in-depth Details About The Fertility Treatments
Janya Fertility treatments
Numerous couples face infertility dilemmas in their life. Change in lifestyles, poor eating habits, stress, age and other factors have resulted in rise of such cases around the globe.
The biggest concern is the isolation that such couples face in their life. They are unable to talk to anyone in their family about their problems. Many of them are fearful or uncertain about the medical treatments. They are unsure, scared and oblivious about fertility treatments. Needless to say, the lack of education about such topics has only aggravated their infertility dilemmas.
These couples desperately want to start their family with having their own child. But, they are uncertain about the prospects of having a child with assistance from fertility treatments in India. The dilemma can only be resolved with the assistance of a medical professional.
It should be noted that infertility problems are more common than generally perceived. And the number is actually on the rise, especially in metropolitan regions. So, it is highly recommended that such couples consult a specialist. In this manner, their fears and queries can be resolved in the right manner.
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Prior to commencing any treatment, it is important that a number of investigations are carried out to gain a clearer understanding of the patient’s current situation so that we can devise a tailored treatment plan that is most appropriate. Some of the commonly performed tests also known as Pre IVF investigations.
– FEMALE PARTNER TESTS –
Ovarian Function Tests : The most important aspect of an IVF cycle is to understand the ability to recruit and retrieve multiple follicles. Certain Hormone levels are checked before deciding to go ahead with any treatment:
Serum AMH Level : An Anti-Mullerian Hormone (AMH) test is a routine blood test in assisted conception that gives some insight into the remaining quantity of eggs and number of fertile years a woman has. It is useful for those women who have been trying to conceive for over six months, and want to check her ovarian reserve is suitable for the age. Serum AMH Level can be measured at any point of the menstrual cycle. A woman can also have her AMH tested while still on birth control pills.
TSH Level : A thyroid-stimulating hormone (TSH) test is a common blood test used to determine if the thyroid is functioning normally. The TSH screening test is also used to help evaluate pituitary gland function. TSH is produced by pituitary gland that regulates thyroid functions and the hormone is essential for a baby to develop normally during pregnancy. To get the best results, TSH is conducted for patients four hours after the last meal on an empty stomach.
LH Level : The LH blood test measures the amount of luteinizing hormone (LH) in blood or urine. The test is used to determine if a woman is ovulating, or have trouble getting pregnant or irregular periods. LH blood tests can be measured on the 2, 3, and 5 day of menstrual cycle. Fasting is not required for this test. A patient can take all medications as prescribed by the doctor.
Transvaginal (pelvic) Ultrasound Exam A transvaginal ultrasound is a test that is used to see woman’s reproductive organs like the uterus, ovaries, cervix, and vagina. It is also used to diagnose pelvic pain, menstrual and gynecological problems, abnormal bleeding and certain types of infertility. A transvaginal ultrasound is done with your bladder empty or partly filled.
Antral Follicle Count Test : Antral follicle count (AFC) or basal antral follicle count is a transvaginal ultrasound study that measures a woman’s ovarian reserve or her remaining egg supply. The ovarian reserve reflects her fertility potential. The basal antral follicle can be measured and counted on Day 3 of the menstrual cycle by using ultrasound. The cycle Day 3 hormone levels are used as indicators to determine ovarian reserve and the woman’s chances for pregnancy with in vitro fertilization.
Evaluation of the Uterine Cavity : The embryos that develop in the lab during an IVF cycle will eventually be placed into the uterine cavity. Therefore, it is critical that the cavity is normal. The most common procedure used to investigate the shape of the uterine cavity is Hysterosalongogram (HSG) and hysteroscopy. These tests are scheduled between the end of menses and the onset of ovulation.
HSG : is an X-Ray test that looks at the inside of the uterus and the shape of the fallopian tubes. These tests are usually carried out in the Radiology Department in the hospital.
Hysteroscopy : viewing of the uterine cavity through a lighted scope in order to diagnose and treat causes of abnormal bleeding. Hysteroscopy is done using a hysteroscope, a thin, lighted tube that is inserted into the vagina to study the cervix and inside of the uterus. Hysteroscopy can be either diagnostic or operative.
