IUI (intrauterine insemination), IVF (in vitro fertilization), ICSI (intracytoplasmic sperm injection)
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1. Infertility Workup


The goal of IVFQuick Infertility Workup is to raise awareness about the disorder of infertility and motivate the public to understand their reproductive health.

The workup encourages the prospective couples to meet our physicians and specialists, and learn how the team works with you to develop an individualized treatment plan unique to your emotional and lifestyle needs.

EVALUATION AND DIAGNOSIS

The preliminary workup of the infertile couple consists of a semen analysis, detection of ovulatory function by various methods, and evaluation of tubal patency by HysteroSalpingoGram (HSG) with concomitant fluoroscopy. Additional evaluation of pelvic anatomy, either by laparoscopy and/or hysteroscopy may be considered as a part of the initial workup if there is an abnormality on HSG, or later if no source for infertility can be found.
Purely diagnostic laparoscopy for the infertile woman is being used less commonly as more couples are progressing towards the Assisted Reproductive Technology (ART), a medical procedure used primarily to address infertility. It includes procedures such as in-vitro fertilization. Other procedures such as Y chromosome mapping, anti-sperm antibodies, Sperm Penetration Assay (SPA), or other tests of sperm function may be used in certain cases.
The assessment consists of a comprehensive history, physical examination, calculation of ovulation, semen estimation, as well as uterotubal review. Furthermore, follicle-stimulating hormone (FSH), and estradiol levels obtained on the third day of the menstrual cycle could possibly be useful in women older than 35 years of age.
The workup abridges the risks for adverse pregnancy outcomes after Assisted Reproductive Technology (ART), to cultivate an approach to counseling couples regarding these risks, and institute a research agenda.

2. Diagnostic Laparoscopic


The most effective method to detect and figure out female infertility problems is through laparoscopy. Laparoscopy is a minor and extremely safe surgical procedure that allows a fertility doctor to see inside the abdomen using a fiber optic or camera instrument at the end of a tube. In the female anatomy, the uterus, fallopian tubes, and ovaries compose the female reproductive system. These organs are located in the pelvis, which is at the bottom of the abdomen and above the leg joints. Laparoscopy allows the fertility doctor to see abnormalities that might interfere with a woman’s ability to conceive a pregnancy. The most common problems include damage to fallopian tubes or uterus, problems with the cervix, ovulatory disorders, endometriosis, and uterine fibroids.

WHAT IS A LAPAROSCOPE?

Laparoscopy is performed using a very thin fiber optic telescope called a laparoscope. To figure out if there are any issues with female infertility, the laparoscope is inserted into the abdomen (usually through the belly button). The fiber optics allow a light to access images of the inside of the abdomen.

For the procedure, carbon dioxide (CO2) gas is inserted into the abdomen prior to insertion of the laparoscope. This lifts the abdominal wall and allows for some separation of the organs inside the abdomen, making it easier for the fertility doctor to produce images of the reproductive organs during the procedure.

If abnormalities are found during the laparoscopy, additional instruments can be placed into the abdomen through tiny incisions. The incisions are usually made at the pubic hair line on the left and/or right side. Along with the laparoscope in the belly button, this forms a triangle that, allowing the fertility doctor to perform virtually any surgical procedure instead of performing a traditional surgery where a large, “open” incision has to be made.

Laparoscopy is performed using general anesthesia. This means that the patient is completely asleep during the entire procedure. In fact, depending on the procedure, the women can even leave after a rest of a few hours.

WHAT ARE THE BENEFITS OF LAPAROSCOPY FOR INFERTILITY?

Better Diagnosis of Female Infertility Causes

Laparoscopy allows the diagnosis of female infertility problems that would otherwise be missed. For example, a woman who has severe endometriosis can be diagnosed for the disorder using an ultrasound. A woman with mild endometriosis can only be diagnosed using a clearer, more effective procedure such as laparoscopy.

Another disorder that can only be identified through a laparoscopy procedure is a pelvic adhesion. Also known as scar tissue, an adhesion cannot be detected through an ultrasound, x-ray or CT scan. A Pelvic Adhesion is a band of scar tissue which causes two parts of your tissue to stick together that are not meant to be joined together. An adhesion may involve any organ within the pelvic area including the bladder, uterus, fallopian tubes, and ovaries. Usually, this action of sticking together occurs after an abdominal surgery among 93% of people, while 10% of the cases are unrelated to surgeries. Pelvic adhesions can interfere with the ability to conceive if the adhesion bands are too thick, and make it difficult for the egg to get access to the fallopian tubes at the time of ovulation.

Minimally Invasive Diagnostic and Treatment Procedure

Many people view laparoscopy as a minimally-invasive surgery than traditional surgery. Traditional surgery requires making an incision in the abdomen which is several centimeters long. This in turn means that the patient has to spend 2 to 3 nights in the hospital. Laparoscopy utilizes 1 to 3 smaller incisions. Each incision may be half a centimeter to a full centimeter in length at most. Most of the time, patients who have gone through a laparoscopy will be able to go home the same day as the procedure. In other words, a hospital stay is not usually required!

