hospital Kuala Lumpur (PHKL) is proud to offer a stellar assortment of services catering to all couples who face difficulty conceiving. With a wide range of treatment options and dedicated medical personnel committed to helping couples achieve successful outcomes, PHKL is fast becoming a reputable name in the field of reproductive medicine.

Fertility Assessment

Successful treatment outcomes first begin with an in-depth investigation of your personal medical history and your attempts to conceive. Our foremost goal is to provide you with treatment outcomes that guarantee the possible chance of success. Here, a comprehensive fertility assessment is provided as an essential step to achieve optimal conception outcomes.

For women:

  • Consultation with a fertility specialist
  • Trans-vaginal/ abdominal ultrasound scanning
  • Blood tests
  • Special investigation includes the use of hysterosalphingogram (HSG) or saline infusion sonography for uterine and tubal evaluation, hysteroscopy, laparoscopy, cyst aspiration, and many more.

For Men:

  • Semen analysis
  • Blood tests

Intrauterine Insemination

IUI is a form of fertility assistance which involves a laboratory procedure that separates fast-moving sperm from slow, sluggish, or immobile sperm. The fast moving sperm, which has a high potential to fertilise with an egg, is placed in the woman’s uterus close to the time of ovulation in the middle of her monthly cycle. The overarching aim of this procedure is to increase the number of sperm that reach the fallopian tubes, thus increasing the chance of successful fertilisation.

IUI is not effective with:

  • Women who has blockage of both fallopian tubes
  • Women above 40 years old
  • Severe endometriosis
  • Severe pelvic scarring
  • Severe male factor infertility
 

In Vitro Fertilization (IVF)/ Intracytoplasmic Sperm Injection (ICSI)

IVF techniques can differ from clinic to clinic and often depends on individual circumstances. A typical IVF treatment may involve

This process uses a combination of oral fertility medication and injectable fertility hormones to stimulate the production of multiple ovarian follicles. Ovarian induction allows for the production of more than one egg by the ovaries, under the premise that with more eggs available for fertilisation, the patient has greater choice of embryo formation.

This is a very useful procedure for women who suffer from irregular periods and who fail to ovulate. The goal of controlled ovarian hyperstimulation is to increase a woman’s monthly fertility rates to approximate that of a healthy 20 year-old female.

Throughout the fertility drug treatment, your doctor will monitor the growth of the eggs via vaginal ultrasound scans and possibly hormonal blood tests. Once the egg size is deemed to be appropriate, a final triggering injection is done to allow final maturation of the eggs. Oocyte retrieval will be scheduled 34 to 38 hours post-triggering

During OPU or follicle aspiration (FA), the eggs are collected through an aspiration needle with ultrasound guidance. This procedure is typically performed under general anesthesia. You might feel cramping and experience a small amount of vaginal bleeding after the procedure. This is perfectly normal. Your doctor will inform you about the number of eggs retrieved at the end of procedure.

* During OPU procedure, your eggs are aspirated and collected into a tube.

It is common practice for sperm to be collected around the time of oocyte retrieval. The fresh semen sample will be investigated to select the sperm with the best motility and morphology for fertilisation purposes.

In the case that a fresh semen sample is not available on the day of oocyte retrieval, a frozen semen sample may be used instead. Men are recommended to have their sperm frozen as a back-up supply option before commencing any IVF treatment. This is to ensure that viable sperm can be obtained to support fertilisation purposes.

There are two techniques typically used to fertilise an egg. This is accomplished either via the conventional IVF technique or the intracytoplasmic sperm injection (ICSI) technique. The conventional IVF technique involves mixing the woman’s eggs with her partner’s sperm to allow natural selection of sperm for fertilisation purposes. There are several limitations to this fertilisation technique which include patients with low number of eggs retrieved. Males with low sperm quality (azoospermia) are not viable candidates for fertilisation using the conventional IVF technique.

ICSI, on the other hand, bypass the natural selection of sperm by the egg. ICSI involves selection and injection of single spermatozoa into egg cytoplasm by an embryologist. ICSI was invented initially to help fertilization in a couple with male infertility, these include oligozoospermia (low sperm count), azoosperma (no sperm found in ejaculate) with subsequent testicular biopsy sample, etc. However, with promising higher fertilization rate compare to conventional IVF, most of the IVF laboratory now offers ICSI as the first choice of treatment in majority of IVF cycle, regardless of male fertility status.

