If a woman after marriage, with unprotected intercourse does not become pregnant she is called infertile.
Is it related to age of the woman?
Yes, The woman is most fertile between age of 18-24 (60-80%). The fertility goes down as age advances & becomes as low as 10-5% after the age of 40
Is it related to time period after marriage?
Just after the marriage, due to more frequency of intercourse, chance of pregnancy is more. More the years of marriage the couple has more unexplained infertility.
When should the couple see the infertility specialist?
After marriage, if the couple is unable to get pregnancy within one year of their expecting it, they should see the infertility doctor immediately & should not waste time.
W hat is Superovulation?
In this treatment medicines like Clomiphen Citrate, Letroze & hormonal injections of FSH & LH or recombinant FSH are given daily to get more than one follicle which then is made to rupture by giving injection of HCG. This process increases chances of pregnancy by 30-40%. The risk of multiple pregnancy & ovarian hyperstimulation syndrome (OHSS) is there, so this is to be done judiciously.
What investigations does a couple have to undergo in infertility work up?
Routine investigations include blood counts including HIV & HbsAG in both partners.
Tests for checking tubal patency- HSG, SSG
HSG- hysterosalpingography: In this, a radioopaquedye is injected inside the uterus and X- ray is taken to see the tubes and uterus.
SSG- Sonosalphigography saline is injected into the tubes and checked by 3D color Doppler ultrasound machine.
Tests for ovulation
BBT- Basal body temperature chart, urinary LH, Serum Progesterone on 21 st day of the menses, ultrasound follicular monitoring, and endometrial biopsy on 2 nd day of the menses to see the ovulation.
Special Investigation
Hormone assays- On 2nd day of the menses – FSH, LH, E2 (estradiol) serum Prolactin, TSH
Video endoscopy
Hysterolaparoscopy - In this, we inspect uterus, tubes ovaries and tubal patency with the help of endoscopes.
Transvaginal Ultrasonography
What is diagnostic hysterolaparoscopy (Video endoscopy)? Is it necessary in all cases?
Diagnostic hysterolaparoscopy is a small operation done under anesthesia (GA). It is a day care procedure and patients are discharged on the same day. In this operation a laparoscope is introduced inside the abdomen, and the uterus, tubes, ovaries, pouch of douglas and bowel is visualized.
Tubal patency is confirmed by injection of dye. Small corrective operations are also done through laparoscope such as ovarian drilling, adhesiolysis ,excision of myomas, endometriomas, cauterisation etc. Through hysteroscopy the uterine cavity is visualised. Polyps, fibroids, septum etc is diagnosed & treated.
Tubal ostias can be visualized and can be treated if necessary. At the end of a hysteroslaparoscopy the diagnosis of infertility is definitely established and a treatment plan is made. It is better to do a hysteroslaparoscopy in all cases of infertility before strong treatment. However it may be differed or delayed in some cases such as:
• Young patients just married with no obvious disease who may be given trial by direct Treatment Cycle.
• Cost Consideration: If patient refuses to spend for it then alternative methods of determining tubal potency such as HSG or sonosalpingography may be performed.
• If patient has undergone laparoscopy earlier.
• If patient is unfit to undergo operation.
A good diagnostic hysteroslaparoscopy is the gold standard basic investigation in infertility work up.
Is it necessary to get all these investigations done and spend so much money?
A good work up pays in the long run. Results will come faster and cheaper in the long run. Incomplete work up will result in half hearted treatment which will delay pregnancy and total cost will go up.
What are the usual treatment options given to the patient?
Usually during a hysterolaparoscopy, undergoing problems are diagnosed and treated. The following treatment options are available to the patient:
1) Planned Relations
2) Super ovulation with intra uterine insemination. In super ovulation with IUI the woman is given hormones (oral and injectables) to stimulate her ovaries to produce more eggs.
Follicular developments is monitored using serial ultrasonography when the follicles are mature, a hormonal injection is given to help them rupture. Then an intra uterine insemination is done using washed capacitated sperms. If the sperm count is good then this procedure has a 40-50% success rate and the patient has a good chance of getting pregnant in 3 cycles.
What is IVF-ET (In Vitro Fertilization Embryo Transfer) Test-Tube baby? When is this needed to be done?
IVF-ET is needed to be done is patients with blocked fallopian tubes. It may also be done in other forms of infertility where IUI super ovulation has failed. In this the woman is subjected to controlled ovarian hyper stimulation using hormonal injections.
Many more injections are required because we want to retrieve as many eggs as possible. Once the follicles have reached an appropriate size, egg aspiration is done and the eggs are collected in a petridish with a media. Capacitated sperms are then mixed with eggs and fertilisation is achieved .
Once embryos are formed then they (2-3 embryos) are transferred into the uterus on day 3 or day 5. Progesterone support is then given chemical pregnancy is diagnosed by B-HCG on day 30 of menstrual cycle. Live pregnancy is confirmed by 5 weeks by seeing a live foetal heart on vaginal sonography.
What is ICSI and when is it done?
ICSI is Intra Cytoplasmic Sperm Injection . In this, a single sperm is injected into the oocyte (egg) using a robotic micro manipulator. Other steps are same as IVF.
Indications of ICSI include:
a. Severe Oligospermia
b. Azospermia where sperms are retrieved from epididymis or test.
c. Failed fertilization in IVF
In fact ICSI has revolutionized treatment of male factor infertility.
What are the other options for patients with nil sperms or very low count of sperms?
The other options apart from ICSI are:
a. Donor insemination
b. Adoption
Donor may be bought from sperm bank. Many case of donor sperm donor must be screened for VDRL, HIV, HbsAg, genetic disorders, Blood Group, caste, educational status, built color of skin, hair, eyes and any other specific features are also taken into consideration.
What is operative Endoscopy – How does it help in infertility?
With advance technology, minimal invasive method can be used to remove different obstructions in the way of woman's fertility.
• With operative hysteroscopy – septum, fibroid & polyps & adhesions (synuchiae) inside uterus can be removed. Cornual catheterization can open the proximal tubal block.
• Operative Laparoscopy- Along with checking the uterus, tubes & ovaries it can treat the diseases like, fibroids, endometriosis, ovarian cysts, Dermiod, Polycystic ovaries, adhesions & also do Tubal microsurgery.
