Fertility

Diagnostic Services For Infertility

Hysterosalpingography : This is done to check the patency of the tubes as well as get an idea of the uterine cavity. Around the 6th to 8th day postmenstrual day a dye is inserted in the uterine cavity with the help of a cannula. Then X ray pictures are taken and spill of the dye through patent tubes is recorded on X ray.

Saline infusion sonography. Similar procedure can be done with introduction of saline into uterine cavity and visualization through ultrasound. The flow of saline is noted.
Laparoscopy and chromopertubation : This is done under general anesthesia and a laparoscope connected to a camera can visualize the tubes. A dye is passed through the uterus and its spill is noted from the tubal opening.

Transvaginal sonography This is an ultrasound done through the vagina to assess the uterus tubes and adnexa. It is done after emptying the bladder. The ultrasound probe is introduced into the vagina. Uterus and ovaries are visualized for any pathology. Growth of the follicle is noted.

Semen analysis

It is an important part of assessment of the male. We do an advanced semen analysis where we measure the count, motility and morphology. The semen is given by the male partner and tested immediately. We have in house facilities of a separate semen collection room. Semen analysis is the first and basic test of the male. It not only tells us about the quantity of the sperm but also about the quality and fertilizing potential.

Evaluation of male patient

Male infertility is dealt with in a specialized way. All men have the facility of advanced semen analysis. The causes of male infertility could be testicular, pretesticular, or post testicular. A complete hormonal assessment is done where needed. A genetic analysis may be needed in patients with extremely low sperm counts. In cases of azospermia (absent sperms) testicular or epidydimal sperm extraction can be done and an ICSI performed. See section on TESA, PESA for azoospermia.

Hormonal tests

Various hormones tell us about the status of the ovaries. This includes follicle stimulating hormone, lutienizing hormone, thyroid, prolactin, AMH. All these hormones are done at a single place.

3D ultrasonography

Conventional sonography provides two-dimensional views of three-dimensional structures The obvious advantages are that 3D ultrasound offers more rapid and reproducible image acquisition as well as enhanced visualization and post-processing capabilities. Its main applications include assessment of uterine congenital anomalies, intrauterine pathology, tubal patency, polycystic ovaries, ovarian follicular monitoring and endometrial receptivity.

It provides accurate measurement of organ dimensions and volumes, improved anatomic and blood flow information, improved assessment of complex anatomic anomalies, a better specificity in regard to the confirmation of normality and standardisation of the sonographic examination procedure

Ovulation induction and follicular monitoring

It is done transvaginally and involves series of ultrasounds to see growth of the follicles and endometrium. It helps in identifying the time when egg is mature in order to do IUI or egg retrieval in IVF. It involves process of serial ultrasonic monitoring of the ovarian follicles that helps in identifying egg maturation status as well as is used for determination of uterine lining thickness. For women under fertility medication, follicle monitoring assists in assessing response to treatment and in making adjustment to the fertility medication dosage during treatment in event of seeing inadequate response.

IUI: Intrauterine Insemination

Intrauterine insemination (IUI), also known as artificial insemination, is a fertility procedure in which sperm are washed, concentrated, and injected directly into a woman's uterus. The most common indications for IUI are cervical mucus abnormalities, low sperm count, low sperm motility, increased sperm viscosity or antisperm antibodies, unexplained infertility, and the need to use frozen donor sperm. In natural intercourse, only a fraction of the sperm make it past the woman's cervical mucus into the uterus. IUI increases the number of sperm in the fallopian tubes, where fertilization takes place.

Studies show that IUI, or artificial insemination, is most successful when it is coupled with fertility drugs that recruit multiple follicles. This technique often is called controlled ovarian stimulation and IUI.

IUI sometimes is recommended for couples with unspecified infertility who have been trying to have a baby for six to 12 months. You should have a thorough infertility evaluation before trying IUI.

Male Partner Requirements for IUI

IUI relies on the natural ability of sperm to fertilize an egg in the fallopian tubes. Studies show that IUI will not be effective in cases where the male has low sperm counts or poor sperm shape (also known as sperm morphology). Sperm tests are required, therefore, in order to indicate:

  • Sperm count (number of sperm per cc)
  • Sperm motility (percentage of sperm moving)
  • Sperm morphology (shape)

Female Patient Requirements for IUI

The patient should have normal day 3 blood test results, open fallopian tubes, and a normal uterine cavity.

Women with ovulatory disorders can be candidates for IUI if they respond adequately to fertility drugs. In these cases, hormone treatments stimulate follicle growth and the IUI is timed to take place after ovulation is induced. Hormone treatments are usually used even for women without an ovulatory disorder.

Women with mild endometriosis may benefit from IUI if they do not have a distortion of the pelvic structures.

