Infertility Treatment

What is infertility?

Infertility is

What is infertility?

Infertility is defined as the inability to conceive after 12 months of unprotected, regular sexual intercourse.

How common is the problem?

Infertility is a medical condition that affects up to one in six couples of reproductive age.

What influences the infertility?

The single biggest influence on a couple’s chances of getting pregnant is woman’s age. Male infertility plays a close second to this, together affecting almost half of all infertile couples. As couples wait longer to have their first baby, establishing careers, relationship and financial stability first, the outcome is often increased difficulties in conceiving naturally.

What are the causes of infertility?

Causes of infertility are varied and can include:

• Problem with the production of sperm or eggs.
• Structural or functional issues with the female or male reproductive systems.
• Hormone or immune conditions in men, women or both.

How do we assess female infertility?

The first step for couples seeking fertility treatment begins with a thorough assessment of both partners, including a detailed medical history and number of routine tests.

To measure female fertility, the following tests are often performed:

• Ovulation test – a quick blood test to asses if the woman is producing an egg each month or not.
• Ultrasound scan – a scan to look at the condition of the uterus and presence of issues like fibroids, cysts or Polycystic Ovarian Syndrome (PCOS).
• Ovarian Reserve (AMH Test) – a blood test that measures the level of AMH hormone to help estimate the number of eggs she has, especially when they are at risk of decreased ovarian reserve. Eg: advanced maternal age/ history of previous ovarian surgery / history of cancer chemotherapy or pelvic radiation.

Sometimes fertility specialists also perform additional tests, including a hysterosalphingogram (HSG), sonohysterogram or a diagnostic laparoscopy, to better assess the condition of the woman’s fallopian tubes, ovaries and uterus.

How do we assess male infertility?

The most important diagnostic test to assess male infertility is a semen analysis. In nearly all cases, man does not display any obvious outward signs or symptoms that may indicate an issue  with his fertility.

Specialist Andrology assessment of sperm is essential to measure:

• The number of sperm, volume and consistency of the sample.
• The size and shape (morphology) and ability to move (mobility) of the sperm, both of which can interfere with penetration and fertilization of an egg.

What treatment options are available for infertility?

There are numerous treatment options for couples struggling with infertility. At the simpler end of the scale, follicular tracking by ultrasound, to detect ovulation is an important starting point for many couples, as they are taught to identify the most fertile days of woman’s cycle. This helps them to time intercourse accordingly for the best chance of conceiving. A step up from this, Ovulation Induction uses medication to regulate the woman’s cycle so she is ovulating regularly.

Intra-uterine Insemination (IUI) is another option for couples with unexplained infertility and is a simple way to achieve pregnancy. A prepared sperm sample is injected into the upper part of a woman’s uterus around the time she is ovulating; ovulation can occur either spontaneously or with hormone treatment.

A more advanced treatment option, In vitro Fertilization (IVF) is used in cases involving male and female fertility issues and requires the retrieval of eggs from the woman’s ovaries so they can be fertilized with the man’s sperm in the laboratory. The resulting embryos are then inserted into the woman’s womb to achieve pregnancy.

In case of severe male infertility, Intra Cytoplasmic Sperm Injection (ICSI) is the gold standard in treatment options. Used alongside IVF, an embryologist only needs one live sperm cell in the semen sample for selection and injection directly into the body of the female egg to enable fertilization daily.

Overview of an IVF Cycle

IUI- Intrauterine Insemination

What is the right time to have a baby?

Women 35 years and older are encouraged to get medical advice if they haven’t conceived within 6 months of trying naturally, while women under 35 years can try for up to 12 months before seeking medical help. Starting early and getting the right help is the key to success when trying for a baby.

Reference

• Diagnostic evaluation of the infertile female; a committee opinion:practice committee, ASRM: Fertility and sterility, vol 103, no6, june 2015, 0015-0282
• Diagnostic evaluation of the infertile male; a committee opinion:practice committee, ASRM: Fertility and sterility, vol 103, no3, March 2015, 0015-0282

What is IVF?

