The advanced fertility center has all the investigations and treatment modalities or the treatment of infertility under one roof

The following services are availiable here

1. Intrauterine insemination (IUI)

2. Invitro fertilization (IVF)

3. Intracytoplasmic sperm injection (ICSI)

4. Invitromaturation (IVM)

5. Blastocyst culture and transfer

6. Assisted hatching (AH)

7. Freezing (cryopreservation) of sperm and embryos

8. Vitrification of eggs and embryos

Other Related Services offered

Andrology

1. Semen analysis


2. Sperm function tests


3. Sperm freezing

Endocrinology

• Estimation of FSH, LH, pRL, E2, hCG, T3,T4.TSH, prog.

Ultrasound and Doppler studies for Infertility, Obstetrics, & Gynecology.

Consultation by reputed experts in specialities like medicine, surgery urology, endocrinology, Andrology and psychiatry.

Controversy still exists regarding the occurrence of ovarian cancer following frequent use of these hormones
The incidence of congenital malformations or any abnormalities in the babies born through this procedure is not at all high. Infact the incidence of this is same as that in naturally conceived babies, which is in the range of 1-5%.

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IVF

What is IVF?

IVF is an acronym for invitro fertilisation, which literally means “ in glass”. This is more commonly known as “test tube baby” treatment. During the initial years scientists were using test tubes in which the eggs and sperm were put together to achieve fertilisation. This is now known as “ conventional IVF”.

Since 1966 Dr. Patric Steptoe, a gynaecologist and Dr. Robert Edwards, a scientist had been tirelessly working on an alternative solution for conception. Their hardwork bore fruit on 25th of July 1978 with the birth of the first
 IVF baby Louise Brown in England.

Any form of assisted conception procedure where the process of fertilisation takes place outside the body is a form of IVF. Hence intracytoplasmic sperm injection ICSI is also a form of IVF.

Conventional IVF was originally devised to treat women with blocked or absent fallopian tubes.

Today it is indicated for numerous reasons viz:

Steps in IVF

Investigations required:

Male:     1.HIV/HbsAG
              2. Semen Analysis
Female:1. HIV/HbsAG
              2. Basic Pelvic scan done on 2nd or 3rd day of                   the period
              3. Serum FSH/ LH/ Prolactin done on 2nd or 3rd                   day of the period
              4. Mock transfer –done in the previous cycle.
              5. Hysteroscopy
              6. Laparoscopy  May or may not be required.

 

All these investigations need to be done 1-2 months prior to going through the IVF cycle. And the couple will go through a counseling session prior to starting them on any medications for IVF. Once the couple decides to go through the IVF cycle, following will be the protocol

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1. On day 2nd or 3 rd of her period a repeat baseline scan is done.
   The doctor decides on one of the following protocols.

Long protocol:

Flare/ short Protocol:

Dual Suppression:
On Day 5 of the period Oral contraceptive pill (OCP) is given for 20 -21 days for suppression of the reproductive hormones. From the 15th day of starting the OCP, GnRh analogs are started and the protocol is same as mentioned in the long protocol section.

Antagonist protocol:

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Embryo transfer:

Luteal support:
1. Progesteron supplementation in the form of injections or vaginal pessaries is given for 14 days after ovum pick-up. This helps in maintain a good uterine lining (endometrium) so as to facilitate pregnancy.

2. Estrogen supplementation in the form of oral tablets are also given for 10 days from the day of ET.

The success rates for ART depend on many factors:

Oocyte / Egg Retrieval / Aspiration:  

This is a procedure which involves the removal of the egg from the ovary.  The eggs are located within a fluid filled sac called as follicle.  The number of these follicles and their sizes are determined by sonography.  During the phase of follicular monitoring. This is a day-care procedure and does not require any overnight stay in the hospital.

Oocyte aspiration is done under USG and with short general anaesthesia.   The patient is expected to be fasting from previous night.    A fine needle is passed through the vagina into the follicles within the ovary.  The follicular fluid which will contain the eggs is aspirated through this needle into a sterile test tube.  This is then passed over to the IVF lab through a hatch adjacent to the OT.  In the lab, this fluid is scanned under the microscope and the eggs which are now also surrounded with the supporting cells are washed and kept in the incubator. 

This procedure takes not more than 20 – 30 minutes and the patient is allowed to go home 4 -6 hours after the procedure the same day.  She can continue with her regular house / office activities from the next day till embryo transfer. 

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ICSI

What is ICSI ?

Intracytoplasmic sperm injection ICSI is an invitrofertilization procedure in which a single sperm is injected directly into an egg.

