Infertility and IVF Treatment

Ques: What is infertility?

Infertility is defined as not being able to conceive even after trying for over a year of having unprotected intercourse. Nearly 15% of the couples fail to have children naturally, and the cause could be either in you or your partner, or a combination of reasons. Infertility also includes the cases where the female is unable to sustain pregnancy.

Ques: What are the causes of infertility?
Infertility can be attributed to various factors in males and females, but there is no single underlying reason for it.
Female infertility could be due to ovulatory and anatomical disorders. These could be either due to inability of the egg to reach uterus or inability of the ovaries to release egg. It could also be due to damaged fallopian tubes. Sometimes a fertilized egg fails to attach to the uterus lining; and at times, an attached embryo fails to survive. Female infertility could also be due to certain other conditions such as autoimmune disorders, diabetes, tumors, and cancers, and certain hormonal problems such as thyroid or hyperprolactinemia. In certain other cases, infections such as Chlamydia, tuberculosis, gonorrhea in the womb can also contribute to infertility in women.
Whereas, male infertility could be due to blockage of sperm production or decreased sperm count. Apart from these, there are other risk factors, which could contribute to infertility in many, if not all the cases. These risk factors could be lack of sufficient nutrition, excessive smoking, sexually transmitted infections, or exposure to certain chemicals such as pesticides, herbicide, lead metal etc.

Ques: What is IVF treatment?

IVF is an Assisted Reproduction Technique(ART), in which union of the eggs and sperms is done in a laboratory dish, and after fertilization, the resulting embryo is then transferred to the woman's uterus. It involves Five Basic Step which are super ovulation (stimulating the development of more than one egg in a cycle), egg retrieval, fertilization, embryo culture, and embryo transfer.

Ques: At what stage should we consider undergoing IVF treatment?

ART is a treatment option for couples with various types of infertility. It has been successfully used to overcome infertility due to blocked or damaged tubes, endometriosis, repeated IUI failure, unexplained infertility,poor ovarian reserve, poor or even nil sperm count(through sperm retrieval techniques like TESA/PESA) .

IVF can be normally performed for counts which are more than 5 million per ml. For counts less than 5 million per ml., ICSI is a better option. At Fortis Bloom IVF Centre, the successrate of IVF are in the region of 40-50% per started cycle in women <35 years of age, which are comparable to the leading units in the world.

Ques: What are the precautions one has to take while undergoing IVF treatment?

IVF treatment is generally very patient friendly nowadays and patients can carry on with their routine activities as usual. Certain precautions that should be observed during treatment include:

  • Avoid excessive caffeine, smoking, alcohol and drugs
  • Avoid heavy lifting, strenuous exercising and bouncing activities
  • Avoid sexual intercourse and orgasms

Once pregnant, the patient can lead her normal life, like any other pregnant woman. However, she should be careful to have all her medications regularly and remain in constant touch with her doctor.

Ques: How many times can one go for IVF treatment? Are there any age restrictions for the same?

There is no restriction to the number of attempts for IVF, and women have even conceived in their 11th cycle, but generally a couple should try a maximum of 4 attempts of IVF/ICSI. If one fails to conceive, it is advisable to opt for either egg donation/embryo donation/sperm donation/adoption.

There is no age limit for taking an IVF treatment, as long as the couple is healthy. With options of egg donation and embryo donation, women can now conceive even after menopause.

Ques: What are complete lines of treatments available for infertility patients here?

  • IUI (Intrauterine insemination)
  • IVF (In vitrofertilization)
  • ICSI (Intracytoplasmic sperm injection)
  • IMSI (Intracytoplasmic morphologically selected sperm injection)
  • Assisted Laser Hatching
  • Blastocyst Culture & Transfer
  • Embryoscope
  • Egg/Sperm/Embryo Donation
  • Embryo Freezing
  • Oocyte Freezing
  • Sperm Retrieval

Infertility Treatment FAQ's

Know about various infertility treatment process.

INSEMINATION

No. In Intra Uterine Insemination (IUI) semen is directly put into the uterus. It is a technique used for couples with fertility problems based on specific causes. These causes are:

Cervical hostility: This means that the cervix is not permeable for semen, shown after the Post Coitum Test.

