• IVF-ET
• Intrauterine Insemination
• Intra-cytoplasmic sperm Injection
• Hysteroscopy
• Laparoscopy

In vitro fertilization - Embryo Transfer in non-medical terms is referred to as "test tube baby". It involves the picking up of eggs from a woman, fertilizing them outside the body with the husband's sperm, and replacing the resultant embryos into the patient's uterus.

IVF is the treatment of choice for couples with the following:
Blocked fallopian tubes
Severe abnormalities in the semen parameters.
Unexplained infertility.
Genetic diseases in either parent resulting in miscarriages/stillbirths.
Women whose ovaries are failing due to age or other causes. Such women can undergo IVF with donated oocytes.

1. Downregulation

Down regulation is accomplished by administering a drug called gonadotrophin releasing hormone agonist (GnRHa). The response is monitored by blood tests and ultrasound scans. The treatment duration may vary between 8-21 days depending on the individual response.

2. Ovarian stimulation.

Injections called gonadotrophins are the most commonly used injections to develop a good number of follicles in the ovary. They are given daily till the follicles reach a diameter of 18-22mm. This takes on an average 10-12 days of treatment. On occasions ovarian stimulation may be achieved by tablets such as clomiphene citrate in combination with gonadotrophins. Hormonal assays in the blood and ultra sound scans are carried out at regular intervals to assess the response to these drugs. At the same time the endometrial lining is also assessed.

3. Ovulation trigger

This is accomplished by administration of another drug called Human Chorionic Gonadotropin or HCG, which is necessary for final maturation of the egg prior to ovulation. The next step i.e. oocyte retrieval is then scheduled at 34-36 hours after administration of HCG.

4. Oocyte retrieval or Ovum pick up

This is a short, safe, outpatient procedure performed vaginally under ultrasonographic guidance. It is usually done under sedation but general anesthesia can also be used. The patient should be fasting for at least 5 hours prior to the procedure. The procedure is carried out in sterile surroundings under aseptic conditions. The aspirated fluid is examined under the microscope to identify the eggs. The eggs are removed and washed and placed in small dishes containing the culture medium.
The dishes are kept in a special incubator.

After-care

There may be mild cramp like pain or slight bleeding from the vagina which ' will subside in a few hours.

Oral antibiotics are given to the woman as prophylaxis against infection.

The woman goes home 2-3 hours after the procedure.

The patient should not drive for 24 hours after the procedure.

5. Sperm preparation

On the day of egg pick-up the husband is required to produce a semen sample by masturbation in a clean wide mouthed container supplied by the lab.

There should be a period of abstinence of 2- 3 days. If the husband cannot be present at the scheduled time a semen sample is collected in advance and the semen analyzed and frozen for use during the IVF treatment.

6. Fertilization

A measured volume of the prepared sperm suspension is added to the dish containing the eggs 3-6 hours after egg collection. The following day the dish is checked for fertilized eggs. They are then placed in fresh dishes of culture medium and replaced in the incubator.

7. Embryo transfer (ET)

ET is carried out on any one day, between the 2nd day and 5th day after oocyte retrieval.

ET is a simple and straightforward procedure done under aseptic conditions.
No sedation is required.

The embryos are gently placed in the uterine cavity through a fine cannula introduced directly into the uterus via the vagina and cervix,. Normally 2 or 3 embryos are placed in the
uterine cavity. Increasing the number would
involve risk of multiple pregnancies.

After-care

The woman has total bed rest for 6 hours after ET. After that she can resume her normal activities.
• Blood tests are carried out at regular intervals thereafter

8. Implantation

Once the embryos are transferred, it should follow the natural event of implantation.

The embryo hatches out of its shell covering (zona pellucida) and implants into
the endometrium by burrowing into it. It then continues to develop to the fetus.

By 2 weeks after embryo transfer, the embryo starts producing the hormone
human chorionic gonadotrophin (hCG). Detection of this confirms the presence of a pregnancy.

9. Outcome

A blood test indicating hCG levels to confirm pregnancy is done on the 28th day of the cycle.

In order to support a conception the woman is given progesterone in the form of injections. It is continued till 12 weeks of pregnancy or stopped when the first pregnancy test is negative.

In cases of a failed outcome, normal menses usually resumes within 2 week

This is some background information about the procedure. For further queries or information please contact our Clinic. We would be happy to be of assistance.

Intrauterine insemination (IUI), one of the methods of artificial insemination, is a simple and safe treatment modality in infertility aimed at overcoming the natural barriers to the passage of the sperms from the vagina to the fallopian tubes. During IUI, a prepared semen sample with adequate numbers of motile, normal sperms suspended in a nutrient medium are directly placed in the uterine cavity, thus bypassing the need for sperms to travel from the vagina to the uterus. This is done around the predicted time of ovulation. With IUI the number of sperms that reach the fallopian tube is increased by as much as 25%.

