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FERTILITY

General information:

Over 80% of couples in the general population will conceive within 1 year if the woman is under 40 years of age and they do not use contraception and have regular sexual intercourse. People who are concerned about their fertility should have vaginal sexual intercourse every 2 to 3 days to optimize the chance of pregnancy.

Definition of Infertility:

Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. About 85% of couples may be expected to achieve pregnancy within that time interval without medical assistance, evaluation may be indicated for as many as 15% of couples.

Who should be evaluated for infertility ?

Evaluation for infertility is indicated for couples who fail to achieve a successful pregnancy after 12 months of regular unprotected intercourse. Earlier evaluation and treatment may be justified, based on medical history and physical findings. Early evaluation is warranted after 6 months for couples in which the female partner is >35 years old.

What can be the propable cause for female infertility?

Disease in the Uterus
1. Fibriod
2. Adhenomyosis
3. Polyp
4. Intrauterine adhesion

Tubal cause
1. Tubal Block
2. Hydrosalphinx
3. Adhesion

Ovarian cause
1. PCOS (failure to ovulate)
2. Endocyst
3. Poor Ovarian reserve
4. Premature Ovarian failure

Peritoneal cause
1. Endometriosis
2. adhesion

Cervical cause
1. Antisperm antibodies
2. Cervical stenosis

What are the various treatment options ?

1. Ovulation Induction with Timed Intercourse
2. Intra Uterine Insemination (IUI)
3. In vitro Fertilization (IVF/ Test Tube baby)
4. Donor Oocyte (Donor Egg)
5. Donor Embryo
6. Surrogacy
7. Adaption

What is IUI(Intra Uterine Insemination )?

It is a process in which washed semen sample is transferred in to the uterine cavity



Usually preferred in Young patients, Mild Tubal factor, PCOS, Mild to
Moderate Sperm abnormality etc.

Steps performed in IUI (Intra Uterine Insemination ):
1. washing of Sperm
2. Insemination of Sperm in the Uterus

How does it helps?

1. Improves the Quality and the number of Sperms
2. IUI(Intra Uterine Insemination ) sample have more than 80 to 90 % motile Sperm
3. More Sperm reach the Oocyte and improves chances of Fertilization

What is IVF(In vitro Fertilization) ?

In Vitro Fertilization is process in which male and female gametes are fertilized outside the body and once the embryo is formed it is then transferred in to the uterine cavity.

Preferred in Elderly, severe male factor, Poor Ovarian Reserve, Premature Ovarian failure, Previous multiple cycle of failed IUI (Intra Uterine Insemination ) etc ...
Procedure of It involves

1. Ovarian stimulation starting on day 2 or 3 of period
2. Monitoring of stimulation with USG and Blood test at regular interval
3. Trigger injection once more than 3 follicle reach 17mm
4. Oocyte aspiration 36 hrs after Trigger injection
5. Semen sample is given by the partner on the day of Oocyte aspiration
6. Fertilization of Oocyte by the Sperm
7. Culture in the Incubator
8. Checking embryo quality
9. Transfer of Embryo on Day 2 (4 cell) or day 3 ( 8 cell) or on Day 5 (Blastocyst stage)
10. Luteal Phase support is started post Embryo Transfer for 14 days
11. Blood test for pregnancy Beta HCG is done 14 days after transfer of Embryo

Intracytoplasmic Sperm Injection (ICSI)

Is a specialised form of In Vitro Fertilisation (IVF) that is used for the treatment of severe cases of male-factor infertility. Intra-cytoplasmic sperm injection (ICSI) differs from conventional in vitro fertilisation (IVF) in that the embryologist selects a single sperm to be injected directly into an egg, instead of fertilisation taking place in a dish where many sperm are placed near an egg.
ICSI is commonly recommend if:
* There is very low sperm count
* Sperm abnormalities have been identified, such as poor morphology (abnormal shape) or poor motility (not moving normally)
* Failure of fertilisation or an unexpectedly low fertilisation rate in previous IVF cycle.
* Surgically collected from the testicles or epididymis
* Frozen sperm are used in the treatment which is not of optimum quality More Sperm reach the Oocyte and improves chances of Fertilization

