Overview – Female Infertility
If the woman is more than 35 years old, and has been trying unsuccessfully for more than 6 months, further consultation regarding investigation and treatment should be considered rather than waiting for a year. If the female has a history of gynecological problems, or if it is known that the partner has a low sperm count, they should not delay seeing a specialist regarding the fertility status. Women who are 40 years and over are advised to begin investigation and treatment after 3 months of trying.
Pregnancy depends on many factors: Female Infertility
Ovulation and the production of healthy eggs – Ovulation is the development and release of an egg from a women’s ovary. This occurs once in the menstrual cycle usually about 14 days before the end of the cycle. This is the fertile time for a woman
The ability of eggs to travel through the tubes to reach the sperm.
Enough healthy sperm being produced – Sperm take about 64 days to develop and are produced in the testes. Sperm is expelled in seminal fluid on ejaculation. There may be 100 million sperms produced at ejaculation though relatively few, i.e. several hundred, will reach the fallopian tubes.
Sperm being able to travel through the cervix to reach the egg.
The sperm’s ability to fertilize the egg-which can be dependent on the number of sperm produced and the quality of the sperm. By quality we mean such things as the sperm’s motility (ability to move forward) and shape.
A fertilized egg becoming a healthy embryo.
Successful implantation of the embryo in the uterus
What is Male Infertility and what should you know about it?
Infertility is a condition and not a disease. A couple is said to be Infertile if they fail to conceive even after having unprotected sexual intercourse continuously for one year. Couples who fail to conceive after a year should see the doctor for some kind of intervention. It is a fact that male and female have an equal contribution in a couple’s infertility and both should undergo testing before starting treatment.
Is Your Sperm Fertile? Are You Concerned?
Increasing environmental pollution, altered lifestyle habits & with enormous stress are you sure your sperm is fertile enough? Added to this you will find articles everywhere with varying conclusions which confuse you further. This brochure justifies the need for a basic semen testing and also highlights the recent advancements in diagnosing infertility in men.
Why should I see a doctor? It is my wife who is not conceiving, hence she should be tested!!!!
Well, this is the common myth among every one. It is a fact that male and female have an equal contribution in a couple’s infertility and both should undergo testing before starting treatment.
We are trying for a baby since last 6 months with no luck? Am I Infertile? When should I see the doctor?
Remember it takes on average a year or more for a woman to conceive so not getting pregnant straight away is normal. A couple is said to be Infertile if they fail to conceive even after having unprotected sexual intercourse continuously for one year. Couples who fail to conceive after a year should see the doctor for some kind of intervention.
How do I know if my semen sample is good enough to father a child?
Along with semen analysis there are certain specialized functional tests like sperm vitality, Hypo-osmotic swelling (HOS) test, Acrosome Intactness Index (AI), Nuclear chromatin decondensation test (NCD), sperm DNA fragmentation Index (DFI), Reactive oxygen species (ROS) assessment in semen help us to predict the fertilizing ability of sperm.
My semen analysis reports and my partner’s reports are normal, but we are still not conceiving? Is test tube baby procedure the only resort?
As discussed above semen analysis alone is not helpful in diagnosing a couple with infertility. Semen analysis along with the sperm functional tests will give us a better understanding of the sperms fertilizing ability and this helps the clinician to select a suitable modality of treatment. Recent research has proven that DNA fragmentation Index (DFI) & Reactive oxygen species assessment (ROS) assessment have got a significant prognostic role in management of male infertility. Test tube baby procedure or IVF (In-Vitro Fertilization) is always used as a last resort and is never the first choice to be considered.
Intra Uterine Insemination
Intrauterine insemination (IUI) is a fertility treatment that involves placing sperm inside a woman’s uterus to facilitate fertilization. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization.
Indications For IUI
For Men
Ejaculation failure [ because of diabetes, multiple sclerosis, spinal cord injury and retrograde ejaculation, psychological
Low sperm count
Poor sperm quality
Anti Sperm Anti bodies
Freezing of semen for future IUI use [for the men who is undergoing vasectomy, chemotherapy or radiotherapy] when husband is away
For Women
Mild endometriosis
Cervical mucus hostility
Process
Before intrauterine insemination, ovulation stimulating medications may be used, in which case careful monitoring will be necessary to determine when the eggs are mature. The IUI procedure will then be performed around the time of ovulation, typically about 24-36 hours after the surge in LH hormone that indicates ovulation will occur soon.
