Thin endometrium
A Blog by Dr Tan Heng Hao
There have been tremendous innovations and improvements in IVF technologies over the last few decades. What we will never overcome are the biological effects of aging on our patient’s eggs. I remember the wave of excitement that greeted my patients when it was announced in 2020 that Singapore had lifted the age limit of 45 years for women undergoing IVF treatments. Although this was a progressive step forward, I had to continually remind them that the change had not fundamentally impacted the detrimental effects of ovarian aging.
As fate would have it, I met a 46-year-old patient who had consulted me for IVF that same year. Both husband and wife were pleasant and level headed, despite failing multiple cycles of IVF treatments overseas. It was discovered that she was also suffering from a condition called Ashermann’s syndrome – a condition that occurs when scar tissue forms inside the womb cavity from previous surgery. This makes it even more challenging for an embryo to implant successfully.
Though I remained objective in my assessments, I did remember feeling pessimistic inside. Till then, we had not treated that many IVF patients above 45 years, not to mention knowing of any success stories in this group of patients. This harsh reality and statistic had to be made known to the couple, and it was something that I had not particularly relished in my counselling process.
To add to the complexity of the situation, there certainly wasn’t any successful IVF livebirths in any patient who was above 45 years of age and also suffering from Ashermann’s syndrome.
We had a thorough discussion and it further affirmed in me the importance of understanding contexts and perspectives from a patient. What made me determined to help them to the fullest was the fact that this was possibly their last attempt before calling time to their IVF journey. Egg donation options were not on their minds and I have always known that from every patient’s viewpoint, it was always easier emotionally to start an IVF treatment than to end it. Embarking on an IVF journey always represented optimism and hope while making the decision to stop signified pessimism and the end of a lifelong dream.
The injections started and after 2 long weeks of stimulation, we managed to harvest 6 matured eggs when she was 46 years and 272 days of age – 93 days shy of her 47th birthday.
2 good graded blastocyts ( Day 5 embryos) were frozen. This move was deliberate as we needed to surgically treat her womb condition before transferring the embryos back in.
In Mid of 2020, a hysteroscopy surgical procedure was performed to free the cavity of the scarring. This was achieved using a thin lighted telescopic device, inserted into the womb cavity under deep sedation. It was imperative to prime the womb lining through oral estrogen tablets and to allow it to heal properly. These illustrated the importance of adhering to good reproductive surgical principles to enhance success rates. In the month after, we proceeded to transfer these 2 embryos in a medicated frozen embryo transfer regime. This allowed us to use more estrogen tablets to thickened the womb lining further.
I remember vividly that in the last consultation visit days prior to the transfer, the patient verbally expressed her thoughts of postponing this transfer, much to the surprise of her husband and me. As we deep dive into the reasons, it was evident that this was a case of cold feet as they had encountered multiple failures in the past and it was understandable that she dreaded a repeat of the emotional distress. We managed to resolve these issues and she mustered up her courage to proceed as planned.
Again, this reinforced my notion that as clinicians on every of our patient’s IVF journey, we need to be more than just a doctor addressing their medical needs. It requires patience, empathy, and a non-judgmental attitude and the journey is often not just a medical issue but a psychological and emotional one. These were the same words that I told a Straits Times reporter when I was interviewed during the award ceremony for the Singapore Health Quality Service in 2019.
Adjunct Associate Professor Tan Heng Hao (left) and physiotherapist Yap Thian Yong won the Superstar Award, the highest accolade under the Singapore Health Quality Service Awards.
I still remember the sense of excitement that gripped the team as we waited eagerly for the pregnancy test results that day. I do not know how the couple had reacted to the positive pregnancy blood test when she received the news, but I can only imagine that it was one mixed with euphoria, relief, and disbelief.
4 weeks post embryo transfer, a fetus with one fetal heartbeat was seen on a transvaginal ultrasonography. It was surreal seeing this miracle of life, a mere 6 months after we first met in the clinic. As we could not genetically screen these embryos, we had to battle 2 other obstacles – miscarriage rates were known to be more than 50 % while the risk of Down syndrome babies was at its highest in this age group. Under such circumstances, I have always believed in the notion of not looking past the next visit at every consult, as it makes the entire pregnancy journey easier to bear.
Weeks turned into months and before we knew it, a healthy baby was delivered after she turned 47 years of age. The family had since relocated and I wish them the very best as they prepare for their next phase of family life.
To the best of my knowledge, this has been oldest reported livebirth in a woman with Ashermann’s Syndrome following in vitro fertilization–embryo transfer with her own eggs.
As I reflected on this case, it brings to me important lessons and take-homes. It offered me insights into what being an IVF specialist means.
- I have always and will remain appreciative when patients look me up for their problems. There are options available to them, and the fact that they entrust their fertility hopes into my hands is not to be taken for granted. Hence, we must always try our best and strive to be empathetic to their issues.
- No matter how bleak or positive their chances are, every couple will always ask me if they will get pregnant with the next IVF cycle. While we need to remain grounded, we should never write off anyone’s chances and I have always believed in the philosophy of “Never say never” in IVF. Every couple deserves their right to make an informed choice, and once that decision is taken, it’s a case of “Now is always better” to prevent the detrimental effects of aging from further setting in.
- There were multiple factors that contributed to this success story:
- We have nearly perfected our freeze thaw programs and embryo culture systems. IVF technologies have improved by leaps and bounds and credit must be given to these laboratory advancements as they had been instrumental towards her success.
- For the longest time prior to 2020, there had been great inertia in raising the age limit of IVF over concerns that it offers our patients false hope. This legislative move of lifting the age limit yielded an immediate benefit for this patient. Personally, this success story of ours single handedly vindicates our government’s decision and demonstrated the progressiveness of our ART legislations. Nonetheless, we must not get carried away, and are obliged to properly counsel our patients and find ways to reduce the potential risks during the pregnancy.
- I have always believed that good reproductive surgical principles should complement IVF successes. In such instances, surgeries can be double edges swords and may at times delay the IVF process while affecting the total egg yield. Just as it is important to emphasize on what needs to be done at surgery, it is also equally important to time the surgery in relation to the IVF cycle. The aim is always about harvesting good quality eggs as soon as possible and preparing the womb environment well for the embryo implant.
- On numerous occasions, I have asked myself what would be the most important for success here? My answer would have to be down to sheer grit on the part of the patient. This human factor of resolve and perseverance when all hope is lost, is still the single most important ingredient in unifying all other factors for success. This is something that both science and legislation can never and will never replace.
