A. ART includes all fertility treatments in which both eggs & sperms are handled. In general, ART procedures involves eggs retrieval from the ovaries, combining them with sperm in the laboratory and returning them to uterus.
Q. What is IVF ?A. In IVF procedure eggs are combined with partner’s sperm in a laboratory dish, once fertilized, resultant embryos are transferred into uterus in hope for implantation.
Q. What is ICSI ?A. Intracytoplasmic sperm injection is a procedure where a single sperm is injected into an egg with the help of micromanipulator instrument, and once fertilized embryos are placed into uterus.
Q. What is GIFT ?A. Gamete Intrafallopian transfer is a procedure where retrieved eggs and sperms are placed together in fallopian tube & fertilization happens inside your body and the embryo implants naturally. Although, this procedure was once commonly practiced, it’s rarely used today because the success with IVF is greater.
Q. What are the precautions or restrictions during an IVF cycle for a lady ?A. Physical restriction :
- Heavy exercise like aerobics, jogging, weight lifting are prohibited during ovarian stimulation until the pregnancy test results are known.
- Smoking / alcohol consumption should also be avoided during stimulation.
- If a lady is under some medical treatment , please consult the doctor whether prescribed medicine are safe during stimulation protocol. As some medications may interfere with the fertility medication.
Emotional issue :
As IVF cycle may be an emotional and stressful time for some couple, it may be helpful for a lady to talk to a supportive person like friend or a close family member. She can also take a help from counselor from the fertility clinic.
A. On the day before ooycte pick up media in which oocyte need to be kept in CO2 incubator for equilibration. Media for sperm preparation and for follicular rinsing are also kept for equilibration.
- Percentage of CO2 in Incubator and temperature is checked with the fyrite kit and thermometer respectively.
- The pH of the media & osmolarity is also checked.
- Oocyte identification and grading are always done in laminar hood, under microscope having a hot plate with temperature 37°C.
- Once the oocyte identification is done, it will be kept in special endotoxin free disposable petridish in special media. These petridishes are labeled with patient name and ART identification number.
- A special needle is used to aspirate the follicle under ultrasound guided scanning machine.
- The male partner are asked to collect the semen in a special container with his identification number. Semen is proceeded to get motile spermatozoa for insemination.
- Embryology lab is a restricted entry area with a special air modules fixed to have a complete particle free area.
If positive what will be the next step and if negative , when couple can try again ?
A. The blood pregnancy test is performed 12th day after the embryo transfer. If positive, patient is asked to repeat the blood test and ultrasound to ensure successful pregnancy by visualizing fetal heart beat on 30th day after embryo transfer. A good antenatal care is required for a successful pregnancy. We have all the facility for that.
If pregnancy test shows negative result, couple can wait one or two complete menstrual cycles before beginning another ART cycle. Some times tests are required, that may delay subsequent cycles.
A. The miscarriage rate is about the same for ART as the general population. Since for ART patient we observe fetal sac in early stage, we often know about spontaneous miscarriages in the very early stages of pregnancy. These miscarriages probably go unnoticed in the general population.
Q. What can be done to improve sperm quality required for ART cycle ?A.
- Spermatogenesis or sperm production cycle takes about 3 months time. Sperm quality on the egg retrieval day is often related to what happened in the male’s body 3 months ago. Listed below is guide lines to help ensure that semen specimen on oocyte pickup day is of best possible quality.
- A fever more than 101°C within 3 months prior to ART treatment may adversely affect sperm quality, sperm count and motility may appear normal, but fertilization may not occur. Body temperature should be maintained below 100o C with medicine during or before ART cycle.
- Keep the use of alcohol or cigarettes to a minimum before and during ART cycle. Do not use any 'recreational' drugs.
- Any other medicine use should be brought into notice of fertility specialist doctor.
- Avoid hot tubs, spas, jacuzzis, or saunas during 3 months prior to ART cycle.
- Avoid heavy exercise, physical activity at a moderate level is acceptable and encouraged.
