Pregnancy Preparation

Fertility is complex and sensitive issue. The inability to conceive comes as a surprise to most men and women, all of whom assume that pregnancy will immediately follow marriage or after a contraceptive method is discontinued. However, that is not the case with approximately 10% to 15% of couples.

The thought of childlessness is very disheartening and couples that have difficulty to conceive may experience frustration, jealousy, guilt and anger. They need assistance We at Sridhar Hospital believe that every couple has a right to parenthood. We will do everything in our capacity to make the dream of parenthood come true. Fertility is complex and sensitive issue, we are better qualified to assist and guide you through various treatments.

We provide you with some basic concepts of fertility for your understanding if it turns out that you have a fertility issue; you have no reason to feel depressed or concerned, as we Dr.Sridhar Hospital are more than happy to assist you overcome the problem to achieve your dream of parenthood through latest technology in assisted conception.

The science and art of assisted conception technology has rapidly evolved in recent years. The clinicians and embryologists at the forefront of these developments will widen the scope of the treatment services to many people who were not successful in their quest to parenthood.

Ovulation Induction

OI is method of treatment used for women who either don't ovulate (release an egg) or don't ovulate regularly. Fertility drugs (tablets or injections) are used to help women to ovulate and so that they have the chance to conceive naturally. The most common groupings include drugs, which work on the brain, drugs which stimulate the pituitary gland and those which act directly on the ovaries themselves.

The woman's natural cycle and follicular tracking (ultrasound monitoring) are used to help assess the day of ovulation and couples are then advised the best time to have intercourse.

Intra Uterine Insemination (IUI)

What is intrauterine insemination (IUI) and how does it work?

Intrauterine insemination (IUI) is a laboratory procedure where fast moving sperms are separated from more sluggish or non-moving sperms. The fast moving sperms are then placed into the woman's womb at the time of ovulation (when egg is released).

What are the indications of IUI?
o Unexplained infertility
o Ovulation problems
o Male partner experiences impotence or premature ejaculation
What are the pre-requisites for IUI?
o At least one patent fallopian tube assessed by laparoscopy / HSG / Hysterosonogram.
o No significant problem with the sperms (numbers or quality or shapes).
o Normal uterine cavity evaluated by hysteroscopy / saline sonography / HSG
What are IUI options?
o IUI with or without fertility drugs / injections (clomiphene / gonadotrophins) – as IUI can be given with or without fertility drugs to boost egg production.
How does IUI work?
For Women:
Step 1. Women not using fertility drugs IUI is done based on their ovulation. It can be done follicular tracking vaginal ultrasound or ovulation predictor kits usually between day 12 and day 16 of the monthly cycle

Women using fertility drugs to stimulate ovulation, developments of eggs are monitored by vaginal ultrasound scans. As soon as an egg is mature, trigger (hormone) injection given to release the egg.

Step 2. The sperms are inserted 36 to 40 hours later, by the doctor through the vaginal speculum (a special instrument that keeps your vaginal walls apart).
A small catheter (a soft, flexible tube) is then threaded into the womb via your cervix. The best quality sperm are selected and inserted through the catheter The whole process takes just a few minutes and is usually a painless procedure but some women may experience a temporary, menstrual-like cramp.

For Men
Step 1. Men will be asked to produce a sperm sample on the day the treatment takes place by masturbation.
Step 2. The sperms are washed to remove the fluid surrounding them and the rapidly moving sperm separated out
Step 3. The rapidly moving sperm are placed in a small catheter (tube) to be inserted into the womb.
What are the chances of success from intrauterine insemination (IUI)?
o It is difficult to assess success rates for intrauterine insemination (IUI) because success depends upon the cause of infertility and whether fertility drugs are used to stimulate egg production
o It is around 15% for women aged under 35.
What are the risks of IUI?
o Intrauterine insemination (IUI) itself is normally quite straightforward and safe.
o The risks are associated with the fertility drugs that are used with this treatment which are allergic reactions etc.,
o Multiple pregnancies and Hyperstimulation in stimulated cycles.
o The use of ultrasound scanning before ovulation means that if there are more than two mature egg follicles present, the cycle can be abandoned