– MALE PARTNER TESTS –
Male fertility testing can include surgical procedures such as a testicular biopsy and vasography. These tests are designed to identify blockages, as well as problems with sperm production.
Semen Analysis : A semen analysis is the most common test and is used to determine the quality and quantity of the sperm, motility-the sperm’s swimming ability, morphology- the shape of the sperm, count- the number of individual sperm and vitality- the capacity of the sperm to live and last. Semen analysis is to be done with abstinence of 24-72 hours.
IUI or intrauterine insemination is a simple medical procedure that involves deposition of washed sperms into the uterus of a patient. The process is aimed at aiding the process of conception. This Assisted Reproductive Technology method is safe and effective in treating infertility, especially when dealing with natural barriers. In IUI treatment, a semen sample in a nutrient medium is placed in the uterine cavity, which in turn allows sperms to reach uterus.
- Conditions Warranting IUI
- Poor semen quality with low counts or motility.
- Impotency or premature ejaculation in males.
- Problems in cervix that could lead to obliteration of sperms.
- Ovulation disorders such as Poly Cystic
- Ovary Syndrome – In case of unexplained infertility where causes are unknown, IUI is advocated.
In Vitro Fertilization also known as IVF is a technique of assisted reproductive technology for infertility treatment. In vitro Fertilization (IVF) involves putting the eggs and sperm together outside the human body, by natural selection the egg will usually allow only one sperm to enter and this leads to the fertilization process in the laboratory.
After fertilization, the embryo are allowed to grow for a short period of time before being implanted it in a woman’s uterus. A successful pregnancy can be confirmed about 2 week later. IVF treatment is one of the most common and effective techniques available for improving the chances of pregnancy in women.
IVF can be used to treat infertility with the following patients :
- Blocked or damaged fallopian tubes : The damage or blockage in tubes makes it difficult for an egg to be fertilized or for an embryo to travel to the uterus.
- Male Infertility : Men with low sperm concentration, weak movement of sperm (poor mobility), or abnormalities in sperm size and shape can make it difficult for sperm to fertilize an egg.
- Unexplained infertility : One in six couples suffers infertility problems and sometimes the causes remain unknown despite investigation
- Ovulation disorders : mean when ovulation fails to occur and are present in up to 20 percent of infertile couples.
- Premature ovarian failure : also known as premature ovarian insufficiency (POI) is the loss of function of the ovaries before age 40.
- Endometriosis : Endometriosis occurs when the lining of the uterus (womb) grows starts to outside of the uterus.
Natural Cycle IVF
Natural cycle IVF also known as ‘Natural IVF’ is a treatment similar to traditional IVF but without the use of fertility drugs. Natural cycle IVF simply follows a woman’s menstrual cycle, which is monitored with a monthly ultrasound. You body selects your natural egg, usually around the tenth day of your cycle, the egg is retrieved and combined with the sperm to allow fertilization to occur. Once fertilization occurs, the resulting embryo is implanted into the woman’s uterus. Natural cycle IVF with ICSI uses the body’s natural ovulation process, without the help of follicle-stimulating hormones to boost egg production and induce ovulation.
Advantages of Natural Cycle IVF
- No fertility drugs are used for ovarian stimulation, reducing the risk of side effects such as OHSS.
- Natural Cycle IVF treatment can be repeated in consecutive months. Women who have an unsuccessful traditional IVF -treatment must wait three months before attempting a second cycle.
- Natural cycle IVF is less expensive as couples do not pay for fertility drugs.
- Natural IVF works perfectly even for older women.
- It greatly reduces the chance of multiple births.
Intracytoplasmic Sperm Injection (ICSI) is an advanced form of in vitro fertilization procedure that helps to treat sperm-related issues. Male infertility is much complex than the female one and there are various parameters that need to be looked into. That is why, ICSI treatment has helped for so many couples that help a successful fertilization to occur. In ICSI treatment procedure, a single sperm is directly injected into an egg.
Our doctors use special tools and equipment to perform activities like picking up the best sperms and inserting them in the egg. Both activities are very critical, delicate and complicated. The sperms are injected to the core of the eggs and the process requires very high precision and perfection.