Cryopreservation

Cryopreservation of embryos is the process of preserving an embryo at sub-zero temperatures. Cryopreservation is used in infertility programs to freeze and store extra eggs & embryos from an in vitro fertilization cycle. There are 2 methods currently used for freezing in Slow freezing and Vitrification (ultra-rapid freezing)

Vitrification

Termed Vitrification, it involves freezing the embryo about 600 times faster than slow freezing technique. Vitrification in contrast to slow freezing is an efficient method for cryopreservation. This ultrarapid process is so fast that it literally allows no time for intracellular ice to form. As a result, vitrification avoids trauma to the embryo.
In conventional (slow) freezing, 20-30% of embryos do not survive the freeze-thaw, and those that do survive have less than half the likelihood of generating a pregnancy as do fresh embryos. In contrast, vitrified embryos have a better than 90% freeze-thaw survival rate, and a pregnancy generating potential that is comparable to fresh embryos.

Donor oocyte

In cases of turner syndrome, premature ovarian failure, poor ovarian reserve, Advance maternal age, previous IVF(In vitro Fertilization) cycle with poor oocyte or embryo quality.

Donor is screened for her personal and family history of any disease, infection and genetic abnormality in her or in the family.

How donor oocyte helps?
1. Better quality of oocyte and embryo
2. Improved implantation and pregnancy rate.

Donor Embryo

Is indicated when both oocyte and sperm abnormality are present in the couple so both, oocyte and sperm which are used are taken from the donor.

What is Surrogacy?

Surrogacy is when another woman carries and gives birth to a baby for the Couples who want to have a child

Who is eligible for surrogacy?

1. Absence of uterus (congenital or acquired)
2. Significant uterine anomaly (e.g., irreparable Asherman syndrome; unicornuate uterus associated with recurrent pregnancy loss)
3. Absolute medical contraindication to pregnancy (e.g., Pulmonary hypertension, serious medical condition that could be exacerbated by pregnancy or cause significant risk to the fetus.

Male infertility

Is mainly due to abnormality in the semen parameters.
Various abnormalities of sperm are as follows:
1) Oligozoospermia, refers to semen with a low concentration of sperm and is a common finding in male infertility
2) Asthenospermia is the medical term for reduced sperm motility. Complete asthenozoospermia, that is, 100% immotile spermatozoa in the ejaculate
3) Teratospermia is a semen alteration in which there is a large number of spermatozoa with abnormal morphology
4) Azoospermia is the term used when there is a complete absence of sperm in the ejaculate
5) Oligoasthenoteratozoospermia is a condition where there is a combination of all the above abnormality are present in the semen.
• One of the important and basic test for assessment of male factor infertility is Husband Semen Analysis.

Parameter Lower reference limit
Semen Volume (ml) 1.5 (1.4 - 1.7)
Term sperm number (106 per ejaculate) 39 (33 - 46)
Sperm concentration (106 per ml) 15 (12 - 16)
Total motility (PR. + NP. %) 40 (38 - 42)
Progressive motility (PR. % ) 32 (31 - 34)
Vitality (live spermatozoa, %) 58 (55 - 63)
Sperm morphology (normal forms, %) 4 (3.0 - 4.0)
Various modalities of treatment available for treating Azoospermia (Obstructive/Non Obstructive)
1) PESA: percutaneous epididymal sperm aspiration. This involves the same needle and syringe technique but the needle is placed directly into the epididymis.
2) MESA: microsurgical epididymal sperm aspiration. An open surgical sperm retrieval procedure that uses an operating microscopy to locate the tubules of the epididymis precisely, so that large numbers of sperm can be extracted.
3) Percutaneous biopsy: percutaneous biopsy of the testis. This is similar to TESA, but a larger needle is used.
4) TESA (testicular sperm aspiration), which is performed by sticking a needle in the testis and aspirating fluid and tissue with negative pressure.
5) TESE: testicular sperm extraction. This involves opening up the scrotum and taking a large volume of testicular tissue, perhaps from several regions of the testicle. Sperm are then retrieved using a microscope to identify individual sperm
6) Microdissection TESE. A similar technique but a microdissecting microscope is used to pinpoint the tissue to be removed. This aims to cause less damage to the structure inside the testicle, and to therefore have fewer after effects such as blood supply problems caused by tiny blood vessels being cut. It also appears to increase the number of sperm that can be retrieved