IVF Treatment

o IVF techniques can differ from clinic to clinic, often depending on your individual circumstances.
o A typical IVF treatment may involve:
For women:
Step 1. Suppressing the natural monthly hormone cycle
o As a first step of the IVF process you may be given a drug to suppress your natural cycle.
o Treatment is given either as a daily injection (which is normally self-administered unless you are not able
o to do this yourself. This continues for about two weeks.
Step 2. Boosting the egg supply
o After the natural cycle is suppressed you are given a fertility hormone called FSH (or Follicle Stimulating Hormone). This is usually taken as a daily injection for around 12 -14 days
o This hormone will increase the number of eggs you produce - meaning that more eggs can be retrieved and fertilised. With more fertilised eggs, the clinic has a greater choice of embryos to use in the treatment.
Step 3. Checking on progress
o Throughout the drug treatment, the clinic will monitor the progress. This is done by vaginal ultrasound scans and, possibly, blood tests and trigger (hormone) injection will be given for final maturation of eggs (usually more than 3 follicles of greater than 18mm in size).
Step 4. Collecting the eggs
o After 34-38 hours of trigger injection, the eggs are usually collected by ultrasound guidance under sedation or anaesthesia. This involves a needle being inserted into the scanning probe and into each ovary, The eggs are, in turn, collected through the needle
o Cramping and a small amount of vaginal bleeding can occur after the procedure.
For men:
Step 5. Fertilising the eggs
o Collected eggs are mixed with husband's sperm and cultured in the laboratory for 16–20 hours. They are then checked to see for fertilization.
o Those that have been fertilised (now called embryos) are grown in the laboratory incubator for another one - two days before being checked again. The best one or two embryos will then be chosen for transfer.
o After egg collection, medication is given to help prepare the lining of the womb for embryo transfer. This is given as pessaries, injection or gel.
Step 6. Embryo transfer
o One or two or three embryos can be transferred.
o The number of embryos is restricted because of the risks associated with multiple births. Remaining embryos may be frozen for future IVF attempts, if they are suitable
Step 7. Other treatments
o Some clinics may also offer blastocyst transfer, where the fertilised eggs are left to mature for five to six days and then transferred

Male Factor Infertility

In approximately 30-50 percent of infertile couples, the husband is either the sole or a contributing cause of infertility. Therefore, a semen analysis is mandatory. The man is usually asked to abstain from ejaculating for at least 48-72 hrs although that is not mandatory in all cases. He will then produce a semen sample by masturbating in to a clean labelled plastic specimen pot provided in a private room at our centre or at home. Sometimes two semen analyses (2-3 months apart) are recommended, since sperm quality can vary over time.