- Refrain from ejaculation for 2-3 days, but not more than 5 days prior to semen collection on oocyte pick up day.
A. A woman is born with a full complement of eggs. There are far more eggs than will ever be used during a normal life time. IVF procedure have no measurable “lowering” effects.
Q. Is it possible to have a child after tubectomy operation?A.
- Yes, woman can also be a mother after tubal ligation operation. We offer tow procedures for that.
- Tubal Recanalization : This minor surgical procedure is done of outpatient basis with a success rate of about 80%. The other option is
- IVF-ET : In this procedure eggs are fertilized outside the body and resultant embryos are transferred to the uterus , thus bypassing the fallopian tube.
A. Following are the indication for egg donation
- Poor egg quality
- Premature ovarian failure
- Age
- Previous multiple IVF failure
- Genetic cause
In this procedure eggs are retrieved from recipients either known or unknown donor, fertilized with husband’s sperm and resultant embryos are transferred to recipient’s uterus. Success rates are extremely high with this process.
Q. Can couple choose the sex of child prior to IVF ?A. There are methods for determining the sex of a child, one involves the removal of a one cell from the embryo and other involves sperm sorting prior to insemination. Neither of these methods is guaranteed and we discouraged them for any reason other than screening of genetic disease.
Q. How many eggs one can expect from an IVF cycle ?A. The no.of eggs retrieved is related to age, FSH values and ovarian reserve.
Q. What is a day-3 FSH?A. FSH value on 3rd day of menstrual cycle gives an indication of ‘ovarian reserve’. These values gives the information to select the IVF protocol. How much medication is required for stimulation and insight into the potential success rates of IVF.
Q. What are the chances of multiple birth after an IVF or ICSI cycle ?A. A single healthy pregnancy is the goal of any fertility clinic. The multiple birth rate is depend on age, uterine condition, embryo implanted and quality of embryos. In our clinic 30% is twin pregnancy rate and 3% higher order birth rate.
Q. When should one can consider IVF ?A. Following are the indication for IVF consideration.
- Tubal problem
- Male factor
- Endometriosis
- Uterine problems
- Unexplained infertility
- Age
- Previous IUI failure
- Ovulatory problems
- Antibody problems that harm sperm or eggs
- Cervical inhospitality
A. These are the basic five steps of an IVF cycle.
- ovulation induction :- injectables medicines is used to stimulate development of multiple mature follicles
- Egg retrieval : when the follicles are mature, the egg aspiration procedure is performed to remove the eggs. An ultrasound guided vaginal aspiration with special ovum pick up needle is simple and easy procedure.
- Fertilization and embryo culture: sperms are either mixed or injected into an oocyte on various times interval depending upon the maturity of the oocyte. The resultant embryos are cultured for 3 or for 5 days.
- Embryo transfer : with the help of embryo transfer catheter embryos are delicately transferred near the top of the endometrial cavity.
- Pregnancy test : About 11 days after embryo transfer a blood test is done for pregnancy hormone
A. Assisted hatching [AZH] is a form of embryo micro manipulation that involves the creation of an opening in the outer covering called zona pellucid of the embryo. The procedure helps a normal, growing embryo hatch from the covering and implant in the uterus. This procedure increases the implantation rate. This thinning of zona can be done by three different ways chemical hatching, mechanical hatching and the latest is with diode laser technique.
Q. How long one need to take rest after embryo transfer and when couple can have sexual relations ?A. After embryo transfer lying flat in a bed is best. Once can lie on one side or back, whoever is more comfortable. For sexual activities, as such there is no scientific studies done on this subject, but it is okay to resume normal sexual relations after three to four days from transfer.
Q. What is reproductive immunology ?A. Woman’s immune system might react against sperm, preventing fertilization or against an embryo, which either stops the embryo from implanting or rejects the embryo early in pregnancy, resulting in a miscarriage.
Q. What is PGD and who can have it ?A. Preimplantation Genetic Diagnosis [PGD] is a technique that enables individuals with a specific inherited condition in their family to avoid passing on this condition to their children.