Laparoscopy is not linked with or causes any adhesions. At the same time, nor does it prevent them post reproductive surgery.

WHEN IS LAPAROSCOPY RECOMMENDED?

Generally, laparoscopy is recommended for couples who have already completed the basic infertility evaluation which includes assessing for ovulation, ovarian reserve, ultrasound, hysterosalpingogram (HSG) for the female, and semen analysis for the male. Some couples may elect to skip laparoscopy in favor of proceeding to other fertility treatments such as superovulation with fertility medications combined with Intrauterine Insemination or In-Vitro Fertilization.

However, there may be instances where the fertility doctor may have a high suspicion that problems or disorders causing infertility could be better diagnosed using a laparoscopy. One such instance is if a woman has a history of a severe pelvic infection or a ruptured appendix. In this case, it would increase the likelihood of her having pelvic adhesions and therefore, she would be more likely to benefit from and would be recommended a laparoscopic procedure for infertility.

LAPAROSCOPY VERSUS IVF

Pelvic adhesions and endometriosis are two commonly encountered problems during a laparoscopy, and can also be effectively treated using IVF. Since IVF is less invasive than laparoscopy and has a very high success rate, some couples will opt to entirely skip the laparoscopy procedure, and proceed directly to IVF. Even if a woman has severe adhesions that are not treated, this would not impact on her ability to conceive a pregnancy with IVF. This is because IVF bypasses traditional pregnancy conception and thus the fallopian tubes, and uses syringes and other instruments.


3. SEMEN ANALYSIS


Doctors recommend a Semen Analysis to their patients when couples are facing problems with pregnancy conception. This analysis helps determine the cause behind infertility. If the issue is male infertility, the causes are usually either low sperm count or sperm dysfunction. The semen analysis is the primary assessment tool for male fertility potential and evaluation of semen characteristics. The accuracy of the result is dependent on following the proven and correct methods of analysis that are regularly audited and checked for quality control. Variations in laboratory techniques significantly influence the reliability of the results of the analyzed semen. This may lead to a longer process for investigating male infertility, and possibly even to inappropriate treatment.

QUALITY MEASURES

Collection and analysis laboratories must go through a quality assurance program to ensure that the doctors analyzing semen samples use methods, instruments, and reference values in accordance with the 2010 Laboratory Manual by the World Health Organization.

SAMPLE COLLECTION

The sample has to be collected in a private room near the laboratory in order to limit the exposure of the semen to fluctuations in temperature, and to control the time between collection and analysis. The optimum time for collection is within 30 to 60 minutes of ejaculation.


The sample should be collected after a minimum 36 to 72 hours (2 to 6 days) of sexual abstinence. However, the abstinence should not last longer than this time period to avoid the sperm becoming less active or lazy. If additional samples are required, the number of days of sexual abstinence should be as constant as possible between each visit.
The man should be given clear written and spoken instructions concerning the collection of the semen sample. These should emphasize that the semen sample needs to be complete and that the man should report any loss of any fraction of the sample. Loss of any fraction of the sample can give an inaccurate result since before analysis, nobody can tell which sperms would be the most active and ideal from the semen sample.

4. SPERM DNA FRAGMENTATION TEST


About 50% of all infertility cases are related to male infertility due to issues with the sperm. The first step in the sperm analysis is through the semen analysis, which determines sperm motility, concentration, and morphology. However, there are further steps involved as well that best help the doctor determine the full cause behind abnormal embryo development if the sperm’s DNA makeup is what is causing the problems. This parameter that diagnoses male infertility and provides a full diagnosis is known as the Sperm DNA Fragmentation Test. This is a test to determine damage occurring during any of the natural reproductive and bodily processes listed below:

  • Spermatogenesis: the process of sperm formation
  • Apoptosis in the seminiferous tubule epithelium: the natural sperm cell death as part of organism growth and development in the testes
  • Defects in chromatin remodeling during the process of spermiogenesis: defects in the final process of DNA rearrangement into an accessible state during sperm maturation
  • Oxygen radical induced DNA damage during sperm migration from the seminiferous tubules to the epididymis: damage to DNA caused by free radicals during sperm migration from the sperm production, maintenance, and storage in testes to the duct along which sperm passes further
  • The activation of sperm caspases and endonucleases: the activation of sperm cell death mediators and the enzyme that splits DNA
  • Damage induced by chemotherapy and radiotherapy
  • The effect of environmental toxicants transported through the reproductive tract

The need to diagnose sperm at a nuclear level is necessary to prescribe as well as further improve treatment for the infertile couple.

INTRODUCTION

Recently, there has been an increased emphasis on sperm quality. This is because Sperm Analysis in itself only tests the actual sperm and its characteristics, and not the DNA.
Sperm is crammed with a large amount of DNA inside that makes up for 50% of the subsequent embryo and child’s genetic makeup. DNA is a protein structure that carries all the essential information. The Sperm’s DNA is susceptible to damage during its journey from the site of its production to its arrival at the egg.