IVF (In-vitro fertilization) or test

What is IVF?

IVF (In-vitro fertilization) or test tube baby as it is commonly called is a procedure in which the eggs and the sperms are fertilized outside the body and then transferred back to the womb after 2-5 days.

Who needs an IVF?

IVF may be considered if,

• you have been diagnosed with unexplained infertility
• your fallopian tubes are blockedother techniques such as fertility drugs or intrauterine insemination (IUI) have not been successful
• other techniques such as fertility drugs or intrauterine insemination (IUI) have not been successfulthe male partner has fertility problems and an abnormal semen analysis
• The male partner has fertility problems and an abnormal semen analysis
• you are using your partner’s frozen sperm in your treatment and IUI is not suitable for you
• you are using donated eggs or your own frozen eggs in your treatment
• you are using embryo testing to avoid passing on a genetic condition to your child.
• If you have severe endometriosis

What do I expect during my treatment cycle?

Your treatment cycle would be as follows

Step 1: Once you have decided to go ahead with IVF, you will undergo a day care procedure called hysteroscopy to assess the suitability of the uterus to hold the baby. It is generally done one month before your IVF cycle and involves the introduction of a small camera into the womb through the vagina to visualize the inside of the uterus. You will be given anaesthesia during the procedure and hence there will be no pain.

Step 2: Your husband has to freeze one semen sample as a back up.

Step 3:  Typically your treatment would begin on the second or third day of periods. It involves a scan and hormone tests followed by daily injections for about 8-10 days, along with monitoring by scan and hormone tests in between. Once the eggs are sufficiently grown as per the scan and hormone tests, you will receive injection Hcg as a ovulation trigger.

Step 4: Egg retrieval is performed transvaginally 35 – 36 hours later, with light anaesthesia, using a transvaginal ultrasound guidance. You will be discharged same evening, unless there are problems associated with bleeding, undue pain or ovarian hyperstimulation.

Step 5: After retrieval, eggs are assessed for their maturity. Meanwhile husband has to give a fresh semen sample. Mature eggs are injected with the sperms on the same day and grown in the incubator for 3-5 days.

Step 6: The final step is the embryo transfer. 3-5 days after your egg retrieval, two or three embryos are selected and gently transferred into the womb using an abdominal ultrasound guidance. The procedure is usually painless, no anaesthesia is required and you will be discharged in about two to three hours.

Step 7: You will be given certain supportive medications starting from the day of egg retrieval till your pregnancy check. You will be called for a pregnancy check 16-17 days after your embryo transfer.

What precautions do I take during the IVF treatment?

• Eat a healthy diet rich in fruits and vegetables
• Be stress free and relax your mind
• Avoid intercourse during the treatment.
• Don’t do strenuous job during the treatment as your ovaries are enlarged and they may twist sometimes causing acute pain.

How do I prepare myself for an egg retrieval procedure?

You will get admitted to the hospital early in the morning, between 6am – 7am and you have to be empty stomach atleast 6-8 hours before the procedure. You will be administered light anaesthesia as intravenous medication. The procedure is done vaginally using the scan guidance and a small needle. The entire procedure takes about 20-30 minutes. Post procedure you may have slight pain or bleeding which usually subsides with medication. You will be discharged about 6 hours later.

What do I expect during embryo transfer?

It is done 3-5 days following the egg retrieval, which will be decided by your clinician. No anaesthesia is required as it is a painless procedure. Rarely during your initial assessment if it is found that getting into the uterus is difficult or if you are very uncooperative, you may be given light anaesthesia. Your bladder has to be full before the procedure as it is done under abdominal scan guidance. Do not wear perfume/ deodorant or powder on that day as they are harmful to the embryos. Two or Three embryos are gently transferred to the uterus using a small catheter. You will lie down for about 15 – 30 minutes after the procedure and later you can pass urine. No need to take bedrest until your pregnancy check.  This does not increase your chances of becoming pregnant.

