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Diagnosis and treatment

Infertility

If you and your partner are struggling to have a baby, you’re not alone. A big percent of couples in India and across the world are fighting a battle against  infertile. Infertility is defined as not being able to conceive despite having frequent, unprotected sex for at least a year for most couples. Infertility may result from an issue with either you or your partner, or a combination of factors that interfere with pregnancy. Fortunately, there are many safe and effective therapies that significantly improves your chances of getting pregnant.

Diagnosis and treatment
Diagnosis and treatment

At GarbhaGudi, we have been delivering miracles every day for over ten years now. We have on board a team of infertility specialists like clinicians, embryologists, andrology technicians and paramedical staff who work closely with you to develop a personalized fertility treatment plan. Before starting with any infertility investigations or treatment, our doctors work to understand your general and sexual habits. Based on this, they may make recommendations to help you conceive naturally.

We offer a wide range of infertility treatment like IUI, IVF, donor programs (egg donors, semen donors, embryo donation), surrogacy and more. As a leading destination for fertility treatments for Indians and foreigners, our fertility center offers hope to patients around the world. The treatment plan for a couple is decided based on various factors like what’s causing infertility, how long has one been infertile, age, lifestyle, genetic issues, earlier treatment taken etc. When normal pregnancy doesn’t occur, couples can often achieve a pregnancy with the use of assisted reproductive technology or ART.

At GarbhaGudi, we offer treatments to both men and women for infertility.

Infertility treatments for men
Infertility treatments for men

In some cases, improving lifestyle and behavioral factors can improve chances for pregnancy. Discontinuing select medications, reducing or eliminating harmful substances, improving frequency and timing of intercourse, regular exercise may help.

TIP : An andrologist is a doctor who specializes in diagnosing and treating male sexuality and male infertility related issues. He is usually an urologist who has done super-specialization in treating male sexual health and male fertility issues

  • Medications. We may prescribe medications to improve sperm count along with an increase in testicular functions like sperm production and quality.
  • Surgery. Certain conditions may require surgery to reverse a blockage and in other cases surgically repairing a varicocele may improve overall chances for pregnancy.
  • Sperm retrieval. There are some techniques to obtain sperm when ejaculation is a problem or when no sperm is present in the ejaculated fluid. Examples are: Testicular Sperm Extraction, Testicular Sperm Aspiration, Microsurgical Epididymal Sperm Aspiration, Percutaneous Epididymal Sperm Aspiration, Microsurgical Testicular Sperm Extraction etc. Recovery after sperm retrieval depends on the method used and recovery time can range from a few hours to a couple of days.

Infertility treatments for women

Thanks to advances in medical treatments, conceiving is a lot easier today for women facing infertility. Some treatments offered at GarbhaGudi are: Ovulation stimulation to regulate or induce ovulation for pregnancy, surgery to restore fertility, surgical intervention to correct physiological issues like cysts, fibroids, myomas, endometriosis, PCO etc. and assisted reproductive techniques like IUI, IVF, assisted hatching, donor egg, embryo and sperm. In cases where it’s not possible for the woman to carry forward pregnancy, we also offer surrogacy in accordance with the Government of India’s rules and regulations.

What is Assisted Reproductive Technology?

Assisted reproductive technology (ART) is the name given to the gamut of all fertility treatment available in medical field for treating infertility. An ART team includes gynecologists, fertility specialists, surgeons, andrologists, physicians, psychologists, embryologists, lab technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy. Some forms of ART are mentioned below.

Assisted Reproductive Technology
IUI or Intrauterine insemination
IVF or In Vitro Fertilization
Intra-Cytoplasmic Sperm Injection (ICSI)
Assisted hatching
Using donor eggs or sperm
Surrogacy
Infertility
Diagnosis and treatment

Infertility is defined as not having the ability to conceive despite having frequent, unprotected sex for a minimum of a year for couples or over six months if the woman is aged 35 or older.

Women who get pregnant but are unable to remain pregnant

If there are difficulties in conceiving a baby due to issues in you or your partner

Infertility is not just a problem in women, men can be infertile too. Both men and women are likely to possess fertility problems. Pregnancy may be prevented by issues in you or your partner or a combination of factors.

Symptoms

The sole symptom of infertility is not getting pregnant. There may be no other symptoms. Sometimes, a woman with infertility may have irregular menstrual periods or no periods at all. For a man, hormonal problems which causes changes in hair growth or sexual function may be the signs of infertility

When to see a doctor

Normally a doctor is not consulted for infertility unless you have been trying to have a baby, when the woman is aged 35 or older and have been trying to conceive for six months or longer.

A woman

  • Aged over 40
  • Having irregular or absent periods
  • Having very painful periods
  • Has known fertility problems
  • Has been diagnosed with endometriosis or pelvic disease
  • Has had multiple miscarriages
  • Has undergone treatment for cancer

For a man

  • Has Low sperm count or other problems with sperm
  • A history of prostate, testicular or sexual problems
  • Has undergone treatment for cancer
  • Has small testicles or swelling in the scrotum
  • Has others in the family with infertility problems

Causes for Infertility

Every step related to ovulation and fertilization has to go on correctly to get pregnant. Sometimes the issues that cause infertility in couples are hereditary or they develop sometime later in life.

Infertility causes can affect one or both partners:

  • In about one-third of cases, there is a problem with the man
  •  In about one-third of cases, there is a problem with the woman
  • Issues with both the man and the woman, or no known cause for the remaining one-third of the cases.