WHO QUALIFIES FOR THE SPERM DNA FRAGMENTATION TEST?

  • Couples going through repeated miscarriages
  • Women 40 years and above
  • Aged couples
  • Smokers and/or drug addicts
  • People working in chemical industries
  • Oligo Astheno Teratozoospermia (OAT): a condition with low sperm quantity, motility, and abnormal sperm morphology – commonest cause of male infertility
  • Repeated fertilization failures
  • Arrested cleavage in ICSI: natural split in cells getting blocked during Intracytoplasmic Sperm Injection, a specialized form of IVF for severe male infertility treatment

STEP BY STEP PROCEDURE

  • 1. The semen sample is diluted in a culture medium.
  • 2. The Spermatozoa is immersed in an agarose micro gel which separates the DNA molecules. This immersion is then spread out on a microscope slide.
  • 3. The sample undergoes treatment with acid denaturation and a lysis solution.
  • 4. The treated sample is then dehydrated, stained and set up for a microscopic visualization to check for results and effect on the sample.

SPERM CLASSIFICATION WITHOUT DNA FRAGMENTATION FOR NORMAL SPERMATOZOA:

  • Spermatozoa with Large Halo: A sperm whose width is similar or higher than the minor diameter of the core
  • Spermatozoa with Medium Halo: A sperm whose size is between those with large and with very small halo
  • Spermatozoa with Fragmented DNA: Spermatozoa without Small Halo: The halo width is similar or smaller 1/3 of the minor diameter of the core
  • Spermatozoa that is Degraded and without Halo: A sperm that shows no halo and presents a core irregularly or weakly stained
  • Others: Cell nuclei which do not correspond to spermatozoa

5. SURGICAL RETRIEVAL OF SPERM


Prior to initiating treatment for a couple where the man is suffering from azoospermia, it is important to distinguish whether the lack of sperm in the ejaculate is from an obstructive or non-obstructive process, or if it is caused by any other infertility problems.

Surgical sperm retrieval may be a treatment option for men with:

  • Vasectomy
  • Congenital absence of the vas deferens (men born without the tube that drains the sperm from the testicle)
  • An Obstructive Azoospermia – obstruction stopping sperm release due to an injury or an infection
  • Spermatozoa that is Degraded and without Halo: A sperm that shows no halo and presents a core irregularly or weakly stained
  • Non-Obstructive Azoospermia - the testicles generate such a low quantity of sperm that they are unable to reach the vas deferns

TREATMENT METHODS FOR OBSTRUCTIVE AZOOSPERMIA

Men with obstructive azoospermia may father children through either of the following options:

  • Surgical correction of the obstruction which may produce pregnancy by intercourse, and avoid the need for assisted reproductive technology
  • Retrieval of sperm from the male reproductive system for in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI)

NON-OBSTRUCTIVE AZOOSPERMIA

A common observation for testicular sperm samples is that the retrieved spermatozoa are immobile or have a sluggish twitching motion. In this situation, some sperm production is focally present within the testis, despite the fact that an inadequate number of sperm is released from the testis to make it into the ejaculate. After several hours of in-vitro incubation, testicular sperm typically show some motility. The lack of initial motility does not necessarily reflect a lack of probability for testicular sperm, since these sperm have never acquired motility. Non-motile ejaculated sperm have acquired and lost motility, as sperm viability is lost, rendering the sperm useless for Intracytoplasmic Sperm Injection (ICSI), which is an in-vitro fertilization (IVF) procedure in which a single sperm cell is injected directly into the cytoplasm of an egg.

SURGICAL TECHNIQUES

Testicular Sperm Percutaneous Aspiration (TESA)

  • TESA is the process of removing a small portion of tissue from the testicle.
  • The testicular tissue is teased under the microscope and viable sperms are recovered.
  • This procedure is recommended to men who have no sperm in ejaculation.
  • Simple, fast, low-cost, non-surgical procedure

Microsurgical Testicular Sperm Extraction (Micro TESE)

  • Micro TESE is surgical procedure in which testicular tissues are taken from testicle under microscope.
  • The tissue samples that are taken are then put into a series of processes, and live sperm cells are separated.
  • This procedure is also recommended to men who have no sperm in ejaculation.
  • Sperm retrieval is high and lower chances of damage of testicle

Percutaneous Epididymal Sperm Aspiration (PESA)

  • The PESA procedure involves placing a small needle into the testicle epididymis in order to aspirate seminal fluid.
  • Afterward, motile sperms are extracted from seminal fluid.
  • This process is used to retrieve sperms in individuals who do not have sperm in their ejaculate due to a blockage.
  • Painless, simple, quick, low-cost procedure

6. Intrauterine Insemination (IUI)


HOW DOES PREGNANCY OCCUR NORMALLY?