What is ICSI? How does it differ from IVF?

ICS

IVF 

ICSI – Intracytoplasmic sperm injection, is an IVF procedure in which a single sperm is injected directly into an egg whereas in IVF, about 50,000 to 1,00,000 sperms are inseminated around the eggs and one of them penetrates the egg on its own. ICSI increases the fertilization rates especially in male factor infertility and cases of previous fertilization failure.

What is the success rate?

Success rate varies with multiple factors especially the age of the women, egg and the sperm quality and the underlying cause of infertility. Over all the success varies between 40-50 %. Success decreases as the age of the woman increases.

What is frozen embryo transfer?

Surplus embryos after your transfer can be frozen and kept in liquid nitrogen at -180 degree Celsius, for later use.

What are the complications?

Two most important complications of IVF are

• Multiple pregnancy (20-25%)
• Ovarian hyperstimulation syndrome which occurs due to excessive response and can be prevented b appropriate modifications in the medications
• Rarely ovaries may twist causing acute pain and may require a laparoscopy

When can I know if I have become pregnant?

You will be tested for beta HCG – a blood test to confirm pregnancy 14 to 16 days after your embryo transfer.

Is my pregnancy going to be more riskier after IVF?

There is no evidence to show that IVF babies have increased rate of abnormalities. The pregnancy outcome will be like a normal conception but your doctor may have a low threshold for intervention when the problem arises.

References

• Fertility: assessment and treatment for people with fertility problems.NICE clinical guideline ;– Issued: February 2013.
• van Loendersloot LL, van Wely M, Limpens J, Bossuyt PM, Repping S, van der Veen F (2010). “Predictive factors in in vitro fertilization (IVF): a systematic review and meta-analysis”. Human Reproduction Update 16 (6): 577–589.

What is ovulation?

Usually each month one ovary

What is ovulation?

Usually each month one ovary will be stimulated by hormones produced in the brain.  These cause a small cyst or follicle to grow on the ovary in which an egg develops.  Another hormone then causes the follicle to release one egg to travel down the fallopian tube where it can be fertilised by the sperm which swims up from the vagina. This usually occurs around 14 days after the beginning of a period, but can vary between 11 – 16 days.

What is ovulation induction?

Ovulation induction is a simple process which encourages the ovaries to release eggs, to maximize your chance of conception through intercourse or artificial insemination (IUI). It suits women who are producing low levels of hormones for ovulation, or who are not ovulating at all. Medication in the form of tablets or injections needs to be taken to stimulate hormones for egg production.

Who needs ovulation induction?

If a woman is not ovulating by herself then ovulation induction may be required. The most common causes of failure to ovulate are

• Stress
• Weight fluctuations
• Polycystic Ovarian Syndrome (PCOS)

Other causes may include disorders of the pituitary gland, thyroid gland and raised prolactin levels. In some cases failure of ovulation is due to the ovarian failure. This may occur following treatment for cancer or may be the start of the menopause – premature ovarian failure.

What is clomiphene citrate?

Clomiphene is a fertility drug that can increase the chance of ovulation occurring. It is an anti estrogen and the most commonly used drug for inducing ovulation.

How should Clomiphene be taken?

Clomiphene is taken for 5 days early in the menstrual cycle – typically from day 2 to 6 of the cycle or day 3 to day 7. It is taken orally at the same time every day.

What are the potential side effects of clomiphene?

Bloating, pelvic pain, nausea, vomiting, insomnia, light-headedness, constipation, breast discomfort, fatigue and a change in menstrual flow can all occur while taking clomiphene. If you develop blurred or altered vision please discontinue clomiphene and contact the doctor.

What are the chances of conceiving with clomiphene?

For women whose only infertility problem is anovulation, up to 80% of patients will ovulate using this medication and 50% of those will conceive. Clomiphene may be combined with intrauterine insemination to boost the success of the medication by placing the sperm and egg in closer proximity to each other.

