INDORE

Female Fertility

Female Fertility- Treatment and Testing

Female Fertility Test

Tubal Patency Test

  • Tubal disease can account for 25-35 % of female factor infertility.
  • Tubal patency test is done to check if fallopian tubes are open.
  • It can be done if couple have fair chance of pregnancy by natural sexual intercourse or by intra uterine insemination ( IUI )
  • Basic procedure in all types of tubal patency test involves pushing a liquid into0 uterocervical canal & checking if it is coming out through fallopian tubes into peritoneal cavity.

What are various methods of tubal patency test ?

There are 3 main type of tubal patency tests-

  • Hystero -salpingography(HSG): A radio opaque dye is pushed into uterine cavity & its flow is visualized using X ray.
  • Sono -Salpingography (SSG): Here pre medicated normal saline is pushed into uterine cavity & its flow is visualized using ultrasonography.
  • Laparoscopy with chromopertubation: It is done under general anaesthesia. A liquid dye is pushed into uterine cavity & its flow is directly seen by doing laparoscopy.

The advantage laparoscopy of is that any corrective surgery can be done during same procedure.

When we should consider tubal patency test ?

  • History of tubal ectopic pregnancy
  • History of pelvic infections or pelvic inflammatory disease.
  • History of pelvic or lower abdominal surgery.
  • Endometriosis

What are the chances of pregnancy after tubal patency test ?

Pregnancy chances depend upon various complex factors like

  • Age of woman
  • Ovarian reserve
  • Duration of infertility
  • Whether block is in proximal (uterine end) or distal (ovarian end) part of tube
  • The quality of sperm
  • Experience of surgeon if any corrective surgery is planned.

Endometrial Receptive Array

What is ERA ?

-ERA is an abbreviation for Endometrial ReceptivityArray or Analysis.

-This is specialised  genetic test carried out on a tiny portion of the woman’s uterine  lining to determine  the most appropriate day to transfer embryo during an IVF cycle.

Who can benefit from ERA?

Endometrial Receptivity Array test is done in couple with repeated implantation failure.

How is ERA test done?

  • Endometrial biopsy for ERA test can be done in natural ovulation cycle or after giving hormonal treatment.
  • After endometrial biopsy the genetic material is extracted from the endometrial tissue.
  • The extracted genetic material (RNA ) is tested for 236 genes which are normally expressed during implantation window.
  • The result of ERA is reported as pre receptive or non-receptive
  • ERA test may be repeated in some cases when report is pre or post receptive.
  • This guides us to decide the most suitable day for embryo transfer.

Is there any limitation of ERA test?

  • A normal ERA test (receptive) does not guarantee delivery of a healthy baby.
  • Pregnancy may fail to start & continue if there is embryo abnormality.
  • ERA checks the receptivity of endometrium during physiological implantation window.
  • Similarly ERA cannot tell us about condition of uterus to carry pregnancy till healthy delivery.

Decreased Ovarian Reserve

Ovarian reserve is the number as well as quality of the remaining eggs in both ovaries at a given age.

Egg quality directly affects embryo development & the ‘take home baby ‘rate.

Ovarian Reserve Test ( ORT ) helps to determine the chances of natural conception as well as with treatment.

It is very important to identify women with low ovarian reserve so that they can take important decisions regarding their own fertility in a timely manner.

 

Following are the risk factors for Decreased ovarian reserve :

  • Family history of early menopause
  • Ovarian surgery especially for endometrioma.
  • Surgical removal of part of ovary (for cystectomy) or removal of one whole ovary (Oophorectomy )
  • Cancer survivors after pelvic surgery , chemotherapy or radiotherapy
  • Smoking
  • Ovarian inflammation -endometriosis & pelvic infection etc.
  • Unexplained infertility
  • Poor response in previous IVF cycle
  • Known case of certain genetic conditions like Turner syndrome & mutation carriers like Fragile X /FMR1 /BRCA -1

 

Ovarian reserve should be tested in following conditions also :

  • Planning fertility preservation
  • Candidate for IVF
  • Planning to delay pregnancy for personal reasons

 

Ovarian reserve can be determined with Ovarian Reserve Test ( ORT ):

  • USG for Antral Follicle Count (AFC scan) – Good for number of eggs.
  • Blood test for determination of Anti Mullerian Hormone ( AMH ) – Good for number of eggs & quality to some extent.
  • Blood test to assess function of ‘Hypothalamic -Pituitary -Ovarian axis’ – Follicle Stimulating Hormone (FSH,) Luteinising Hormone (LH) & Estradiol.

 

Caution while interpreting result of ORT :

  • None of above test can predict the chance of pregnancy with 100 % accuracy.
  • Most important factor determining chance of conception is quality of oocyte which cannot be assessed precisely with any available test.
  • A woman with good ovarian reserve may face difficulty in having a healthy baby due to issues in sperm quality or implantation issues.
  • Woman with low AMH & AFC also can conceive with individualised treatment protocol.
  • Women with low ovarian reserve should consult a fertility specialist to discuss their treatment choices.

