| FAQ's About Infertility
What happens at the first appointment ? It is
preferred that you bring along all available previous tests that you and your
husband have undergone and the medicines you have takes. The doctors will review
your menstrual history, past tests and treatments and then examine you. A general
as well as gynae . Check up will be done and certain investigations will be ordered
as required in your case. After the basic tests are done, your doctor will discuss
the various treatments. Options and a plan of treatment will be decided. You are
free to ask any questions and get your doubts cleared.
If the treatment
is IVF/ ICSI, the plan would include blood tests , counselling, ovarian stimulation,
egg collection, embryo transfer, luteal phase support and test for pregnancy.
An
appointment is given at a later date to review the result of tests ordered and
modify the treatment plan where appropriate. What advise
would you given to an overseas couple who to come to India for IVF treatment ?
It
would be useful if you can arrange for your blood to be tested for FSH level on
day 2 of the menses in your home country. You and your husband should arrive in
India just after your menses have stopped. This would allow you time for preliminary
consultation,
Counselling and tests. The treatment of IVF takes about 6-8 weeks,
during which you will be required to visit the center 6-8 times. If your husband
can not afford this time he can come for about 5-7days. This visit can be scheduled
around the expected time of egg retrieval which will be told by the IVF specialist.
If however he is busy on those dates, he can come earlier for a few days when
his sperms can be frozen and subsequently used for IVF or ICSI as required.
What accommodation is available close to Chawla Nursing Home ? The
following are some of the nearby hotels which are within walking distance :
Hotel
Raddison
Hotel Leo Fort
Hotel Kamal Palace
Hotel Shingar
Hotel
President What are the factors which influence outcome
? The chance of pregnancy is influenced by your age and
your basal FSH level. In general, the younger you are the better the outcome.
The
chance of pregnancy is dependent on the number of embryos transferred and the
condition of the lining of the uterus. Although more embryos transferred increase
the chance of pregnancy it also results in a higher chance of multiple pregnancy
with its associates problem of premature births. In practice, two or three embryos
are transferred.
What is ICSI ?
Intra Cytoplasmin
Sperm Injection (ICSI) is modification of IVF. ICSI is a procedure in which one
immobilized sperm is sucked into a very narrow pipette and then injected inside
the egg, allowing fertilization to take place. It is usually employed when sperms
are unable to enter eggs by their own power. Most forms of male infertility can
be solved by use of ICSI and sperm donation is less necessary.
What
is Assisted hatching ?
Some women have egg shells (zona pellucida) which
are hard and which may prevent the developing embryo from hatching and implanting
in the uterus. In order to assist in hatching an opening is made in the shell
of the egg. This can be done either mechanically, optically (laser) or chemically
(acid). In ICSI cases, the egg shell has already been weakened by the insertion
of the sperm injecting pipette. In theory, this would allow hatching to occur
more easily What is Embryo transfer ?
This is the
process in which embryo formed after fertilization of eggs & sperms are placed
inside your uterus using a flexible catheter. This procedure is painless. Insertion
and removal of the catheter are done slowly with ultrasound guidance. After the
catheter is removed, it is checked under the microscope to ensure that all the
embryos have been placed in the uterus. What is the Ideal
Number of embryos to be transferred ?
Usually two embryos are placed inside
your uterus at a time. This is because the chance of pregnancy is low when only
one embryo is transferred. On the other hand, there is the possibility of a triplet
pregnancy with three embryos are transferred. Triplet pregnancy carries a higher
chance of premature delivery and should be avoided.
The actual decision in
each case would depend on various factors. The transfer of three embryos is considered
if you are about the age 37, have a raised basal FSH level, embryos are not of
very good quality or have been unsuccessful in pervious attempts at IVF. Is
bed rest necessary after embryo transfer ?
There does not appear to be
any difference in the chance of pregnancy whether there is best rest or not. However,
it is preferred that you do not engage in strenuous activities. Can
I have Sex with my husband during the two weeks after embryo transfer ?
Coitus
during the two weeks after embryo transfer does not have a adverse impact on the
chance of pregnancy. However if your ovaries are big in size, your doctor may
advise you to abstain from sexual relations. What is Implantation
?