What are gonadotrophins?

Gonadotropins are fertility medications that contain FSH or LH alone or in combination. In contrast to clomiphene, which is given by mouth, gonadotropins are given by injections. A related medication is hCG, which is structurally similar to LH and mimics the natural LH surge. There are a variety of commercially available gonadotropin preparations.

How will the cycle be monitored while on ovulation induction drugs?

Ultrasound:

The doctor will often use one or more ultrasound scans to obtain an actual image of the ovaries and to regularly monitor follicle growth in the ovary beginning on or before day eight of the cycle, as follicles mature, they grow larger. Through ultrasound, the doctor will observe the effects of treatment on follicle growth and size, and decide when to give hCG injection (human chorionic gonadotrophin) to assist with the release of the egg.

Blood tests:

Testing the blood every few days for oestrogen levels can monitor the response to treatment with FSH therapy.

Your progesterone level is usually checked six to eight days after you ovulate (about day 21 of a day 28 cycle). This is because progesterone levels rise following ovulation, peaking five to nine days after ovulation. This is known as your luteal phase. After the midluteal period, your serum progesterone levels will begin to fall if the egg is not fertilized.

What are the side effects of gonadotropins?

There are potential risks and complications associated with the use of gonadotropins. Side effects should be discussed prior to taking these medications. Despite intensive monitoring, up to 30% of gonadotropin-stimulated pregnancies are multiple. Of the multiple pregnancies, about two-thirds are twins and one-third are triplets or more. Premature delivery is a known risk for multiple pregnancies. The greater the number of fetuses in the uterus, the greater the risk of premature delivery. Premature delivery can subject the newborn to complications such as severe respiratory distress, intracranial hemorrhage, infection, cerebral palsy, and death. Some patients pregnant with triplets or more choose to undergo a procedure known as multifetal pregnancy reduction in an effort to decrease these risks.

In addition to problems associated with high order multiple gestation, another serious side effect of gonadotropin therapy is ovarian hyperstimulation syndrome (OHSS), in which the ovaries become swollen and painful. In severe cases, fluid accumulates in the abdominal cavity and chest. In about 2% of gonadotropin cycles, hyperstimulation may be severe enough to require hospitalization. Careful monitoring of ovulation induction cycles with the use of ultrasound and/or measurement of serum estradiol levels, in conjunction with adjustment of gonadotropin dosage, will enable the physician to identify risk factors and prevent most cases of severe OHSS. When serum estradiol levels are rapidly rising and/or too high, or an excessive number of ovarian follicles develop, one method of best prevention is to withhold further gonadotropin stimulation and delay hCG administration until estradiol levels plateau or decline. Alternately, hCG can be withheld so that ovulation fails to occur, thereby lessening the severity of OHSS.

When should I test for pregnancy?

Most menstrual cycles are approximately 28 days long and ovulation occurs 14 days prior to the onset of menstrual flow.  If you are pregnant the menstrual flow will not come.  Test for pregnancy using a home pregnancy test 28-30 days after your last menstrual period.

If your period does not come, continue to test for pregnancy every second day.  Contact your doctor if your menstrual period does not come 35 days after your last period and the pregnancy test remains negative.  Please also contact your doctor if you become pregnant! Please remember you may not conceive during the first cycle.  Indeed, most patients require a few months of clomiphene treatment and sometimes dosage adjustments are required.

Reference:

Ovulation Problems and Infertility: Treatment of ovulation problems with Clomid and other fertility drugs Advanced Fertility Center of Chicago. Gurnee & Crystal Lake, Illinois

What is hysteroscopy?

Hysteroscopy is a procedure

What is hysteroscopy?

Hysteroscopy is a procedure to look inside your uterus. It is done using a narrow tube-like telescope with a camera called a hysteroscope, which is inserted into the vagina to examine the cervix and inside of the uterus. Hysteroscopy can be either diagnostic or operative.