Causes for male infertility:

  • Abnormal sperm production or function because of genetic defects, undescended testicles health problems like diabetes, or infections like chlamydia, gonorrhea, mumps, or HIV. Enlarged veins within the testes (varicocele) can also affect the quality of sperm.
  • Problems with the delivery of sperm because of structural problems, blockage within the testicle, sexual problems, like premature ejaculation; certain genetic diseases, like cystic fibrosis, or damage or injury to the reproductive organs.
  • Overexposure to environmental factors like pesticides, chemicals or radiation. Cigarette smoking, alcohol, marijuana, anabolic steroids, and taking medications to treat bacterial infections, hypertension, and depression can also affect fertility. Frequent exposure to heat, like in saunas or hot tubs ( the raised body temperature can affect sperm production).
  • Damage related to cancer and its treatment, Cancer treatments like radiation and chemotherapy can impair sperm production severely.

Causes of female infertility

Causes of female infertility may include:

  • Ovulation disorders, which affect the discharge of eggs from the ovaries. These include hormonal disorders like polycystic ovarian syndrome. Hyperprolactinemia, a condition during which you’ve got an excessive amount of prolactin — the hormone that stimulates breast milk production may also interfere with ovulation. Either an excessive amount of thyroid hormone (hyperthyroidism) or an insufficient thyroid hormone (hypothyroidism) can affect the cycle or cause infertility. Other underlying causes may include an excessive amount of exercise, eating disorders, or tumors.
  • Uterine or cervical abnormalities, including abnormalities with the cervix, polyps within the uterus, or the form of the uterus. Noncancerous (benign) tumors within the uterine wall (uterine fibroids) may cause infertility by blocking the fallopian tubes or stopping an embryo from implanting within the uterus.
  • Inflammation of the Fallopian tube (salpingitis) can cause the blockage or it may damage the fallopian tube which is caused by pelvic disease, which in turn is caused by endometriosis, adhesions, or sexually transmitted diseases.
  • Endometriosis – Endometrial tissue grows outside of the uterus may affect the function of the ovaries, uterus, and fallopian tubes.
  • When the ovaries stop working and menstruation ends before age 40 which is called Primary ovarian insufficiency (early menopause), the cause of which is not known, certain factors are associated with early menopause, including systemic diseases, certain genetic conditions like Turner syndrome or carriers of Fragile X- syndrome, and radiation or chemotherapy treatment.
  • Pelvic adhesions, bands of connective tissue that bind organs which will form after pelvic infection, appendicitis, endometriosis, or abdominal or pelvic surgery.
  • Cancer and its treatment- Certain cancers, particularly cancers of the reproductive system often impair female fertility. Both radiation and chemotherapy may affect fertility

Risk factors of infertility similar to both men and women

  • Age- Women’s fertility declines with age, women are most fertile in their 20s which gradually reduces in the mid-30s, and it drops rapidly after age 37. Infertility in older women is because of the lower number and quality of eggs, and health problems that affect fertility. Men over age 40 could also be less fertile than younger men.
  • Tobacco use- Smoking tobacco or marijuana by either male or female may reduce the likelihood of pregnancy. Smoking also reduces the effectiveness of fertility treatment. Miscarriages are more frequent in women who smoke. Smoking can cause erectile dysfunction and a lower the sperm count in men.
  • Alcohol use- There is no safe level for alcohol use during conception or pregnancy. Alcohol use may contribute to infertility in women. For men, heavy alcohol use decreases the sperm count and motility.
  • Being overweight-Being overweight may increase the chances of infertility. For men, sperm count also could be affected by being overweight.
  • Being underweight. Women with eating disorders, like anorexia, bulimia, and women who follow a very low-calorie or restrictive diet increases the risk of infertility.
  • Exercise issues – A scarcity of exercise contributes to obesity, which increases the danger of infertility. Rarely ovulation problems could even be associated with frequent strenuous, intense exercise in women who aren’t overweight.

Various medications and medicines also can affect male fertility

Chemotherapy or radiation which is used for cancer, Sulphasalazine, which is used for Rheumatoid Arthritis or ulcerative colitis, Calcium channel blockers, which are used for high blood pressure, Tricyclic antidepressants, anabolic steroids, which are used for improved athletic performance or hormonal issues like delayed puberty, recreational drugs like marijuana and cocaine.

– Exposure to toxins, such as pesticides, herbicides, and heavy metals

Prevention

Most of the types of infertility are not preventable.  Several conscious efforts may increase your chance of pregnancy.Have regular intercourse several times around the time of ovulation for the absolute best pregnancy rate. Intercourse beginning a minimum of 5 days before and until every day after ovulation improves your chances of getting pregnant. Ovulation usually occurs within the centre of the cycle — halfway between menstrual periods, for most women menstrual cycles are about 28 days apart.

Men

Although most kinds of infertility are not preventable in men, these strategies may help:

  • Avoid drug and tobacco use and drinking an excessive amount of alcohol, which can contribute to male infertility.
  • High temperatures found in hot tubs and hot baths should be avoided, as they will temporarily affect sperm production and motility.
  • Exposure to industrial or environmental toxins should be avoided as they may affect sperm production.
  • Limit medications which will impact fertility, both prescription and non-prescription drugs. Talk to your doctor about any medications you are taking regularly, but don’t stop taking prescription medications without medical advice.
  • Exercise moderately. Regular exercise may improve sperm quality and increase the possibilities for achieving a pregnancy.