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*An embryologist is performing ICSI procedure, injecting single sperm into the egg cytoplasm to achieve fertilization.

Embryo transfer refers to a step in the process of assisted reproduction in which embryos are placed into the womb of a female with the intent of pregnancy. The transfer takes place after the eggs have been collected and fertilised in the laboratory. The exact procedure for embryo transfer depends on the clinic you choose.

At NewLife@PHKL, we practise 100% blastocyst transfer and we encourage patients to undergo this procedure to improve their chances of a successful pregnancy. Our clinical data has shown that blastocyst transfer improves clinical pregnancy rates more than 50% for each attempt.

Blastocyst transfer is a simple procedure that does not require any form of anesthesia, with only an ultrasound to guide the doctor in the process.

The procedure involves the following:

  • Embryos are cultured in the laboratory incubator for five to seven days until they become blastocysts. A blastocyst is an embryo which has developed into a multi-cellular mass five to seven days after the sperm has fertilized the egg.
  • During embryo culture, not all embryos could develop into blastocyst stage. Some embryos may experience arrested (stopped) development at any stage of the process. Only good quality embryos will develop into a blastocyst which then allows for easier selection of the best quality embryos for transfer.
  • With blastocyst transfer, the number of transferred embryos could be reduced to only one or two blastocysts to decrease the risk of multiple pregnancies. The remaining embryos will be frozen for future IVF treatment if they are deemed suitable.

* During embryo transfer, your embryo (s) will be loaded into a catheter from a culture dish before transfer back to your womb to establish pregnancy

A blastocyst formation happens 5 to 7 days after fertilization. A blastocyst consists of inner cell mass that eventually form the embryo, and outermost layer of cells called trophectoderm that becomes part of supporting structure during pregnancy.

Embryo Freezing

s not more than three embryos will be transferred to achieve pregnancy, the remaining embryos will be frozen and stored for future IVF treatment. Some embryos might develop into good quality ones while others might stop development at any stage before the transfer altogether. Yet others may develop with a high fragmentation rate, which is an indicator of poor quality embryos.

Only the good quality embryos will be frozen for future use while the remaining poor quality embryos will be discarded as they may not survive the freezing and thawing procedure. The good quality embryos will be stored in liquid nitrogen at a temperature of minus 196 °C for future usage.

 

Frozen-thawed embryo transfer (FET)

Unused embryos are frozen in liquid nitrogen (vitrification) and when a couple decides to add to their family, they have a choice of using a previously frozen embryo. The procedure for FET is the same as using an embryo transfer in a fresh cycle. No anesthesia is required but only ultrasound guidance to allow optimal placement of embryos at implantation side of the womb. Patients are fully conscious during the procedure and may even observe the transfer of the embryo into their womb on an ultrasound monitor.

Egg Freezing

Newlife@PHKL is proud to provide egg freezing service to female patients. This is a process in which a woman’s eggs (oocytes) are extracted, frozen and stored. Later, when she is ready to become pregnant, the eggs can be thawed, fertilised, and transferred to the uterus as embryos.

One of the main benefits of egg freezing is that it enables women to preserve their fertility until a time when they are ready to become pregnant. Freezing also serves as a fertility preservation option for women with cancer as cancer therapy usually has detrimental effects on a woman’s ovaries and egg production, thus affecting her reproductive capacity.

However, it is important to understand that egg freezing is relatively a new technique in the field of fertility medicine, and that not all eggs will survive the freezing and thawing procedure. Women should also be forewarned that those eggs that do survive may not be able to be fertilised.

During egg freezing procedure, the eggs are loaded onto a device called cryotop and stored in liquid nitrogen until required.

 

Sperm freezing

Just like how women can freeze their eggs to preserve their fertility for future use if they so wish, men can similarly have their sperm frozen for future use in fertility treatment. Sperm freezing is a highly successful procedure that has been utilised in the field of fertility medicine for almost 40 years. Sperm is kept in liquid nitrogen at a temperature of minus196C, and can be stored for many years without the quality being adversely affected.