What is diagnostic hysteroscopy?

Diagnostic hysteroscopy is used to diagnose problems of the uterine cavity. It can sometimes be clubbed with laparoscopy [In laparoscopy, your doctor will insert an endoscope (a slender tube fitted with a fiber optic camera) into your abdomen, through the navel, to view the outside of your uterus, ovaries and fallopian tubes.]

What is operative hysteroscopy?

Operative hysteroscopy is used to correct an abnormal condition that has been detected during a diagnostic hysteroscopy. If an abnormal condition is detected during the diagnostic hysteroscopy, an operative hysteroscopy can often be performed at the same time, avoiding the need for a second surgery. During operative hysteroscopy, small instruments used to correct the condition are inserted through the hysteroscope.

Why it is done?

A hysteroscopy may be done to:

• Find the cause of severe cramping or abnormal bleeding
• See whether a problem in the shape or size of the uterus or if scar tissue in the uterus is the cause of infertility
• Look at the uterine openings to the fallopian tubes. If the tubes are blocked, your doctor may be able to open the tubes with special tools passed through the hysteroscope (tubal cannulation)
• Find the possible cause of repeated miscarriages. Other tests may also be done.
• Find and remove a misplaced intrauterine device (IUD)
• Find and remove small fibroids or polyps
• Look for endometrial cancer
• Use heated tools to remove problem areas in the lining of the uterus (endometrial ablation)
• Place a contraceptive implant (such as Essure) into the opening of the fallopian tubes as a method of permanent sterilization
• Determine the cause of unexplained bleeding or spotting in postmenopausal  women

When is operative hysteroscopy used?

Your doctor may perform hysteroscopy to correct the following uterine conditions:

• Polypsand fibroids —Hysteroscopy is used to remove these non-cancerous growths found in the uterus.
• Adhesions—Also known as Asherman’s Syndrome, uterine adhesions are bands of scar tissue that can form in the uterus and may lead to changes in menstrual flow as well as infertility. Hysteroscopy can help your doctor locate and remove the adhesions.
• Septums—Hysteroscopy can help determine whether you have a uterine septum, a malformation of the uterus that is present from birth.

Abnormal bleeding— Hysteroscopy can help identify the cause of heavy or lengthy menstrual flow, as well as bleeding between periods or after menopause. Endometrial ablation is one procedure in which the hysteroscope, along with other instruments, is used to destroy the uterine lining in order to treat some causes of heavy bleeding.

How safe is hysteroscopy?

Hysteroscopy is a relatively safe procedure. However, as with any type of surgery, complications are possible. With hysteroscopy, complications occur in less than 1 percent of cases and can include:

• Risks associated with anaesthesia
• Infection
• Heavy bleeding
• Injury to the cervix, uterus, bowel or bladder
• Intrauterine scarring
• Reaction to the substance used to expand the uterus

When should the procedure be performed?

Your doctor may recommend scheduling the hysteroscopy for the first week after your menstrual period. This timing will provide the doctor with the best view of the inside of your uterus.

What type of anesthesia is used for hysteroscopy?

Anesthesia for hysteroscopy may be local, regional, or general:

• Local anesthesia:the numbing of only a part of the body for a short time
• Regional anesthesia:the numbing of a larger portion of the body for a few hours
• General anesthesia:the numbing of the entire body for the entire time of the surgery

The type of anesthesia used is determined by where the hysteroscopy is to be performed (hospital or doctor’s office) and whether other procedures will be done at the same time. If you are having general anesthesia, you will be told not to eat or drink for a certain amount of time before the hysteroscopy.

How is hysteroscopy performed?