Women

For women, these strategies may increase the possibility of becoming pregnant

  • Quit smoking- Tobacco has many negative effects on fertility, to not mention your general health and thus the health of a foetus. If you are considering pregnancy it is better to quit smoking.
  • Avoid alcohol and recreational drugs- These substances may impair your ability to conceive and have a healthy pregnancy. Don’t drink alcohol or use recreational drugs, like marijuana, if you’re trying to get pregnant.
  • Limit caffeine. Women trying to get pregnant might want to limit caffeine intake. Ask your doctor for guidance on the safe use of caffeine.
  • Exercise moderately. Regular exercise is a must, but exercising very intensely can affect your periods and become infrequent or absent which in turn can affect fertility.
  • Bodyweight extremes- Being overweight or underweight can affect your hormone production and cause infertility.

Infertility testing

If you’ve been trying to conceive and have not been able to have a baby then you should plan to see a doctor.

Some tests are performed to assess fertility

For a Man

Your doctor will first take your medical history, you may be asked about your general health, your sexual history and factors that might affect your fertility.  A physical examination will be done, where your genitals will be examined for any structural abnormalities or lumps.

A semen analysis will be done. Your doctor will ask you to provide a sample of semen. This sample will then be checked to determine the percentage of sperm present and whether the sperm are shaped normally and moving properly.

Depending on the results of your initial exam and semen analysis, your doctor might want to perform additional tests.

These tests may include:

  • Hormone testing
  • Genital ultrasound
  • Genetic testing

For a woman

Your doctor will first take your medical history. You may be asked about your present status of your health, your sexual history, and any conditions or illnesses that would contribute to infertility.

Then your pelvic area will be examined to see for abnormalities like fibroids or conditions like endometriosis or PID (Pelvic Inflammatory Disease).

Your doctor will want to ascertain if you’re ovulating monthly. This will be determined with an ovulation kit or through blood tests.

An ultrasound scan of the abdomen may be done to examine the ovaries and uterus.

Other common tests for women include:

  • Hysterosalpingography, which is a type of X-ray to evaluate the fallopian tubes and uterus.
  • Laparoscopy which uses a camera to look at the inside of the uterus.
  • Ovarian reserve testing, which uses different hormone tests to work out a woman’s potential for conceiving relevant tests include the FSH (follicular stimulating hormone)

Infertility treatments

The treatment that is recommended will depend upon many factors

Cause for infertility, if known

  • How long you’ve been trying to conceive
  • Age of you and your partner
  • Overall health of both, you and your partner

After the consultation- Depending on your personal preferences and the treatment options available treatment is given

For a Man

Depending on the cause of male infertility, treatment options for men can include surgery, medication, and assisted reproductive technology (ART).

Surgery can fix obstructions that are preventing sperm from being present within the ejaculate. It also can correct conditions like varicocele. In some cases, sperm are often retrieved directly from the testicles after which it is utilized in ART treatments.

Hormonal imbalances, ED (Erectile Dysfunction), and infections that affect the sperm count can be treated with medications.

ART refers to treatments like in vitro fertilization and intracytoplasmic sperm injection where fertilization is done in a lab outside the body. Sperm for ART treatments are often received from ejaculate, extraction from the testicles, or a donor.

For Women

The treatment for female infertility also can involve surgery, medication, and reproductive assistance like ART. Sometimes a combination of treatments is needed to address female infertility.

Due to the advancement of infertility treatments, surgical treatment is rarely done. Surgery can improve fertility by,

  • correcting abnormally shaped uterus
  • unblocking the blocked fallopian tubes
  • removing fibroids

Reproductive assistance can involve methods like IUI (Intra Uterine Insemination) and ART. During IUI, sperms are injected with the help of a long thin tube called the catheter into a woman’s uterus near the time of ovulation.

IVF is one sort of ART and involves the removal of eggs that are then fertilized with a man’s sperm in a laboratory. After fertilization, the embryo is placed back to the uterus.

The medications that used to treat female infertility work like the hormones that are naturally produced in a woman to either encourage or regulate ovulation.

Web Page Content for Intrauterine Insemination (IUI)               
Diagnosis and treatment

What is IUI?

IUI or Intrauterine Insemination is a form of fertility treatment where the male partner’s semen sample is “washed”, concentrated and then placed directly into the uterus. This puts the sperms in the semen sample closer to the egg, which would have reached the fallopian tube, thereby facilitating fertilization. Couples who are facing an issue of infertility can  opt for Intrauterine Insemination (IUI) to attain parenthood.

 

The objective of IUI is to increase the chances of becoming pregnant.This is possible if the sperm fertilizes the egg and if the fertilized egg implants properly in the uterus. IUI is commonly known as ‘donor insemination’ or ‘artificial insemination’. It is minimally invasive and an affordable form of fertility treatment.

 

Who can take IUI treatment or when is IUI treatment suggested?