Idiopathic subfertility: No cause has been found for this inability to conceive

Male subfertility: The sperm quality is decreased. Clinics use different ranges for sperm count in which they perform IUI.

Sperm Antibodies: This includes inability for vaginal ejaculation with decreased sperm quality, for example in men with retrograde ejaculation or spinal cord injury.

IUI can be performed either in a spontaneous ovulatory cycle (cervical hostility) or in a cycle with ovarian stimulating hormones (idiopathic sub-fertility and male sub-fertility/sperm antibodies). The stimulation is mostly done with Clomiphenecitrate or Gonadotrophines.

Nowadays, the indication may be relaxed to include all cases where routine treatments have failed. These patients can be given 3-6 cycles with Gonadotrophin stimulation with Intrauterine Insemination, before they opt for IVF/ICSI.

1. What is the success rates of IVF?

The success rates of the IVF technique have been improving gradually in the recent past. However, the birth rates vary and are dependent on the expertise of the clinics providing these services. The European IVF centers have reported around 25% and above success rates of these techniques in leading to pregnancy. Moreover, the French IVF registry (FIVNAT), in 1993, reported a 25.4% pregnancy rate for each embryo transfer out of a total 23,025 oocytes retrieved. The success rates may vary from place to place, but ideally, a woman under the age of 40 can successfully get pregnant after 3 to 4 cycles of IVF treatment. In addition, the success rates are largely dependent on the conditions of individual patients. Data shows that the clinics doing IVF treatment for the women above the age of 40 report lesser success rates as compared to those treating women below the age of 35.

2. What is the duration of one IVF or ICSI cycle?

One complete IVF or ICSI cycle takes approximately six to eight weeks. First, the normal menstruation cycle of the woman is regulated by injection or nasal application of specific hormones each day. This part of the cycle can expand from a few days to several weeks. When the ovaries become inactive, as shown on ultrasound control and laboratory findings, the stimulation of the ovaries is initiated by muscular or subcutaneous injections of hormones. The main stimulation period is 12 days, depending on the reaction of the ovaries. The ovum pick up takes place within two days after stopping the stimulation. Now the real IVF or ICSI follows in the laboratory. When fertilization occurs, embryos are transferred into the uterus after two to four days and drugs supporting the uterus are given. After approximately 15 days, a pregnancy test will show whether the IVF treatment has been successful or not.

Assisted reproductive technologies (ART) refer to several different methods designed to overcome barriers to natural fertilization such as anatomical problems (e.g. blocked fallopian tubes). One of these techniques, in-vitro fertilization (IVF), has now been practiced for more than 15 years. Overall, the estimated number of infertile patients currently treated by ART is around 20%.

3. What is Cryopreservation?

Cryopreservation means preserving in a frozen situation. The best-known Cryopreservation is of semen. This is mostly done in case of cancer of the testicles before treatment of the cancer. Furthermore, Cryopreserved semen is used in donor insemination. It is also possible to freeze fertilized eggs after IVF or ICSI. If more embryos are left after an IVF or ICSI procedure, then they can be frozen and transferred another time. In this way, there is a larger chance of pregnancy while only one IVF or ICSI cycle is performed. For human oocytes, Cryopreservation is much more difficult. Only a few experiments have shown successful results. The attention of researchers now is on developing a way to freeze ovarian tissue and, to obtain the oocytes in it after thawing. This procedure is not yet fully refined, but once it is refined, it can offer great opportunities in the future. We, at the 'Babies and Us Fertility Center' have started doing preliminary research work in this area.

4. What is TESE or PESA?

TESE (Testicular Sperm Extraction) is a technique in which the sperm is collected out of the testicles after operation. In PESA (Percutaneous Epididymal Sperm Aspiration), the sperm is collected out of the epididymis by simple aspiration, without opening the skin.

TESE or PESA techniques are developed for patients who have no sperm cells in their sperm due to an undeveloped or obstructed spermatic cord. The cause of obstruction can be a former sterilization, an infection of the epididymis or congenital absence of vas deferens. TESE or PESA is not possible when the testicles make no sperm cells at all. An ICSI (Intra Cytoplasmatic Sperm Injection) procedure will be done if the sperm cells are obtained.