Abnormal / Insufficient Sperm count / quality
o The most commonly encountered problems in men involve abnormal or insufficient sperm count. Problems can be either not enough sperm is being produced, or the sperm is of poor quality. The quality is usually determined by motility and shape. A normal sample will show 20 million sperm per millilitre at least half of which will be active. Depending upon the count / shape / motility different terminologies are used like oligospermia (low count), asthenospermia (poor motility), teratospermia (abnormal shapes).
o Further, various specialized sperm functional tests like sperm Hypo-osmotic swelling (HOS) test, DNA fragmentation Index (DFI), Reactive oxygen species (ROS) assessment, Nuclear chromatin decondensation test (NCD), Acrosome Intactness Index (AI), can be performed to predict the capacity of sperm to fertilize the oocyte (egg) but unfortunately there is not which can be done to treat the abnormalities in sperm. Some fertility drugs and antioxidants might improve count and volume. Majority of male infertility problems requires advanced assisted reproductive technique called Intra-Cytoplasmic Sperm Injection (ICSI).
Absent sperm (Azoospermia)
o The absence of sperm in the semen analysis sample is termed as azoospermia. It can be due to blocked or absent tubes (vas deferens) or damaged testicles. The vas deferens does sperm transport function (and also storage) from the testicles (the site of sperm production) to the ejaculate
o Hence, related investigations for the above conditions like genetic screening cystic fibrosis, chest X ray for bronchiectasis are done
o If all the investigations are normal then a simple surgical procedure called surgical sperm retrieval (SSR) procedures like percutaneous sperm retrieval (PESA) / testicular sperm aspiration (TESA) / testicular biopsies can be performed to retrieve the sperm from the site of blockade or from the site of production
o If absence of sperms are due to the defect in the spermatogenesis (production of the sperm in the testes), then chromosomal analysis especially Y chromosome and its associated genes responsible for spermatogenesis are done to evaluate the cause and also it will predict the possibility of sperm retrieval by SSR. Usually, this is followed in severe oligoasthenoteratozoospermia (< 3 million count with low motility and severe abnormal forms).
Drugs/Medications/Life style
o Smoking, Alcohol, recreational drugs (Cocaine and Marijuana), environmental pollutants, sedentary life style have negative effect on the semen parameters. Certain medications like sulfasalazine used to treat Rheumatoid Arthritis and Crohn's Disease can decrease your sperm count, however the effects are only temporary and you should return to normal after your course of treatment. Long-term use and abuse of Anabolic Steroids will reduce the number of sperm you produce and affect their motility. The cancer treatment sometimes can severely reduce your production of sperm; however advances in sperm freezing can take the precaution of freezing sperm in advance to cancer treatment for future fertility. Artificial Insemination of Donor (Our unit do not offer this service)
o Donor insemination (DI) uses sperm from a donor to help the woman become pregnant.
o DI - IUI uses intrauterine insemination with donor sperm.
What are the indications for DI?
o Partner is unable to produce sperm
o Partner's sperm count or quality is so poor that it is unlikely to result in the conception of a baby, unless intra-cytoplasm sperm injection (ICSI) is carried out
o Partner has a high risk of passing on an inherited disease e.g., HIV / Hepatitis etc.
o Women who do not have a male partner.

Intracytoplasmic Sperm Injection (ICSI)

o This technique involves the injection of a single sperm into an egg to increase the chance of fertilization where sperm quality is poor.
o The process of treatment and the success rate is the same as for IVF with 1/2/3 embryos being placed inside the uterus 2/3/5 (blastocyst transfer) days following egg collection

Reproductive Surgery - (Fertility enhancing surgical procedures for women)

Fertility enhancing surgical procedures such as tubal surgery, treatment of endometriosis, ovarian cysts, removal of fibroids (open / laparoscopic / hysteroscopic) and correction of abnormalities of the womb (uterine anomalies) are offered by consultants specifically trained in reproductive surgery. Most procedures are performed by minimal access surgeries (laparoscopic / hysteroscopic surgery), which minimizes patient recovery times. The surgical management of patients by the same consultants managing fertility treatments allow for individualized treatment and a seamless transition from surgery to fertility treatment.

Diagnostic Hysteroscopy: Hysteroscopy is a minor surgical procedure that involves placing a lighted telescopic instrument (hysteroscope) through the neck of the womb (uterine cervix) and visualizing any abnormalities within the wall of the uterine cavity.

Operative Laparoscopy: The below mentioned procedures performed through laparoscope is called operative laparoscopy. This minimally invasive surgery requires special training and equipment. Gynaecologic surgeons must be specially trained to perform laparoscopic myomectomies / ovarian cystectomies / tubal surgeries / adhesiolysis / treatment to endometriosis. The objective of these procedures is to treat the causes of the infertility to enhance the fertility potential. Risks may include bleeding, injury to the intestines or other pelvic tissues and very small risk of premature ovarian failure, hysterectomy and rupture of the uterus in future pregnancy. Scar tissue formation after surgery is usually less than with open surgery and recovery time is much quicker as the abdominal incisions are minimal.