A semen sample will be washed by the lab to separate the semen from the seminal fluid. A catheter will then be used to insert the sperm directly into the uterus. This process maximizes the number of sperm cells that are placed in the uterus, thus increasing the possibility of conception.
The IUI procedure takes only a few minutes and involves minimal discomfort.
Results
The success rate depends on the age of the woman conceiving. It also depends on the reason of infertility and the number of washed sperm that actually made up the concentrated volume. IUI’s success rate is around from 10 to 30% per cycle, keeping in mind various factors that affect conception.
Intra-Cytoplasmic Sperm Injection
ICSI treatment or Intracytoplasmic sperm injection treatment is a very effective means of fertilizing the eggs in a lab after retrieving the eggs from the woman's body. The treatment is generally used in case of male infertility problems and makes use of specialized equipment for selecting sperms and injecting it into the egg.
Indications For ICSI
Regarding male fertility : It is used in cases of azoospermia, oligozoospermia, criptozoospermia, asthenozoospermia, teratospermia, oligoasthenozoospermia, oligoasthenoteratozoospermia, men who underwent vasectomy, men with an infectious disease ( HIV, hepatitis, etc.), men who have frozen their sperm before undergoing radiotherapy or chemotherapy, or failure of ejaculation under normal conditions.
Regarding female infertility: If a low number of oocytes is obtained after follicular puncture or egg retrieval, or if the zona pellucida is very thick after oocyte retrieval, or in cases of poor egg quality.
Repeated failure to achieve pregnancy after several cycles of conventional in vitro fertilization.
Egg fertilisation failure using conventional IVF.
Microinjection of unfertilised oocytes using conventional IVF.
In-vitro maturation of immature oocytes.
When a Preimplantation Gentic Diagnosis is required in cases of couples with some genetic alteration or when it is necessary to know which ones are genetically normal embryos.
In cases of immune fertility with a low number of antisperm antibodies and after repeated failure of previous artificial cycles, or in cases of immune infertility with a high number of antisperm antibodies
Process
The ICSI treatment is performed after the eggs are retrieved from the female partner
A specialized pipette is used for holding the mature egg
A special, sharp needle is used for picking up one sperm
The hollow needle holding the single sperm is inserted through the eggshell and it penetrates the core of the egg
Once the sperm has been successfully injected into the cytoplasm, the needle is removed
After 1-2 days, the eggs are checked for fertilization
Results
The ICSI procedure involves stripping cells from around the egg and injecting a needle into the egg. A small percentage of eggs, often the less healthy eggs, may be damaged by these procedures and degenerate (5-10%). Sometimes eggs fail to fertilize normally or arrest at an early stage of development. ICSI pregnancy rates and live birth rates are similar to those achieved with IVF. However, studies have shown that blastocyst formation is reduced compared to IVF cycles, particularly in cases of poor sperm motility and morphology. The arbitrary selection of sperm (rather than relying on the natural fertilization process) has potential for increased risks of genetically abnormal embryos and birth defects including infertility.
Egg Donation
Egg donation is a readily available procedure where by the eggs of another female, egg donor is used to make the embryos. The egg donors are properly screened. (Healthy, YOUNG, proven fertile females of good family backgrounds, educated, good looking, good complexion/caucasions/wheatish/dark coloured are available with us and are physically matched according to requirement to the patient).
Indications for Egg Donation
Poor fertilization of eggs inspite of good quality sperm.
Failure to achieve a viable pregnancy following repeated attempts at IVF or other assisted reproductive technologies.
Absent ovarian function due to previous surgery, radiation, or chemotherapy.
Premature ovarian failure.
Menopause
The presence of genetic disorder that have high likelihood of being transmitted via the women’s eggs to the offspring.
Women over the age of 40
Elevated follicle stimulating hormone levels (greater than 12 mIu/ml) on 3rd day of the menstrual cycle.
