Infertility

The brief details of the procedures is as under

• Ovulation induction: During this period we follow the growth of the follicles and the hormones they produce. If it is a stimulated cycle then a subcutaneous injection of Gonadotrophins administered daily for an average of 10-12 days. Depending on the stimulation protocol used, the duration might be longer and there might be an addition of a second injection for a few days. During the stimulation phase, usually 3-4 sonograms are needed to evaluate the size of the follicles and hormonal levels to evaluate what the follicles produce. The dose of the medications used is accordingly adjusted. When most of the follicles reach 17-20mm in diameter, an injection is administered to mature the oocytes and trigger the ovulation. The oocyte retrieval is scheduled 32-36 hrs later.
• Oocyte retrieval: In stimulated cycles where more than one oocyte needs to be retrieved, under short general anaesthesia the aspiration of the fluid of the follicles is done transvaginally with a hollow needle that is sonographically guided. At the other end of the needle there is a tube that is connected with a suction device that collects the aspirated fluid in specimen bottles. These are handed to the embryologists that identify the oocytes and count them in real time. After the procedure the patient is monitored for 1-2 hrs in order to make sure that everything is ok. Mild pain / discomfort in the lower abdomen can be expected that dissipates during the day.
• Intrauterine insemination (IUI): This entails deposition of washed and capacitated sperm into the uterus at the time of spontaneous or induced ovulation. Several techniques are available for sperm washing such as layering, double spin or density gradients. The success rate with this procedure is in the lower range of 10 – 20% and generally 3 – 6 cycles are generally tried before proceeding to higher ART forms.
• In-vitro fertilization and embryo transfer (IVF-ET): This was called as test tube baby procedure where after controlled ovarian hyperstimulation with gonadotropins and follicles size of 18 mm, hCG is administered and the oocytes are aspirated at 36 hours post hCG (before they rupture) and transfered to the IVF laboratory. Here they are cultured in petri dishes containing culture medium. Subsequently, the oocytes are fertilized with the husband’s sperm after 4 – 6 hours of incubation. Indications for this procedure include tubal block, severe endometriosis and severe PCOD, unexplained infertility and infertility due to any cause refractory to conventional medical and surgical management. Success rates is in range of 30 – 40% per cycle and 3 – 5 cycles are recommended before opting for alternate treatment options.
• Intracytoplasmic sperm injection (ICSI): This technique is better than other methods and is especially indicated for male factor infertility which does not respond to conventional management. Males with severe oligo or asthenosoospermia are can still have their own child with this method. Patients Wife’s oocytes are aspirated and with special microscope with a micromanipulator, a single sperm is picked up in fine microneedle and injected manually into the oocyte. Embryos are transferred after 48 to 72 hours. The success rate is 30 – 40% chance of conception per cycle.
• Oocyte donation: Women who are menopausal or suffering from premature ovarian failure can still become pregnant with donated oocyte. Here, the uterus is prepared for conception with estrogen / progesterone priming. Once suitable oocytes are available, IVF is performed with the husband’s sperm and the embryos transfered to the recipient. Success rate is 60 %.This technique is also of immense value to patients with repeated IVF failures owing to poor ovarian reserve (low AMH or high FSH levels).
• Therapeutic insemination with donor sperm (TID): Patients suffering from severe male factor infertility who cannot afford ICSI or patients with primary testicular failure can opt for donor sperm from a semen bank. The success rate is 25% per cycle.
• Embryo donation: In the event of the wife being menopausal and the husband being azoospermic, the infertile couple can still hope for a pregnancy with embryo donation. The success rate with embryo donation is 70% in the presence of a normal endometrium.
• PGD/PGS (Pre-implantation Genetic Diagnosis/ Screening): The removal of one or more cells (embryo biopsy) from the developing embryo in the laboratory during an IVF cycle in order to do genetic tests. In the case of PGD we test for specific inherited diseases in order to clarify which embryos do not have the disease and only transfer the healthy ones back in the uterus. This is recommended to couples that are known to be carriers of a specific disease. In the case of PGS we screen in order to see which embryos have normal karyotype (number and size of chromosomes). These are the embryos that usually will result in a normal pregnancy. This technique is recommended when we have recurrent implantation failures despite a good number of embryos. The embryo biopsy is done at the day 5 or 6 stage (Blastocyst) and a few cells are removed from the trophectoderm part of the blastocyst, which is the part that is going to form the placenta in the future. Biopsy at the D3 stage or polar body biopsy have been abandoned since they are inferior in accuracy and have been shown to have detrimental effects on the embryos. The main disadvantage of the PGS technique is that it is still very expensive and this is why it is reserved for selected cases.