Indications

Sexual problems in the male impotence; premature ejaculation.

The cervix is hostile and thereby destroys the sperms, as evidenced by certain tests.

Impaired semen quality low or absent counts, low motility etc.

Unilateral tubal block

Unexplained infertility all tests for infertility in the male and female are normal, yet the woman is unable to conceive.

Initial work-up

Through a comprehensive history, examination and laboratory investigations the following facts are confirmed.

The ovary contains healthy oocytes or eggs, the fallopian tubes are patent or open and the uterus is normal.

The semen sample contains a sufficient number of motile normal sperms.

The husband or donor has no infectious diseases or genetic abnormality.

Ovulation Induction

IUI may be performed at the time of ovulation in a natural menstrual cycle or in a cycle where the ovaries have been stimulated by certain drugs. Ovulation induction or stimulation of the ovaries, is the administration of certain drugs which act on the.ovaries and stimulate them to produce more eggs, thus improving the chances of conception. The woman is asked to attend the clinic on the 2" d day of her menstrual cycle. After an ultrasound examination to check her uterus she is prescribed medication to stimulate her ovaries. Such drugs are administered to ensure that the ovaries produce more than one egg to improve chances of conception.

Timing of ovulation

To predict the time of ovulation, the woman will have to undergo ultrasound examinations on alternate days from the 8"' or 10"' day of her cycle. At the predicted time of ovulation insemination is carried out with the prepared semen sample. Sperms have the ability to fertilize for up to 48 hours and a mature egg is capable of being fertilized for approximately 12-18 hours after ovulation

Preparation of the semen sample

Abstinence is to be observed 3-4 days prior to the procedure. On the day of the insemination the husband gives a semen sample in a wide-mouthed sterile container provided by the Clinic. The sample should be obtained by masturbation and not coitus interuptus. Facilities ensuring privacy are available at the Clinic for this purpose. After the specimen has been given for processing, the couple can leave and return for the insemination 1 -2 hours later.

The semen sample is assessed for volume, count and motility. The semen is then washed, which in essence refines and concentrates the sperms enhances the fertilizing capacity of the semen specimen. Only motile normal sperms are obtained thereby eliminating all other contents. The sperms are suspended in a nutrient medium and this sample is used for insemination.

Frozen semen of the husband may also be used for insemination. This is done when the husband cannot be present at the time of insemination. However a fresh sample is preferred.

The Insemination Procedure

IUI is a relatively simple and straight forward technique performed transvaginallyas an outpatient procedure.

There is no need for the woman to fast or rest before the insemination procedure.

The woman is asked to pass urine so that her bladder is empty.

The woman lies on a couch or bed with her hips raised on a pillow.

The mouth of the uterus called the cervix is visualized by means of an instrument inserted into the vagina. The cervix is cleansed of mucus. The anterior lip of the cervix is held with a forceps. All these do not cause pain to the woman.

The IUI catheter with the processed semen sample is gently introduced into the uterus.

The processed semen is injected slowly into the uterus over 30-60 seconds.

The woman is asked to continue lying down for the next 30 minutes.

She is then allowed to leave and can resume her routine activities immediately on return.

Insemination is usually performed on two consecutive days in any one cycle.

At our Centre couples are generally advised to attempt two or three cycles of insemination. If they fail to conceive their records are reviewed for re-evaluation of treatment.

After care

After IUI the woman will be asked to take some medications which help make the uterine lining or endometrium receptive to implantation of an embryo.

There is no restriction in activity. There is no need for bed rest, diet and travel restrictions.

Side effects

Side effects are extremely rare and may include uterine cramps in about 5% of
patients, spotting in about 1% and gastro intestinal upsets or nausea in about 0.05% of patients.

Sterile conditions ensure that infection very rarely occurs. Antibiotics are not necessary for the woman or her partner either before or after the procedure.

In normal conception a million or more sperms are mustered to fertilize one egg. In Intra Cytoplasmic Sperm Injection (ICSI), a single sperm is injected into a single egg with the help of an instrument called the micromanipulator. Infertile couples with severe male factor infertility (poor sperm count, motility, or morphology) can be treated with Intra Cytoplasmic Sperm Injection. Now, even azoospermic men with no sperm in their ejaculate, have a chance to father a biological child. ICSI is a safe, high tech but simple procedure, performed world wide with good success rates.

