Gouri Hospital

We offer a wide variety of laboratory techniques to help patients achieve success with assisted reproduction. These include:

• Intrauterine insemination (IUI)
• In vitro fertilization (IVF) with standard insemination
• Intracytoplasmic sperm injection (ICSI)
• Blastocyst culture
• TESA, MESA, PESA and TESE  for male factor
• cryopreservation

IUI: Intrauterine insemination

Intrauterine insemination (IUI) has a long history and is much less “hi-tech” than some other methods of assisted conception. IUI can help couples where the man has a low sperm count or poor motility (the ability of the sperm to move), as long as there are sufficient levels of healthy, motile sperm to make the treatment worthwhile. If not, IVF or ICSI will be more suitable. Because sperm is placed directly inside the woman, IUI can also help couples who are unable to have intercourse because of disability, injury, or difficulties such as premature ejaculation. It is also recommended for women with mild endometriosis, and is often used as the first line of assisted conception treatment for couples with “unexplained infertility”.

The development of the ovarian follicles is monitored with ultrasound .When ovulation has occurred, the male partner is asked to produce a semen sample. This sample is prepared in the laboratory, and is then introduced into the woman’s uterus (womb) by means of a fine catheter, with the aim of getting the sperm nearer to the egg.

Examples of catheters used for IUI

Women usually remain lying down for 5-10 minutes following the procedure. Since the sperm is above the level of the vagina, it will not leak out when she stands up. There are no restrictions on activity following the IUI procedure.

How the IUI procedure is performed.

The amount of motile sperm available for IUI is very important. The chances of success with IUI are best if the total motile sperm count at the time of insemination is > 5 million. If the total motile sperm count is below one million, success rates are very low. Therefore, in vitro fertilization or donor sperm insemination is usually performed for these cases.

Donor insemination can be used in cases where the man is producing no sperm in the ejaculate, or for couples who do not wish to undergo the ICSI procedure.

In vitro fertilization (IVF)

In vitro fertilization (IVF)is the most effective treatment for women with absent, blocked or damaged fallopian tubes. IVF is a major treatment in infertility when other methods of assisted reproductive technology have failed. It is now used to treat a wide range of fertility problems.

Fertility drugs are used to stimulate the ovaries to produce multiple follicles. Each follicle should contain one egg. The chances of pregnancy are increased if more than one egg can be obtained and fertilized. The response to stimulation is monitored by ultrasound scan measuring the number and size of the developing follicles in the ovaries and by measuring the blood oestrogen level. The final preparation for egg collection involves a hormonal injection given to the woman 36-40 hours pre-operatively. This mimics the natural process which triggers the eggs to complete their maturation making them ready for fertilization.

The eggs are collected vaginally using ultrasound guidance, under general or local anaesthesia. After egg collection the eggs are fertilised by sperm outside the womb, in vitro.Embryo transfer is usually done two or three days after egg collection. Even on day five it can be done as desired by the embryologist.

ICSI: Intracytoplasmic sperm injection

Intracytoplasmic sperm injection (ICSI) is an in vitro fertilization procedure in which a single sperm is injected directly into an egg. This procedure is most commonly used to overcome male infertility problems, although it may also be used where eggs cannot easily be penetrated by sperm, and occasionally as a method of in vitro fertilization, especially that associated with sperm donation.

Couples go through the same preparatory processes as with IVF, namely ovulation induction and egg collection. Under high-power magnification, a glass tool (holding pipette) is used to hold an egg in place. A microscopic glass tube containing sperm (injection pipette) is used to penetrate and deposit one sperm into the egg. After culturing in the laboratory overnight, eggs are checked for evidence of fertilization. After incubation, the eggs that have been successfully fertilized (zygotes) or have had 3 to 5 days to further develop (zygotes or blastocysts) are selected. Two to three are placed in the uterus using a thin flexible tube (catheter) that is inserted through the cervix. The remaining embryos may be frozen (cryopreserved) for future attempts.

ICSI.