Chromotubation (Dye Test for tubal patency): It is a procedure usually done during an infertility work-up. During laparoscopy, a colored dye will be introduced into the uterine cavity being injected through the cervical canal during the procedure and then observed as it comes out of the ends of the tubes into the peritoneal (abdominal) cavity to check tubal patency.

Tubal Surgery for daaged fallopian tube(s):

Adhesiolysis (freeing the tubes): If the tubes and ovaries are covered in fine adhesions from previous pelvic inflammation, eggs in the ovaries have no access to the open end of the fallopian tubes and a pregnancy is not possible. The laparoscopic adhesiolysis procedure performed to surgically remove all adhesions (salpingo-oophorolysis).

Tuboplasty (Unblocking the fallopian tubes): The blocked outer end of the tube is opened at laparoscopy. These procedures are called Salpingostomy or Neosalpinostomy (creation of new opening in the tube).

Salpingectomy (removal of tube(s) if badly damaged): Collection of fluid in the fallopian tube (hydrosalpinx) damages the tube; this will put the women at risk of ectopic pregnancy and also decreases the IVF success rates. This is due to the back flow of fluid from hydrosalpinx may be toxic to the embryo's transferred and it will prevent from implantation. Hence, it will be better to remove the fallopian tube to optimize IVF success rate and prevent ectopic pregnancies.

Ovarian cystectomy & other ovarian procedures:

Ovarian drilling for treatment of PCOS: PCOS can be treated with drugs or surgery. The advantage of having surgery is that it does not increase the risk of multiple births. In this procedure (ovarian drilling), a heated needle (electro diathermy) is used to destroy some of the extra follicles (the sacs in which eggs develop) which are producing an excess of male hormones.

Surgical Treatment to endometriosis: Laparoscopy is the most common (gold standard) procedure used to diagnose and to remove mild to moderate endometriosis. If at laparoscopy deposits of endometriosis in the ovaries and pelvic ligaments are found, these may be destroyed at the time with electro diathermy. If the endometriosis is more extensive, further surgery is offered where the endometriotic tissue is removed by Cautery / excision of endometriosis

Endometriotic ovarian cyst(s) removal or aspiration: A common complication of endometriosis is the development of a cyst on an ovary. This blood-filled growth is called an ovarian endometrioma or an endometriotic or chocolate cyst.

Other benign ovarian cyst(s) removal: Ovarian cysts are fluid-filled sacs in the ovaries. They are very common in women, especially during the childbearing years. Ovarian cysts usually cause no symptoms. Most ovarian cysts will disappear without any intervention. However, they can persist, increase in size and can create a dull ache or a sharp pain if one twists or ruptures. Laparoscopic treatment includes draining (aspiration) , cutting out part of it, or removing it completely (cystectomy).

Mobilization of ovaries & fallopian tubes from bowel and pelvic adhesions
Myomectomy (Surgical removal of fibroids through laparoscopy)

Operative Hysteroscopy

The operative procedures performed through hysteroscope for removing the any uterine abnormality or pathology (fibroids / polyps / septum / cornual tubal blocks/ division of intrauterine adhesions etc.) is called operative hysteroscopy.

This is the most situated approach to remove the above-mentioned uterine abnormalities. Electrosurgical loops / mechanical scissors can be used through operative hysteroscope to remove or treat the abnormality within the uterus.

Gynaecologic surgeons must have specialized training to perform this type of surgery. Risks of the procedure again are minimal but may include puncturing the uterine wall, bleeding and fluid overload (special fluids are used to fill the uterine cavity during the procedure for better visualization of abnormality and this fluid can be absorbed rapidly into the bloodstream). Following resection, there is some risk of intrauterine scarring. Recovery is rapid and there are no incisions.