Poor responders (less than 3-4 eggs)
Unexplained failure of IVF consecutively (3 cycles)
Process
The egg donation process consists of two phases. In the first phase, ovarian hyperstimulation, donors receive a series of hormonal drugs which cause the ovaries to produce multiple mature eggs during one menstrual cycle. During the second phase, egg retrieval, mature eggs are removed from the donor through a surgical procedure called transvaginal ultrasound aspiration. Egg donors should expect to spend around 60 hours for screening, testing, and medical appointments throughout the course of the procedure.
Results
Egg Donation Success Rates
IVF donor eggs reverse the biological clock if you are considering IVF over 40 or IVF over 45 (IVF at 50) or even IVF over 50, as long as you are under 51 years of age. Overcoming many of the fertility problems caused by age. Using donor eggs also is extremely successful for women who have suffered premature ovarian failure, recurrent miscarriage and other problems. Thanks to donor egg IVF treatment, women who have been unable to conceive using their own eggs can IVF success and experience the joys of pregnancy and motherhood.
Blastocyst Culture
Blastocyst culture is medical advancement in which embryo is grown in laboratory for about a week and now it is kept only for two to three days. This time period enables the embryo to grow and reach up to the blastocyst stage as far as embryo development is concerned. There has been great improvement of nutritive solutions that actually support the growth of embryo and it is now widely used in clinical treatments as well.
This term portrays the procedure, when the developing embryo is cultured in specialized media for better development during the basic formative changes before being implanted back into the womb.
Indications
The transfer of blastocysts obtained by co-culture with 'Vero' (African green monkey kidney) cells was offered to infertile couples with the following indications:
Repeated failure of implantation
Patients in whom multiple pregnancies had to be avoided (malformed uterus or risk of descending uterus)
Patients where embryo development potential had to be assessed
Replacement of supernumerary embryos frozen at the blastocyst stage.
Process
Embryos are typically cultured for 3 days (cleavage stage with 4-10 cells) before being transferred into the uterus. By extending the culture to 5 or 6 days (blastocyst culture), some embryos will develop to the blastocyst stage (up to hundreds of cells). This allows the embryologist to select more advanced embryos with better potential for implantation at the time of the transfer.
A significant benefit of blastocyst culture and transfer is the reduction of multiple births that can result from IVF, since there are fewer embryos (1 or 2) to be transferred.
Results
The embryos which survive for 4-6 days are more likely to produce the fruitful results. This enables embryologists to select from the more advanced embryos with better potential for implantation.
The biggest advantage of Blastocyst Culture and Transfer method is that it significantly reduces the risk of multiple pregnancies. Also, the pregnancy and implantation success rate is higher in this technique because it is easy to determine the robust embryos after developing for 4-6 days hence only the competent embryo are transferred to uterus.
Embryo Donation
A couple’s infertility or subfertility problem may be due to a combination of factors and may affect both man and woman. If standard IVF treatment fails or offers very small chance of success, the transfer of a donor embryo into the woman’s womb may be the only way to conceive.
Embryo Donation is for couples struggling with infertility in which eggs and sperms are absent. It is a cost-effective, well established and successful technique for conceiving.
Indications for embryo adoption
Single women having difficulty getting pregnant with own egg and donated sperm with help of otherfertility treatments.
Couples having difficulty getting pregnant with own egg and sperm with help of other fertility treatments
Process
We’re often able to schedule your donor-embryo IVF transfer, whether using fresh or frozen gametes, in less than six weeks from booking. We’ll explain your medical protocol and prescription very carefully and advise on any additional tests you may need.
Most donor-embryo IVF recipients start oral stimulation drugs a few weeks before travelling. (The protocol for fresh donated embryos starts earlier as you’ll be matched, and your cycle synchronised, with a specially-selected egg donor.) We’ll let you know exactly when to take your medication, have your scans and travel out.