STAGES OF EMBRYO DEVELOPMENT

Day of egg retrieval. Motile sperms are selected by the swim-up procedure for IVF or ICSI.

An egg shortly after retrieval

A mature egg without its ‘cumulus’ cells.

ICSI

A fertilised egg displaying male and female ‘pronuclei’

A 4 Cell Embryo on day 2

A 8 Cell Embryo on day 3

Morula stage on day 4

Blastocyst on day 5

Blastocyst embryo starting to hatch from its shell on day 6

A healthy blastocyst will implant within about one to two days following IVF transfer, very soon after blastocyst hatching.

Testicular Biopsy:

Among one of the most common male infertility tests that examine the underlying causes of fertility problems is the testicular biopsy. This fertility test involves the removal of testicular tissue in order to analyze any abnormalities that may be causing infertility. Sperm is produced in the testicles, and any testicular abnormalities can seriously affect male fertility.

The following are some fertility complications that may be identified by a testicular biopsy:

• The absence of cells needed to produce sperm maturity
• Hypospermatogenesis (the production of abnormally low numbers of sperm)
• Germinal cell aplasia (lack of germ cells that enable sperm production)
• Evidence of previous testicular infection
• Abnormalities of Leydig cells

A testicular biopsy involves a small surgical procedure that takes place while a patient is under light sedation. This involves the insertion of a small needle into the testis in order to obtain a small sample of tissue. The procedure can take between fifteen minutes to a half an hour. The tissue that is extracted is then prepared for laboratory analysis to determine the presence of sperm. This sperm can then be used in infertility treatments usingassisted reproductive techniques (ART). More specifically, the sperm retrieved can be injected into an egg for fertilisation using intracytoplasmic sperm injection (ICSI) or in vitro fertilisation (IVF). The retrieved sperm can be stored and frozen for later use.

Cryopreservation:

Cryopreservation refers to the storage of a living organism at ultra- low-temperature such that it can be revived and restored to the same living state as before it was stored.

Embryo Cryopreservation (Freezing): Embryo cryopreservation (the process of freezing, storage and thawing embryos) can enhance pregnancy rates by allowing excess embryos not replaced in a fresh embryo transfer to be stored for future use.

Embryo freezing may also be performed when a fresh embryo transfer is not performed for any of the following reasons: (1) Risk of ovarian hyperstimulation syndrome (OHSS), (2) Poor quality endometrium (a thin uterine lining), (3) Intermenstrual bleeding, (4) Planned “banking” cycle in which the patient elects to store all embryos, (5) Extremely difficult embryo transfer.

Embryos are placed into straws or vials containing anti-freeze or cryoprotectant solutions. These are transferred to a programmable biological freezer which is used to achieve a controlled slow rate of cooling. During cooling, cells dehydrate and as the temperature is reduced, more ice forms and water is removed gradually from the cells. Slow cooling is continued to ~ -35°C at which point embryos are rapidly cooled by plunging into liquid nitrogen (-196°C). Embryos are kept in storage tanks of liquid nitrogen until thawing is performed.

Vitrification:

Vitrification in IVF can allow freezing of spare embryos with better post-thaw survival rates and higher pregnancy and live birth rates from the frozen embryo transfer cycles. We started vitrification of embryos in our IVF lab and have seen excellent post-thaw embryo survival and high pregnancy rates after frozen embryo transfer procedures.

Semen Cryopreservation

Semen freezing is useful for men who find it difficult to ejaculate on demand which may result in their inability to produce a sample on the day of egg collection.

Sperm from two sources can be frozen: from ejaculates or from fluid extracted in the operating room during surgical procedures (vasal, epididymal and testicular sperm specimens). The sperm is usually frozen for a period of one year; at that time, future arrangements are discussed. It is generally believed that sperm that have been through the freeze-thaw process are no more likely to result in birth defects than freshly ejaculated sperm.