In PGD one or two cells from an embryo are removed and tested for he presence of specific faulty gene. Only the embryos free from condition will then be transferred.
A. Estrogen is added to maintain the hormonal balance with in the endometrium. During egg retrieval, estrogen producing cells are aspirated along with the eggs, so there is a tendency estrogen level to drop. If the estrogen level within the endometrium is too low in relative to progesterone level, destabilization of lining can occur to cause bleeding.
Q. Can polyps interfere with implantation ?A. Any anatomical defect within the uterine cavity [polyps, sub mucous fibroids, adhesions or septum] may decrease the chance of pregnancy or increase the risk of miscarriage. The uterine cavity can be evaluated by hysterosalpingogram [HSG] or hysteroscopic – mini surgical procedure, which allows the confirmation of the defect as well as treatment. Uterine polyps are benign [99%] out growths of the endometrial lining. The polyp acting as a “ foreign body” in the cavity may cause chronic irritation and interfere with embryo implantation . Hysteroscopic polyectomy [removal of poly p] improves pregnancy outcome in infertile women and should be considered prior to IVF.
Q. What is PCOS ?A. Polycystic ovarian syndrome is a problem caused by having abnormal levels of certain hormones in woman’s body. In PCOS, ovaria are larger than normal and there are a series of underdeveloped follicles that appear in clumps. If these cysts cause a hormonal imbalance, a pattern of symptoms may develop, which is called syndrome. These symptoms are the difference between suffering from polycystic ovary syndrome and from polycystic ovaries. PCOS is the name given to a metabolic condition in which a woman will have symptoms that reflect imbalances in reproductive and other hormones.
Q. Does male obesity play a role in infertility ?A. Many scientific studies demonstrated a dramatic increase in sperm DNA fragmentation in obese man, leading to the significant reduction in sperm quality. There may be an increase in the miscarriage rate for men with high-level fragmented DNA damage. Increased sperm DNA fragmentation due to oxidative stress may be due to many reasons.
Age more than 50 years, smoking, heat exposure, obesity and environmental toxins. Some of this sperm DNA fragmentation may be reversed. Use of antioxidants may improve sperm count, motility and possibly morphology before an IVF cycle.
A. Hypothyroidism [decreased thyroid function] is more common in woman with symptoms of cold intolerance, weight gain, dry skin, and menstrual irregularities such as menorrhagia [heavy perids] and/or amenorrhea [missed periods] , as well as galactorrhea [breast discharge].
Increased TSH [Thyroid Stimulating Hormone ] production by the pituitary adversely affects the pituitary’s production of FSH [Follicle Stimulaitng hormone], which normally regulates ovarian hormone production thus leading to infertility and / or miscarriages.
Hypothyoridism can be treated with oral thyroid supplementation. If pregnancy occurs, due to increased metabolic demand more supplementation of oral thyroid medicine is require
A. POF is a loss of ovarian function in women under 40 years, when monthly periods stop and estrogen level is low, which causes menopausal symptoms . The cause for POF includes autoimmune conditions or genetics. POF can be permanent, temporary or periodic and there may be residual ovarian function. Some women with POF may intermittently produce estrogen and even ovulate spontaneously or with the help of potent fertility drugs. Doctor will guide the patient about the options for their fertility treatment.
Q. What are the indication for considering donor egg ?A. Following are the reasons for donor egg.
- Age more than 40 years
- High level of FSH hormone
- No ovaries
- Premature ovarian failure
- previous IVF failure
- Benign or malign formation on ovaries [increased level of oncomarker Ca-125]
- Genetic disease
A. WHO [World Health Organization ] has established six semen parameters for semen analysis and there are
- sperm concentration
- morphology
- overall motility
- volume
- viscosity
- total motile count
A. In women with high level of stress may cause disturbances of ovulation, and in men impaired sperm production. Stress reduction will help to cope up with infertility. Suggestion for stress reduction will be open talk partner, exercising regularly , stress relieving activities such as yogo or meditation , avoiding excessive intake of caffeine or other stimulants and to take emotional support from relative or friend.