Results
Embryo donation success
Embryo donation success The success of embryo donation depends in large part on the original center involved in the embryo freezing. Some centers are very proficient at freezing embryos and have high survival rates when thawing the embryos and high pregnancy rates using frozen embryos. Some centers do not do as well. The survival of frozen embryos is critically reliant on the program that froze them and less so with the center that thaws them. There are many other variables such as:
The age of the woman providing the eggs
The cause of the donating couple’s infertility
The “quality” of the embryos when they were frozen
The developmental stage of the embryos when they were frozen
The number of frozen embryos available for donation
Semen Banking
Sperm banking is the term used for collection and storage of semen, a fluid containing sperms.Sperm can be stored for indefinitely. There are reports of normal pregnancies from frozen sperm stored even for 12 years.However, each person’s sperm reacts differently to the freezing procedure.
Semen banking service is available only at Govt. authorised centres. There is not any Govt. authorised centre for semen banking in Punjab. A nearby centre is located at Chandigarh, a Govt. authorised centre for semen banking services.
IVF
In Vitro Fertilization (IVF)
IVF refers to a procedure where the woman's eggs are removed from her ovaries and fertilised with the man's sperm in a laboratory. The embryos formed are then put back into the uterus to achieve a pregnancy.
Who does IVF Treatment help?
IVF was initially offered to patients with bilateral tubal block. Today, its indications include mild to moderate male factor infertility, couples who are unable to conceive after first and second line procedures like ovulation induction (OI) and intra-uterine insemination (IUI), patients with endometriosis, Polycystic Ovarian Syndrome (PCOS) who have not conceived with routine treatments and those with unexplained infertility.
What are the Chances of IVF Success?
This depends on various factors like; age of the patient, type and duration of infertility, ovarian response, type of procedure (fresh or vitrified embryo transfer, self or donor eggs). Your consultant will be able to give you a prognosis after proper evaluation. While there is no guarantee, we do our best to ensure you find happiness. IVF team at Jaipur Health Care is consists of experienced doctors, who have years of experience in successfully treating infertile couples. Jaipur Health Care & Test Tube Baby Center is one of the best IVF clinics in India with good success rates
. The processPreparatory tests
These depend on you and your partner's age and medical history. These include basic evaluation mentioned in infertility assessment above. In addition, we will also advise routine blood reports to check your physical fitness. Extra tests to check hormone levels or determine ovarian reserve maybe advised as required.
Treatmenta. Commencement of the treatment
You must come for a check up on the specified day of your menstrual cycle between 9 am to 6 pm at our clinic.
b. Ovarian stimulation
.Medications will be administered to stimulate the ovaries to produce several eggs in order to increase the chances of pregnancy. You could undergo one of the two protocols available, based on your case history and reports. Your doctor will discuss this with you.
In the Long Protocol, you will be given injections from the 21st day of the previous menstrual cycle. You will need to come back on the 2nd or 3rd day of your next menstrual cycle to start the actual ovarian stimulation. The Antagonist Protocol requires fewer injections and the entire treatment begins on the 2nd day of the menstrual cycle.In both protocols, injections have to be taken approximately at the same time every day. It is advisable to come to the hospital for your injections, but if you can't, our medical staff will teach you how to self-administer the injections or you can have them taken locally by a doctor. These medications can cause mild side effects like acidity and some discomfort.
c. Ultrasound examination
A vaginal ultrasound examination is conducted at regular intervals to assess the response of the injections on your ovaries. If the response is poor, there is a possibility that your doctor might advise you to cancel the IVF cycle. This will be a joint decision between you and your doctor.
d. hCG injection/GnRH injection
This is given to trigger the final maturation of the eggs and make them ready for collection, which happens about 34 to 36 hours later.
e. Ovum pick-up (egg collection)
Eggs are removed from the ovaries under general anaesthesia, with the help of transvaginal sonography. The procedure takes 15-30 minutes and the number of eggs collected will depend on your response to the injections. You can go home approximately 2-3 hours after the procedure. Occasionally one could have some vaginal spotting and some abdominal discomfort, but this settles in a day or two.