However, it is important to bear in mind that not all sperm will survive freezing and thawing procedure and it is common to observe reduced sperm motility (movement) after the thawing process. There may be a problem with number and quality of the sperm, especially in men who are about to undergo cancer treatment. Their underlying illness may have caused a reduction in the sperm count or in their motility. In such situation, it may be advisable to freeze even more specimens if time and treatment permits.

However, sperm freezing is always recommended as a back-up option to support male reproduction in men with ejaculation problem before IVF treatment. Men engaged in high-risk occupations or sports are also recommended to have their sperm frozen in case of an injury that affects reproductive capacity.Those with diabetes or a family history of the disease are also good candidates for the procedure as diabetes is known to cause erectile problems.

During sperm freezing procedure, the sperm sample is loaded into a straw and stored in liquid nitrogen until required.

Semen Analysis

Semen analysis, also known as a sperm count test, evaluates the health and viability of a man’s sperm. Semen is the fluid containing sperm that is released during male ejaculation.

A semen analysis measures three major factors of sperm health:

  1. The number of sperm
  2. The shape of the sperm
  3. The movement of the sperm, also known as “sperm motility”

Below are the parameters that will be observed during semen analysis test and the explanation on the findings.

Macroscopic Examination


  • Connector.

    Appearance

    A normal ejaculated semen has a homogenous (equivalent) and grey-opalescence in colour.

  • Connector.

    Viscosity

    To check the consistency/stickiness of ejaculated semen.

  • Connector.

    Semen Volume

    The normal range of semen volume is/above 1.5 ml per ejaculate.

  • Connector.

    pH

    To determine the acidity and alkalinity of semen fluid. The normal pH of semen is approximately 7.2-8.0.

Microscopic Examination


To determine the number of sperm in the ejaculation. Normal range is 39 x 106 per ejaculate.
The number of sperm (in millions) per millilitre. Normal range is 15 x 106 per ml.
Sperm movement rate
Sperm moving actively, either linearly or in a large circle, regardless of speed.
A grading system for semen movement

  1. Rapid progressive motility
  2. Slow or sluggish progressive motility
  3. Non-progressive motility
  4. Immobility (static)
The Sperm Shape

Sperm that is considered normal would have oval shape head, well-defined acrosomal region comprising 40-70% of the head area. Mid-piece should be slender, less than 1 µm in width, about one and a half times the length of the head, and attached axially to the head. Cytoplasmic droplets should be less than half the size of normal head. The tail should be straight, uniform, and thinner than mid-piece, uncoiled and approximately 45 µm long.

Categories of morphology defect of sperm:

  1. Head defects: large, small, tapered, pyriform, round, vacuolated amorphous heads, double heads, head with small acrosomal area or any combination of these.
  2. Neck and Mid-piece defects: ‘bent’ neck, asymmetrical insertion of the mid-piece into the head, thick or irregular mid-piece, abnormally thin mid-piece or any combination of these.
  3. Tail defect: short, multiple, hairpin, broken tails, bent tails, irregular width tail, coiled tail, any combination of these.
  4. Cytoplasmic droplets: the droplet greater than one-half of the area of a normal sperm head.

Round cells in the ejaculate include spermatogenic cells (e.g. immature sperm cells) and non spermatogenic cells (ephitelial cells and white blood cells).

Graded as Low, Medium or High

Includes anything observed in the semen that cannot be identified as sperm, round cells, or other common cellular components. Some minor debris is common.

Categorize as scanty or heavy.

*Sperm staining is performed to observe the morphology (shape) of the sperm

How to Prepare for Semen Analysis

Your doctor will let you know what you should do in preparation for the semen analysis.

Semen analysis is conducted by:

  1. Masturbation
  2. Sex with a special condom (only special condom provided by IVF laboratory is allowed. Normal condom over the counter is designed with spermicide (sperm killing) property, thus not suitable for semen analysis test as we require motile sperm for analysis)

It is very important to follow these instructions for accurate results.