A pregnancy is the result of the union between sperm of the man and egg of the woman. This union is called fertilization. Normally only one egg is produced in a menstrual cycle and in the case of a regular monthly cycle, this usually happens in the middle of the month. This production and availability of an egg ready for fertilization is known as ovulation. The egg remains available for uniting with the sperm for about 24 hours, after which it disappears. This means that chances of a pregnancy to occur are at the maximum at the time of the egg release.

WHAT IS IUI?

IUI stands for "Intra-Uterine Insemination". Through this treatment, a semen sample is collected from the man from the hopeful couple for what is known as semen analysis, which checks the sample for characteristics and fertility levels (link Semen Analysis page here). After this, around the time of ovulation, another semen sample is collected and then introduced into the uterus of the woman through a special plastic tube. The processing of the semen ensures that the good quality sperm from the semen sample is injected into the uterus. The objective of this procedure is to bring together the egg and the sperm to provide a higher possibility of pregnancy.

IUI PROCESS

The IUI process includes the following five steps:

  • Semen analysis
  • Monitoring of female ovulation
  • Obtaining the sperm sample
  • Washing and preparing the sperm sample
  • Injection of the prepared sample into the uterus

WHO CAN QUALIFY FOR AN IUI TREATMENT?

An IUI treatment and procedure is generally recommended or suggested to couples facing infertility or conception problems. This includes unexplained infertility to try and kick start the pregnancy conception by bringing the egg and the sperm in closest proximity to each other without going for IVF treatment. It is also recommended to couples where the man, through a semen analyzed diagnoses is suffering from a low sperm count or other male factor infertility disorders. Doctors also recommend this to couples where the woman is suffering from cervical mucus disorders or problems.

WHAT HAPPENS IN THE IUI PROCEDURE?

Once a couple is recommended and agrees to go through with the IUI treatment for female, male, or unexplained infertility or disorders, they will be required to follow all the steps in the IUI procedure.

You both will undergo physical examinations and analysis for infertility or sub-fertility.
As a couple, the woman may be required to make several clinic visits while on her period for bloodwork, ultrasounds, and medication instructions, where the medication can be for both, the man and the woman.

In the case that your doctor prescribes you medication, you’ll usually be told to start taking them while on your period.

About a week after starting the medication, you’ll likely be asked to get another ultrasound and possibly some bloodwork.

Depending on your test results, your doctor will determine when you’re ovulating, and that is when you and your partner will next return to the clinic. This is typically 10 to 16 days after starting the prescribed medications.

The day of the procedure, you both will be asked to come in.

Your male partner will provide a semen sample, which will immediately be taken to a lab where it will be “washed.” This is a process where the seminal fluid and other debris are removed so that the sperm is concentrated and unlikely to irritate the uterus.
You will be asked to lie down on the exam table as you normally do for a pelvic exam.
Your doctor will insert a very small, thin, and flexible catheter containing the concentrated sperm through your vagina, which will be injected right into your uterus.

WHO CAN BENEFIT FROM IUI TREATMENT?

This treatment is suitable for those couples in whom:

  • The semen contains fewer sperm or their movement is slow.
  • Both the man and the woman are not found to show any apparent cause of sub-fertility. This is called unexplained sub-fertility.
  • IUI is recommended in some cases of endometriosis.
  • IUI can be carried out if tubes of the woman are open and the semen analysis is within required parameters.

WHAT IS OVARIAN STIMULATION AND WHY IS IT HELPFUL?

Your chances of pregnancy would increase if more than the usual single egg is produced. If there are multiple eggs available to fertilize, the probability of conceiving a pregnancy increases as the number of eggs produced increases. For this purpose, medication may be prescribed by the doctor. This process is known as ‘ovarian stimulation’. There are various medications in the form of tablets, capsules, and injections available which may be prescribed either alone or in combination.

The chances of getting pregnant through IUI are 10% to 15%. This success rate may seem low, but it should be noted that despite the underlying infertility or sub-fertility disorder, this method provides positive results, as compared to the usual negative response through natural pregnancy attempts.

WHAT IS MONITORING?

As an egg starts to grow, it accumulates a small amount of fluid around itself, forming fluid-filled sac which is called a follicle. The follicle gradually enlarges in size and ultimately bursts open to release the egg. A growing follicle can be seen on an ultrasound scan, and by measuring its size, the approximate time of egg release can be predicted. This assessment of the egg’s size is known as monitoring. The schedule of these scans varies according to the medication that is given for ovarian stimulation.

HOW MANY TIMES CAN A COUPLE ATTEMPT AN IUI PROCEDURE?

From a medical point of view, there is no limit on the number of times this treatment may be attempted. Generally, a few attempts are necessary for the couple to conceive a pregnancy. Usually, around 3 to 6 attempts are made by couples for a positive response to show...

However, it is a matter of personal decision for the individual couple for the number of attempts they would try.

7. In vitro fertilisation (IVF)


In vitro fertilisation

The term In-Vitro Fertilization (IVF) literally means fertilization “in glass” and refers to the process where a woman’s eggs are fertilized outside of her body in the laboratory. The subsequent embryos are then transferred back into the uterus a few days later.