Indications:

1. Couples with severe male factor infertility who do not want donor sperm insemination.

Sperm concentrations of less than 15-20 million per ml OR Sperm motility less than 3 5% OR Very poor sperm morphology

• Couples having IVF who have had a previous cycle with no fertilization - or a low rate of fertilization (low percentage of mature eggs that are normally fertilized).
• All couples having IVF who have a very low yield of eggs at the egg retrieval . In this scenario, ICSI is used to try to get a higher percentage of eggs fertilized than with conventional insemination of the eggs.

Procedure:

The woman goes through a typical ovarian stimulation protocol during which fertility drugs are administered to the female partner to aid in the production of multiple eggs. The eggs are then surgically removed as in oocyte retrieval. For ICSI, sperms can be obtained either from the ejaculate or by any kind of sperm retrieval techniques. In case it is not possible to obtain sperms by this method, sperms can be recovered from the testes by means of a small surgical procedure. These procedures can be carried out under local or general anesthesia, and are as follows.

Retrieval of Sperms:

• Micro Epididymal Sperm Aspiration (MESA), a delicate surgical technique using the microscope to aspirate sperm from the epididymal region.
• Percutaneous Epididymal Sperm Aspiration (PESA), in which a small needle and a local anesthetic are used to aspirate sperm from the epididymis.
• Testicular Sperm Biopsy (TESE), in which a small biopsy of testicular tissue is taken under anesthesia. TESE is the ultimate option when no sperm are obtained with MESA or PESA.

These procedures are done on an outpatient basis.

Sperm obtained by ejaculation, or through MESA , PESA, TESE must be processed well before the ICSI procedure is carried out. The selected sperm is injected into the mature eggs retrieved from the woman, checked for fertilization, allowed to grow in the lab for about three to five days and then on day three or day five of egg retrieval, selected embryos are replaced in to the uterus. Sperm may also be retrieved ahead of time and frozen for future use.

How is ICSI performed?

• The mature egg is held with a specialized holding pipette.
• A very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm.
• This needle is then carefully inserted through the zona (shell of egg) and into the cytoplasm of the egg.
• The sperm is injected into the cytoplasm and the needle carefully removed.
• Injected oocytes are released from the holding pipette, washed and transferred to a small drop of fresh medium.
• After injection of the sperm, the eggs are incubated for 16-18 hours, then examined for fertilization.
• The resulting undamaged embryos are then either transferred back to the woman's uterus, using standard IVF techniques, or can be frozen for transfer at a later time.

Fertilization and pregnancy rates with ICSI:

Generally fertilization rates are more in ICSI procedure, when compared to conventional IVF (60-85%). Pregnancy rates for in vitro fertilization procedures with ICSI are higher than conventional IVF without ICSI. This is because in many of the cases needing ICSI the female is relatively young and fertile with good egg quality as compared to some of the women having IVF for reasons other than male factor infertility.

Pregnancy & delivery are expected to proceed as normal. No complications in terms of abortions, congenital abnormalities or pregnancy complications result due to the ICSI procedure per se.

This is some background information about the procedure. If you have any further queries please approach the clinic to schedule an appointment with one of our doctors. We would be happy to be of assistance.

What is hysteroscopy?

Hysteroscopy is the direct visualization of the uterine cavity and the cervical canal through a telescope-like instrument called the hysteroscopy. Visualization of the uterine cavity will note the presence of any masses (polyps), bands (adhesions), uterine deformities (septum) and nature of the uterine lining or endometrium. The opening of the fallopian tubes (ostia) into the uterine cavity can also be visualized.

Hysteroscopy can serve as an aid to diagnosis as well as treatment for certain conditions. The former is termed as a diagnostic hysteroscopy, while the latter is referred to as an operative hysteroscopy.

What are the indications for a hysteroscopy?

Infertility

Abnormal uterine bleeding

Abnormal hysterosalpingography (X-ray of the uterus) findings.

When is it performed?

Hysteroscopy is an outpatient or day-care procedure performed between the 7th & 10 th day of the menstrual cycle. Prior to the procedure, it is important to ensure that the patient is in good health by a clinical examination and certain laboratory investigations such as routine blood and urine tests.

Hysteroscopy should not be performed in the presence of

Uterine bleeding

Pelvic infection

Cancer of the cervix or uterus.

Procedure

The procedure is performed in the operation theatre under intravenous sedation and/or local anesthesia.

The woman should report on the morning of the procedure on an empty stomach after an overnight fast.

The patient is placed on the examination table in a specific yet comfortable position.

Initially a pelvic or vaginal examination is done to assess the position and size of the uterus.

The hysteroscopy is introduced into the uterus via the vagina and cervix after the cervix has been adequately opened or dilated by instruments called dilators.