There are various reasons where a couple may be advised IUI, to attain the joy of parenthood. IUI is recommended in the following situations:

  • Unexplained Infertility: IUI is advised here along with medications to induce ovulation.
  • Infertility due to endometriosis: where medication is prescribed for healthy egg production.Opting for IUI increases the chances of conception.
  • Issues with the cervix or cervical mucus: cervical mucus tends to increase infertility. Since IUI helps the sperms bypass the cervix, this allows the sperms to enter the uterus directly and therefore increases the number of sperms available for fertilization.
  • Low sperm count:  IUI gives an option of inserting the available number of healthy sperms directly into the uterus for fertilization to take place.
  • Decreased sperm motility: Semen preparation techniques used in IUI can increase the motility of healthy sperms and thereby increase the chances of fertilization.
  • Problems with ejaculation or erection: Couples with such an issue can opt IUI, as it allows the insertion of healthy motile sperms into the uterus and thereby increase the chances of fertilization.
  • Same-sex couples wishing to conceive: IUI with donor sperm allows LGBT couples to attain parenthood.
  • A single woman’s desire to have a baby:  IUI with donor sperm fulfils the wish of a single woman to conceive and attain parenthood.
  • A couple wanting to avoid passing on a genetic defect from the male partner to the child:  IUI with donor sperm can help such couples have a healthy baby.

 

IUI is a non-invasive and a painless procedure and can be done with your natural cycle with minimal medication. During ovulation, sperm cells are collected from the male partner and used in IUI. The chances of conception can increase with a combination of IUI and ovarian stimulation. The ovarian stimulation to produce multiple eggs could be achieved with specific medications that stimulate the growth of eggs in the ovaries.

 

 

PROCEDURE OF IUI:

  1. You must visit your fertility doctor during your menstruation cycle for the blood test, ultrasound, and receive instructions about medications.
  2. You will have to visit your fertility doctor for an ultrasound scan and blood test as per the advice.
  3. Depending on your test results, you will have to visit the fertility clinic to examine if you are ovulating, which is after 10 to 15 days of starting your medications.
  4. The doctor may advice you to take regular medicines / injections to improve egg development.
  5. Semen samples from your partner will be collected on the day of the procedure or well before, and stored.
  6. Sperms are washed to remove seminal fluid and other debris. Specific semen preparation technique will be employed to improve semen parameters, based on the specific sample.
  7. You will be made to lie down. Your doctor will use a vaginal speculum to open the vagina gently.
  8. The washed and prepared sperms will be loaded into a long and thin tube, which is then gently inserted into your vagina (under ultrasound guidance) and the semen sample is ejected close to the fallopian tube. Care is taken not to injure the endometrium or other parts if the uterus.
  9. You will be advised to relax in a reclined position for about thirty minutes.
  10. You might experience slight discomfort or mild cramping during the procedure. Sometimes there is spotting or vaginal bleeding.
  11. You are advised for a pregnancy test two weeks after the IUI procedure.

 

What are the risk factors associated with IUI?

There can be chances of infection, but an experienced fertility doctor takes all precautionary measures using sterile instruments. If you are on fertility medication during IUI, then there are chances of multiple pregnancies. Your fertility doctor will adjust the medication and keep monitoring you to avoid further complications. You may experience ovarian hyperstimulation syndrome when there is an over-response to fertility medication.

Consult your doctor if you experience these symptoms:

  • Nausea and vomiting
  • Shortness of breath
  • Severe abdominal pain or pain in the pelvic area
  • Dizziness or light headedness
  • Bloating of the abdomen
  • Diarrhoea

 

Advantages of IUI:

  • Affordable
  • Less stressful and Non-invasive
  • Fewer medications involved

 

Disadvantages of IUI:

  • Low success rate
  • Multiple pregnancies can lead to high-risk pregnancy
  • Chances of decreasing the miscarriages is low when compared to IVF
  • Addresses some of the infertility issues only, not all.

 

IUI Success Rate:

The success of IUI depends on several factors like your health, age, cause of infertility, medications used to influence the success of IUI . Having an open discussion with your fertility doctor to understand your health and infertility issues will help you get clarity of which best procedure to opt. At GarbhaGudi, we are consistently achieving extraordinary success rates in IUI. The worldwide average IUI success rate is around 12-14%. At GarbhaGudi, we are able to achieve more than 27% success in IUI. This is due to various factors like

  1. Well trained clinicians and lab personnel
  2. World-class infrastructure and latest equipment
  3. Tailor made treatment protocols depending on the patient’s clinical profile
  4. Adoption of the latest treatment methods, systems and processes
  5. Continuous process improvement, since 10 years
  6. Usage of the best medicines, processing media, consumables and injections

 

Summary

Intrauterine Insemination is a painless, non-invasive, less-risky, and inexpensive procedure. If you are facing infertility issues and want to know if IUI is the right treatment for you, then consulting a fertility doctor can be helpful.

In vitro fertilization
Diagnosis and treatment

What is IVF and how does it work

IVF or In Vitro Fertilization is one of the more widely known types of Assisted Reproductive Techniques (ART). IVF works by using a combination of medicines and surgical procedures, to help the sperm fertilize an egg. Here the eggs are fertilized outside the human body and implanted in the uterus.These procedures can be used to help couples struggling with infertility and also in prevention of genetic problems.

A pregnancy starts with fertilization – when a woman’s egg joins with a man’s sperm. Fertilization usually takes place in the fallopian tube within the woman, which is a tube like organ that joins an ovary to the uterus. If the fertilized egg ( which is now called an embryo)successfully travels down the fallopian tube and implants in the uterus, an embryo starts growing on the endometrial wall, in the uterus

When this normal process of fertilization does not take place in couples who are planning to have a baby, advanced techniques of Assisted Reproductive Techniques (ART)are utilized to increase the chances of conceiving a healthy baby.