Women with severely damaged or blocked fallopian tubes are not candidates for IUI.

Washed and Concentrated Sperms are injected into uterus Directly
In Vitro Fertilization (IVF) Treatment

The technique of IVF consists of bringing about the fertilization of the oocyte and the spermatozoa in the laboratory instead of in the woman’s fallopian tube. IVF involves induction of ovulation in order to obtain multiple oocytes, thus making available more embryos with which higher pregnancy rates can be achieved. Serial determination of plasma estradiol levels and daily monitoring of ovarian follicular growth by ultrasonography would indicate the response to ovarian stimulation. At the appropriate moment of follicular growth, the follicles are aspirated to obtain the oocytes. The oocytes are mixed with appropriately capacitated spermatozoa from the husband (or the donor, if the medical condition indicates the use of donor sperm) and is kept in an incubator for fertilization which is observed microscopically after 16 to 18 hours. Embryos are transferred into the uterine cavity between days 2 to 6 after oocyte aspiration. If implantation ensues, pregnancy can be confirmed by 14 to 16 days after embryo transfer by determining the presence of hCG in a blood or urine sample.

Common indications:

Blocked or absent fallopian tubes– Fertilisation of the egg occurs on its journey through the fallopian tube so if the tubes are blocked or absent, this process cannot occur.

Endometriosis – This is when the lining of the womb can be found covering other pelvic structures such as the ovaries, pelvic ligaments, peritoneum (lining of the pelvis), bowel, and bladder. This causes irritation and inflammation which can lead to scarring. It is also associated with infertility, although the reasons for this are not fully understood.

Irregular ovulation – For ovulation to occur, part of the brain prompts the pituitary gland to secrete hormones for the ovaries to ripen eggs during the menstrual cycle. If the menstrual cycle does not occur or is irregular, ovulation may also be irregular or absent.

Low sperm count or motility –, If there are not enough sperm released in the semen or the sperm that are released are not motile enough to make it to the woman’s reproductive system, conception is not possible.

Unexplained Infertility – In some cases, after all investigations have been completed, no medical reason is found to explain the inability to conceive

Intracytoplasmic Sperm Injection (ICSI) Treatment

Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technology (ART) used to treat sperm related infertility problems. ICSI is used to enhance the fertilization phase of in vitro fertilization (IVF) by injecting a single sperm into a mature egg. The fertilized egg is then placed in a woman’s uterus or fallopian tube.

i) Intracytoplasmic sperm injection (ICSI) is used to treat severe male infertility, as when little or no sperm are ejaculated in the semen. Immature sperm collected from the testicles are usually unable to move about and are more likely to fertilize an egg through ICSI.

ii) Some couples may choose to try ICSI after repeated in vitro fertilization has been unsuccessful.

iii)ICSI is also used for couples who are planning to have genetic testing of the embryo to check for certain genetic disorders. ICSI uses only one sperm for each egg. So there is no chance the genetic test can be contaminated by other sperm.

BLASTOCYST TRANSFER

This technique involves culture of embryos to day 5 in the incubators, using special media, to provide the required nutrients for growth outside urerus. The purpose of culturing is to witness the possible in uterus growth events in the lab and ensure that the embryos are capable of further growth once transferred within the uterus. It also helps filter out those embryos which may be genetically incompetent to grow in uterus. However it cannot be universally applied as not all embryos thus grown reach blastocyst stage and they also have a high potential to get arrested. The lab must have an existing good implantation rate to be able to get success out of this procedure. The media and culture conditions must also be optimal. Some clinical studies have experienced blastocyst rates of 40-65 % and an implantation rate of about the same. Another advantage is that multiple pregnancies can be avoided by transferring a single blastocyst.

However in some cases we do sequential transfers -2 embryo transfer (day2 and day 5) in order to avoid denial of an embryo transfer relying only on blastocysts. This procedure also has its indications and with newer media emerging it may prove to be more effective in the coming years.

    The benefits of doing a blastocyst transfer are:

  • Higher pregnancy rates, as embryos that developed into blastocysts less likely to be abnormal
  • Selecting the ‘toughest’ embryos that managed to survive outside the body for 5 days
  • Avoiding multiple pregnancies like triplets as fertility doctors only transfer no more than two blastocysts.
Treatment of Male Infertility

Male infertility is usually caused by problems that affect either sperm production or sperm transport. Through medical testing,we may be able to find the cause of the problem. About two-thirds of infertile men have a problem with making sperm in the testes. Either low numbers of sperm are made and/or the sperm that are made do not work properly.

Sperm transport problems are found in about one in every five infertile men, including men who have had a vasectomy but now wish to have more children. Blockages (often referred to as obstructions) in the tubes leading sperm away from the testes to the penis can cause a complete lack of sperm in the ejaculated semen.