Embryo Transfer

What is embryo transfer?
o Embryo transfer takes place after eggs have been collected and fertilized in the laboratory. Depending on the situation between one and three of the best quality embryos are selected and then transferred to the woman's womb
o An embryo must successfully attach itself to the wall of the womb for pregnancy to begin
How does embryo transfer work?
o The exact procedure for embryo transfer depends on the clinic you choose. A typical procedure may involve the following:
Step 1. Two to three days after the eggs are fertilized, the best quality embryos will be selected for the transfer back in to the womb.
o A maximum of three embryos can be transferred back in to the womb.
o If women have good quality embryos, those that are not transferred can be frozen. Some clinics may also offer blastocyst transfer, where embryos are transferred five to six days after fertilization.
Step 2. The doctor doing the embryo transfer inserts a speculum into the vagina.
o A fine tube (catheter) is passed through the cervix, normally using ultrasound guidance. The embryos are passed down the tube into the womb.
o This is normally a pain-free procedure and usually no sedation is necessary, but you may experience a little discomfort because you need a full bladder if ultrasound is used.
Step 3. It is generally recommended that you lead a gentle lifestyle during the few days after embryo transfer.
Step 4. About two weeks after the embryo transfer, you will be given a pregnancy blood test. If it is positive, you will have a scan about two weeks later.
What are the risks of embryo transfer?
o There are no significant risks relating to the embryo transfer process itself.
o If you have never had a baby or if the canal of the cervix has not been assessed before the in vitro fertilization (IVF) cycle was started, there can occasionally be difficulties in passing the embryo transfer catheter through the cervix.
o While it is possible to stretch the cervical canal at the time of transfer, your specialist might prefer to avoid such interventions at this time.
o In extreme cases, your specialist may decide that it is in your best interests to delay the embryo transfer and freeze all suitable embryos until after the cervix has been stretched.
o There are significant risks if more than one embryo is transferred: you may want to consider single embryo transfer.
What are my chances of getting pregnant after embryo transfer?
o Female fertility diminishes with age, so if you are using your own eggs, on average, the younger you are, the higher your chances of success.
o For women receiving stimulated IVF using fresh embryos created with their own eggs, the percentage of cycles reaching embryo transfer that resulted in a pregnancy are as follows:
o 30-40% for women aged under 35
o 25-30% for women aged between 35-40
o 15% for women aged between 40-42

Blastocyst Transfer

What is blastocyst transfer?
o A blastocyst is an embryo that has developed for five to six days after fertilization.
o With blastocyst transfer, embryos are cultured in the laboratory incubator to the blastocyst stage before they are transferred to the womb.
o At this time, one or two of the best quality blastocysts are selected and then implanted into the woman's womb. A blastocyst must successfully attach itself to the wall of the womb for a woman to become pregnant.
When is the blastocyst transfer done?
o Many clinics are now offering blastocyst transfer as a means of improving chances of pregnancy after single embryo transfer. This is particularly useful for younger women with a good prognosis for pregnancy from in vitro fertilization (IVF).
o Your doctor may also suggest you try blastocyst transfer if you have produced good quality embryos in a previous IVF cycle but they failed to implant in the womb.
o It is not normally recommended if women produce fewer than normal healthy eggs or embryo's (usually < 5 good quality day 5 embryo's).
How does blastocyst transfer work?
o The procedure for blastocyst transfer is similar to that for normal embryo transfer, but instead of being implanted into the womb after two or three days, the embryos are allowed to develop for five to six days before transfer.
What are the risks of blastocyst transfer?
o Not all embryos will develop to produce blastocysts in the laboratory. Embryos can stop developing at the four-cell stage (day two) and progress no further.
o The embryologist may advise your consultant that in your case it is safer to consider a day two-three embryo transfer than risk having no blastocyst to transfer on day five-six.
o As with normal embryo transfer, due to the risks of a multiple birth if more than one blastocyst is transferred, you may want to consider single blastocyst transfer.
What are my chances of having a baby with blastocyst transfer?
o Female fertility diminishes with age, so if you are using your own eggs, on average, the younger you are, the higher your chances of success.
o For women receiving stimulated IVF using fresh blastocysts created with their own eggs, the percentage of cycles reaching blastocyst transfer that resulted in a live birth was:
o Up to 45 % for women aged under 35