WHO NEEDS IVF?
Previously, IVF was used in circumstances such as tubal factor. IVF is also suggested if unassuming treatments fail. Below is a list of common indications for the IVF treatment:

    • Fallopian Tube Damage / Tubal Factor
    • Male Factor Infertility
    • Endometriosis
    • Age Related Infertility
    • An-ovulation
    • Unexplained Infertility

    STEP BY STEP GUIDE THROUGH THE IVF PROCEDURE

    • Preliminary checkup of the couple
    • Baseline hormone levels of woman
    • Drug treatment (injections) to stimulate egg growth
    • Ultrasound monitoring of treatment
      • To measure the growths of follicles
      • To adjust dose of drugs
    • Prevention of serious side effects (such as Ovarian Hyper Stimulation Syndrome)

    TECHNIQUES OF MONITORING

    • By Trans-Vaginal Ultrasound Scanning (TVS)
    • By measuring hormones in blood
    • Egg pickup
    • Semen collection & processing
    • Review of eggs after 24 hours for fertilization and division
    • Embryo Ttransfer (ET)

    INDICATIONS
    The IVF procedure is precisely suggested for women with absent, blocked or damaged fallopian tubes. It is also often used in cases of unsolved infertility, in some cases of male factor infertility, and can be used in combination with ICSI (intracytoplasmic sperm injection) in cases of severe male factor infertility.

    Described below is the procedure:

    Stimulation of Ovaries to Encourage Development & Maturation of the Eggs
    Under the attention of a consultant gynecologist, the woman is given fertility medications to motivate her ovaries to produce many follicles. Follicles are the small fluid filled structures which grow on the ovaries, each of which will hopefully contain an egg. The number and size of the developing follicles is measured by trans-vaginal ultrasound scans. The exact number of follicles which develop varies between patients, but the average is about 10. The final preparation for egg retrieval involves a hormone injection which mimics the natural trigger for ovulation. Egg retrieval takes place 35-36 hours after this injection.

    Retrieval of the Eggs
    Egg retrieval is a minor theater procedure which is carried out on an outpatient basis under general anesthesia. The trans-vaginal ultrasound probe is used to visualize the ovaries and a needle attached to the probe is passed through the vaginal wall into the follicles. The fluid within each follicle is aspirated and then examined in the IVF laboratory for the presence of an egg. After identification, the eggs are washed and transferred into special culture medium in Petri dishes in an incubator.

    Fertilization of the Eggs and Culture of the Embryos
    While the egg retrieval is proceeding, the sperm is also prepared. A semen sample is provided by the male partner and, in the laboratory, a concentrated preparation of the best motile sperm is extracted from the semen sample. This sperm preparation (containing approximately 150,000-200,000 sperm) is added to the dishes containing the eggs, and they are incubated together overnight.
    In some couples, an alternative form of insemination is required called ICSI, which involves injecting a single sperm into each egg using a very fine needle, rather than mixing the eggs and sperm in a dish.
    Irrespective of the method of insemination used, on the morning after egg retrieval, the eggs are examined to see which have fertilized.
    Fertilized eggs (zygotes) are then routinely cultured in the IVF laboratory until day 5, at which time 1-2 of the best embryos are selected and transferred back into the woman’s uterus. Any additional, good embryos that are not transferred on either day 5 can be frozen.

    Embryo Transfer
    Embryo transfer is a simple theatre procedure that does not routinely require anesthesia. The embryos are placed into the uterine cavity by the doctor/IVF nurse by means of a fine catheter inserted through the cervix. The precise positioning of the embryos is confirmed by abdominal ultrasound, hence the woman is required to have a full bladder for the procedure.

    WHAT ARE THE CHANCES OF SUCCESS?
    Normally, at good centers all over the world, the average chance of success is 40%. Having this outlook may help you think about trying more than one cycle, and feel less discouraged if the first one doesn’t work.

    HOW LONG DOES THE TREATMENT TAKES?
    A single cycle of IVF takes up to 4 to 6 weeks to complete. The couple can expect to spend about half a day at the clinic for egg retrieval and fertilization procedures.

    USE OF DONOR’S SPERM

    We strictly use husband’s spermatozoa (male sperm) and wife’s egg. Donor’s spermatozoa (male sperms), egg and surrogacy facilities are not available in our clinic.

8. Intracytoplasmic sperm injection (ICSI)


To all external appearances, Louise Brown looked exactly the same as thousands of other babies. But as the first child born through In-Vitro Fertilization, she was regarded quite exceptional in the history of mankind.

For generations, before IVF, there was not much that doctors could do to help infertile couples, specifically where all male factor was involved (disorders of sperm production).

However, science has progressed extensively in the field of male infertility treatments. With the options of procedures like Intra Cytoplasmic Sperm Injection (ICSI), the possibilities of parenthood for the distressed couples have increased drastically.

WHAT IS ICSI?

ICSI is highly comparable to conventional IVF as eggs and sperm are collected from each partner. The difference between the two procedures is the technique of attaining fertilization.

