In-vitro fertilization (IVF) is a process in which your eggs are collected from your ovaries and are mixed with your husband’s sperm in a test tube or plastic dish with the objective of one sperm entering one egg and combining to produce one embryo. One to three embryos are then placed in your uterus for implantation and development into one or more babies. IVF is recommended if you are unable to conceive in a natural way or when other treatments have not succeeded in producing the baby that you so earnestly desire.

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 mature eggs. Even so, some of the eggs may be sub-optimal in quality. If the level is very high and is in the menopausal range, this indicates that there are no eggs left in the ovary which are capable of ripening.

This is a fluid filled structure which houses the developing egg (oocyte). The covering of the follicle contains cells which produce the female hormone called Estradiol 17beta (Estrogen). After release of the egg (ovulation), these hormone producing cells switch to producing the implantation supporting hormone called Progesterone. After ovulation a yellow colored, progesterone releasing corpus luteum is left behind in the ovary.

The main complication of IVF is ovarian hyperstimulation syndrome (OHSS). The second complication is multiple pregnancies with more than one pregnancy e.g twins, triplets or quadruplets. The third is ectopic pregnancy. The other rare complications include bleeding and infection from the needle puncture at egg collection. The other rare complication that may result from an enlarged ovary is ovarian torsion. The ovary may twist upon itself and result in torsion, or it may bleed or rupture, requiring operation. Sometimes a functional cyst persists after the cycle is over.

OHSS is a medical condition affecting the ovaries of some women who take fertility medication to stimulate egg growth. Symptoms are set into 3 categories: mild, moderate, and severe. Mild symptoms include abdominal bloating and feeling of fullness, nausea, diarrhea, and slight weight gain. Moderate symptoms include excessive weight gain (weight gain of greater than 2 pounds per day), increased abdominal girth, vomiting, diarrhea, darker urine, decreased urine output, excessive thirst, and skin and/or hair feeling dry (in addition to mild symptoms). Severe symptoms are fullness/bloating above the waist, shortness of breath, pleural effusion, urination significantly darker or has ceased, calf and chest pains, marked abdominal bloating or distention, and lower abdominal pains (in addition to mild and moderate symptoms).

When two or more of your leading follicles are 20mm 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 8mm.

You will not have food nor drink for six hours before the procedure. You will empty your bladder and be placed under a short general anesthesia for usually less than fifteen minutes. A 14 gauge needle will be inserted under vaginal probe ultrasound scanning. The follicles will be emptied systematically and the aspirated fluid will be examined under a dissecting microscope for the cumulus-oocyte complex. Antibiotics will be given and after a five hour rest, you can go home. You may experience a little lower abdominal discomfort for a short while and some pain relief medicine will be given to you to bring home. There may be some bleeding from the vagina after egg collection. This is usually minimal and would stop within two days.

Intra Cytoplasmic Sperm Injection (ICSI) is a 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 sperm are unable to enter eggs by their own power. Most forms of male infertility can be solved by use of ICSI.

Fertilization depends on the quality of the eggs and sperm. With ICSI, the main variable is egg quality. Egg quality depends on your age and basal FSH level. Fertilization is increased with ICSI.

This is the process in which fertilized eggs are placed inside your uterus using a flexible catheter. This procedure is painless. Insertion of the catheter is done slowly. Removal of the catheter is also done slowly. After the catheter is removed, it is checked under the microscope to ensure that all the embryos have been placed in the uterus.

There does not appear to be any difference in the chance of pregnancy whether there is bed rest or not. However, it is preferred that you do not to engage in strenuous activities.

It has not been proven that avoiding coitus during the two weeks after embryo transfer makes any difference to the chance of pregnancy. However, most couples prefer to abstain from coitus.

This is the process by which the hatched 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 and you will not be able to feel it.

Bleeding may be due to implantation of the embryo or detachment of the embryo or early menses. It is preferred that you do the urine test for pregnancy at the designated time (usually two weeks after embryo transfer) in order to clarify the reason for the bleeding.

It is preferred that the urine test for pregnancy be done two weeks after the embryo transfer. Doing it earlier may produce a negative result even if you are actually pregnant because the level of HCG from the very early pregnancy is not sufficient to show up in the urine test.

