Investigations of Infertile couple:

When a couple comes for consultation at Vansh Fertility Center we follow an investigation protocol before a treatment plan is created for them.

The investigations carried on the couple is directed to diagnose the problem area and to find out if male sperms are capable to fertilize? And do the woman ovaries release an oocyte in every mensuration cycle and are the fallopian tubes open enough to allow the fertilization?

Investigation that can be proposed for male partners:

• Semen Analysis

• Semen Culture

• Penile Haemodynamic Studies

• Rigiscan

• USG Scan of scrotum

• Hormonal Assays

• Karyotyping etc.

Similarly, for females the investigation methods could be:

• Psychological Assessment Tests

• Hystero Salpingo Gram (HSG)-the status of the uterine cavity and tubes

• Ultrasound Scan

• Hormonal Assays

• Endocrinological investigation

• Hysteroscopy

• Laproscopy etc.

Management of Infertility:

No two individuals are same, similarly no two cases can be worked on a fixed formula. Each couple has their own problems and complexity to be discussed and understood. At this stage the consulting doctor at Vansh explains and educate the couple about the issue, make them understand the treatment options available along with and possibilities of success of each applicable method.

It is quite possible that more than one infertility factors may exist at the same time or it is even possible that a slight stimulation can cure the infertility issues.

The treatment Plan may include one or more than one step stated below:

• Sex Therapy

• Sex Counselling

• Treatment with medicines

• Surgical Therapy

• Hormone Replacement Therapy

• Vacuum Suction Devices

• Behaviour Modification Therapy

• Supportive Psychotherapy

Intra Uterine Insemination (IUI):

The process to place washed and prepared sperms into the uterine cavity in an attempt to achieve pregnancy is named as IUI i.e.Intra Uterine Insemination. Here the semen used may from the male partner or from a donor. We monitor the follicular phase of the female by hormone testing and ultra sonography technique.The insemination is done to coincide with the ovulation in females, this maximises the chance of pregnancy. The ovulation could be natural and monitored or induced through medications and then monitored before the sperms are placed in the uterine cavity by the help of a catheter placed in the uterus through cervix.

This process is mostly applied with the patients with mild endometriosis, low sperm counts, poor sperm motility, greater percentage of abnormal sperms, sexual dysfunction, one sided tubal block, polycystic ovaries and also with unexplained infertility.

Women often have a 10 to 20 percent chance of getting pregnant with just one IUI cycle. The more cycles of IUI you undergo, the higher the chance is for a pregnancy. With 3 to 6 cycles of IUI, pregnancy rates can be as high as 80 percent. The pregnancy rate with IUI is similar to, or just slightly lower than, pregnancy rates of fertile couples that become pregnant on their own.

In vitro fertilization (IVF):

IVF (In Vitro Fertilization) ia a process where the fertilization takes place in a glass dishes or testtube, Vitro is the Latin word meaning "in glass". Thus the complete process where the ovaries are stimulated by administered fertility drugs resulting in the production of no. of eggs, these eggs are then collected in a culture dish and fertilized with prepared sperms. The prepared embryos as a result of fertilization carried outside the body using advanced laboratory procedures and techniques with the help of specialized lab infrastructure are then transferred to the womb of the female partner, is called In Vitro Fertilisation.

This process was introduced initially to solve the cases where the females had damaged tubes but today the success of the IVF treatment has turned it into first line treatment in case of endometriosis, tubo-peritoneal disturbances, pelvic adhesions, PCOD and cases of unexplained infertility, Tuberculosis with damaged tubes/uterus lining, Reduced sperm count and motility, High age, Hormonal disturbances and Premature Ovarian Failure. Even the patients with repeated failures of IUI also get help in child birth through IVF method.

Time Factor involved: One cycle of IVF takes four to six weeks to complete. The couple has to spend about half a day at Vansh Fertility center the egg retrieval and fertilisation procedures. Again you will have to visit us after two to three days for the embryos to be transferred to your uterus, or between five to six days with blastocyst transfer.

Repeated cycles: If there are any extra embryos, these may be frozen for future use. This is in case the first cycle doesn't succeed, or you want another baby after your successful treatment.