Less common causes of infertility include: sexual problems - partners difficulty enter the woman’s vagina for fertilisation to take place; low levels of hormones made in the pituitary gland that act on the testes; and sperm antibodie. In most men sperm antibodies will not affect the chance of a pregnancy but in some men sperm antibodies reduce fertility.

Diagnosis can involve a medical history from the man to find out whether there are any obvious health problems that could affect fertility.

A physical examination is done, along with a semen analysis to check the number, movement and shape of the sperm in the ejaculate.

Blood tests may also be done to check the hormone levels that control sperm production.

Genetic investigations to test for chromosomal anaomalies or Y chromosome microdeletion.

Male infertility treatment options include
  • 1. Surgery
  • 2. Medication
  • 3. Hormone treatment
    Two of the most common treatments include
  • 1. Intrauterine insemination (IUI)
  • 2.Intracytoplasmic sperm Injection
TESA/PESA

PESA (Percutaneous Epidydimal Sperm Aspiration) and TESA (Testicular Sperm Aspiration)

PESA (Percutaneous Epidydimal Sperm Aspiration) and TESA (Testicular Sperm Aspiration) are procedures that are performed to obtain sperm in certain cases of male infertility. PESA or TESA can be performed on men that have zero sperm counts due to either a sperm production problem or a blockage in their reproductive tract, such as the result of a vasectomy, congenital absence of vas deferens, or infection.

A. Percutaneous epididymal sperm aspiration (PESA) is a technique used to extract sperms in the event of a possible blockage of the vas deferens. A small needle is inserted through the skin of the scrotum to collect sperm from the epididymis, where sperm are usually stored after production in the testes. It can also be used to extract sperm for Intracytoplasmic Sperm Injection (ICSI).

    PROCEDURE
  • PESA is carried out under local anaesthetic.
  • A fine needle will be inserted into the epididymis. Sperm can then be removed with gentle suction.
  • Mild painkiller may be administered to the patients, in case of any discomfort after the procedure.


B. TESTICULAR SPERM ASPIRATION (TESA)
TESA or testicular sperm aspiration is one of the surgical sperm harvesting techniques used for retrieving sperm in patients. A number of surgical sperm retrieval or recovery methods have been devised to recover sperm from the male reproductive tract.

    Procedure
  • A needle biopsy of the testicle is done as an office procedure using local anaesthesia
  • A small incision is made in the scrotal skin and then a spring loaded needle is gently inserted into the testicle.
  • The amount of tissue obtained is low because the thin needle removes only a thin sliver to tissue.

    Indications
    Indications of ICSI with testicular spermatozoa (TESA)
  • Extensive scarring, rendering MESA/PESA impossible.
  • Germ-cell hypoplasia (hypospermatogenesis).
  • Germ-cell aplasia with focal spermatogenesis.
  • Sertoli cell-only syndrome with focal spermatogenesis
  • Frozen Embryo Replacement Cycle (FERC)

If the cycle has produced more than two (or three) good quality embryos, those that aren’t transferred, may be frozen for future use. These embryos will be frozen at extremely low temperature (-180°C), which ensures that they do not deteriorate over the number of years they are stored.

In a Frozen Embryo Transfer Cycle, the woman takes medications to prepare her womb to receive these embryos. The advantage of frozen embryo implantation treatment is that there is no need to use hormone injections to stimulate the ovaries.

An ultrasound scan is performed to assess the lining of the uterus to determine whether it is ready to receive the embryo. Once the lining is ready, embryos are thawed and transferred.

Vitrification, frozen embryo transfer

Vitrification

In case there are more number of embryos formed they can be preserved and used in the next cycle. The preservation is done by a rapid freezing (cooling) technique where they are stored at -180 degrees C in liquid nitrogen. They are well preserved for years and can be used in the next cycle if the first is unsuccessful or for another pregnancy. This also brings down the cost as injections for stimulation of ovary are not used in a frozen cycle.

Frozen Embryo Transfer Cycle (FET)

All the surplus embryos are Cryopreserved by Vitrification. These embryos will be frozen at extremely low temperature (-180°C), which ensures that they do not deteriorate over the number of years they are stored. These are then in subsequent cycle deposited in the uterus. Frozen Embryo cycle is a much easier cycle on the patient as she does not need to take any medication for production of eggs, she only needs to take much lighter medicines to prepare the uterus. An ultrasound scan is performed to assess the lining of the uterus to determine whether it is ready to receive the embryo. Once the lining is ready, embryos are thawed and transferred.There is no egg retrieval procedure and, the thawed embryos are transplanted into her uterus.

DONOR PROGRAMME

Our centre offers the following donor programmes to fulfill the needs of the couple.

Therapeutic Donor Insemination ( TDI )

All our donors undergo mandatory screening for viruses and samples are adequately matched to suit the couple.

