Diagnosis of Infertility

A woman’s age is a significant factor determining the success of ART. One must also consider that there is an increased risk for birth defects with advanced maternal age. We will need to discuss your case and can help you evaluate and make decisions about these risks. At our center, improved culture techniques, the procedure of Laser Assisted Embryo Hatching and Preimplantation Genetic Testing (PGT) have enabled many women in the age group of 35-43 to have healthy babies. For women around the age of 40, ICSI can be offered with limited success. If PGT is offered along with ICSI and if genetically normal embryos are transferred, then pregnancy rates would increase to around 40-50%. For women aged 43 and above, use of Donor Eggs may be a better option although we have recorded pregnancies in this group when PGT was offered along with ICSI.

In the IVF technique, the oocyte and a calculated number of sperm are placed together in a petri dish in a nutrition-based medium for the fertilization process to take place. However, in cases where the sperm count, motility and morphology are poor, the chances of fertilization with IVF decrease.

In ICSI, a single sperm is directly injected into the cytoplasm of an oocyte. ICSI overcomes problems of low or no sperm count, low or no motility and poor shape of the sperm. ICSI is also helpful in cases of egg problems.

ICSI is the treatment of choice in many conditions such as azoospermia (absence of sperm in the ejaculate). In such situations, ICSI can be performed using sperm retrieved from the testes (TESA or Micro TESA) or the epididymis (PESA). Other indications for ICSI are previous failed fertilization with IVF and when Preimplantation Genetic Testing is offered.

One key factor to keep in mind is that sperm quality generally decreases with age. This means that, in general, younger men will have higher-quality sperm than older men. Therefore, if you are concerned about your fertility and want to preserve your sperm for future use, freezing your sperm earlier in life may be a good option. 

Another thing to keep in mind is that certain medical conditions or treatments may impact your fertility.

IMSI stands for Intracytoplasmic Morphologically Selected Sperm Injection.

In this procedure, the sperm’s image is enlarged 7000 times using a special optical lens. This helps us select sperm which are normal in shape and size and have a normal nucleus (where the genetic material is stored). In our experience the use of IMSI has increased pregnancy rates in Male infertility and in those couples who have had failed ICSI in the past.

The IMSI microscope also allows us to inspect eggs at a high magnification so that the quality of the eggs can be assessed better.

An ultrasound scan is a painless procedure using high frequency sound waves to produce an image of the body’s internal organs or the fetus on a television screen. Ultrasound scans are an essential part of all forms of Assisted Reproduction and may be required at various stages of treatment. Scans are used in the preparation of the ovaries and uterus for Assisted Reproduction. For example, the doctor may want to know how the eggs are maturing inside the ovary by measuring the growth of the follicles and will judge the readiness for embryo implantation by measuring the thickness of the uterine lining. One of the reasons for the improvement in the IVF/ICSI procedure is the simplicity of oocyte retrieval by transvaginal ultrasound. In some situations, embryo transfer can be carried out under ultrasound guidance.

The basic steps in an IVF-ICSI treatment cycle are evaluation and pre-treatment of the couple, ovulation induction, egg retrieval, sperm insemination or sperm injection, fertilization, embryo culture and embryo transfer.

(1) Evaluation and Pre-treatment

• Pre-conception counseling: It is very important for a couple to understand the ART procedure. Our team will guide you through the physical and emotional aspects of IVF.
• Anatomic Assessment: A HSG may be recommended. Operative techniques such as laparoscopy and hysteroscopy are sometimes suggested in order to maximize the chances of success.
• Hormonal tests: Baseline TSH, Prolactin, FSH, AMH and LH may be recommended.
• Semen analysis and Semen freezing: Semen Analysis determines whether IVF,  ICSI or IMSI would be the preferred method of fertilization.
• A urology consultation for the male partner may be suggested, in severe male factor infertility.
• We recommend freezing of Semen prior to IVF so that we have a “backup” sample to be used in the event that a fresh semen sample is not available on the day of egg retrieval or ovulation.
• Testing both partners for Infectious Diseases: Screening both partners for infectious diseases like HIV and Hepatitis B & C is essential.

