TOPIC: 2 or 3 Embryos
Q	At age 39 years, TTC 5 years, if we're lucky enough to have three good embryos should we transfer all 3 or go with 2? I know the risk of twins and triplets but would you say one's chances are increased given the circumstances if we go with 3?
A	We follow the guidelines as stipulated by the American Society of Reproductive medicine when it comes to the number of embryos transferred stating the following: -Below the age 38: 1 or two embryos depending on the couples wishes. -Between age 38 to 40: 3 embryos -Over age 40: Up to 5 embryos This is evidence based and is ultimately to give the couple the best chance of a pregnancy with the lowest miscarriage rate. In a study including about 1200 patients, there were only 2 twin pregnancies and no triplets. So at age 39, transfer 3 embryos if possible.
	TOPIC: Follicle Targets
Q	What Number of Follicles is considered within an Average Range for IVF? If you could set a target for the amount of follicles you retrieve, how many would be optimal? What is your average retrieval in your practice and what is the highest number ever retrieved?
A	This is a very controversial topic, especially nowadays with the advent of the so called “soft stimulation or minimal stimulation approach” However, as described in the literature, we aim to harvest between 8 to 12 oocytes per attempt. This is however dependent on patient age and ovarian reserve volume and is not always possible. As an average, we manage to harvest approximately 6 to 8 oocytes per cycle.
	TOPIC: Intragam
Q	What are the advantages of using intragam to help the body to not reject the embryo? is this a common practise?
A	The usage of intravenous immunoglobulin is not, and should not be common practise. It is an intervention that is not without complications e.g. high temperature, joint and muscle ache, rigors, headache etc. Therefore, it should be used for specific indications such as HLA type incompatibility and at the physicians discretion.
	TOPIC: High Thyroid Antibodies
Q	How does high thyroid antibodies but normal TSH,T3 & T4 levels affect infertility? Could high thyroid antibodies in anyway delay or stop one getting their period or interfere with ovulation?
A	The thing that is clear about thyroid antibodies is the fact that some studies show there to be a higher miscarriage rate and a possibly a lower implantation rate. There is however also studies to show it not to be the case. At the end of the day, with a normal TSH and T4 level, the prognosis seems to be good.
	TOPIC: Egg Freezing
Q	Is there any means of freezing eggs before they have been fertilised and if so, what is the procedure when thawing them for transfer, ie...would we have to do ICSI to fertilise them because they have been frozen?
A	Egg freezing is becoming a very common intervention. It is still in its infancy though, and fertility clinics specializing in egg freezing only reports a take home baby rate of 4% at most. Therefore, one needs a very good reason to freeze eggs, and delaying childbearing is definitely not one of them. After thawing, ICSI is the worldwide method of choice due to the denuded nature of the eggs and to try and ensure fertilization.
	TOPIC: ICSI Miscarriage
Q	Is the rate of miscarriage higher in ICSI than in IVF?
A	The miscarriage rate in ICSI is higher than in IVF. This is due to the fact that ICSI is usually done when the male gamete is compromised in some way, leading to an inferior quality embryo, ultimately leading to a higher miscarriage rate.
	TOPIC: Sperm Collection Medium
Q	What is the purpose of the medium provided for collecting sperm before IVF/ICSI procedure (the pink fluid)?
A	There is a difference between “collecting” sperm in media and preparing sperm in media. If one “collects” sperm in media, this is usually because the sperm has a higher than 50% antibody titre and the aim is to bind excess antibodies before agglutination of the sperm. Preparing sperm for AI, IVF etc is done im medie in order to get rid of debris and non viable sperm and to concentrate the best sperm into a small volume.
	TOPIC: Immunotherapy
Q	My FS wants to implement immunotherapy with my current IVF/ICSI/DE cycle. This includes Intragam and Clexane. Can dr give me some more info on these injections as well as an estimated cost? Is it really necessary and will it help at all?
A	Low molecular weight heparin, i.e. Clexane, is usually prescribed when the patient is suffering from clotting disorders, immune disorders such as anti phospholipids syndrome etc. It has a profound positive effect on the outcome, but can be a very expensive therapeutic intervention.( I am not sure of the approximate cost) Some physicians will prescribe it empirically, depending on the patients history, with good results and should ultimately be left up to the discretion of the attending physician.
	TOPIC: PGD
Q	In what cases would dr recommend PGD testing? How much does PGD cost?
A	PGD arrived with a “bang” and everybody thought it to be the long awaited saving grace of the IVF specialist. However, it turned out not to be. Nowadays the feeling among reputable authors on the subject is that it should only be applied to couples with known single gene defects like Cystic Fibrosis or Tay Sachs disease etc. This is due to 2 factors: 1) The pregnancy rate seems to be lower in the biopsied embryo group. 2) There are no long term studies yet to ascertain the long term outcome. For that reason, routine PGS is not encouraged unless a valid reason can be found. Costs vary from clinic to clinic and can be quite expensive.
	TOPIC: Donor Eggs 2/3 Embryos
Q	I have had 4 IVF's, putting back only 2 embryos each time (3 singleton miscarriages, 1 BFN). We are now doing a donor egg cycle. Would it be better to put 3 embryos back or 2 again?
A	In donor egg cycles, the donor should ideally be between the age of 21 to 33. For that reason alone one should not transfer more than 2 embryos maximum in order to avoid high order multiple pregnancies which in itself can turn out to be disastrous. It all revolves around the age of the egg.