Prior to the procedure, your doctor may prescribe a sedative to help you relax. You will then be prepared for anaesthesia. The procedure itself takes place in the following order:

• The doctor will dilate (widen) your cervix to allow the hysteroscope to be inserted
• The hysteroscope is inserted through your vagina and cervix into the uterus
• Carbon dioxide gas or a liquid solution is then inserted into the uterus, through the hysteroscope, to expand it and to clear away any blood or mucus
• Next, a light shone through the hysteroscope allows your doctor to see your uterus and the openings of the fallopian tubes into the uterine cavity
• Finally, if surgery needs to be performed, small instruments are inserted into the uterus through the hysteroscope

The time it takes to perform hysteroscopy can range from less than 5 minutes to more than an hour. The length of the procedure depends on whether it is diagnostic or operative and whether an additional procedure, such as laparoscopy, is done at the same time. In general, however, diagnostic hysteroscopy takes less time than operative.

What can I expect after the procedure?

If regional or general anaesthesia is used during your procedure, you may have to be observed for several hours before going home. After the procedure, you may have some cramping or slight vaginal bleeding for one to two days. In addition, you may feel shoulder pain if gas was used during your hysteroscopy. However, if you experience any of the following symptoms, be sure to contact your doctor:

• Fever
• Severe abdominal pain
• Heavy vaginal bleeding or discharge

Will I have to stay in the hospital overnight?

Hysteroscopy is considered minor surgery and usually does not require an overnight stay in the hospital. However, in certain circumstances, such as if your doctor is concerned about your reaction to anaesthesia or in case of operative procedures, an overnight stay may be required.

When do I call the doctor?

If you have any of the following problems mentioned below:

• Heavy vaginal bleeding or discharge (more than a normal menstrual period)
• Fever
• Severe abdominal or pelvic pain or cramping
• Problems urinating
• Shortness of breath
• Vomiting

References

• American College of Obstetricians and Gynecologists. FAQ: Hysteroscopy. www.acog.org. Accessed 1/25/2013
• American Society for Reproductive Medicine. Laparascopy and Hysteroscopy: A Guide for Patients. www.asrm.org. Accessed 1/25/2013
• Cain J, ElMasri WM, Gregory T, Kohn EC. Chapter 41. Gynecology. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, eds. Schwartz’s Principles of Surgery. 9th ed. New York: McGraw-Hill; 2010

What is egg donation?
Egg donation is the process by

What is egg donation?
Egg donation is the process by which a woman donates eggs for purposes of assisted reproduction. It typically involves In-vitro fertilization technology, with the eggs being fertilized in the laboratory; more rarely, unfertilized eggs may be frozen and stored for later use.

Who needs an egg donation?

Congenital absence of eggs

• Turner’s syndrome
• Gonadal dysgenesis

Acquired reduced egg quantity / quality

• Oophorectomy (surgical removal of ovaries)
• Premature menopause(before 40 years)
• Those who have taken cytotoxic chemotherapy or pelvic radiotherapy for cancers
• Advanced maternal age
• Compromised ovarian reserve

Other

• Diseases of X-sex linkage
• Repetitive fertilization or IVF failure
• Ovaries inaccessible for egg retrieval

How does it work?

• Once you decide to go ahead with egg donation, you have to register in the donor bank who would provide you with an anonymous donor matching your requirements. Neither your identity nor the donor’s identity will be revealed to each other, but you will have access to all the requisite information about the donor.
• Donors are usually young (<30 years) and are thoroughly screened according to ICMR guidelines.
• Menstrual cycle of the donor and the recepient are matched.
• Donor is started on injections for about 8-10 days to grow the eggs and simultaneously the recepient’s uterus is prepared with hormonal tablets.
• Once the oocytes are retrieved from the donor, they are injected with the recepient’s husband’s sperms, cultured in the incubator for 3-5 days and later 2 or 3 of the embryos are transferred into the recepient’s womb. Rest are frozen for future use.

What is the success rate?
Egg donation has a high success rate of about 55-60% and almost an 80– 90% success rate after four repeated treatment cycles.

What is embryo

What is embryo freezing?

It is a process where in the unused embryos are frozen at -180 degrees in liquid nitrogen using a method called vitrification.