The uterine cavity and the opening of the fallopian tubes are visualized completely.

The procedure is short and lasts between 2-7 minutes.

After-care

The woman can usually leave after 1 -2 hours.

Antibiotics are given to prevent infection and analgesics are
prescribed to relieve pain.

In some patients there may be mild cramping pain in the abdomen for a
few hours after the procedure.

Uterine bleeding (mild to moderate) may occur for a few days after the
procedure.

The woman may resume work the next day.

In case of any discomfort, sexual intercourse may be avoided for 48
hours.

Complications

Complications of diagnostic hysteroscopy are rare and seldom life- threatening.

They include perforation of the uterus (a hole punctured in the uterus), cervical trauma, infection etc.

OPERATIVE HYSTEROSCOPY

This is a procedure which involves introducing accessory instruments such as scissors, biopsy forceps, electrosurgical or laser instruments, through channels in the hysteroscopy. These instruments are used to cut or burn tissues. Operative procedures are generally day-care procedures performed under general anesthesia. Treatment may be performed at the same sitting as a diagnostic hysteroscopy or at a later date.

This is some background information about the procedure. If you have any further queries, please approach the clinic to schedule an appointment with one of our doctors. We would be happy to be of assistance.

Laparoscopy is a procedure used in the diagnosis and management of problems in gynecology including infertility. It is performed using an instrument called the laparoscope, which is a slender miniature telescope with a light source. It enables visual inspection of the pelvis and abdomen. Laparoscopy is a fairly safe and simple day- care procedure.

Indications

Detection of abnormalities in any of the pelvic organs (uterus, tubes and ovaries). Examples - endometriosis, uterine fibroids and presence of adhesions in the pelvis.

Diagnosis of unexplained pelvis pain.

Removal of an intrauterine contraceptive device (e.g.: Cu-T) that
has entered the abdominal cavity from the uterus.

To assess patency of the fallopian tubes, i.e. whether the tubes are
blocked or open.

Generally laparoscopy does not form the first line of investigation in infertility.

Relative Contraindications

Pregnancy

Infection in the abdomen or pelvis.

Severe heart disease

Relative contraindications are obesity (>100kg) and previous multiple abdominal surgeries.


Procedure

Prior to the procedure, the woman is required to undergo some blood and urine tests to confirm overall good health.

The woman comes in the morning after an overnight fast.

Laparoscopy is better performed under a short acting general anesthesia.

The woman is appropriately positioned and the procedure is carried out under aseptic precautions.

A small nick is made on the abdomen, below the umbilicus, through which a special slender needle is inserted into the abdominal cavity. Carbon dioxide is passed through the needle in order to distend the abdomen and move away the bowels, for easy visualization of all the organs.

The needle is removed and the laparoscope is introduced through the
same incision. The uterus, tubes, ovaries and the pelvis are visualized
through the laparoscope.

The dye test is carried out with the laparoscope still in place.

Distilled water mixed with a few drops of a dye called methylene blue is slowly instilled into the uterus through a cannula or hollow tube passed into the uterine cavity via the vagina and cervix.

Passage of this blue colored fluid through the tubes and its subsequent
spill from the outer ends into the pelvic cavity is visualized through the
laparoscope. This confirms whether the tubes are patent (open) or not.

At the end of the procedure the carbon dioxide that has been instilled is made
to escape from the abdomen (as much as possible) by gently pressing the
sides of the abdomen.

Operative Laparoscopy

Operative procedures are performed by the introduction of accessory instruments into the abdominal cavity in a manner similar to the introduction of the laparoscope. These instruments either hold, cut or burn tissues. The procedure is monitored on a screen by means of a video camera attached to the laparoscope. Some of the procedures that can be performed are:

Removal of adhesions in the pelvis.

Removal of uterine masses in the uterus, tubes or ovaries.

Removal of an unruptured tubal pregnancy

After care

The patient is given antibiotics to prevent any infection, and analgesics to relieve pain. Oral intake is begun 2-4 hours later.

The patient is allowed to leave 4-6 hours later.

There may be pain in the shoulders or a sensation of bloodedness due to
remaining gas in the abdomen. This settles within a day or so, as the gas is
slowly absorbed.

Normal work may be resumed after a day's rest.

Complications

Complications are rare and may include:

Accidental entry into a blood vessel or bowel or any of the pelvic organs. Management will involve abdominal surgery i.e. opening of the abdomen and repairing the defect.

Entry of air into a blood vessel and thus into the blood circulation,termed as, embolism. This is an emergency and will require intensive care.

Infections

This is some background information about the procedure. If you have any further queries, please approach the clinic to schedule an appointment with one of our doctors. We would be happy to be of assistance.