It is a micromanipulative technique, which`  is performed under a microscope equipped with high magnification and a specialized micromanipulative system. This allows for precise control during micromanipulation. The equipment used for ICSI is called a micromanipulator.

The supporting cells cumulus cells surrounding the egg are removed by an enzyme called hyaluronidase followed by mechanical removal by special bore pippettes. This procedure is called denuding, following which the maturity of the egg can be documented accurately.

ICSI is a highly successful procedure in skilled and experienced hands. It was mainly devised for patients with male infertility involving low counts, sperm motility or morphology (abnormal sperm shape). ICSI has proved to be a boon especially in males with no sperm in their ejaculate (Azoospermia), and where sperm can be obtained surgically from either the testis or epididymis (TESA/PESA/testicular biopsy).

Indications for ICSI:

 The fertilization rate being higher with ICSI other relative indications would be patients with only 1-2 eggs retrieved. Here the chances of fertilizing that single egg would be higher with ICSI than with IVF.

Procedure of ICSI

        The egg and sperm are manipulated using fine glass pipettes. These are called the holding and the injection pipettes.

Blastocyst culture and Blastocyst transfer

What is Blastocyst culture and Blastocyst transfer?

The embryo reaches the blastocyst stage in 5-6 days. In a natural cycle the embryo is conceived in the fallopian tube. 4 days later it travels to the womb. It forms a blastocyst on day 5-6 in the womb. Hence transfer at blastocyst stage is much more physiological.

day3	day4	day5

 

When embryos are transferred on day 2 or3 we are not very sure of their viability, hence on an average 3 embryos are transferred to increase the chances of pregnancy. This also increases the chances of a multiple pregnancy. With a blastocyst transfer only 1 or 2 blastocysts are transferred, hence reducing the chances of a multiple pregnancy.

Blastocyst culture allows for a natural selection of the best embryo as only the best and robust embryo survives to this stage. This blastocyst has a 50% chance of implanting on transfer. So the implantation rates are improved on transferring a blastocyst due to the selection of the best embryo.
 
Disadvantages of a blastocyst transfer:

• Embryo wastage: About 10-15% of the embryos, which fail to develop to blastocyst in culture, may have done so if placed inside the womb on day 2 or 3.
• No ET: upto 30-40% of the patients may not have any blastocyst for transfer as all of them would have arrested or degenerated leaving nothing for transfer.

 

Indications for blastocyst transfer:

• Patients who have failed to conceive with a day 2 or 3 transfer earlier.
• Patients with 5-6 good quality embryos on day 2.
• As blastocyst transfer reduces the chances of a multiple pregnancy it is advisable in-patients who are not willing for foetal reduction due to personal reasons.

   

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Assisted hatching

What is assisted hatching?

Assisted hatching is one of the newer techniques introduced in 1990 to improve the IVF outcome.

A protective shell called the zona pellucida covers the embryo. When the embryo grows to the blasctocyst stage it hatches out of this shell and anchors itself to the endometrium –inner lining of the womb. Sometimes embryos have difficult time hatching out of this protective layer, especially in older women where the ZP may be hard and tough to allow hatching thus leading to failure of implantation and pregnancy may not occur.Assisted hatching is a procedure wherein a small hole is made in the outer lining of this shell, hence making a potentially weak area, which facilitates easy and effortless hatching of the embryo.

When and how is assisted hatching done?

On day 3 or 4 the embryo starts compacting i.e all the cells start binding with each other to form a ‘chewing gum’ like mass.(photo of c’ted emb) At this stage the cells bind tight with each other and are not loose and independent. Performing AH at this stage reduces the chances of loosing the cells through accidentally created large hole in the zona.

 Assisted hatching being a micromanipulative technique requires training and skill. It is done under the microscope using a micromanipulator. There are different methods of doing this procedure having the same final outcome.

For whom should assisted hatching be done?

Common indications for AH are as follows:

Risks associated with AH

If not done wit expertise the procedure can damage/kill the embryo itself. Some centres have reported a slight increase in the incidence of identical twins (monozygptic). This is so because while making a hole in the zona, the embryo may sometimes split into two giving rise to monozygotic twins.  However there has been no reported increased incidence of birth defects in children born as a result of this procedure.
Rare side effects to the mother from the accompanying steroid and antibiotic may be there.

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Embryo freezing

What is embryo freezing?

Embryo freezing also called “cryopreservation” is a procedure wherein the embryos are frozen and stored in containers for future use. This procedure is done by first keeping the embryos in special freezing solutions for a fixed amount of time.following which they are immersed into liquid nitrogen which is at a temp of -196 deg C. Embryo freezing can be done at any stage of the embryo and once they are frozen they getarrested in that particular stage till they are thawed or warmed.

When is embryo freezing done?