Donor Oocyte Programme ( DOP )

We procure oocytes from female donors who are deemed fit and have no identifiable disorders. Sometimes donors are also the patients undergoing ART who wish to opt for the egg sharing programme either for monetary or humanitarian purpose.

Donor embryo programme

We offer donor embryos for those couples who are unable to use their own gametes owing to genetic conditions or incompatibility, repeated failures with own and with combined female and male factor infertility. Couples who have become pregnant and donate their frozen embryo straws are also part of the source of these embryos.

Laparoscopy and Hysteroscopy Surgery
Diagnostic hysteroscopy and laparoscopy

This is a diagnostic process to find out the exact condition of the uterus, tubes and surrounding structures. This is done with the help of a telescope. The telescope is inserted into the abdomen through the belly button by a very small cut. The hysteroscope is inserted into the uterus through the neck of the womb, which is called the cervix. It is done under general anesthesia.

This is good method of diagnosis as no other investigative tool (ultrasound, hysterosalpingogram) gives a clearer view than this endoscopic method. These endoscopic techniques can be used to correct underlying disorders that can hamper the possibility of a pregnancy, like, ovarian cyst, endometriosis, adhesions (scar tissue) in the abdomen hampering tubal function, uterine fibroid, polyp or scar tissue.

Tubal reanastomosis

Many women who undergo tubal ligation surgery later choose to have children again. One option available to these women is tubal ligation reversal, or tubal reanastomosis. It is done under laparoscopic guidance in cases of tubal blockage. The healthy length of tube is assessed. It should be at least 4-5 cm. A reanastomosis is done laparoscopically. Success rates are dependent on method of ligation and length of healthy tube left.

Recurrent pregnancy loss, PCOS, endometriosis
Recurrent pregnancy loss

RPL is classically defined as the occurrence of three or more consecutive losses of clinically recognized pregnancies prior to the 20th week of gestation. These patients require a thorough investigation before they go in for another pregnancy. Recurrent losses can be because of uterine anomalies, immunological factors like antiphospholipid syndrome, endocrinal factors and genetic defects. All the above need to be investigated and analysed. Specialized early pregnancy care is required which we give our patients to ensure a safe pregnancy.

PCOS
Polycystic Ovary Syndrome clinic focuses on the total health care needs of the patient with PCOS.

Frequent symptoms of PCOS include:
  • Irregular or absent menstrual cycles (“oligo-ovulation” or “anovulation”)
  • Increased dark hair growth on the face, chest or abdomen (“hirsutism”) or male-patterned baldness
  • Acne
  • Excessive weight gain, or difficulty losing weight
  • Infertility

PCOS affects between 1 in 10 women of reproductive age and has a negative impact on a woman’s effort to become pregnant. Women with PCOS are more likely to be overweight and are at an increased risk of metabolic health complications such as high cholesterol, heart disease and diabetes. Adolescent girls with PCOS are more likely to have future problems with infertility, excessive hair growth, acne, obesity, diabetes, heart disease, high blood pressure, abnormal bleeding from the uterus, and cancer. It is crucial to diagnose the condition early, because getting treatment for PCOS reduces a girl’s chances of having serious side effects.

Includes the following services:

  • Treatment of Infertility
  • Diagnosis of polycystic ovary syndrome
  • Regulation of menstrual cycles
  • Management of long term metabolic problems like high blood sugar
  • Management of body hair
  • Individualized nutrition plans and support

Endometriosis Clinic
Endometriosis is a disorder of the female reproductive system in which endometrial tissue (the normal lining of the uterus) is found outside the uterine cavity. This disease is prevalent in women 30-40 years of age, though it can begin in the late teens and early twenties. About 40% of patients with endometriosis will experience some degree of infertility. The primary cause of infertility resulting from endometriosis appears to be a blockage caused by scarring and adhesions in the tubes. These adhesions can prevent the egg and sperm from meeting or prevent the fertilized egg from moving down the tube normally (resulting in an ectopic pregnancy).

Women with endometriosis often, but not always, have one or more of the following symptoms:

  • dysmenorrhea (painful cramps during menstruation)
  • dyspareunia (painful intercourse)
  • dysfunctional uterine bleeding, including heavy periods or unusual spotting
  • In about 30% of women, there are no symptoms except infertility
We Diagnose of endometriosis by a laparoscopy, during which the abdominal cavity, the ovaries, and other structures can be seen.

For a woman who wishes to attempt pregnancy, treatment is:

  • Opening the tubes and removing any adhesions that may affect conception, fertilization, and movement of fertilized eggs down the fallopian tubes
  • If not possible IVF is needed
  • Keeping the disease process in check by decreasing hormonal stimulation to these implants so that they do not grow and slough off, resulting in more damage to surrounding tissues.