  1. Refrain from any sexual activity including masturbation for 3 days prior to the appointment date. No less than two days and no more than five days of abstinence
  2. Before semen collection, wash hands and genital parts thoroughly then towel dry.
  3. During semen collection, avoid using any form of lubricant such as soap, cream etc.
  4. Semen sample collected by masturbation should ejaculate into a sterile collection container provided by the IVF Laboratory.
  5. In cases where intercourse is required, a special condom will be provided by the IVF Laboratory. Use no other condoms as these may contain spermicide which can kill the sperm.

*After ejaculation, cut the condom’s tip off with a pair of scissors to transfer the sample to a sterile collection container provided by the IVF Laboratory.

  1. It is important that the entire ejaculate is collected. Highlight if collection is incomplete, on the Semen Collection Instruction Form provided by the IVF Laboratory.
  2. Label the collection container with patient’s label provided by the IVF Laboratory. You are responsible for the correct name and date of birth on the label before placing it on the container.
  3. For home collection, semen samples must be delivered to the IVF Laboratory within one hour. The sample should be kept as close to body temperature as possible (example in an inside pocket).  Do not expose the sample to extreme temperatures.
  4. The Semen Collection Instruction Form should be filled completely, and return with the sample to the IVF Unit.

Hysterosalpingogram (HSG)

Hysterosalphingogram or HSG, is an X-ray procedure used to see whether the fallopian tubes are patent (open) and if the inside of the uterus (uterine cavity) is normal. The procedure takes fifteen to 30 minutes. This test is usually done after your menstrual period but before ovulation starts, intercourse prior to HSG test is not allowed. Your fertility specialist might request for a HSG test to be done as part of preliminary investigation before suggesting suitable fertility treatment to you.

During this procedure, a radiologist will inject certain dye into your uterine cavity through your cervix and observe the flow of the dye as it passes through your uterine cavity, fallopian tubes and eventually empty into the abdominal cavity. Abnormalities inside the uterine cavity can be detected through observing the x-ray images when the fluid movement is disrupted by the abnormality. The fallopian tubes patency is considered normal when the dye moves and spills out at the end of the tubes.

HSG is considered a very safe procedure. However, some patients may experience cramping during or after the procedure. You may take an anti-cramp medication thirty to forty five minutes before the test. Other side effects that may happen are nausea, dizziness, bleeding, and rarely (1%), possibility of infection after the procedure. For precautionary measures, it would be best to have someone drive you home after the procedure.

 

Surgical sperm retrieval (SSR)

Surgical sperm retrieval is often performed in extreme circumstances such as where no viable sperm are available in fresh ejaculate for fertilisation purposes. This treatment option is also suitable for men who have difficulty releasing sperm due to testicular injury or infection. It is also recommended for men with congenital abnormalities that prevent the release of sperm from the testicles, and for those who have had a vasectomy.

There are several types of surgery available for treating severe male fertility via SSR, and these include:

This procedure involves guiding a small needle through the skin into the epididymis to draw out a small amount of fluid containing sperm.
This procedure involves the use of a small needle to extract relatively mature sperm from the substance contained within the testicles.
This involves the use of the same method as above to remove a small amount of tissue from the testes.

The surgically retrieved sperm can be used for the fertilisation process or frozen for future use. All three procedures are performed under light general anaesthetic. Male patients undergoing any of the aforementioned procedures require only a few hours interment at the hospital before discharged to resume their normal routines.

The surgically retrieved sperm can be used for the fertilisation process or frozen for future use. All three procedures are performed under light general anaesthetic. Male patients undergoing any of the aforementioned procedures require only a few hours interment at the hospital before discharged to resume their normal routines.

Transferring of frozen embryos/eggs/sperm from other Fertility centre

If you have frozen sperm or eggs (known as gamete)/embryos from previous IVF Cycle at other centre, you could always transfer your precious little one to us for further treatment with Newlife@PHKL.

Safe and secure transfer service is provided to protect your little one during the transfer process.

Contact our centre for further information on procedure and charges. You are required to sign the Consent Form before we could transfer your embryos/gamete to Newlife@PHKL. Depending where you had your IVF cycle, the centre might require you and your partner to give consent to them before they could allow the transfer of your embryo/gamete to another centre