As embryo freezing never happens naturally in the human body and hence is not a physiological procedure. Thus some amount of damage to the embryos is expected. More over the capability of the embryos to survive this procedure cannot be predicted. Only good quality embryos are known to survive this procedure and give pregnancies.

When can embryo freezing be done?

Indications for embryo freezing are

• Excess good embryos remaining after few are transferred.
• Patient having a high risk  of OHSS where no Transfer is done
• Poor endometrium which reduces chances of implantation.

    What are the disadvantages of freezing embryos?

As this is not a physiological procedure there is always a risk of damaging/killing the embryos during this procedure. The embryos may be damaged partially or entirely. As long as 50% of the embryo still survives the procedure it has the capability to give rise to a good pregnancy. The ability of the embryo to survive this procedure depends upon the grade, quality and stage of embryo and also method used for freezing them. Thus it is not possible to predict before hand the ability of the embryos to survive this procedure.

The embryo survival by slow method is 60-70% while with vitrification method it is around 90%

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Endometriosis:

A Cause of Infertility

The lining of the uterus, (endometrium), changes every month depending upon the phase of the menstrual cycle. The hormonal response thickens the endometrium in hope of a pregnancy, and thins it in case of failure of a pregnancy thus, bringing on your period.  It is suspected that endometriosis is caused by a regurgitation of the menstrual blood through the fallopian tubes into the peritoneal cavity during their period. This causes the endometrial tissue to implant outside the uterus.  Women who have never had children or women who have a family history of endometriosis are more at risk to suffer from this disease.
Following are the sites which can be affected by endometriosis:

These implants are responsive to the hormonal changes. Thus these implants outside the uterus also bleed just like the endometrium does during periods. This bleeding can lead to formation of adhesions, which is scar tissue. Adhesions can cause pain as they cause the organs to stick to each other. Severe and long standing endometriosis is also known to affect the female gamete (egg) adversely. This change is irreversible and no treatment is available till date to help improve the egg quality in endometriosis. Once the egg quality is affected then the results of IVF are also compromised.

Symptoms
1. Pelvic pain.
2. Excess pain and bleeding during periods.
3. Pain during passing motion or urine.
4. Painful intercourse.
5. Inability to conceive.

Treatment

I. Medications
Pain can be very incapacitating in these conditions hence it is common to start by treating the pain first with nonsteroidal antiinflammatory drugs (NSAIDs).  Hormones are also used frequently to treat pain.  Drugs like GnRH (Gonadotropin-releasing hormone) are also used.   These hormones halt the function of the ovaries, creating a temporary menopausal state thus preventing the endometriotic sites from bleeding.

2.Surgery
Surgery is done with the intention of removing as much endometrial tissue as possible. This is usually done by burning or removing the tissue. The surgery is usually performed via laparoscopy or laparotomy.  The more severe the disease, the higher the risk of a recurrence.

Infertility and Endometriosis
As menstruation stops during pregnancy so does the growth of endometriosis. Once diagnosed Patients with endometriosis should hasten their decision to conceive. These patients should be enrolled into infertility treatment with ovulation inducing agents and IUI or AST depending on the severity of disease without wasting much time.

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Foetal Reduction:

Selective fetal reduction is the practice of reducing the number of fetuses in a multiple pregnancy (three or more fetuses) to twin pregnancy.  The aim is to avoid the medical issues related to multiple births like premature births, low birth weights, placenta low lying and associated (DM & PIH).  It is done during first trimester i.e., 8wks by vaginal route under transvaginal ultrasound guidance or by 11 -12 wks by transabdominal route by ultrasoud guidance.  Common practice is to inject a chemical solution or to prick the heart of fetus and stop its functioning.  The dead fetus is reabsorbed in to woman’s body.  There is always a small chance of the other remaining fetus getting harmed in the process but this is less than the risk of continuing with triplets or higher order pregnancy.

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Hysteroscopy:

Hysteroscopy is an endoscopic procedure. A scope is introduced through vagina, cervix and the uterus.Sterile Saline is then used to distend the uterine cavity for better visualization of the uterine cavity.  Operative tools like small scissors, biopsy forceps can be introduced and fibroids, synechiae, polyp, septum can be cut or removed.

The only risk involved is injuring the uterus by making a hole in its wall.If this hole is small it will heal on its own without any treatment.  Infections, fluid imbalance when surgeries are performed for longer period of time are the other risks involved. Most patients return to normal activity the very next day.

Apart from visualizing the uterine cavity hysteroscopy can also be used to tackle the following

• intrauterine adhesions
• Uterine fibroids inside the cavity.
• Endometrial polyp
• Uterine developmental anomalies.

 

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