f. Sperm collection
Usually, a fresh semen sample is collected on the day of ovum pick-up (egg collection). Some men find it difficult to produce a semen sample on request, so it may be collected elsewhere and brought to the centre within 30 minutes of collection. Generally, to produce the best sample, abstinence of 3-5 days is recommended and lubricants should not be used. However, if a fresh sample cannot be produced on the same day or if the husband is not available on the day of egg collection, a previously frozen sample can also be used. In fact we encourage you to have a semen sample frozen for this eventuality
.g. After ovum pick-up
Following ovum pick-up, the eggs will be fertilised in the lab either by standard IVF or by ICSI. The next day, the embryologist will examine the eggs for fertilisation and later on for further development of embryos. If there are more than three well developed embryos, it is possible to freeze them for a later transfer, if necessary.
h. Embryo transfer
This is performed 2, 3 or 5 days after egg collection. The day of the embryo transfer and the number of embryos to be transferred will be discussed with you. In this procedure the embryo is transferred through the cervix into the uterus via a thin, soft plastic tube guided by sonography. After the transfer, you will be given a course of medication to support the lateral phase.
If there are excess good quality embryos, it is possible to freeze them for a later use.
i. Pregnancy test
About two weeks after the embryo transfer, you will be given a beta-hCG test to check if gestation has been achieved. If the test is positive, a vaginal ultrasound scan will be performed 1 week later to confirm the pregnancy and view the gestational sac
.If the beta-hCG test is negative, further treatment will depend on whether you have frozen embryos or not.
Precautions after an IVF treatment
• Any vigorous exercise, heavy lifting and other activities that involve jarring or potentially jarring movements
(cycling, jogging, skiing, tennis etc.) are generally discouraged. All routine day to day activities are allowed.
• Take medications as prescribed by the treating doctor as these have been prescribed to improve your chances of achieving pregnancy. If you become pregnant you might be asked to continue some of these medications until the 12th week of pregnancy when the body usually starts producing enough.
• Avoid smoking, exposure to cigarettes, alcohol and exposure to X-rays.
• Please consult your doctor before taking any medication.
(cycling, jogging, skiing, tennis etc.) are generally discouraged. All routine day to day activities are allowed.
• Take medications as prescribed by the treating doctor as these have been prescribed to improve your chances of achieving pregnancy. If you become pregnant you might be asked to continue some of these medications until the 12th week of pregnancy when the body usually starts producing enough.
• Avoid smoking, exposure to cigarettes, alcohol and exposure to X-rays.
• Please consult your doctor before taking any medication.
PESA
Percutaneous Epididymal Sperm Aspiration (PESA) uses a needle to penetrate the scrotal skin and draw a small amount of sperm from the epididymis while Percutaneous Testicular Biopsy removes small cores of testes tissue.
Indications
Absence of the vas deferences
Past infections which result in obstruction
Cases who had vasectomy and surgical reversal failed
Process
PESA or Percutaneous Epididymal Sperm Aspiration (PESA), does not require a surgical incision. A small needle is passed directly into the head of the epididymis through the scrotal skin and fluid is aspirated. The embryologist retrieves the sperm cells from the fluid and prepares them for ICSI.
Results
WHAT IS THE SUCCESS RATE OF THIS PROCEDURE?
In vitro fertilisation (IVF) treatment using PESA/TESA sperm is a commonly performed procedure and has similar success rates to routine IVF.
TESA
During your semen analysis, if it shows that you don’t have sperm within your ejaculate, there are various techniques of surgically retrieving the sperm, which is known as Surgical Sperm Retrieval (SSR).In such a case the sperm is retrieved from the tissue in a man’s testis using one of the two SSR methods – Testicular Sperm Aspiration (TESA) or Testicular Sperm Extraction (TESE).
Process
Two techniques - Epididymal sperm retrieval & micromanipulation have revolutionized treatment of male infertility in the past decade. Men with congenital bilateral absence of the vas defences (CBAVD) or reproductive tract obstruction are now able to achieve pregnancies with use of these advanced techniques.
In cases where the epididymis Does not contain any sperm, because of impaired sperm production, the method of TESA (Testicular Sperm Aspirationmay be used. TESA involves performed by sticking a needle into the testis and aspirating fluid and tissue with negative pressure.
Results
In vitro fertilisation (IVF) treatment using PESA/TESA sperm is a commonly performed procedure and has similar success rates to routine IVF.