Ultrasonography

Ultrasound imaging makes use of ultrasound waves to visualise internal organ of body.

 

Baseline Pelvic USG

1st visit USG is done in detail to assess following conditions which may affect fertility :

  • Ovarian reserve
  • PCOD
  • Endometrioma in ovary
  • Stage 3-4 endometriosis
  • Any ovarian cysts
  • Fibroid
  • Adenomyosis
  • Polyp
  • Endometrial thickness
  • Any abnormality in shape or size of uterus
  • Hydrosalpinx
  • Health of your pregnancy.

 

Antral Follicle Count Scan (AFC scan)

Ovarian reserve is checked by doing Antral Follicle Count ( AFC) during initial visit itself.

Antral Follicles are tiny 2-10 mm follicle, each containing 1 egg.

Follicular Monitoring Scan

Growth of the follicle, uterus lining thickness & ovulation timing are checked by doing follicular monitoring USG.

Oocyte retrieval & Embryo transfer

Retrieval of oocytes ( eggs ) from ovaries & transfer of embryos into the uterus are done under ultrasound guidance.

USG guided ovarian cyst aspiration

Cyst aspiration can be done as day care procedure to drain ovarian cysts.

We offer following USG services using 2D & 3 D technique.

Use of ultrasound in men

For men ultrasound is done in few select cases to assess following conditions:

  • Varicocele
  • Penile blood flow assessment ie, penile doppler cases of erectile dysfunction
  • Accessory male glands in few cases if there is low sperm count or suspected infection
  • Volume of testis in men with very low or nil sperm count.

Female Fertility Treatment

Ovulation Induction

  • Ovulation Induction aims at correcting ovulation disorder.
  • First step is correction of any condition causing ovulation problem like thyroid , prolactin or adrenal hormonal issues, extremes of body weight etc.
  • Fertility drugs called ovulogens are given to induce growth of ovarian follicles containing eggs.
  • These medicines are commonly oral tablets (like letrozole, clomiphene citrate & tamoxiphene citrate) or sometimes gonadotrophin hormone injection (Recombinant FSH/urinary FSH)
  • Usually Ovulation Induction treatment is done for 3-4 cycles.

Who can benefit from Ovulation Induction :

  • Women with PCOD -the aim is to induce ovulation of 1 follicle.
  • Woman with unexplained infertility- the aim is to induce growth of 2-3 follicles.
  • Couple who are advised to undergo IUI.

 

What to expect during Ovulation Induction

  • Ultrasound on day 2/3 of period to rule out any ovarian cyst.
  • Fertility medicines are started from day 2-5 of menstrual cycle.
  • Follicular monitoring ultrasounds from day 8 of period in 1st OI cycle .It is repeated once in 2-3 days.
  • Ovulation trigger with injection of HCG( Human chorionic gonadotrophin ) is given once the follicle size is 18-20 mm.
  • Regular sexual intercourse is encouraged during fertile period
  • If IUI was advised , it is done on the day of ovulation
  • Urine pregnancy test with home testing kit 14 days after ovulation.

 

Success rate after OI

  • Usually 8- 16% success after 1 cycle of OI is expected.

  • It depends on many factors like underlying pathology , age of woman , semen quality & duration of infertility , condition of fallopian tubes etc.

Platelet Rich Plasma Therapy

  • PRP is platelet rich plasma extracted from patient’s own blood.
  • Platelets are rich in growth & healing factors.
  • These growth factors promote healing of tissue.
  • There is no risk of getting any viral or bacterial infections as PRP is extracted from patients own blood.

General outline of PRP treatment

  • Approximately 50 ml blood is collected & centrifuged to separate PRP extract.
  • This PRP is injected into ovaries or instilled into uterine cavity to promote the tissue healing & regeneration.

PRP for ovarian rejuvenation

  • PRP can encourage improvement in egg quality, number and response to fertility  
  • PRP is injected into 2 points in each ovaries with help of special long needles.
  • Peak improvement in ovarian function is expected in 1-3 months.

PRP for endometrial rejuvenation

  • Persistently thin endometrium to promote the growth on endometrial lining .
  • RIF cases to improve endometrial receptivity.

Intracytoplasmic Sperm Injection

  • ICSI is advanced modification of IVF  to fertilise egg with sperm .

  • During ICSI each oocyte is held & injected individually with selected sperm by trained embryologist .

  • That is why the term ICSI- Intra Cytoplasmic ( of oocyte here ) Sperm Injection is used .