ICSI treatment is recommended when the male partner has very low sperm count, poor morphology or poor motility.
In IVF programme, embryos are usually transferred on the second or third day following egg retrieval at the four-to-eight cell stage. The IVF embryos must continue to grow for two or three more days to reach the blastocyst transfer stage (50-150 cells) before they are ready for implantation into the uterine wall (endometrium). Recent advances in IVF laboratory treatments have allowed for the successful culture of embryos to the blastocyst stage.
Blastocyst is an advance embryo which is developed for about 5-6 days, after fertilization. Blastocysts have two different cell types and a central cavity. A healthy Blastocysts should begin to hatch from the outer shell called the zona pellucida by the end of the sixth day. Within 24 hrs of hatching, it will begin to implant in to the lining of mother womb.
Blastocysts may have a better potential to implant into the uterine wall than earlier stage embryos. Many embryos stop growing at the four-to- eight cell stage, probably because of some inherent problem. Therefore, fewer embryos will have the ability to grow to the blastocyst stage. Those that successfully reach the blastocyst stage are probably more developmentally competent than earlier stage embryos. As well, their stage of development when replaced into the uterus is very similar to what it would be in a natural conception cycle.
Couples who have had unsuccessful prior attempts with IVF or IVF/ICSI despite having many good quality eggs retrieved are being offered blastocyst culture as an alternative treatment. The ability to select the most viable embryos for transfer and implantation should improve their chance of achieving a pregnancy.
The embryos will be cultured in the IVF laboratory for 5 days after egg retrieval. At least 5 good quality embryos (6 to 8 cells) should be available on the third day after egg retrieval to maximize the chances of obtaining a blastocyst. Couple can have the discussion with doctor whether this option will benefit them or not.
Cryopreservation is the method of keeping the embryos, sperms, gametes, tissues from ovaries or testicles in an extremely low temperature with an intention of the use in future. Samples can be kept intact for the future use and there is a huge saving of cost and resources. There is increased efficiency and reduced discomfort and inconvenience to the couple.
We perform the task in two steps. Firstly, the sample is collected from the female or male partner and kept in special tubes that look like straws. These tubes are stored below zero degree Celsius temperature and there is a special solution used to prevent the specimens from getting frozen. This solution is called cryopreservant and the specimens are thawed before they are used.
There are multiple protocols for cryopreservation and they vary in terms of the storage temperature, type of cryopreservant, time required for freezing and thawing and the type of specimen
It is very obvious that there is an increase of efficiency with the help of cryopreservation. The embryos, sperms or matured eggs extracted once can be used later without having the hassles of extracting again. This saves great amount of time, energy and money. There is no need to go for the stimulation of the ovaries again and again. The woman gets relief from the physical discomfort multiple times.
Lower risk of hyper stimulation syndrome : It is a dangerous condition when ovaries are stimulated multiple times using medicines and it can cause death as well. If the process of IVF gets done multiple times and every time there is a stimulation of the ovaries to produce the egg, then it creates a lot of strain on the ovaries. Cryopreservation avoids it by using eggs that got extracted one time. In case of IVF, doctors used to implant more than one egg in order to increase the probability of success. With cryopreservation technique, it is not required to do so. Doctors can implant one or maximum two embryos in one attempt and keep preserve the others.
Preservation of the fertility : Interestingly, cryopreservation can be used to preserve the fertility for people who have threat of losing the same. For example, females with a history of early menopause or couples undergoing chemotherapy or radiotherapy have a risk of losing fertility early. In such case, they can preserve the embryo or sperm for later use.
Assisted hatching is a scientific technique that can improve the implantation of embryos into the women’s uterine lining, by creating an opening through which the embryo can hatch out. Just prior to embryo implantation, the developing embryo must “hatch” out of its outer shell (zona pellucida). Some embryos seem to have a thicker shell that may decrease their ability to implant. This may be due to the age of the woman or other unknown reasons.
Assisted Hatching is recommended for :
- Women who is over 37 years and using their own eggs.
- Women with Higher FSH.
- Women with recurring IVF Failure.
- Women whose embryo exhibit thick Zona Pellucida (More than 17 Microns).
- Post thaw embryos.