ICSI – STEP-BY-STEP IVF GUIDE

  1. 1. Ovarian Stimulation

Stimulation

The ovaries are stimulated with medication to promote the growth of follicles containing the eggs.

Control
The response of the ovaries is monitored with ultrasounds and/or blood tests, to control the size and quantity of follicles.

EGG Release

To assist with the final maturation of the egg and loosening of the egg from the follicle wall, an injection of Human Chorionic Gonadotrophin (HCG) the trigger is administered.

Egg Retrieval

The egg retrieval is performed 35-38 hours after the trigger under ultrasound guidance, and takes place while you are sedated.

  1. 2. Fertilization

 

Sperm Selection

The motile sperm are prepared and selected for insemination. During sperm selection a medium called Sperm Slow is used. This medium contains Hyaluronan (HA) which binds sperm that are more likely to have intact DNA and thus allows selection of these bound sperm for injection. By selecting the sperm that are bound to HA and using them for ICSI, the embryologists are preferentially using the better quality, more mature sperm.

EGG Assessment

The cumulus cells surrounding the egg are removed by a gentle enzyme so maturity of the eggs can be clearly observed.Only genetically mature eggs (MIl) can be injected using ICSI.

  1. 3. Intra Cytoplasmic Sperm Injection (ICSI)

 

Involves the injection of a single sperm directly into a mature egg.

  1. 4. Fertilization

 

The dishes are placed in an incubator and checked for fertilization 16-18 hours after insemination.

Culture

Grow in lab for 2-5 days

Embryo Transfer

The embryo chosen for transfer is loaded into a transfer catheter which is passed through the cervix into the uterus, and gently released. Generally, only one embryo is transferred, in exceptional cases two.

  1. 5. Vitrification

 

The good quality embryos that are not transferred are frozen and stored. Frozen embryos can be used in subsequent cycles if the first cycle is not successful.

  1. 6. Luteal Phase & Pregnancy Test

The Luteal Phase is the two-week period between the embryo transfer and the pregnancy test. You will be encouraged to limit your activity for 24 hours after the embryo transfer. Your pregnancy blood test will be approximately 14 days after embryo transfer.

 

WHAT ARE THE CHANCES OF SUCCESS?

Chance of success are about 40%, nonetheless in any given couple, chances of success are determined by countless factors among which quality of semen and egg retrieved from the couple are significant to the procedure for chances of conception. The success rate of ICSI/IVF seems to be low but one should bear in mind that undeniably in typical couples, the likelihood of conceiving a pregnancy in any given cycle is 1 in 6 to 1 in 9.

 

HOW MANY ATTEMPTS OF ICSI/IVF CAN BE MADE?

From a medical point of view, there in no limit on the number of attempts, but one has to take into consideration the emotional and financial stress involved in this treatment.

 

Please remember anyone can be affected by infertility and while it can be a challenging experience, the good news is that our specialists can help you explore the options available to achieve your dream of having a baby.

9. SPERM / EMBRYO FREEZING


Sperm and Egg freezing is the most successful method of preserving a man’s/women’s fertility so they can try and conceive a child (ren) at a later time in their lives.

It gives you the freedom to plan and time the birth of your child, while at the same time providing protection from the possibilities of deteriorating health later for either your partner or you. This procedure also helps provide more chances of having a healthy baby.

 

YOU MAY WANT TO CONSIDER FREEZING YOUR SPERM IF:

    • You have a condition, or are facing medical treatment for a condition, that may affect your fertility.
    • You are about to have a vasectomy and want sperm available in case you change your mind about having (more) children.
    • You have a low sperm count or the quality of your sperm is deteriorating.
    • You have difficulty producing a sperm sample on the day of fertility treatment. 
    • You are at risk of injury or death (for example, you’re a member of the Armed Forces who is being deployed to a war zone.

     

    WHAT IS SPERM FREEZING?

    Sperm Freezing is the course of collecting, analyzing, freezing and storing a man’s sperm. Sperm freezing process is also called as Cryopreservation or sperm banking.

    There are two major sperm freezing techniques such as:

    Slow Freezing

    This technique involves advanced sperm cooling over a period of two to four hours in two or three steps. The specimen is then plunged into liquid nitrogen at minus 196 degrees Celsius.

    Rapid Freezing

    It requires direct contact between sterile straws holding the samples and nitrogen vapors for eight to ten minutes which is followed by immersion in liquid nitrogen at minus 196 degrees Celsius.

    Sperm freezing is a very safe and standardized procedure. There are no risks or side effects while collecting semen samples naturally through masturbation. If surgical procedure is required then there are small risks such as bleeding or discomfort.

    Freezing your sperm and embryos is very common now. The process of freezing them is called Vitrification. It appears that sperms/eggs/embryos can all be frozen successfully for an indefinite period of time with no harm to them or any pregnancy that results from them. There are no increased risks of genetic problems in children born from frozen embryos or sperm. These children appear to be as normal as children who are conceived naturally.