In an IVF cycle, eggs are retrieved from the ovaries and sperms are collected from the ejaculate (or surgically retrieved from the husband’s testes if ejaculation is not possible or if ejaculate has no viable sperms). These sperms are then allowed to fertilize the egg outside the body, in the laboratory. This fertilization can happen if the sperms and eggs are kept in close proximity to each other (called as conventional IVF) or is forced by pushing the sperm into the egg (through a process called as ICSI). The fertilized eggs are then cultured and ‘grown’ in the lab in conditions that mimic the woman’s uterus. The fertilized egg gets all nourishment from the culture media that it is kept in. An embryologist monitors the growth of the embryo. When the embryo has grown sufficiently, it is either transferred into the uterus of the woman (called fresh embryo transfer) or is frozen for a future transfer (called as frozen embryo transfer).

One full IVF cycle takes about three weeks but sometimes the procedure is split into parts, to manage certain challenges in the couples. This may delay the process.

IVF can be done using the woman’s own eggs and the male partner’s sperms or it may involve sperms, eggs or embryos from anonymous donors. Sometimes a gestational carrier (a woman who has an embryo implanted in her uterus) might be used. Such a carrier is called a surrogate mother and the process is called a surrogacy.

When is IVF advised?

  • Blocked or defects in fallopian tubes-Fertilization normally occurs in the fallopian tube and then the embryo travels down to the uterus where it gets implanted. Blocked or defects in fallopian tubes hinders the fertilization and movement of the embryo to the uterus .
  • Ovulation disorders.If ovulation is not regular or absent then fewer eggs are available for fertilization.
  • Premature ovarian failure -A woman normally goes into menopause between the age of 42-56, but in premature ovarian failure her ovaries stop working normally much earlier
  • Endometriosis –Endometriosis occurs when the uterine tissue implants and grows outside of the uterus and causes inflammatory changes in the pelvis. It often affects the function of the ovaries, uterus and fallopian tubes preventing the implantation of the embryo on the uterine wall. Endometriosis is one of the major cause for infertility.
  • Uterine fibroids -Uterine Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s and 40s. Uterine fibroidscan interfere in the fertilization process where the egg and sperm are unable to meet, or the implantation process of the embryo,it can also affect the growth and positioning of the baby.
  • Poor ovarian reserve – It occurs when a woman’s ovaries loses its reproductive potential, which can cause infertility. In Poor ovarian reserve the quality and quantity of the woman’s eggs are diminished and usually occurs around menopause.Aging is the primary cause of poor ovarian reserve.
  • Women with ovulation troubles due to advanced age -The peak reproductive years of a woman is in her 20s. Fertility (the ability to get pregnant) starts to decline in her 30s, once you reach your mid 30s there is a rapid decline in fertility, getting pregnant naturally is unlikely for most women by age45.
  • Individuals with a genetic disorder – Certain genetic factors affect fertility. Genetic abnormalities are of two types – single gene defects and chromosomal abnormalities. After the eggs are retrieved and fertilized, they’re screened for certain genetic problems though not all the genetic problems can be found. Embryos that don’t contain the identified problems can be transferred to the uterus.
  • Women with removed fallopian tubes– IVF is advised in women who have had their fallopian tubes removed surgically either due to blocked tubes or a past ectopic pregnancy or tumor.
  • Unexplained infertility- In Unexplained infertility the cause of infertility is not known despite evaluation for common causes.
  • Repeated IUI failuresIUI or intrauterine insemination is a relatively simple treatment for infertility, it may be done with or without fertility drugs. The procedure involves – transferring semen that has been washed in a special way directly into the uterus with a thin catheter. IVF is advised when repeated IUI procedures fail. The possible reasons why IUI fails might depend on age, egg quality , the sperm quality, the timing and endometriosis.
  • Male factor infertility with diminished counts, motility or morphology-Maleinfertility refers to a male’s inability to cause pregnancy in a fertile female. Male infertility is commonly due to deficiencies in the semen and semen quality. Low sperm counts are often associated with decreased sperm motility and abnormal morphology,
  • A problem called varicocele-This happens when the veins on a man’s testicle(s) are too large. This heats up the testicles. The heat can affect the number or shape of the sperm.
  • Other factors of male infertility –The factors that cause a man to make too few sperm or none at all may be advised for IVF
  • Poor motility of the sperms -Poor motility of the sperm may be caused by the shape and size of the sperm which makes it difficult for the sperm to fertilize the egg. Sometimes injuries or other damage to the reproductive system block the sperm or changes the shape of the sperm .
  • Fertility preservation for cancer or other health conditions – Cancer treatment, such as radiation and chemotherapy, could harm your fertility, If you’re about to start treatment for cancer, you can opt IVF for fertility preservation . Women can have eggs harvested from their ovaries and frozen in an unfertilized state for later use. Or the eggs can be fertilized and frozen as embryos for future use.
  • Surrogacy – Women who don’t have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF using another person to carry the pregnancy (gestational carrier). In this case, the woman’s eggs are fertilized with sperm, but the resulting embryos are placed in the gestational carrier’s (or surrogate mother’s)

How do you prepare for IVF ?