How long can the embryos be stored?

The embryos are normally stored upto five years subject to periodic renewal of charges. If you wish to continue beyond that period, the centre has to be intimated about it. If you wish to discontinue before five years,

again you have to intimate the centre and you have the option of either discarding them or donating them for research or donating them for third party reproduction (as an anonymous donor).

What is the procedure for frozen embryo transfer?

The frozen thawed embryos can be transferred into the uterus either in a natural cycle or in a downregulated cycle.

• Natural cycle FET: It can be done if you have ovulatory cycles. Your cycles would me monitored by scans for follicular growth and ovulation and the embryos are transferred at the appropriate time following ovulation.
• Downregulated FET: Your natural cycle is suppressed using medications and a period is artificially induced, Followed by hormonal medication to prepare the uterus.Once the lining of the uterus is ready, the embryos are transferred at the appropriate time.

What is the success rate of Frozen Embryo transfer?

Once the frozen embryos are thawed to room temperature, only about 80-85% of them survive. Upon transferring these embryos the success rate is good as a fresh embryo transfer.

What is oocyte freezing?

Oocyte freezing or egg freezing is a relatively new treatment where in the ovaries are stimulated with hormonal medications for about 8-10 days, follicular growth is monitored by serial scans and blood tests. Once

What is oocyte freezing?

Oocyte freezing or egg freezing is a relatively new treatment where in the ovaries are stimulated with hormonal medications for about 8-10 days, follicular growth is monitored by serial scans and blood tests. Once the follicles are ready, a HCG trigger is given and oocyte retrieval is planned after 36 hrs. These oocytes are vitrified and stored in liquid nitrogen at -180 degrees.

Who are the candidates for oocyte freezing?

Oocyte freezing may be considered

• If you are diagnosed with a cancer requiring chemtherapy or radiotherapy which is likely to destroy the ovarian reserve.
• if you are concerned about your age but are not yet ready to bear children.

How long can the oocytes be frozen?

Oocytes can be stored upto five years subject to periodic renewal of the freezing charges. If you wish to continue beyond that period, the centre has to be intimated about it. If you wish to discontinue before five years,

again you have to intimate the centre and you have the option of either discarding them or donating them for research or donating them for third party reproduction (as an anonymous donor).

What happens when the frozen oocytes are to be used?

Once you decide use the frozen oocytes, your endometrium is prepared with hormones similar to the frozen embryo transfer cycle. The vitrified oocytes are thawed at appropriate time and ICSI is done. The resulting embryos are cultured for 3-5 days and then transferred.

What are the chances of having a baby with frozen oocytes?

Oocyte freezing is not as efficient as embryo freezing and results in a much lower survival rates than the embryo freezing.  The success rates are much less than the fresh or frozen embryo transfer and vary from center to center.

• Semen Analysis
• Doppler ultrasound for varicocele
• Reversal of vasectomy
• Vaso – vasal and vaso – epididymal anastomosis for ductal blockage
• Microsurgical varicocelectomy
• Treatment of male

• Semen Analysis
• Doppler ultrasound for varicocele
• Reversal of vasectomy
• Vaso – vasal and vaso – epididymal anastomosis for ductal blockage
• Microsurgical varicocelectomy
• Treatment of male medical and sexual problems
• Sperm freezing
• Surgical sperm recovery from the testes (TESE, PESA)

What is sperm freezing?

Sperm can be

What is sperm freezing?

Sperm can be frozen for future use either in artificial insemination or other fertility treatments, or be donated. Donated sperm has to be stored for six months before it can be used in treatment, in order to screen the donor for infections.

Who needs to freeze the  sperms?  

It is indicated in

• cancer patients as a part of the fertility preservation strategy in those who are scheduled for cytotoxic chemotherapy.
• Stored as a back up when patients are undergoing fertility treatment especially when they have low counts/ collection problem or deteriorating semen parameters.
• It is also stored for donation for a period of six months as a part of the donor quarantine for infectious diseases.