    At IVF Quick Centre, we have all cutting-edge facilities for a sperm freezing procedure. We take a wide-ranging methodology to treating infertility diseases and our efforts are supported by infertility specialist doctors with vast experience and advanced technology.

    We recognize the emotional pain of infertility due to the inability to conceive and for that we provide support, direction and counseling throughout the journey with us. 

    Men/Women Have A Biological Clock – You Should Consider Freezing Your Sperm/Egg/Embryo to Enjoy Parenthood in the Future!

10. PREIMPLANTATION GENETIC DIAGNOSIS (PGD/PGS)


If you or your partner have a family history of genetic disorders or basically need the confidence that comes from exploring the best resources available, it is important to consider the use of genetic testing during your treatment. Not only does this state-of-the-art technology make IVF safer, as we are reducing the risk of pregnancy loss and at the same time we may ensure transfer of only the healthiest embryos. Genetic tests are performed on embryos to ensure the health of the chromosomes. Normally, there are 24 chromosomes (22 autosomes and an X and a Y chromosome).

 

WHAT IS PGD/PGS?

Pre-Implantation Genetic Diagnosis/Screening is a reproductive technology used with In-Vitro Fertilization (IVF) for screening and diagnosis of genetic diseases in early embryo prior to implantation and pregnancy.

 

THE DIFFERENCE BETWEEN PGD AND PGS

It is not unusual for patients to ask about the difference between PGD and PGS. The difference is extensive and yet elusive. The purpose of PGD is to diagnose abnormal embryos to confirm that they are not transmitted back into your uterus and improve your chances of conceiving a healthy baby. PGD can only be run if you know that you or your partner are carriers of a genetic condition. A specific examination will be created to test for the detailed disorder(s) that a couple is known to have.

PGS on the other hand will screen for and identify unidentified chromosomal abnormalities. This is better for patients who have a history of miscarriages or failed IVF cycles due to unidentified conditions. Most of our patients undergo PGS or Pre-Implantation Genetic Screening. It is advisable to discuss with your Genetic testing team the best option in your particular case to ensure a successful and healthy conception.

 

STEP BY STEP PGD

    • Initial checkup of husband & wife
    • Standard Hormone Profile of wife
    • Drug treatment (injections) to boost egg production & maturation
    • Ultra sound monitoring (TVS)
    • Monitor growth of follicles
    • Regulate drug doses
    • Prevent serious side effects i.e. Ovarian Hyper Stimulation Syndrome (OHSS)
    • Monitoring is carried out by:
      • Transvaginal ultrasound scanning (TVS)
      • Calculating hormone level in blood
    • Egg Pick Up
    • Semen collection and processing
    • ICSI: A single spermatozoon is injected into the egg under special (ICSI) microscope with micro-manipulator
    • PGD: Blastomere aspiration carried out at 6-8 cell stage of embryos (day 3 post fertilization)
    • Genetic screening of blastomeres performed through FISH technique
    • Transfer/Implantation of healthy embryos

     

    STEP BY STEP PGS

    We use the most progressive technology, NGS (Next-Generation Sequencing) to implement the PGS test:

    • Facility to detect aneuploidies, mosaicism and segmental alterations
    • Swift technology allowing embryos to be transferred in frozen cycles
    • New diagnostic prospects including the measurement of mitochondrial DNA copy number (Mito-Score)

     

    Our technology and experience allows to analyze 24 chromosomes.

     

    WHO QUALIFIES FOR PGS/PGD?

    • Advanced maternal age of 35 years or above
    • 2 of more recurrent miscarriages of unknown cause
    • 2 of more assisted reproductive cycles without pregnancy
    • Male factor: semen with low sperm concentration, below 5 million per ml
    • 1 previous pregnancy with chromosome abnormality, especially in an assisted reproduction cycle

     

    “The longer you wait for something,
    The more you’ll appreciate it when you get it.
    Because anything worth having is definitely worth waiting for.”

11. CARRIER GENETIC TEST (CGT)


Human beings naturally inherit one healthy and one faulty copy of all genetics. In order to determine if one or both of the healthy parents are carriers of a recessive genetic disease, couples hoping to conceive a pregnancy are recommended to take the Carrier Genetic Test (CGT). The CGT is a simple DNA test done prior to pregnancy which prevents the baby from being born with any or all of the recessive or active genetic diseases present in the DNA of the parents. This is the most advanced way to plan your baby. CGT allows us as your doctors to determine which genes are altered in each person.