Various screening procedures have to be done before beginning an IVF cycle 

  • Ovarian reserve testing – The concentration of follicle-stimulating hormone (FSH), estradiol (estrogen) and anti-mullerian hormone in your blood during the first few days of your menstrual cycle are done to determine the quantity and quality of the eggs. Test results along with an ultrasound of your ovaries help  the doctor to predict how your ovaries will respond to fertility medication.
  • Semen analysis – Semen analysis is done as a part of fertility evaluation before starting the IVF cycle
  • Infectious disease screeningBoth the partners are screened for infectious diseases, including HIV.
  • Uterine exam -The inside lining of the uterus will be examined before you start IVF .This might involve a sonohysterography an ultrasound to create images of your uterine cavity.

Procedure of IVF

 IVF involves several steps like ovarian stimulation, egg retrieval, sperm retrieval, fertilization and embryo transfer. One cycle of IVF can take about two to three weeks sometimes several cycles may be required.

Ovulation induction

  • The process of IVF begins with fertility medications and hormones, which are given to the woman for about 10 – 12 days to stimulate the growth of multiple eggs in the ovary.  Transvaginal ultrasound scans and hormone analysis is done to know the status of growing eggs.

One may need several different medications, such as

  • Medications for ovarian stimulation  follicle-stimulating hormone (FSH) or luteinizing hormone (LH) or a combination of both are injected to stimulate the ovaries. These medications stimulate more than one egg to develop at a time.
  • Medications for egg (oocyte) maturation –Specific medicinescalled triggers, like Lupride or HCG, are given to help maturation of the eggs when the follicles are ready for egg retrieval.
  • Medications to prevent premature ovulation These medications are given to prevent your body from releasing the developing eggs too soon.
  • Medications to prepare the lining of your uterusProgesterone supplements may be given on the day of embryo transfer to make your uterus more receptive for implantation.
  • One to two weeks of ovarian stimulation will be needed before the eggs are ready for retrieval.

To know the status of  the eggs  your doctor will perform:

  • Vaginal ultrasound- an imaging of your ovaries to monitor the development of follicles (fluid-filled ovarian sacs where eggs mature)
  • Blood tests-  are done to see your  response to  the medications given for ovarian stimulation. For example, estrogen levels increase as follicles develop, and progesterone levels remain low till ovulation. These will give an indication on how the woman’s body is responding to the hormones being injected.

Egg retrieval

Egg retrieval is done  34 to 36 hours after the final trigger injection and before ovulation. Once eggs are grown sufficiently and matured with the administration of the trigger injections, eggs are extracted through a minor surgical procedure called follicular aspiration that uses ultrasound to guide a hollow needle through the pelvic cavity to extract the eggs.  Patient is given general anaesthesia to decrease or eliminate potential discomfort.

Egg retrieval is done by a method called Transvaginal ultrasound aspiration. An ultrasound probe is inserted into your vagina to identify follicles and then a thin needle is inserted into an ultrasound guide to go through the vagina and into the follicles to retrieve the eggs.An abdominal ultrasound may be used to guide the needle if the ovaries are not accessible through a Transvaginal scan. Multiple eggs are removed from the follicles through a needle connected to a suction device. You may experience cramping and feeling of fullness or pressure after egg retrieval. Mature eggs are placed in a nutritive liquid (culture medium) and incubated. Healthy and mature eggs will be mixed with sperm to attempt to create embryos or ICSI procedure will be done to fertilize the eggs.

 

Fertilization

The male counterpart is asked to produce a sample of semen by ejaculating. The sperms and eggs are put together in a dish and stored in laboratory in a controlled environment to encourage fertilization.  In certain cases, a process called ICSI is undertaken where the sperms are pushed into the egg, without damaging the eggs. This will ensure fertilization.

The fertilized egg is stored in a special growth medium for about 48 hours until it divides and becomes an embryo containing 6-8 cells. At the same time, the woman is given supplements of progesterone hormone to prepare the uterus lining for implantation of the embryo.

Conventional insemination– Healthy sperm and mature eggs are mixed and incubated overnight.

Intracytoplasmic  sperm injection (ICSI) – In ICSI, a single healthy sperm is injected directly into each mature egg. ICSI is often used if fertilization attempts during prior IVF cycles failed.

 

Embryo Transfer

The embryos are usually transferred into the woman’s uterus three to five days after egg retrieval and fertilization.  A catheter or small tube is used to transfer the embryos into the uterus.  This procedure is usually painless for most women, although some women may experience mild cramping.  After successful transfer of embryos, implantation takes place inside the uterus resulting in pregnancy which can be detected by blood tests after 16 days of embryo transfer. If the test turns out to be positive, you go through the pregnancy phase as a regular pregnancy. a healthy and successful pregnancy happens through IVF treatment.

Fertilization is attempted using two common methods:

 

Frozen Embryo transfer

In an IVF cycle, one or more embryos develop and these embryos are usually frozen for later use. Usually, only one or two embryos are transferred into the women’s uterus during an IVF cycle as there are more chances of multiple pregnancies. The remaining embryos are frozen for future use. A fresh embryo transfer is done after two to five days after egg retrieval. A frozen embryo transfer is a procedure where a frozen embryo is retrieved from the cryo preservation tanks (filled with liquid nitrogen), it is thawed to normal room temperature, brought back to life and is then transferred into the woman’s uterus. The process of transferring into the uterus is the same as in a fresh transfer.

 

After the Embryo Transfer procedure

There may be a slight discomfort after the embryo transfer, normal daily activities can be resumed.Vigorous activity should be avoided. Breast tenderness due to high estrogen levels, mild bloating, cramping, constipation are some of the side effects seen after embryo transfer.