This is the process by which the embryo attaches itself to the internal
lining of your uterus and starts to take nutrition and oxygen from you. This takes
place a few days after embryo transfer. When is the earliest
time I can do a test for pregnancy ? Blood test for detection
of pregnancy is done fourteen days after the embryo transfer. Doing it earlier
may produce a negative result even if you are actually pregnant because the level
of HCG very early pregnancy is very low. On the other hand, if you are given implantation
(Luteal) phase support in the form of injections of HCG (Profasi) you may get
a positive result even if you are actually not pregnant. Hence, it can be misleading
to do the pregnancy test too early. What is the significance
of a raised basal follicle stimulating hormone (FSH) level ?
A raised basal
FSH level means that the number of eggs remaining in the ovary is reduced. A higher
dose of ovarian stimulation medicine would be required to produce ripe eggs. Even
so, some of the eggs may be sub optimal in quality.
If the level is very high
and in the menopausal range, this indicates that there are no eggs left in the
ovary which are capable of ripening. Using eggs from an egg donor may be a more
effective approach. What is ovulation Induction? Ovulation
induction means giving medicines (tablets or injections) for egg formation. Tablets
are given from D3- D5 of menses while injections may be added later on by your
doctor. Ovulation induction is a must for all patients who are not forming eggs
naturally e.g. patients of polycystic ovaries or those who have sub optimal egg
formation. Ovulation induction which leads to formation of more then 1 egg (about
2-4 in number ) is also utilized for increased pregnancy rates in cases of unexplained
infertility or donor insemination. The results of IUI are much better if done
along with injections of HMG/FSH. When do I know that my
eggs are ripe ?
When two or more of your leading follicles are 18mm or
more in average diameter your eggs are mature enough to have the HCG trigger injection.
Usually there will be clear mucus from your vagina and the ultrasound scan would
show an endometrial thickness in excess of 8 mm. How is
egg collection done for IVF ? You will not have food or
drink for six hours before the procedure. You will empty your bladder and be placed
under a short general anesthesia for usually less then fifteen minutes. A needle
will be inserted under vaginal probe ultrasound scanning. The follicles will be
emptied systmatically and aspirated fluid will be examined under a dissecting
microscope for the cumulus oocyte complex.. Antibiotics will be given After a
five hour rest, you can go home. You may experience a little lower abdominal discomfort
for a short while which is relieved on taking a pain killer. What
are the best tests for ovulation ?
Ovulation status is assessed by noting
the menstrual cycle length and regularity. If you have a cycle length shorter
than 26 days, it is useful to do basal follicle stimulating hormone (FSH) test
on the second day of your menstrual cycle to see your egg reserve.
If you have
intervals between menses of longer than 34 days, poly cystic ovarian diseases
(PCOD) is suspected. This is confirmed be finding a ring of small follicles in
your ovaries on ultrasound scanning.
If you have an irregular menstrual cycle
and problem with ovulation is suspected, you will be given an appointment to return
on day 2 of your next menses for your blood to be taken for testing hormones :
Follicle stimulating hormone, luteinizing hormone, Estradiol, Thyroid stimulating
hormone and prolactin. The eggs develope within a fluid filled
structure called follicle. Usually some fourteen days after the first day of the
menses, this follicle bursts open (ovulation) to release the egg (oocyte). The
remaining follicle wall develops into a yellow body (corpus luteum) which produce
a hormone called progesterone. This prepares the internal lining (endometrium)
of the uterus for implantation of the fertilized egg (embryo). A raised progesterone
level some seven days before the expected next menses indicates that ovulation
has taken place. Progesterone also raises the basal body
temperature (BBT). BBT is your body temperature taken on the first waking up in
the morning. When charted over a menstrual cycle, a shift to a higher temperature
is seen at about mid-cycle denoting ovulation. The developing
follicle can be seen by use of a vaginal probe ultrasound scan. In unstimulated
cycle only one of the many small follicles would grow and ovulate. This can be
tracked by using the trans vaginal probe ultra sound scan. In unstimulated cycle,
ovulation is imminent when the leading follicle is more than the 16 mm in average
diameter. However, when you have received medicines to stimulate egg production,
ovulation usually occurs after the leading follicle reaches 20mm in average diameter. The
endometrium can show the influence of progesterone. A biopsy specimen of endometrium
can be used to indicates that ovulation has occurred. However, the biopsy procedure
can be uncomfortable.