5. What does sperm preparation mean?

Normally, spermatozoa are ejaculated in the seminal fluid during intercourse or masturbation. In assisted reproduction technique, sperms are extracted from the semen by a series of processes involving centrifugation and washing, layering (to select the active sperm and leave the immotile or dead sperm behind) or selecting the best sperm by making them swim through a denser medium (Nidacon Puresperm or Spermgrad) and using those that succeed.

6. What are embryos frozen?

The embryo freezing involves successfully storing and preserving the human embryo by storing in liquid nitrogen. Estimated 15-20,000 babies have been born as a result of the freezing technology. Drug-induced stimulation of the ovaries, resulting in super ovulation, leads to an excess of embryos being created that can't all be transferred to the uterus at the same time. The good quality excess embryos can therefore be stored by freezing to transfer it to the uterus later. It should be noted that poor quality embryos do not withstand the freezing process that well, and hence are not generally frozen. This technique allows couples to have more attempts at IVF without the need for the woman to have to undergo another stimulatory cycle of IVF for egg collection.

The success rates following transfer of frozen embryos is about 10-15 % , which is not as good as the fresh cycle success rates. In some countries, freezing of embryos is restricted or banned (For instance, Germany and Switzerland will only allow freezing of the zygote - i.e. before the first cell division of the fertilized egg).

7. What is assisted hatching?

Assisted hatching (AH) may help couples who have had many attempts at assisted reproductive procedures without success. It is a technique, which helps the embryo implant in the endometrium. Embryo implantation is one of the greatest barriers in successful implementation of In Vitro Fertilization (IVF) cycles. When embryos are replaced into the woman's uterus, an outer coating called the Zona Pellucida covers them. Once the embryo is in the uterus, this "shell" must be dissolved in order for the embryo to be able to "hatch". This is a necessary step for implantation. In certain situations, this step is less likely to occur naturally in women of 38 years and older, women with elevated serum FSH levels, women who have failed to achieve a pregnancy in a prior IVF cycle), and in patients with AH. A microscopic glass tube is used to make a small defect in the zona using a very small amount of acid solution to dissolve the outer coating of the embryo. Nowadays this hole is created with the use of a laser beam.

We have already performed more than 300 cycles of Laser Hatching with very good results. Assisted hatching is done on the third day after egg retrieval, and embryos are immediately replaced into the uterus. It has been suggested that treating women with steroids (to suppress the mother's immune system) and antibiotics (to counteract any infections in the uterus) may be beneficial when carrying out assisted hatching. These medications are only given for four days, starting on the first day the eggs are collected.

8. Why are all embryos not implanted in the human body?

After IVF, as after spontaneous conception, embryos are susceptible to chromosome abnormalities. The egg or the sperm may have born the anomaly to start with, but at each cleavage division, mistakes may happen that lead to abnormal daughter cells in the embryo. These abnormal cells may fragment and get lost to the embryo. In case the embryo loses too much cells, its abilities to progress until the blastocyst stage and to implant may be hampered seriously and no pregnancy will follow. In fact, the relatively low implantation potential of human embryos is an example of natural selection, which is very efficient in eliminating abnormal concept uses.

9. How can we improve the implantation rates of human embryos in human IVF?

The implantation rates of human embryos in the human IVF cannot be improved. What all can be done is, the selection of good quality embryos which can give higher pregnancy rates on embryo transfer. Some centers are experimenting with embryo biopsy and Aneuploidy screening to select the genetically soundest embryos. Other centers choose to culture the embryos to a later stage (the blastocyst stage) to select the best ones, and indeed both strategies seem to lead to higher implantation rates. These strategies, however, work only if a sufficient number of embryos are available. The main problem is encountered when a lower number of embryos are obtained from a couple, and thus selection cannot be performed in such a condition contributing to lower pregnancy rates.

The major problem are still couples in whom only a low number of embryos can be obtained, since no selection can be performed there and the pregnancy rates will still remain low.

10. What about the transfer of only one embryo to reduce the incidence of multiple pregnancies?

A group of good prognosis patients shows positive results with such a technique. A quarter of all the couples are good prognosis couples and selective pregnancy seems to work well in these patients, quite similar to the patients undergoing double embryo transfer. Such couples are the ones in which female partner is less than 35 years of age who has been pregnant before, also if these couples are undergoing the IVF treatment for the first time, and good quality embryos are available. More research is going on in this direction to identify the use of selective embryo transfer.