The quality of your embryos is the main determinant for survival and implantation. Expected survival is about eighty per cent. Quality of embryos is determined largely by the quality of your eggs (oocytes).

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 also dependent on the number of embryos transferred. Although more embryos transferred increases the chance of pregnancy, it also results in a higher chance of multiple pregnancy with its associated problem of premature births. In practice, two or three embryos are transferred.

It is preferred that you bring along all available previous tests that you and your husband have undergone to show .The fertility specialist will review your menstrual history, past tests and treatments and then examine you and your husband. You will be given a provisional diagnosis as to the likely cause for your inability to conceive. Based on the findings obtained, a series of additional tests would be ordered and a provisional plan of treatment outlined. If the treatment is IVF, the plan would include blood tests, counseling, ovarian stimulation, egg collection, embryo transfer, luteal phase support and test for pregnancy. An appointment is given at a later date to review the results of tests ordered and modify the treatment plan where appropriate.

IUI is the depositing of washed motile sperm into uterine cavity using a fire plastic catheter, through cervix. IUI is a first step, cost-effective method to enhance the fertility in a woman with patent fallopian tube.

Fertilization occurs within 24 hrs after ovulation while implantation takes about 5-10 days after ovulation.

Follicles grow 1 to 2 mm a day while taking ovarian stimulation drugs and once the leading follicle is more than 17-18 mm it is ready for HCG shot.

Generally 15-16 mm size follicles contain fertilizable eggs. If the smaller follicles are of 15-16 mm size, it might release a mature egg, otherwise, it is most likely that only leading follicles will ovulate and release a mature egg.

Maximum dose for CC is 150-200. It is advisable to move on injectables if there is no response with this dosage, as the risk for ant estrogenic side effects of CC increases sharply on the dosage goes up.

3-4 days gap is ideal for a man. More than 5-7 days old sample may have a risk of poor motility, white cells and other problems.

Medicine protocol for IUI is

  • Clomiphene Citrate from period day 2-6
  • Add injectable if required
  • Follicular growth monitoring from the day 11 of cycle
  • Monitoring of LH surge and estrogen level during the cycle
  • Once the leading follicle reaches 19-20 mm size a slot of hCG.
  • IUI performed after 36-40 hrs of hCG
  • Adjustments in the ovulation induction protocol can be made as per individual need.

Before and after an IUI cycle, avoid heavy exercise, jogging or high impact aerobics.

  • Little rest just after the IUI procedure is advisable.
  • For little pain a simple pain killer like Ibuprofen /Paracetamol can be taken.

It is better to take injections in the morning and around the same time.

In nature, during intercourse sperm are deposited in the vagina and then they have to swim through the cervical mucus. In IUI method, as cervix is by passed there are many sperm available at the site of fertilization. As sperm are placed in uterine cavity, they have to be washed first, to get rid of any dead cells, bacteria and seminal fluid. There are different method for the washing of sperm which takes around 1-2 hours.

Sperm freezing is a good option for couples whose husbands live abroad or are simply not available for the procedure. IUI or IVF can be attempted using frozen semen sample.

All available data indicates that frozen semen does not increase the risk of birth defects. In fact, the freezing process tends to kill off weaker sperm, and may thus lead to survival of best sperm.

IUI procedure works by concentrating the healthiest sperm in the ejaculate and placing the washed sperm into the uterus adjacent to the fallopian tube. This bypasses any potential cervical factor problems and removes the sperm that are less likely to fertilize the egg.

IUI is a fertility treatment often selected by the couple, with at least one patent fallopian tube and who have been trying to conceive for at least one year. IUI also be selected as a fertility treatment with any one of the following conditions.

  • Low sperm count.
  • Decreased sperm motility
  • A hostile cervical condition [too thick cervical mucus]
  • Sexual dysfunction.

For use of fertility drug, a fertility specialist under whom couple is undergoing treatment can make the decision. In general, fertility drugs enhance a woman’s ability to become pregnant with IUI. Most widely used medicine is clomiphene citrate either alone or with combination of injections. Injectable fertility drugs that are more aggressive in stimulating multiple egg release. The more eggs that woman produces during a treatment, the higher the chance for success.

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