 

Results

Doctor will test a sample of the woman’s blood after about 12 days after embryo transfer, to detect whether it is a successful pregnancy.

  • If pregnant, the doctor, in most cases, will handle the case until three months – high risk period. Subsequently, the doctor may refer the woman to an obstetrician or other pregnancy specialist for prenatal care.
  • If not pregnant, the doctor will ask the woman to stop taking progesterone and the woman is likely get her period within a week.

The chances of giving birth to a healthy baby after using IVF depend on various factors:

  • Maternal age –  Younger women are more likely to get pregnant and give birth to a healthy baby using their own eggs during IVF. To increase the chances of success, donor eggs are considered during IVF for women over 41 years or in cases where the egg quality or egg reserve is not sufficient.
  • Embryo status Pregnancy rates  depends on the stage of the embryo, embryos that are more developed (blastocyst) is associated with higher pregnancy rates compared with less-developed embryos (day two or three).
  • Reproductive historyWomen who have previously given birth are more likely to be able to get pregnant using IVF than women who have never given birth.
  • Cause of infertility- Women who have severe endometriosis are less likely to be able to get pregnant using IVF than women who have unexplained infertility. Normal supply of eggs increases the chance of infertility
  • Lifestyle factorsObesity can decrease the chances of getting pregnant and having a baby. Use of alcohol, recreational drugs, excessive caffeine and certain medications also can be harmful. Women who smoke have fewer eggs retrieved during IVF and may miscarry more often.

What are the potential risks of IVF

As with any medical procedure IVF also is associated with some risks-

  • Multiple births – If more than one embryo is transferred to the uterus during the IVF procedure there is a risk of multiple births. Multiple foetuses in a pregnancy  carries a higher risk of early labor and low birth weight, than a pregnancy with a single foetus .
  • Premature delivery and low birth weight-  IVF slightly increases the risk of babies born early with a low birth weight.
  • Ovarian hyperstimulation syndrome – In ovarian hyperstimulation syndrome (OHSS), ovaries become swollen and painful due to the use of fertility injections like HCG. Symptoms normally last a week and include mild abdominal pain, bloating, nausea, vomiting and diarrhea. However, your symptoms might last several weeks if you become pregnant. In some rare cases, a woman may develop a more severe form of ovarian hyperstimulation syndrome and in such cases, the women tends to gain weight and experience shortness of breath because of excess fluid in the chest, pelvic region and in the ovaries.
  • Miscarriage -The rate of miscarriage for women who conceive using IVF with fresh embryos is similar to that of women who conceive naturally,but the rate increases with maternal age.
  • Egg-retrieval procedure complicationsRarely bleeding, infection, damage to the bowel, bladder, blood vessels can occur due to the use of aspirating needle to retrieve eggs. Sedation and general anaesthesia has its own risks.
  • Ectopic pregnancy-when the fertilized egg implants outside the uterus, usually in a fallopian tube, it is called ectopic pregnancy. The fertilized egg can’t survive outside the uterus therefore it is not possible to continue the pregnancy.
  • Birth defects -The age of the mother is the primary risk factor in the development of birth defects, no matter how the child is conceived. So, babies conceived through IVF do not have any higher risk of birth defects. In fact, IVF babies are screened more diligently in the double marker, triple marker and anomaly examinations, thereby giving an opportunity to handle birth defects much earlier.

IVF or test tube baby is a blessing to every couple who cannot conceive. Millions of couples worldwide have benefitted from IVF, over the last few decades. These IVF babies are leading a healthy and normal life, like any other normally conceived child. Couples aspiring to have a baby of their own need not have to be lose hope. They just have to visit a good IVF centre and get the right advice

Frozen Embryo Transfer (Fet) Procedure
Diagnosis and treatment

What does Frozen Embryo mean?

Frozen Embryo involves a procedure where the embryos are frozen after fertilization and subsequent growth. The embryos may be frozen between day 2(four-cell stage) – day 5 (blastocyst stage). Healthy and viable embryos are moved to a ‘freezing machine’ where the temperature is made to drop rapidly to MINUS 150 degrees Celsius and then stored in liquid nitrogen tanks at -196 degree Celsius.

 

What is the procedure involving FET?

A frozen embryo transfer (FET) is a part of IVF treatment, where a cryopreserved embryo, created in an l IVF cycle, is thawed and transferred to a uterus. The process involves preserving an embryo at -150 Celsius temperature, generally at an embryogenesis stage, corresponding from fertilization to the blastocyst stage. A cryopreserved embryo can also be a donor embryo or may have been ‘prepared’ from a donor egg or donor sperm.

In principle, most IVF cycles involve frozen embryo transfers. Fresh embryo transfers are rare. This is because the techniques of FET have improved a lot and the outcome of FET is much better than fresh transfers. Most doctors recommend elective frozen embryo transfer (also referred to as a “freeze all” approach) where a fresh embryo transfer is not opted. Here all the embryos are cryopreserved and transferred in the FET cycle in the next month or so.

 

Why choose a Frozen Embryo Transfer?