Q. What is surrogacy ?A. There are two types of surrogacy.
- Classical surrogacy :- It involves the insemination of a surrogate with the sperm of the father to be. The surrogate – contributes here genes to make up of the child, carries baby to term and then gives baby to intended parents after birth.
- Gestational surrogacy :- embryos are created from the egg from the egg donor sperm from father to be, those embryos are transferred to the gestational surrogate.
A. Pre cycle tests are some of blood test, and scanning which can be done at any infertility clinic with minimal discomfort. Once you are already to start the IVF process you have to take few medicines & injections. Injections are administered subcutaneous with a short needle and discomfort should be tolerable. Only progesterone injection given intra muscularly.
The main procedure involved in IVF is the egg retrieval and this is performed through the vagina with ultrasound and a fine needle. Patients at our center are asleep during this procedure and are cared for by a team of anesthesiologists. Patients have no pain with this procedure and they wake up very quicly with the egg retrieval lasting 10-15 mins. The embryo procedure is again a very simple one. A very light anaesthesia is required when there are specific problems with the cervix.
A. There is no question that the whole process of infertility represents a tremendous loss of control over what should be basic function & this causes initially denial then anger & depression. At our center we have trained counselor – you can talk with them during the early stages of your IVF cycle. So that you may best use certain practices & procedures to cope with the stress of assisted reproduction. It is impossible to eliminate stress completely & each of us needs a certain amount of stress in our lives to keep us vital. The important factor is our response to this stress and we need to learn coping strategies which prevent us from reaction in a way that is detrimental to the whole aim of therapy which is to establish and nuture a pregnancy.
Q. What is ovarian reserve? or a biological clock ?A. A female fetus starts out with more than one million immature eggs and this number decreases steadily so that at the time of puberty, there are approximately 200,000 eggs remaining in the ovaries for future ovulation. Many eggs are recruited each month but in a natural cycle only one egg matures. Menopause refers to the time when all viable eggs have been sued up & this generally occurs in the mid to late 40’S, The biological clock therefore refers to the time starting with puberty & ending with the menopause during which the number of eggs decreases steadily. As a women. Approaches menopoause, the ovaries become more resistant to stimulation producing fewer eggs that they did in the years before. For some women this ovarian resistance can start in the 30’s & even occasionally in the teens and early 20’s. There are number of ways of estimating ovarian reserve: the most common is to measure the FSH & LH on the second or third day of the menstrual cycle. An FSH level over 10 suggest the onset of ovarian resistance.
Q. What are the fertility treatment options for women over 40 years of age?A. For women above forty years chances of getting pregnancy by their own egg decrease if the base line FSH is less that 11 miu/ml. Second their embryos need Assisted Hatching too as it will increase the chances of implantation. 3rd and most important women above 40 should go for Pre Implantation Genetic Diagnosis (PGD) as at these age higher percentage of chromosomal abnormalities and mutation in gene observed.
The other simple and best option is 'egg donation' by any younger lady.
A. Endometriosis is a condition where cells that usually remain confined to the cavity of the uterus, grow outside of the uterus usually on or in the ovaries and also on the surface of the pelvic pain and may also decrease the chances of natural conception by about one-third Patients who require IVF who have endometriosis still have the same chances of a successful outcome as patients of the same age without endometriosis as long as immunological factors that may accompany endometriosis are identified and treated appropriately.
Q. Can fibroids interfere with IVF?A. Fibroids are benign tumors consisting of fibrous tissue and muscle which grow in the uterus. The significance of fibroids relates to not only their size but also their location. Even small fibroids located inside the cavity of the uterus where embryos need to implant, may interface with success and need to be removed. Fibroids that do not encroach on the cavity of the uterus are generally not significant unless they are larger than 5 cm in diameter and also if there are many fibroids causing significant uterine enlargement.