Success Rate: The IVF success rates even in the best centers in the world rarely exceed 30 - 40% per cycle. So, you will have to be very patient and optimistic for the procedure. However cumulative pregnancy rate after 3 cycles is close to 60 - 70%. Although age is also a very important factor it is more favourable for the patient under the age 37 years.

Advantages:

• For most children conceived by IVF there are no long-term problems or side effects.

• IVF can offer you a chance of having a baby even if you are unable to conceive naturally.

Disadvantages:

• A multiple birth, when more than one embryo is transferred to your uterus.

• Side-effects of fertility drugs like hot flushes, headaches and nausea, signs of ovarian hyperstimulation syndrome (OHSS) in case you are a PCOS Patient.

• Increased risk of ectopic pregnancy.

Fertility Enhancing Laparoscopic/hysteroscopy surgeries:

The conditions like fibroids, endometriosis, pelvic adhesions (scar tissue in the pelvis) and uterine anomalies such as a uterine septum and adhesions can be a reason for the infertility. Vansh Fertility centre helps you to get rid of these physical conditions through minor non-invasive laparoscopy and hysteroscopy surgeries.

Laparoscopy is a procedure where internal pelvic organ can be viewed by the help of an instrument called a laparoscope, a small telescope-like instrument with a light on one end which is passed through a small incision through the navel. There is almost no complications involved, procedures that were traditionally only done through large open incisions can now be done with the help of laparoscope.

Laparoscopic procedures are:

• Myomectomy for the removal of large fibroids or multiple fibroids

• Tubal ligation reversal

• Laparoscopic removal of large benign ovarian masses or cysts

• Hydrosalpinx (dilated tubes)

• Endometriosis and adenomyosis

• Abnormalities in the uterus

• Infections (tuberculosis)

• Adhesions due to previous surgery

Similarly hysteroscopy is a procedure where the diagnosis or minor corrective surgeries could be performed using the instrument called Hysteroscope.

Hysteroscopy can cure:

• Adhesions

• Endomental Polyps

• Exsessive Bleeding

• Improves chances of implantation and growth of the embryo and improves chances of conception.

• Uterine Fibroid

• Septum in the uterus

• Congenital anomalies in the uterus

• Removal of embedded IUCDs

Intra Cytoplasmic Sperm Injection (ICSI):

This is a very effective method to fertilize eggs in the IVF lab after they have been aspirated from the female and is mostly used in the cases with the significant male infertility.

For the males with very low sperm count (oligozoospermia), poor sperm motility (asthenozoospermia), number of abnormal sperms (teratozoospermia) or obstructive or non-obstructive azoospermia the sperms can be retrieved and injected directly to the body of the egg with the assistance of a special machine called the micromanipulator.

In ICSI the sperm doesn't have to travel to the egg or penetrate the outer layers of the egg so it helps the patient to have his own child.

For IVF+ICSI procedure the eggs after getting collected are treated to remove its outer layer, for the fertilization the egg must be in the M2 phase of maturity. The mature oocyte is stabilized by holding pipette on the left and from the right side a hollow needle holding the active sperm is inserted to the inner part of the oocyte and the sperm is released for the fertilization. The procedure takes place micromanipulation devices: micromanipulators, microinjectors, micropipettes.

The next day we check the oocyte if the fertilization is done successfully.

Laser Assisted Hatching (LAH):

Assisted Hatching is a laboratory procedure, an advanced Reproductive Technique, used in combination with the assisted reproductive technology procedures such as IVF & ICSI. It is a procedure where a hole is made in the external layer of embryo called Zona Pellucida in cleavage stage embryos (Day 3 of In Vitro development) before being transferred back to the patient’s womb. This opening will assist in the hatching process of the embryo, naturally the wall gets disolved while an embryo reaches the uterus but sometimes it is quite hard and the embryo is not able to break out of it thus causing the infertility.

At Vansh, we use the Laser technology for Assisted Hatching (LAH). A precision laser beam is focused over the zona pellucida making a small opening, between 10-20 microns to facilitate embryo hatching. This process is performed just before the Embryo Transfer. It increases the pregnancy rates by improving implantation of embryo in the endometrial wall of the uterus.

