Intra uterine Insemination (IUI)
In this fairly simple procedure, sperm is placed within the uterus around the time of ovulation. With the aid of an ultra sound scan the exact size, time and state of the ovarian follicles can be known. The semen is washed in a special media and then processed so that the most active and healthy sperms are available, leaving the dead sperm and other debris. This processed sample is placed into the uterus of the woman. And when the woman’s egg travels down her tubes on their own at the time of ovulation, these sperm fertilise it, as would happen naturally.. Ovulation induction combined with IUI is often the first course of treatments. IUI alone offers a good conception rate per cycle while combining ovulation induction with IUI may boost this rate. Gonadotropins combined with IUI offers a 25-30% per cycle conception rate. (Rates worked considering minimal to mild tubal damage, normal to mild sperm abnormalities and women less than 40 years old.)
Surgical and Non Surgical Sperm Aspiration techniques
When the Semen Analysis shows very poor results such techniques are required to retrieve sperm for the IVF or ICSI program. Various techniques such as Vasectomy Reversal, Microscopic Vasovasostomy, Microscopic Epididymovasostomy, Microscopic Vasal Sperm Aspiration, Microscopic Epididymal Sperm Aspiration (MESA), Testicular Sperm Retrieval from Biopsy(TESA), Transurethral Resection of Ejaculatory Ducts, Sperm Retrieval by Fine Needle Aspiration (PESA) are attempted now. Sperm retrieval from Testicular Biopsy (TESA) is the most commonly practised procedure. Multiple biopsies have succesfully retrieved mature sperm from over 60% of male patients diagnosed as Sertoli cell only syndrome (SCOS) cases. These techniques combined with an ICSI cycle offer hope even to azoospermics and have allowed such couples to have a baby of their own.
In-Vitro Fertilisation (IVF), Embryo transfer and Blastocyst transfrer
In Vitro Fertilisation (IVF) involves removing eggs from a woman, fertilizing them with sperm in the laboratory (in a culture dish, actually, not a test tube) and then transferring the fertilized eggs, or embryos, into the uterus a few days later. More specifically, after super ovulation with hormones to produce multiple eggs, the IVF team retrieves the eggs under ultrasound guidance. The semen is processed meanwhile in special media to obtain the most active and healthy sperm excluding all the dead sperm and other debris cells found in the semen. This processed semen and the retrieved eggs are placed in sterile culture media and kept at normal body temperature inside an incubator, where fertilization and early cell division take place. The team returns the embryos into the uterus at an apprpriate stage of the embryo development. From that point, if the embryos implant successfully, the pregnancy continues as it would naturally.
IVF is a particularly good alternative for a woman who produces mature eggs but can't conceive naturally because of blocked, damaged or absent fallopian tubes and patients with luteinized unruptured follicle syndrome,who develop but doesn't release mature eggs from her follicles. In Vitro Fertilization (IVF) offers a much higher chance of success per cycle for tubal damage than can surgery. Tubal scar tissue is often inside the fallopian tube and surgery can only repair the outside of the tube.
Once the egg is fertilised, it takes around 48 hours for the embryos to develop into a four celled stage. Usually embryo transfer into the uterus is done any time after the four celled stage is attained. Depending on the time of transfer, the embryos may be anywhere between the four celled, six celled or eight celled stage.
When the Embryo is cultured upto the fifth day, it develops into a Blastocyst. The chances of a blastocyst implanting and continuing as a healthy pregnancy is more than that of an embryo at an earlier stage. But it should be noted that the success rates have not increased with Blastocyst transfer. It allows avoiding multiple pregnancy as the number of embryos required to be transferred is lesser in the blastocyst stage.
Intra Cytoplasmic Sperm Injection (ICSI)
Intra Cytoplasmic Sperm Injection or ICSI has brought a revolution in Assisted Reproduction, offering lot of hope for infertile couples and a much higher success rate for the ART programs. Intra Cytoplasmic Sperm Injection is a micromanipulation technique developed to help achieve fertilization for couples with severe male factor infertility or couples who have had failure to fertilize in a previous In Vitro Fertilization attempt. The procedure overcomes many of the barriers to fertilization and allows couples with little hope of achieving successful pregnancy to obtain fertilized embryos.
The ICSI procedure like an IVF program requires that the woman partner undergo ovarian stimulation with fertility medications so that several mature eggs develop. These eggs are then aspirated through the vagina, under ultrasound guidance, and incubated under precise conditions in the embryology laboratory. The semen sample is prepared by centrifuging (spinning the sperm cells in a special medium). This process separates live sperm from debris and the dead sperm. The micromanipulation specialist picks up a single live sperm in a special needle and injects it directly into the egg. Fertilisation is almost assured with an ICSI program. Through the ICSI procedure, many couples with difficult male factor infertility problems such as oligospermics and azoospermics have achieved pregnancy. The success rates of ICSI programs are higher than a regular IVF program.
Pre Implantation Genetic Diagnosis (PGD)
Pre Implantation Genetic Diagnosis offers the latest technology for diagnosis of Genetic disorders before implantation of the Embryo in the uterus. This is an alternative to Pre-natal genetic diagnostics which can only detect disorders once the embryo has implanted and grown into a foetus. PGD offers the hope of a healthy baby in couples with genetic disorders. The embryos cells are taken before implantation or transfer into the uterus and examined for genetic disorders. Taking a cell or two at this stage does not hamper the normal growth and health of the foetus as all cells at this stage are totipotent (capable of growing into a full foetus by itself). PGD is done by techniques such as Fluorescent in-situ hybridisation(FISH) and karyotyping.
Cryopreservation or freezing allows preservation of sperms in future spontaneous ovulation cycles and embryos in future frozen cycles of IVF. This is an advantage if many eggs are retrieved and fertilized.
Saving eggs for future use by fertilizing them with sperm and then freezing them as pre-embryos can be helpful. Frozen pre-embryos can be transferred during subsequent spontaneous (natural) ovulation cycles without subjecting the woman to any additional medications and another egg retrieval. At the right time during succeeding treatment cycles, the frozen pre embryos are thawed & transferred into the uterus.
The ability to preserve pre-embryos for future use lowers the total cost of repeated IVF treatments since the most costly first few stages (ovulation induction, egg retrieval, fertilization) don't have to be repeated. Another advantage is that one or more pre-embryos can be transferred during a natural ovulation cycle when the woman's uterus is naturally ready for implantation.
Cryopreservation of sperms also are particularly useful when the husband is not living with the wife. This allows the wife to go ahead with the IVF program while the husband is away. In the state of Kerala, in India this facility is valuable for many couples whose husbands are in the Gulf states, so that the wives can continue treatment in their absence. Sperm freezing is also relevant for patients undergoing surgery or radiation or chemotherapy that can affect their fertility. Sperm can be frozen before the therapy and maybe later used for an IVF or ICSI program if desired.
Egg freezing and Ovarian Tissue freezing
Freezing eggs and then using it succesfully for a live pregnancy is still at research level. Though eggs can be frozen the quality of the eggs are affected. Research is on to find a suitable cryo preservant for eggs which can preserve the quality as well. But excised ovarian tissue has been frozen and then later transplanted back to the patient to obtain mature eggs from the woman. This technology is relevant for patients undergoing surgery or radiation or chemotherapy that can affect their fertility. Such women can have their ovarian tissue frozen for later use before the procedure.
For the worst hit patients we provide Donor programs. Patients who have no chance of obtaining their own sperm or egg, can opt for donor programs and thereby the couple can have a natural pregnancy, though the genetic material of the off-spring is different. After completing all medico-legal formalities and signing appropriate informed consent forms patients can chose to join such a program.