Embryo Freezing

What is embryo freezing and storage?
o During in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) treatment, fertility drugs are used to stimulate the ovaries to produce more eggs than usual. These are then fertilized with your partner's, or a donor's sperm to create embryos.
o Because there is normally a number of unused embryos, some people choose to freeze the good quality unused embryos for use in later treatment cycles or for donation.
What is my chance of having a baby using frozen embryos?
o Due to the freezing and thawing process, chances of having a baby using a thawed frozen embryo are lower than with a fresh embryo.
o Chances of becoming pregnant with a thawed frozen embryo are not affected by the length of time the embryo has been stored for.
What are the risks of freezing embryos?
o Not all embryos will survive freezing and eventual thawing when they come to be used. Very occasionally no embryos will survive.
o It is not uncommon for those embryos that do survive freezing and thawing to lose a cell or two. Ideally the embryos should continue to divide between thawing and transfer.
o As embryo transfer is involved in using frozen embryos, the same risks apply.

Pre-implantation Genetic Diagnosis (PGD) / Genetic Diagnosis of Embryos

What is pre-implantation genetic diagnosis?
o Pre-implantation genetic diagnosis (PGD) is a technique that enables people with a specific inherited condition in their family to avoid passing it on to their children. It involves checking the genes of embryos created through IVF for this genetic condition.
o Pre-implantation genetic diagnosis involves carrying out tests on embryos created through in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) to detect certain inherited conditions or abnormalities.
o This helps to ensure that only unaffected embryos are selected before they are transferred to the womb.
o Conventional pre-natal tests for genetic diseases cannot be carried out until the 12th week of pregnancy.
o Testing embryos before they are implanted could help you and your partner to avoid having to make the difficult decision whether to have an abortion if either of you is the carrier of a genetic condition and the embryo is affected.
What are the indications for PGD?
o Genetic testing of the embryos may be recommended if:
o Women have had a number of abortions because possible genetic condition in the baby
o If the couple already have a child with a serious genetic condition
o If either of the or one of couple have a family history of a serious genetic condition
o Which genetic conditions can be tested for during PGD?
o PGD can be used to test for over 100 genetic conditions, but commonly tested chromosomes are 21,18,13 and sex chromosomes. This procedure may also be called Pre-implantation genetic Screening (PGS).
What are the risks of PGD?
o Most of the risks involved in PGD treatment are similar to those for conventional IVF
o Some embryos may be damaged by the process of cell removal
o Testing may not be 100% reliable or conclusive
How does PGD work?
The procedure for PGD is likely to be as follows:
Step 1. Couple undergoes You undergo normal in vitro fertilization (IVF) treatment to collect and fertilize your eggs.
Step 2. The embryo is grown in the laboratory for two - three days until the cells have divided and the embryo consists of around eight cells
Step 3. A trained embryologist removes one or two of the cells (blastomeres) from the embryo.
Step 4. The cells are tested to see if the embryo from which they were removed contains the gene that causes the genetic condition in the family
Step 5. Embryos unaffected by the condition are transferred to the womb to allow them to develop
Step 6. Any suitable remaining unaffected embryos can be frozen for later use. Those embryos that are affected by the condition are allowed to perish
Step 7. About two weeks after the embryo transfer, the woman is given a pregnancy blood test
What is the chance of having a baby with PGD?
It is difficult to assess success rates for PGD because there is currently little data available. Most women use this treatment not because they have fertility problems but because they want to avoid having a child with a genetic disease.
  • As with most fertility treatments, success depends on many factors, including the woman's age and whether a cause of infertility has been identified
  • Sometimes no embryos are suitable for transfer to the womb, for reasons including:
  • Not enough eggs are produced or fertilized in the first place
  • Removing the cells to be analysed damages the embryos
  • The genetic disease affects all the embryos.
  • The percentage of cycles started that resulted in a live birth was:
  • 28 for aged women under 35
  • 25 for women aged between 35-37
  • After 37 years of age results very variable