(2) Ovulation Induction
A woman undergoing IVF/ICSI is given fertility medicines to enhance the growth of the ovarian follicles in order to develop mature eggs.

(3) Hormonal Tests & Ultrasound scans
The developing follicles are monitored for their maturity and size through ultrasound and correlated with blood hormone tests like Estrogen, LH and Progesterone.

(4) Ultrasound Guided Egg Retrieval
Once the follicles achieve maturity, the next step in the IVF process involves an ultrasound guided egg retrieval. Overnight fasting is required. The procedure is done in a sterile operation theatre under mild anaesthesia. After cleansing the vagina, a fine needle is introduced into the vagina under ultrasound guidance and the ovarian follicles are punctured. Then the follicular fluid is aspirated and checked by the embryologist for the presence of eggs. These are handled gently and quickly transferred to the incubator prior to the IVF/ICSI/IMSI procedure.

(5) Insemination of oocytes: IVF/ICSI/IMSI
The semen sample is collected in a sterile container and handed over to the lab. It is then processed and prepared in order to obtain actively motile sperm. The prepared sperm is then used to inseminate the eggs by IVF /ICSI/IMSI in the culture media. For poor quality semen we use microfluidics technology to obtain the best and most viable sperm.

(6) A normally fertilized oocyte
The day after egg retrieval and insemination/injection, the embryologist will examine the eggs and check for fertilization. A fertilized egg will have 2 nuclei in the center, one from the egg and one from the sperm.

(7) Embryo Culture
The fertilized eggs (embryos) will spend about 3-5 days in the laboratory to allow them to develop into the eight-cell or blastocyst stage embryo, at which time the embryo is ready to be transferred into the uterus. We transfer at Day 3 (8 cell stage) or Day 5 (Blastocyst stage) depending on many factors such as the quality of the embryos, the condition of the uterine lining and whether PGT is being done.

(8) Laser Assisted Embryo Hatching
Prior to implantation, the embryo has to escape from its protective shell known as the zona pellucida by a process known as Hatching. If this process is not completed appropriately, implantation will fail and pregnancy will not occur. We offer Laser technology for Assisted Hatching (LAH), where a laser beam is focused over the Zona Pellucida making a small opening of about 30 to 40 microns to facilitate Embryo Hatching.

This technique is particularly useful in cases where the embryos have a thick zona and also in cases of previous failed cycles. We have the latest Laser machine which utilises the Diode system. It is considered as the safest Laser application in ART.

We have achieved the first pregnancy in India using the Diode Laser in 1999.

(9) Embryo Transfer
The resulting embryos are placed back into the uterus with a fine catheter through a simple procedure called embryo transfer. In our centre we perform Cumulus Aided Transfer (CAT) which increases the chances of implantation.

(10) Cryopreservation/Embryo Freezing
Most women who undergo hormonal stimulation for an IVF or a related procedure of Assisted Reproduction produce more eggs than needed for transfer during that cycle. The extra eggs or embryos may be frozen or “cryopreserved” and stored for future transfer.

(11) After Embryo Transfer
Bed rest is not necessary after embryo transfer. Strenuous exercises such as jogging & swimming should be avoided until the pregnancy is confirmed. Otherwise, one can return to regular activities. You can take a regular home-made diet. We recommend avoiding eating papaya and pineapple. Please refrain from sexual intercourse until the BhCG test.

(12) A blood Pregnancy test- the BhCG test
This is done 14 days after embryo transfer. We wish you every success in your quest for parenthood!

