When time is of the essence

Infertile couples who want to start a family should turn to in-vitro fertilisation (IVF) early for a higher success rate, advises Loh Seong Feei, medical director of Thomson Fertility Centre.

After having conducted some 3,000 IVF cycles over the past five years, Dr Loh found that the highest success rate was among women between 30 and 35 years old. However, women seeking IVF are most commonly aged between 36 and 40 years.

Dr Loh says that in his practice, the number of women seeking assisted reproduction has doubled from 2004 to 2009 - from 1,716 to 3,271. There is now a higher acceptance that IVF is the best way to go. "In the past, people were reluctant to start on IVF until they had exhausted all other means. But the success of IVF is very much age-dependent," Dr Loh notes.

Close to half, or 48 per cent, of women younger than 35 years old conceive with one cycle. The pregnancy rate for women aged 35 to 40 years is 33 per cent. At 40 years old, the rate is 12 per cent.

"It's essentially the ovarian reserve which drops with age. The quality of eggs also drops with age. For women above 35, there is a higher chance of abnormal chromosomes which results in Down's Syndrome," cautions Dr Loh.

One deterring factor - besides the cost - is the high burden of treatment. Traditionally, female patients have had to face 40 injections in 30 days.

A study has shown that about 17 per cent of couples drop out of the IVF exercise due to the "physical or psychological burden of treatment". When part of this "burden" comes from the inconvenience of having daily injections, a single-injection treatment that replaces seven injections could make a significant difference.

The launch of Elonva, a new controlled ovulation stimulation drug, now enables just one injection of follicle stimulating hormones (FSH) to replace the first seven injections of any daily conventional IVF drug.

"The actual injection-free days will be four to five days, as the total number of injections is nine, but interspersed over five days," explains Dr Loh.

This is a substantial drop in the number of injections, although the cost for switching to Elonva, the new sustained delivery drug, is about the same.

FSH is the hormone that naturally drives egg production. It stimulates the ovaries to produce multiple eggs in a single cycle. During a normal menstrual cycle, only one egg develops each month. However, when a woman is undergoing assisted reproductive therapy, the goal is to harvest a number of mature eggs in order to maximise the chances of successful fertilisation.

Elonva (corifollitropin alfa injection) is the newest, most novel treatment in IVF, and was introduced in Europe in the last couple of months.

Approval for corifollitropin alfa injection was based on extensive clinical trial data including Engage, the largest double-blind fertility agent trial in IVF performed to date. The study showed that the pregnancy rate was similar to that achieved in patients receiving the conventional daily dose.

"The sustained drug acts like a driver pushing the gas pedal, and then coasting on the road, rather than constantly stepping on the pedal," explains Human M Fatemi, senior medical director for the Centre for Reproductive Medicine in Brussels, Belgium.

In the trial which tested more than 2,500 patients, 33 per cent of them were ready to have their eggs harvested within seven days (which means they only had one injection), 50 per cent within eight days, and 90 per cent within nine days.

New, yet-to-be published data that Prof Fatemi has also showed that not only is the quantity of the eggs important, but also the quality.

The conventional thinking is that with more eggs, the higher the chance of fertilisation. However, recent research shows that if the follicles are pushed too hard and stimulation is not done correctly, with overproduction of eggs, it can also have a negative impact on the receptivity of the womb.

However, by continuing with the number of cycles, Prof Fatemi says, there is such a thing as a cumulative rise in chances. Women on the first cycle have a 48 per cent chance of pregnancy; a 55-60 per cent chance on the second cycle, and a 70-80 per cent chance on the third try.

"The highest rates are experienced by those who persist," he points out.

He expresses surprise at the low IVF rate in Singapore. In Brussels, his centre alone does 6,000 cycles a year. Only 4,000 cycles are recorded in the whole of Singapore - which is extremely low compared to other countries.

"This could be due to the government subsidy policy," he reckons. In Belgium, for example, patients before the age of 43 are reimbursed for six cycles.

In Singapore, a single cycle can set a couple back by between $11,000 and $14,000 in a government hospital. The government has a co-funding limit of $3,000 per cycle for Singaporeans, for up to three cycles only.

Worldwide, one out of five couples is affected by infertility. There has been a significant increase in IVF cycles worldwide in the last 10 to 15 years, says Prof Fatemi. Infertility is often diagnosed after a couple has not conceived after one year of unprotected, well-timed intercourse, or after six months if a woman is 35 or older.

This article was first published in The Business Times.