REASONS FOR INFERTILITY

The term infertility is defined as the inability to conceive despite regular and unprotected intercourse for 1 year. However, risk factors such as the woman’s age, abnormal menstrual periods, history of pelvic inflammatory disease and whether there has been previous abdominal or pelvic surgery, history of undescended testicles may warrant earlier investigations and treatment of infertility. It has been found that female factors are responsible in 40% of cases, male factors account for a further 40%, combined male and female factors account for 10% and the remaining 10% of cases are unexplained.

Infertility is classified into two types:

• Primary infertility if there was no previous pregnancy (approximately 40% of infertile couples).
• Secondary infertility if there was a previous pregnancy whatever the outcome (approximately 60% of infertile couples).

Male Factor Infertility

The treatment of male factor infertility is one of the true success stories in the field of reproductive medicine. Male fertility screening is done through semen analysis. Disorders of sperm quality range from a low count or motility to a complete absence of sperm production. Deformities of the sperm cell shape (morphology) are also important to its ability to fertilize the egg. Mild abnormalities of semen parameters can be effectively treated using techniques that “wash” out the seminal plasma and improve the concentration of normally shaped motile sperm, which are then transferred to the uterus via an intrauterine insemination. However, for more severe conditions this treatment is inadequate. With a total motile cell concentration of less than 10 million cells per ml or a normal morphology of less than 4% by strict Kruger criteria, the chance of fertilization failure is very high, even with IVF. As a general principle, if the male factor cannot be reversed in the man’s body, by simple medical or surgical treatment, then IVF with ICSI represents the only rational approach, the results are excellent. Intrauterine insemination is not an effective way of treating mild to moderate male infertility.

Factors affecting sperm production

The most common causes of low sperm count are temporary and treatable. Research has shown that emotional or physical stress, cigarette smoking or heavy alcohol consumption can affect sperm production and male fertility. Sperm counts usually return to normal levels after such lifestyle issues are addressed. Certain drugs, radiation and radiotherapy may have a detrimental effect on the production of sperm. The presence of a varicocele may lead to a rise in the temperature around the testicles, which may adversely affect sperm production and motility. Testosterone deficiencies and certain autoimmune disorders that cause the body’s defenses to attack developing sperm.

Female Factor Infertility

A woman usually produces a single follicle in the ovaries each month as a result of various hormonal changes. Once the egg which develops within the follicle is mature, it is released. The fallopian tube subsequently picks the egg up and moves it towards the uterus. The quality of cervical mucus at the time of ovulation must be such that it allows free passage of the sperm into the uterus.

There are many different types of infertility experienced by women. Many of the fertility problems can be easily treated. Some of the most common causes of female infertility include tubal blockage, polycystic ovarian syndrome, fibroids and endometriosis. However, there are several other reasons why a woman may experience fertility problems, such as ovulatory disorders (like an ovulation), premature ovarian failure and uterine factors. Egg quality also plays a role in infertility in many women.

The female reproductive system is a very delicate structure that is easily affected by even the slightest change in your body. Because of this, it can be dangerous to alter the system too much. Menstrual suppression, for example, can potentially lead to infertility. Maintaining your health can also help you avoid some infertility risks, like luteal phase defect.

Women with eating disorders find it very difficult to conceive. Anorexics often stop menstruating, making pregnancy impossible until the eating disorder is corrected. Alternately, plus-sized women can also find themselves dealing with various fertility issues.

Age and Fertility

Delayed child bearing is becoming increasingly common in western societies for several reasons: many couples prefer to rear their children only after establishing a stable relationship and financial security, also, there are increasing numbers of late and second marriages.

Although pregnancies in women approaching 50 and beyond are occasionally reported, there is a decrease in fertility (the ability to achieve a pregnancy) with advancing age. The decline is gradual over the reproductive life span of the woman; it is particularly noticeable over the age of 30 and accelerates between 35 and 40 so that fertility is almost zero by the age 45.

A fertilized egg with abnormal chromosomes is the single most common cause of miscarriage: at least half of all miscarriages are due to abnormal chromosomes. The risk of miscarriage is also increased with ageing e.g. the risk of miscarriage at age 25-29 years is 10% while the risk at age 40-44 is 34%. Furthermore, advanced maternal age is associated with an increased risk of chromosomally abnormal offspring.