What are the treatment options using the stored sperms?

After thawing the stored sperms, almost 50% of them do not survive and  there is a definite deterioration in the quality of the semen. Depending on the quality of the thawed sample, it can be used either for IUI, IVF or  ICSI .

Laparoscopic surgery, also called minimally invasive surgery

Laparoscopic surgery, also called minimally invasive surgery (MIS), or keyhole surgery, is a modern surgical technique in which operations are performed far from their location through small incisions (usually 0.5–1.5 cm) elsewhere in the body.

Many conditions can contribute to infertility, including fibroids, endometriosis, pelvic adhesions (scar tissue in the pelvis) and uterine anomalies such as a uterine septum and adhesions (scar tissue inside the uterus – Asherman’s syndrome). They can be treated by fertility enhancing laparoscopic surgeries.

What are the advantages of laparoscopic surgery over an open procedure?

There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:

• Reduced hemorrhaging, which reduces the chance of needing a blood transfusion.
• Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring.
• Less pain, leading to less pain medication needed.
• Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living.
• Reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.

What are the fertility enhancing laparoscopic surgeries?

Fertility enhancing laparoscopic surgeries include:

a.Laparoscopic myomectomy for the removal of large fibroids or multiple fibroids

b.Laparoscopic treatment of advanced stage endometriosis

• Laparoscopic ovarian drilling and chromopertubation

d.Laparoscopic tubal reanastomosis (tubal ligation reversal)

• Laparoscopic removal of large benign ovarian masses or cysts
• Diagnostic laparoscopy and chromopertubation

Usually these procedures are combined with hysteroscopy to assess the uterine cavity better.

ICSI means injection of the sperm into the middle of the egg. ICSI is an effective method to fertilize the egg

How is ICSI done?

As with IVF, the ovaries are first stimulated by injections and eggs are

ICSI means injection of the sperm into the middle of the egg. ICSI is an effective method to fertilize the egg

How is ICSI done?

As with IVF, the ovaries are first stimulated by injections and eggs are retrieved.

IVF with ICSI involves the use of specialized micromanipulator and an inverted microscope that enables embryologists to pick up individual sperms in a tiny specially designed hollow ICSI needle. The needle is then carefully advanced through the outer shell of the egg and egg membrane and the sperm is then injected into the inner part (cytoplasm) of the egg.

What percentage of eggs get fertilized after ICSI?

This usually results in normal fertilization in approximately 70-85% of eggs injected with viable sperm.

Who should be treated with ICSI?

► Men with very low total motile sperm counts

►  In couples who have had poor fertilization with IVF in a previous cycle

►  Men who have no sperms in their ejaculate but need removal from their testes (testicular sperms do not have the capacity to fertilize)

►  When fewer than 5 eggs have been retrieved – here ICSI is done to more eggs fertilized

►  When the number of eggs retrieved are less than 5. Here ICSI is used to get a higher percentage of eggs fertilized than with IVF (just mixing eggs and sperm together).

How is ICSI performed?

► This is performed with a specialized ICSI microscope

►  Under the microscope, the egg is held by a special holding pipette

►  A very fine needle is used to pick up the sperm and immobilize it

►  The needle with the sperm is introduced carefully through the outer layer of the egg(zonapellucida) and then into the cytoplasm of the egg

►  The sperm is then injected into the egg gently and the needle carefully removed

►  The eggs are checked 18 – 20 hours later to see if they are fertilized

Pictures of ICSI – Step 1

Egg has been held in place.

Sperm has been picked up by hollow needle (below X) ICSI needle is ready to pierce the outer covering (zona)

Step 2

Needle has penetrated the outer shell (zona) and is stretching the outer membrane. The sperm is seen at the tip of the needle.

Step 3

The needle is within the cytoplasm of the egg and the sperm is about to be injected inside Fertilization is checked 18 hrs later and the embryos are transferred into the uterus on day 2, 3 or 5.