- Poor responders (less than three embryos).
- Sever endometriosis.
PGD stands for Pre-implantation Genetic Diagnosis to have a healthy baby with your genes.
Who requires PGS / PGD ?
- First child born with genetic defects
- Multiple IVF cycle failures
- Repeated abortions / miscarriages
- Increased maternal age of female partner
- Unexplained infertility in either of the partners
- Repeated embryo implantation failure
- Single gene disorders
Disorders : Cystic fibrosis, B-thalassemia, sickle cell disease and spinal muscular atrophy type 1, Myotonic dystrophy, Huntington’s disease , Charcot-Marie-Tooth disease type 1A, Down syndrome, reciprocal translocations, Human leukocyte antigen (HLA) matching.
Why PGS ?
PGS stands for Preimplantation Genetic Screening, a test to assess genetic forms i.e. the chromosomal material of the embryo before implantation. It helps in checking the embryo’s chromosomes for detection of any chromosomal abnormalities. Chromosomal defects are a major cause for the failure of embryos to implant and result in miscarriages/abortions. PGS analyze the chromosomal status of an embryo by medical screening of all 23 chromosome pairs prior to the transfer in an IVF cycle.
- Frequent miscarriages
- Repeated IVF Failures
- In case of either partners having any hereditary disorders like color blindness or Thalassemia.
- Although it depends on medical condition of patients and doctor decide that PGS is required or not.
- Successful implantation rates.
- Enhances the success rates for single embryo transfer.
- Improve success rates of fertility in females above 35 years.
- Detection of chromosomal abnormalities prior to implantation.
Hysteroscopy is a procedure that involves insertion of a narrow telescope-like instrument through the vagina and cervix into the cavity of the uterus (endometrial cavity). The uterine cavity is then distended with fluid and visualized.
This procedure allows us to see if there are any uterine cavity defects such as :
- Fibroid tumors
- Endometrial polyps
- Intrauterine scar tissue
- A bicornuate uterus or septate uterine malformation
- Other uterine problems
If any defects are found then they should be corrected with operative hysteroscopy which involves placing instruments through ports in the scope that allow us to cut, cauterize, etc. to correct the problem.
Diagnosis : Uterine synchie, Uterine malformations, Interstial tubal occlusion
Therapy : Lysis of synchie, Resection of uterine septum, Removal of interstial tubal block
Laparoscopy is a surgical procedure useful for the diagnosis and treatment of infertility, endometriosis, fibroids, blocked fallopian tubes, ovarian cyst and pelvic pain. This operation allows a direct view of the uterus, tubes, ovaries, other organs and the pelvic cavity in general. Our Virginia fertility specialist received years of training in laparoscopic surgery. Tubal reversal surgery can also be performed laparoscopically.
Laparoscopy also called as minimally invasive surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5 – 1.5 cm) as opposed to the larger incisions needed in laparotomy.
- Shorter hospital stay
- Better cosmosis
- Less postoperative pain and morbidity
- Less tissue handling and fever opportunities for foreign body contamination such as lint and suture
- Decreased postoperative adhesion formation
Diagnostic Laparoscopy is an important tool in evaluation of the patient presenting with acute or chronic pelvic pain.
- Ectopic pregnancy
- Pelvic inflammatory disease
- Adnexal Torsion can be diagnosed in a timely manner
- Laparoscopy also permits evaluation of tubal and peritoneal factors in the infertile patient
Procedures routinely performed via operative laparoscopy include :
- Removal of scar tissue around the tubes and ovaries (salpingolysis and/or ovariolysis) and opening blocked tubes (tuboplasty).
- Removal of ovarian cysts and endometriomas with reconstruction of the ovary to a fully functional state.
- Removal of endometriosis including advanced stage three and four disease involving both bowel and the urinary system. This is often done employing a multidisciplinary approach with a bowel surgeon and through urologist in attendance.
- Removal of uterine fibroids (even those involving the uterine cavity) with uterine reconstruction to a fully functional state.
- Removal of ectopic pregnancies with conservation of the fallopian tube where indicated.
- Tubal reanastamosis after tubal ligation (sterilization).
- Complete hysterectomy performed laparoscopically.