Unexplained Infertility

Unexplained Infertility, cases in which the standard infertility testing has not found a cause for the failure to conceive. Unexplained infertility affects 10% of infertile couples. In the majority of these cases, the failure to reach a diagnosis is not due to inadequate investigations, but is probably due to other factors which cannot be assessed using conventional tests. For example, it is not currently possible to determine if the eggs are actually released at the time of supposed ovulation; if the fallopian tubes are able to pick up the eggs; if the sperm are capable of reaching the site of fertilization; or if the eggs can be fertilized by the sperm.

Diagnosing unexplained infertility is by no means an easy process. It tends to be a diagnosis based on exclusion. Your reproductive endocrinologist will examine you and perform a variety of tests to try to determine exactly what is going on. You may be said to have unexplained fertility if:

· you are ovulating normally

· your fallopian tubes are open and healthy

· you have no pelvic adhesions

· you do not have endometriosis

· your partner has a high sperm count and good sperm motility

· your postcoital test is positive

Q1. Is there help for the couple with a Male Infertility Factor ?

Q2. What is ICSI ?

Q3. What are PESA, MESA & TESE?

Q1. Is there help for the couple with a Male Infertility Factor ?

Yes, sometimes low sperm counts or poor sperm motility requires extra help to fertilise the oocyte (egg). A procedure called ICSI ( Intracytoplasmic Sperm – Injection) overcomes these severe Male Infertility factors.

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Q2. What is ICSI ?

In the lab, the embryologist performs the procedure by capturing an individual sperm cell & injecting it into the mature egg by means of a small pipette with the help of a sophisticated machine
called micromanipulator.

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Q3. What are PESA, MESA & TESE?

These are various sperm collecting techniques to collect sperm from men with azospermia but where sperm is being formed. These are collected from testes or tubes depending upon case to case. These can be successfully used with the technique of ICSI.

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DONOR-EGGS

Q1. Who needs to consider using an egg-donor?

Women who experience problems that lead to depletion of quality oocytes
(eggs) may need to consider an egg donor to assist in getting pregnant. Premature menopause, surgical removal of both ovaries or individuals over 40 who have failed to conceive despite appropriate fertility treatments are the most common individuals seeking an egg donor. Usually this is an anonymous process where the eggs are removed from the donor, fertilisation is allowed to occur & the resulting embryos are then transferred into the recepient’s uterus. Success rates are extremely high with this process.

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Q2. Who can donate the Ova?

Any young healthy woman less than 35yrs of age can donate eggs. She should be preferably from within the family of the patient & with preferably complete family. No matching is required. She can donate eggs even if a sterlisation operation has been performed on her.

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Q1. What is In Vitro Fertilisation (IVF)?

Q2. What is the success rate of IVF?

Q3. Any risks involved in IVF ?

Q4. How long does it take for one attempt of IVF & is hospitalisation essential during any stage of treatment?

Q5. How are eggs collected?

Q6. When is Semen sample required for Fertilisation?

Q7. When & how is embryo transfer (ET) done?

Q8. When & how is pregnancy confirmed?

Q9. What can be done with Spare embryos?

Q1. What is In Vitro Fertilisation (IVF)?

For patients with irreparably damaged fallopian tubes profound oligospermia (Low Sperm counts )or failure to conceive after adequate attempts of intrauterine insemmination, In Vitro Fertilasationhas become the treatment of choice. The technology involves incubating the oocytes(eggs) & sperm in the laboratory
& allowing the resulting embryo (s) to develop for a number of days prior to transferring them into the endometrial cavity (uterus).

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Q2. What is the success rate of IVF?

In the 1980’s pregnancy rates for IVF were relatively low, approx 15%. As the nutrition requirements for the embryo growth within the Laboratory became better understood, conception rates began to increase. As we head into the new millenium, anticipated pregnancy rates for many patients may exceed 50 percent.

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Q 3. Any risks involved in IVF ?