Most of the test show ovulation only after it has occurred
and is not useful in predicting imminent ovulation for the purpose of timing coitus
or insemination. The urine luteinizing hormone test can predict
ovulation within 24 to 36 hrs. This is a do it yourself urine test on the first
morning urine specimen during the five days when ovulation is anticipated. For
tracking of ovulation and timing of coitus or intra uterine insemination, the
preference is to use the vaginal probe ultrasound scan to assess the follicle
size. Since the follicle grows at about 2 mm per day, the time it reaches 20mm
can be predicted. The urine LH test is the used at around the predicted time to
anticipate the day of ovulation more precisely. What
are the Fallopian tube patency tests ?
Your fallopian tubes will be checked
for blockages.
The initial preference is to perform an X-ray examination called
Hysterosalpingogram (HSG). This involves coming on day 7 or day 8 of your menstrual
cycle. You will be brought to X-ray department. Are radio-opaque liquid will be
flushed into your uterus and fallopian tubes. An X-ray is taken to show the liquid
spilling out from your tubes. .Another way to assess whether
your fallopian tubes are blocked is to perform an operation called video laparoscopy
and hydrotubation. This is an invasive procedure involving the insertion of instruments
through the abdominal wall to see your uterus, ovaries and fallopian tubes. It
will be performed painlessly under general anesthesia. Methylene
blue is added to sterile water and flushed into the uterus and out through the
tubes to test the blockage. A major advantage of this procedure is that various
problems which may be the cause of your failure to conceive can also be corrected
at the same time. These are Endometriosis, ovarian cyst and pelvic adhesions.
Even some blocked fallopian tubes can be opened. The laparoscopic procedure can
be used for diagnosis as well as treatment. Since ovulation
induction treatment can help some couples get pregnant with minimal discomfort,
and since the majority of laparoscopic examinations fallopian tubes show no blockage,
the initial preference is to try few cycles of ovulation induction before proceeding
to the operation. What is Hysteroscopy ?
Hysteroscopy
is a procedure of inspecting the inside of the uterus with an optical instrument
(hysteroscope) inserted through the cervix from below. This allows abnormalities
in the uterine cavity to be seen and dealt with. Hysteroscopy performed before
IVF is useful because it permits polyps and other problems within the uterus to
be seen and corrected. It also enlarges and smoothens the canal leading from the
neck of the uterus (cervix) to the uterine cavity proper. This ensures ease of
replacement of the embryo and improves the chances of pregnancy. Hysteroscopy
is usually done as a day surgery procedure. What is operative
laparoscopy for infertility ?
This is minimally invasive operation performed
under general anesthesia where small incisions in the abdomen allow instrumental
access to view the pelvic organs and to correct problems in the pelvis. Laparoscopy
is used for assessing the state of health of the fallopian tubes. The fallopian
tubes are not blocked if there is spillage of methylene-blue tinted water flushed
into the uterus from below. Laparoscopic surgery can permit
the removal of ovarian cyst and myoma, separation of adhesions and destruction
of deposits of endometriosis. The objective is to restore the pelvis into a healthy
state. The best time to perform laparoscopy is after the
menses. The day before the procedure, medicine is taken to clear the intestines.
At
the umbilicus a 1cm incision is made for the laparoscope. The pelvic organs are
inspected and another two or three 0.5 cm incisions are made in the lower abdomen
for specialized instruments to perform the required surgery. The duration of surgery
varies according to task at hand and varies between half an hour to two hours. After
the procedure you will feel minimal discomfort and should be able to go home the
next day and be able to go back to work within a week. If
laparoscopy is done for fertility assessment, it is preferred to also have a hysteroscopic
examination at the same time.
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