 

ICSI is preferred over IVF in following cases:

  • Woman with low number of eggs.
  • Men with very low number of sperms.
  • Men with poor sperm quality.
  • Men with poor sperm motility.
  • Men with perm retrieved after TESA / micro TESA in cases of azoospermia.
  • Couple with previous partial or total fertilisation failure.
  • Couple using frozen sperms.

Medical Genetics

Basic outline of genetic testing of the embryo :

1st step -Genetic counselling to determine if the couple needs genetic test of the embryo & which type of test  should be done .

2nd step -IVF /ICSI procedure to get embryos.

3rd step -Blastocyst culture to get embryos with best implantation potential .

4th step -Embryo biopsy  : Collection of 5-7 cells from blastocyst stage embryo using special microsurgical instruments .

- Implantation & future growth potential of the embryo is not compromised when biopsy is done on blastocyst stage embryos. 

5th step - The genetic material , DNA is extracted from these cells & tested for genetic diseases  using specially made  genetic test probes.

6th step - Transfer of normal embryo in womb

-In most cases cryopreservation of embryo is required till the final result of genetic test is available .

 

There are 3 type of embryo genetic testing :

 

(1) Preimplantation Genetic Testing for Aneuploidies ( PGT-A):

  • Earlier it was called Preimplantation Genetic Screening ( PGS ) .
  • The aim is to look for presence of any aneuploidies ( extra or missing chromosome ) of the embryo .
  • It can help to select the embryos with normal chromosomal pattern which will have highest chance of becoming healthy babies .
  • It is done when there’s no known evidence of a genetic abnormality in either parent.

 

Who can benefit from PGT-A ?

  • Female partner age 38 or older.
  • Couples interested in a single embryo transfer.
  • History of repeated pregnancy loss .
  • History of repeated failed IVF .
  • Couple with more number of embryos can choose to select the normal embryo to decrease ‘ time to pregnancy ‘.
  •  

(2) Pre Implantation Genetic Testing for Monogenic Diseases (PGT-M):

  • It was earlier called Preimplantation Genetic Diagnosis( PGD ) .
  • It is recommended when there is known risk of passing down a genetic abnormality to future offspring .
  • Genetic test report of affected family member is analysed in details to plan treatment for the couple .
  •  

Who can benefit from PGT-M ?

  • Personal or family history of single-gene defects—such as cystic fibrosis, haemophilia, sickle cell anaemia, muscular dystrophy , citrullinemia , multiple exostosis etc.

 

 

(3)Pre Implantation Genetic tests for Structural Rearrangement (  PGT- SR )

  • Chromosomal structural rearrangements are translocations , inversions ,duplications or deletions of part of chromosome .
  • Many time carriers of structural rearrangement are apparently healthy individuals .
  • Most of the times structural rearrangements are suspected & detected only when such individual suffer from repeated IVF failure ,  repeated miscarriage  or birth defects in their babies .

 

Who can benefit from PGT-SR ?

  • In known carriers of chromosomal structural rearrangement normal embryos can be selected by PGT SR.

3rd party reproduction & gestational surrogacy

-Third party reproduction involves use of donor sperm, donor egg or  donor embryo to conceive  or taking help of gestational surrogate to carry the pregnancy.

-The couple who will raise the baby after delivery are called ‘Intended Parents’.

-The person who will donate the sperm, egg , embryo or carry the pregnancy is the ‘Third Party ‘.

-Third party reproduction involves teamwork of your fertility physician, psychological counsellor, gamete donor agencies, gestational surrogacy agency, social worker & lawyer .

 

Who may need egg donation ?

  • Ovarian failure in cases of cancer treatment with radiation, chemotherapy or surgical removal of the ovaries.
  • Carrier of serious genetic diseases.
  • Advanced age & menopausal women .
  • Poor quality embryos during previous IVF cycles due to poor quality eggs.

Who may need sperm donation ?

  • Men with azoospermia with failed surgical sperm retrieval.
  • Carrier of serious genetic diseases.
  • Poor quality embryos during previous IVF cycles due to poor sperm quality.

 

Who may need gestational surrogacy ?

  • Woman who does not have a uterus since birth or have undergone surgical removal of uterus.
  • Woman who has a serious health risk in carrying pregnancy.
  • In few selected cases with history of recurrent miscarriage or IVF failure.

 

It’s very important to avoid any conflict in 3rd party reproduction :

  • You should discuss about other possible ways of biological parenthood.
  • Try to gather all information about 3rd party reproduction.
  • Don’t keep your concerns to yourself.
  • Ask the team of professionals involved in your case.
  • Keep all documents.

Ask for transparency in all steps of the treatment.

Hope this was helpful for basic understanding.

The aim of this discussion is to make anyone with curious mind to understand these condition better. It is not equivalent to detailed in person individualised consultation.

Please contact us

If you want to understand your treatment options.

ICSI Treatment in Indore
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