We at Vansh Fertility center recommend this process if:

• Maternal age 37 years and more.

• Patient with 2 or more previous failed IVF cycles.

• Patients having high Day 3 follicle stimulating hormone (FSH) level.

• Embryos with excessive fragmentation.

• Thick and abnormal egg shell.

• Weak or slow embryo development.

Surgical Sperm Retrieval for Azoospermic Male:

In normal couples, an egg is produced by the female partner and the male partner ejaculates a pool of millions of sperms out of which the most active and the healthy sperm wins the race to fertilize the egg. Thus this completes the fertilization phase and the egg is formed.

Now in case of the men where no sperms are formed i.e. in the case of azoospermia we use surgical sperm retrieval techniques depending upon the case of the individual.

There may be an obstruction in the vas deferens preventing the sperm flow or non-obstructive issue like some genetical problem leading to no sperm release .

Techniques used in case of obstruction:

PESA (Percutaneous Epididymal Sperm Aspiration): Again here a needle is inserted to take out the sperm but this time directly in the epididymis.

Perc Biopsy (Percutaneous Biopsy of the Testis): this is similar to TESA, but a larger needle is used. This is a 14 gauge needle usually used to biopsy testicular tissue and it usually extracts a larger number of sperm.

MESA (Microsurgical Epididymal Sperm Aspiration): it is an open surgical sperm retrieval procedure assisted by an operating microscopy. Here the tubules of the epididymis are located specifically and then the sperms are aspirated giving the best results.

Techniques in case of no obstruction:

TESE (Testicular Sperm Extraction): Here there is no collection of sperms since the problem is with the production of sperms, so through this method the scrotum is opened an testicular tissue from different regions of testicles is collected and then scrutinized under microscope to locate the sperm and collect it.

Micro-dissection TESE: It is quite similar to TESE but here micro-dissecting microscope is used so it can point the sperms in the tissue and thus targeted tissue is extracted instead of random. This results in causing less damage to the structure inside the testicle and improves the count of collected sperms.

Embryo Freezing:

This is the technique to freeze and store the developed embryos for future use. During the fertility treatment through IVF/ICSI many embryos are developed that are not used, so we at Vansh Fertility center has the option of embryo freezing and preserving to be used for the future cycles or to donate.

Although the embryo can be freezed by two ways; Slow Freezing and Vitrification(ultra rapid freezing). At our center, Vansh Fertility Center we use the Vitrification method.

Embryos Freezing can be done in the conditions like:

• Need of using the excess embryos in future IVF or ICSI cycles.

• In-case, your treatment gets cancelled after egg collection due to OHS (Ovarian Hyper Stimulation), uterus lining not prepared for implantation or any other reason which needs to be cured before placing the Embryo, the developed embryos are collected and freezed to be used in the cycles after the required treatment gets over.

• Less eggs and embryos (less than 3 of grade 1).

• Patients with low AMH and poor responders (pooling of embryos).

• History of previous miscarriage.

• History of previous ectopic pregnancy.

Blastocyst culture:

Culture of embryo and maintaining it in vitro upto the stage of Blastocyst and then transfer it to embryo is called Blastocyte culture. This procedure intends to maximize pregnancy rates while minimizing the risk of multiple pregnancies. Traditionally, we transfer the embryos to the uterus on day three after fertilization and that too we transfer three or four embryos at the same time to increase the possibility of successful pregnancy.

However, it is now possible to grow embryos in the laboratory to the blastocyst stage of development, which occurs on day five after fertilization when the embryo has 50-200 cells. The strongest, healthiest embryos make it to blastocyst stage and uptill now they have survived key growth and division processes and have a better chance of implanting once transferred. The selection of potentially more viable embryos allows the embryologist to transfer fewer embryos, often one or two, lowering the risk of high order multiples while maintaining high pregnancy rates.

Blastocyst transfer is not essential for all IVF patients. The technique is most successful with patients who are younger and have a large number of eggs available at retrieval. On average, patients with six or more high quality embryos on day three are the best candidates for blastocyst culture because there is a better chance of more embryos growing successfully to day five.