Depending on the woman’s health conditions and some circumstances, the fertility doctor may advise FET that will help the woman get pregnant now or anytime later in future.  A Frozen Embryo comes with a lot of benefits:

  • Opportunity to cryopreserve the embryos: Several embryos can result from the IVF cycle. Transferring of multiple embryos into the uterus increases the risk of high-order multiple pregnancies (like triplets or quadruplets). To reduce this risk, the doctor might recommend an elective single embryo transfer (eSET) to have a good and safe pregnancy. One can choose to freeze or cryopreserve any “extra embryos” after their IVF cycle.
  • The cryopreserved embryos are of use when a fresh IVF transfer fails. For instance, let’s say you get five embryos from the IVF cycle and your doctor recommends elective single embryo transfer as a fresh embryo transfer. One among the five IVF embryos is transferred into the uterus. The remaining four are cryopreserved. If the embryo transfer doesn’t result in a successful pregnancy, the womanhas two options. She can opt for another full IVF cycle, or can transfer one or two of the cryopreserved embryos. The most cost-effective option would be to transfer one or more embryos from the preserved frozen embryos or the cryopreserved embryos.
  • Plan for another child: Cryopreserved embryos can remain on ice indefinitely. If the couple decide to give their IVF-conceived child, a sibling and if they still have embryos in cryopreservation, those cryopreserved embryos could help attain pregnancy again. The couple don’t have to repeat the whole IVF process.
  • Scope for Genetic Screening: Screening embryos for specific hereditary disease or defects is possible using PGD and PGS. It is done through a biopsy on day three or five post-fertilization, post egg retrieval. PGD and PGS help reduce the risk of passing genetic diseases. This can only be done if the embryos are frozen.

FET is an integral part of pre-implantation genetic testing (PGT). All embryos biopsied are cryopreserved. Once the results come, the doctor can decide which embryos to transfer for the FET-IVF cycles, based on the results of the PGT.

  • Opportunity to choose an Elective Procedure: The woman can opt for an elective frozen embryo transfer with or without PGD/PGS. With the “freeze all” approach, the fresh embryo transfer is not a part of the plan. It can occur with PGD/PGS or without genetic screening. A Fresh Embryo Transfer might be less likely to result in a viable, healthy pregnancy. To avoid this and to be safe, all embryos are cryopreserved three to five days after egg retrieval. After a month, there is a chance of endometrium to form without the influence of ovarian stimulating drugs, when frozen embryo transfer can take place. During that FET cycle, the fertility doctor may prescribe hormonal medications to enhance endometrial receptivity (especially if the woman does not ovulate on her own, doctor might do the FET, with hormonal medications.
  • Plan of Fresh Embryo Transfer has not opted: Fresh embryo transfer might not have been opted, for various reasons. For example, the couple cannot have FET if they the woman has caught a flu or is suffering from any other illness after egg retrieval but before transfer. If the endometrial conditions do not look good on the ultrasound, the fertility doctor may recommend cryopreserving all embryos, then scheduling FET-IVF for a later date.
  • Use as an Embryo Donor: Some couples choose to donate their unused embryos to another infertile couple. If a couple decide to use an embryo donor, their cycle will be a frozen embryo transfer.
  • Risk of OHSS: Ovarian hyperstimulation syndrome (OHSS) is a risk where fertility drugs that can (in severe and rare cases) lead to loss of fertility and even death. If the risk of OHSS appears to be high before a fresh embryo transfer, it gets cancelled. When this happens, all the embryos are cryopreserved. Cancellation is necessary because pregnancy can exacerbate OHSS. It can also take longer to recover from OHSS if the womanis Once she recovers from OHSS, a frozen embryo transfer cycle is planned.

FROZEN EMBRYO TRANSFER OR FRESH EMBRYO TRANSFER, WHICH IS THE BEST?

Studies have found that the success rate of pregnancy is better with frozen embryo transfers than with fresh embryo transfers. Studies have also found that pregnancies conceived after frozen embryo transfer has better outcomes. However, most studies have shown in younger women have a good prognosis. The prognosis for women over 35 years of age is unclear.

If opting for FET, the couple should consult a good fertility expert as they will be the best people to advise further treatment after looking into the medical history.

 

Process of FET

  • Once the woman getsher period, a baseline ultrasound and blood sample testing are done. If all looks good, estrogen supplementation is given. It helps ensure a healthy endometrial lining. Estrogen supplementation is continued for about two weeks, followed by ultrasound and more blood tests.
  • After approximately two weeks of estrogen support, progesterone support is added.Progesterone is given as an intramuscular injection or vaginal suppositories (gel or tablet).
  • The embryo transfer is scheduled based on when progesterone supplements start and on what stage the embryo is cryopreserved. For example, if the freezing of embryo is on day five post-egg-retrieval, then the frozen embryo transfer will be for day six after progesterone supplementation starts.

Risks

A frozen embryo transfer cycle has very little risk. One risk of using IVF (and fertility drugs) is ovarian hyperstimulation syndrome (OHSS). However, you don’t need to worry about OHSS in a FET cycle because ovarian stimulating drugs are not in use. Pregnancies from frozen embryo transfers might be healthier than those from fresh embryo transfers. Research has shown that frozen embryo transfer babies were at lower risk for premature birth, stillbirth, and low birth weight.

Embryo transfer has risks, including an increased risk of ectopic pregnancy and a risk of infection. Depending on the number of embryos transfer, the chance of multiple pregnancies may also be higher (which comes with its own set of risks for a pregnant person and the fetuses they are carrying).

 

Costs

Couple need to plan for a cost that includes investigations, consultations, ultrasound monitoring, hormonal support, and the costs associated with the transfer process. There is usually some amount of luteal phase support – medications that are given as ‘supplement’ for the successful continuation of conception. Cost of a FET cycle is usually much lesser than a full IVF cycle.

 

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