Increased emotional stress because of high cost & time consuming with success rate of 40%. Risks of multiple pregnancies & hyperstimulationsyndrome are all increased.

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Q4. How long does it take for one attempt of IVF & is hospitalisation essential during any stage of treatment?

Patient needs to be in constant touch with the IVF center for about one and a half month from starting medication upto the result of IVF. Out of this period active treatment takes ten to fifteen days during which patient has to visit the IVF Lab. No hospitalizations essential during the treatment cycle.

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Q5. How are eggs collected?

Prior to collection of eggs, patient is given medication in the form of daily injections starting from day 2 of menstrual cycle & response to these injections is monitored with frequent blood tests & Vaginal ultrasound. Eggs are retrieved from the ovaries by a needle with the help of transvaginal sonography guidance. It is done under mild anaesthesia & is a day care procedure. It is done 32-36 hours after
final hormone injection.

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Q6. When is Semen sample required for Fertilization?

Semen is required soon after collecting the eggs. A fresh semen sample is preferred. However if difficulty is anticipated in semen collection, the problem is sorted out in consultation with embryologist by cryofreezing the sample in advance.

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Q7. When & how is embryo transfer (ET)
done?

Embryo transfer is usually done two or three days after egg collection. Even on day five it can be done as desired by the embryologist. Normally no more than 3embryos are transferred into the uterine
cavity by a special catheter. Patient is advised to rest for a few hours.

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Q8. When & how is pregnancy confirmed?

Following ET patient is given Progesterone (hormone) Support & asked to get a blood test done 14 days after E.T. to confirm pregnancy.

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Q9. What can be done with Spare embryos?

The spare embryos can be frozen& these cryopreserved embryos can be used in subsequent cycles & patient need not take the injections for egg
formation.

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Q1. How long should a couple attemptto conceive before seeking advice from an Infertility Specialist?

Q2. How can I tell if I am infertile & how can I determine the cause of infertility?

Q3. What other diagnostic tests can be carried out?

Q4. What is the role of Endoscopy in Infertility?

Q5. Any measures to be adopted to improve the chances of a successful pregnancy?

Q6. Are miscarriages common following Infertility Treatment?

Q1.How long should a couple attempt to conceive before seeking advice from an Infertility Specialist?

For couples who have recently discontinued contraception, the average monthly pregnancy rate approximates 20%. For a typical couple, this means that 50% conceive within 6months and another 30-40% conceivein the subsequent 6months. It becomes increasingly difficult to conceive spontaneously after 12 months of unsuccessful attempt. Therefore, infertility specialists recommend evaluation after 12 months of attempted conception. We also recommend evaluation after 6months inpatients over 35 due to concerns related to an age-related decline in fertility.

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Q2. How can I tell if I am infertile & how can I determine the cause of infertility?

By definition, infertility is the inability to conceive after 12 months of unprotected intercourse. Primarily there are three tests necessary to determine the cause. Initially, the husband has a semen analysis to make certain that there is adequate number of sperm.

The second test is to document ovulation is occurring in the woman by an Endometrial Biopsy or having a simple hormone test, progesterone done one week prior to the next anticipated menses.

Provided both of these are normal, the next test involves an X-Ray. A hysterosalpingogram (HSG) is performed to document that the fallopian tubes are open & to make sure the uterine lining is compatible for embryo attachment. Dye is injected through the cervix into the uterine cavity.

Eventually the dye goes into the fallopian tubes & should flow out through the end of the tubes. This documents that sperm are able to get to the fallopian tubes where fertilization normally occurs & that the egg can be captured by the fallopian tube. These three tests are the cornerstones to infertility evaluation.

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Q3. What other diagnostic tests can be carried out?

Besides the three basic tests – a Vaginal Sonographyis carried out to check the ovaries & the endometrial
lining & any fibroids in uterus or cysts in the ovary are seen. Hormonal Analysis (Day 2 FSH, LH, Prolactin, TSH, E2 ) are also done. Laparoscopy & hysteroscopy are also donewhere indicated.