Success rates for ART procedures are significantly influenced by:

• The age of the woman
• The number and quality of eggs produced following ovarian stimulation
• Quality of the semen
• The number and quality of embryos formed

Pregnancy rates after transfer of a single PGT tested blastocyst are between 40% and 50% at our centre. Chances of pregnancy can be as high as 60% in some cases. The chances of success diminish after 37 years of maternal age. Hence it is very important to try IVF before the biological clock slows down.

As with any medical procedure, the techniques of Assisted Reproduction can be associated with certain risks and complications. These are rarely of a serious nature and can be attended to and treated effectively. The most common are:

Ovarian Hyperstimulation Syndrome (OHSS):

OHSS occurs when too many ovarian follicles have developed as a result of the ovarian stimulation and is associated with ovarian enlargement and accumulation of fluid in the pelvic cavity. This complication occurs in various degrees of severity in approximately 2.5% of women undergoing IVF treatment. Our team of doctors is highly experienced to treat such a condition, should it arise. We can avoid hyperstimulation if a gnRH agonist called Luprolide is given to trigger ovulation instead of HCG. However in that case, all embryos are frozen and subsequently transfered in the next cycle.

Multiple pregnancies:

Although many couples are happy at the idea of completing their families quickly if they get twins or multiples through the IVF procedure, bearing twins increases the chances of prematurity and abnormalities in the babies.

The risk of bearing twins can be cut down by placing a single embryo in the uterus. We highly recommend the practice of transferring only 1 PGT tested euploid blastocyst embryo.

Approximately 10% of infertile couples suffer from unexplained infertility. This simply means that the evaluation of the couple has not led to a defined reason for infertility. However, a more thorough search for a cause should be made, since many subtle abnormalities may be discovered to explain the infertility. Usually such problems are due to:

1. Difficulty in picking up the egg by the fallopian tube
2. Failure of the sperm to fertilize the egg even when in contact with each other
3. Failure of implantation of the embryo into the uterus
4. Presence of local or circulating antibodies
5. Genetic problems
6.  Pelvic infection such as genital tuberculosis.

The option is particularly important for older women since it has been shown that as a woman’s age increases, IVF success decreases. Hence women over 40 years have better success with the use of donor eggs and may be suggested this course of treatment. Also women who prematurely reach menopause are candidates for egg donation. Women with decreased ovarian reserve due to previous ovarian surgery & severe endometriosis also qualify. Women with genetic diseases can also avail of donor eggs. A high FSH (>12) and low AMH (≤0.5) may be indicators for the use of donor eggs.

Cumulus cells surround the oocyte (egg) during its maturation in the woman’s ovary. They continue to surround the egg at the time of ovulation. They are embedded in a matrix, which contains hyaluronic acid. Cumulus cells nurture the egg prior to and after ovulation.

In CAT, a few of the feeder cumulus cells on which the embryo is being cultured are transferred along with the embryo into the uterus. We use cumulus cells as a feeder layer over which the embryos are cultured. These cumulus cells are rich in growth factors such as Insulin-like Growth Factor and Vascular Endothelial Growth Factor. These ensure the proper growth of the developing embryos. In order to improve the technique we go a step further. At the time of embryo transfer we add 30 microlitres of the cumulus cells to the embryos so that the nutrients secreted by the cumulus cells continue to be provided within the woman’s body thereby enhancing pregnancy rates.

In IVF, the term “culture” means to grow or incubate embryos in a defined nutrient medium. In the technique of “Co-Culture”, embryos are grown in a culture medium on top of a proliferating monolayer of cells called “Feeder” or “Helper” cells. The feeder cells assist in the growth and development of the embryo.

We have developed a co-culture system which uses the patient’s own cumulus cells. These would otherwise have been discarded at the time of ICSI. We remove them from the oocyte and make them into a layer of feeder cells for the embryos to develop on. Since the patient’s own cumulus cells are more easily available unlike other cells like tubal or uterine cells, they are ideal for use as feeder cells in a co-culture system.

OUR RESULTS WITH CAT (2006)