 

COMMON DISORDERS DIAGNOSED VIA CGT

CGT allows us to determine most of the common mono-genic disorders, some of which are listed below:

    • Cystic Fibrosis: affects lungs and digestive system; the body produces a sticky mucus that can clog the lungs and the pancreas
    • Spinal Muscular Atrophy: affects spine muscles; causes progressive degeneration of spinal nerves and wasting of linked muscles
    • Autosomal Recessive Polycystic Kidney Disease (ARPKD):affects kidneys; growth of cysts in kidney, can cause kidney failure and affect to liver, heart, blood vessels
    • Nonsyndromic Hereditary Sensorineural Hearing Loss: affects inner ear; not associated with other symptoms
    • Mucopolysaccharidosis: affects entire body and respiratory system; inability of the body to break down sugar molecules
    • Sickle Cell Anemia: affects red blood cells; inadequate quantity of healthy, oxygen-carrying red blood cells
    • Gaucher’s Disease: affects liver, spleen, lungs, bones; enlarged liver and spleen, anemia, easy bruising due to lack of blood platelets, lung disease, bone abnormalities
    • Fragile X-Syndrome: affects brain; learning disabilities, cognitive impairments, delayed speech and language, affects more males than females
    • Beta-Thalassemia: affects blood, blood disorder that affects production of hemoglobin (iron protein)

    While a cure for genetic disorders has not been discovered yet, they can be prevented. Being a carrier does not mean that you are prone to develop an illness. We all are carriers of certain genetic mutations while also being healthy people.

    If both parents are carriers of a mutation in the same gene, the risk of giving birth to a sick child is at 25%. Every person has an average of 2 genetic mutations, where 82% of the individuals are carriers of at least one condition. If both parents obtain a positive result in the Carrier Genetic Test with a mutation in the same gene, the recommendation is to choose PGD, thus preventing their future child to be born with an illness.

12. NON-INVASIVE PRENATAL TEST (NACE)


In the case that during your trimester ultrasound an anomaly is detected, a NACE test is recommended to expecting mothers. NACE stands for “Non-Invasive Analysis for Chromosomal Examination”, and is a prenatal test for you and your baby. It uses the latest sequencing technology to help analyze the fetus’s DNA while comparing it to the mother’s DNA. This helps detect 4 types of anomalies with high accuracy.

The NACE Prenatal Test only requires a regular blood sample from the mother’s arm.

 

WHY SHOULD YOU GET NACE TESTING?

Typically, a human being has 23 pairs of chromosomes, which amounts to 46 individual chromosomes, with 2 copies of each chromosome. If one of the chromosomes is missing or if there is an extra (3 copies instead of the usual 2 of the same chromosome are called a trisomy), it can cause health and/or developmental disorders in the person.

The NACE test detects anomalies and disorders caused by trisomy of:

    • Chromosome 21 – Down’s Syndrome: causes characteristic facial features, physical growth delays, and mild intellectual disorder, mostly affects males
    • Chromosome 18 – Edward’s Syndrome: infants are born smaller than usual with heart defects and kidney malformations, mostly affects females
    • Chromosome 13 – Patau Syndrome: multiple complex organ defects, slow physical development, mostly affects females
    • Chromosome X & Y – Sexual Chromosomes*

    *only in single gestations. For twin gestations, the sexual chromosome information for the fetuses cannot be provided.

     

    WHO QUALIFIES FOR NACE TESTING?

    The NACE Prenatal Test is recommended to all pregnant women with:

    • An abnormal result in their first-trimester screening.
    • A previous Down’s Syndrome pregnancy
    • A suspicious ultrasound finding

     

    WHO CAN BENEFIT FROM NACE?

    • Single pregnancies
    • Twin pregnancies
    • Natural conception
    • IVF
    • Egg donation
    • Women of all ages and BMIs
    • Descendants of same ancestors

     

    OTHER NACE TESTS

    The NACE 24 and NACE 24 Extended tests provide information that the basic NACE prenatal testing does not provide:

    • NACE 24 analyzes and gives information about all 24 pairs of chromosomes (sex included).
    • NACE 24 Extended analyzes and gives information about all 24 pairs of chromosomes and also identifies microdeletions related to the 6 major genetic disorders and syndromes:
      • DiGeorge Syndrome
      • 1p36 Deletion Syndrome
      • Angelman Syndrome
      • Prader-Will Syndrome
      • Cri-du-chat Syndrome
      • Wolf-Hirschhorn Syndrome

13. ENDOMETRIAL RECEPTIVITY ANALYSIS (ERA)


The Endometrial Receptivity Analysis (ERA) Test is a genetic test that uses a small sample of the woman’s endometrial tissue to assess whether or not the endometrial lining is primed to receive an implanting embryo.

The ERA is performed using a biopsy of the uterus lining. The biopsy is implemented during a “mock” FET cycle on the same day that the embryo transfer is typically performed. During the “mock” FET cycle progesterone is managed for four or six days depending on the age of the embryo. Progesterone is a hormone that helps the endometrium become receptive. It involves 236 genes that play a vital role in endometrium receptivity. The biopsy is then timed to be carried out at the end of the progesterone management. Once the biopsy has been obtained, the genes involved in receptivity are examined by the Laboratory and the ERA predicts the endometrium to be “receptive” or “non-receptive” on the day the transfer would have occurred. . ERA test resulted in 73% implantation rate in patient with implantation failure.

 

FOR WHOM IS ERA SUITABLE?

The ERA Test is suitable for women who experience “recurrent implantation failure”.

 

“It’s hard to wait around for something you know might never happen,
But it’s even harder to give up when you know it’s everything you want”