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Q4. What is the role of Endoscopy in Infertility?

A Laparoscopy is particularly helpful in diagnosing & effectively treating endometriosis or pelvic adhesions(scar issue). The incisions for the procedures are small one fourth or half an inch & full recovery is often achievedin a day or two. Most importantly , in individuals with either of these conditions, a laparoscopy can dramatically improved the chances of conception.

Hysteroscopy is used to inspect the cavity of uterus via cervix using a fine telescope called a hysteroscope.
Hysteroscopy is an investigation to assess the conditionof the endometrium( Lining of the uterus) before IVF.

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Q5. Any measures to be adopted to improve the chances of a successful pregnancy?

Avoid extra stress from overwork mental or physical. Both Smoking and alcohol can be harmful to eggs & sperm. Even exposure to passive smoking results in more problems with Infertility. Men can also stay away from heat emitting areas, wear loose under garments& avoid chemical exposure.

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Q6. Are miscarriages common following Infertility Treatment?

No, Infertile women who conceive after fertility treatment have a similar risk of miscarriage when compared to fertile couples. The overall risk of miscarriage is approximately 20% among the general population.

Women who experience bleeding in the first three months of pregnancy however, may be at increased risk of miscarriage. Despite this ,at least two- thirds of patients with bleeding will deliver normally.

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Q7. Is it possible to get pregnant if I’ve had a tubal sterilization?

While this is considered a ‘permanent ‘ form of contraception, patients do have the option of surgically reuniting the fallopian tubes through a process called a microscopic tubalreanastomosis. An alternative to the procedure would be In Vitro Fertilisation (IVF), where the eggs are fertilised outsidethe body with the resulting conception placed into the uterus.

The choice for an individual would require a consultation to consider all other fertility factors.

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1. What is infertility?

2. How Common is this problem?

3. Who is at fault, Male of Female?

4. Do this condition have treatment?

5. What problems in women cause infertility?

6. What causes Male infertility?

7. Do we have a Solution for all these problems?

8. If the fallopian tubes are badly damaged, what can be done?

9. If the Male has Azoospermia , then what?

1. What is infertility?

Infertility is defined as inability to conceive after 1 year of unprotected intercourse. But when the woman is more than 35 years it is better to investigate after 6 months.

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2. How Common is this problem?

About 15% of patients who attend a Gynecologist’s outpatient has this problem.

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3. Who is at fault, Male of Female?

In about 40% cases male & another 40% female are at fault. About 20% cases either both are at fault or there is no reason at all. (What we call as unexplained infertility).

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4. Do this condition have treatment?

Yes, Of Course. The couple should contact the family doctor who can refer them to specialists who practice in this field.

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5. What problems in women cause infertility?

• Uterine defects like adhesions in the cavity of uterus, fibroids, some birth defects like Septate uterus can cause infertility.  One important Cause in India is TUBERCULOSIS which can damage the uterine lining and fallopian tubes.
• Fallopian tubes may be blocked or may not function due to infections, endometriosis or prior surgery of pelvis.
• Ovaries may not ovulate or may have infrequent ovulation.
• Cervical mucus defects might lead to prevention of sperms from swimming through it to the cavity of uterus.

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6. What causes Male infertility?

• Impotence – Inability to consummate the sexual intercourse.
• Premature Ejaculation – wherein the male partner is unable to deposit the semen high up in the vagina.
• Low Sperm Count- (Less than 20 million per ml), low sperm motility, infections in semen (oligo- asthenospermia).
• Total absence of sperm called Azoospermia.

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7. Do we have a Solution for all these problems?

Most of them can be treated. Initial investigations in some of these conditions are expensive and once the cause is found, Solution is there.

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8. If the fallopian tubes are badly damaged, what can be done?

We do a Laparoscopy to find out the extend of damage whether it can be repaired. If it is an irreversible damage as in the case of tuberculosis we have to resort to TEST TUBE PREGNANCY.

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9. If the Male has Azoospermia , then what?

• There are facilities for donor insemination program.
• In some cases ART Might help.

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