Ovulation Induction and Cycle Monitoring:
This is a simple procedure which is the first choice option when the semen is normal and the Fallopian tubes are functioning normally. The wife is given drugs in tablet and/or injectable form to stimulate her ovaries gently so she may form more than one egg. This process of follicle with egg formation is observed and monitored by trans-vaginal ultrasound. Once the follicles are of mature size, an intramuscular injection is administered to achieve the final release of eggs. The couple is advised to practise regular intercourse over the next few days as this is the best time to achieve a pregnancy.
Intra Uterine Insemination
This is usually the second step when Fallopian tubes are normal and the semen report is either normal or has borderline problems. Ovulation induction can be done or the natural cycle may be used. Once the follicles are mature, the couple comes to the centre and the semen sample is collected and processed in the lab. The semen is washed and centrifuged. Then, swim-up technique is used to collect the best quality of rapidly motile sperms. This process takes nearly one to two hours. This is a painless procedure. The couple goes home and for the next few days, intercourse is encouraged. The success rate of this procedure is nearly 10-15%. This procedure can be repeated up to six times if necessary.
In-Vitro Fertilisation (IVF) and Embryo Transfer (ET)
This procedure is commonly known as the ‘test tube baby’. The first test tube baby was born in 1978 in the United Kingdom and since then, thousands of babies in the world have been born using this technique. In case of Fallopian tube pathology, this is the only solution which can be offered. The other categories of patients who can benefit from this procedure include those with polycystic ovarian disease, endometriosis, unexplained infertility, and those who have experienced more than five years of treatment failure. For this technique, the semen analysis must be normal.
Different steps of the treatment are as follows:
- Suppersions and stimulation of ovaries: Different drug protocols are being used to control and enhance ovarian function. The drug protocols are decided according to the patient’s individual requirement. The whole idea is to produce an appropriate number of follicles which will contain mature and good quality eggs. Usually, we aim for 10-15 eggs.
- Monitoring of follicles: This is performed by ultrasound scan and hormonal blood tests. Internal ultrasound scan by vaginal probe is performed. This is a painless procedure and does not need a full bladder. It is done every alternate day after follicles start maturing. Once a satisfactory number and size is achieved, an appointment is given for egg collection after 32-36 hours.
- Egg Collection: It is done by ultrasound guided Follicle aspiration in an operating theatre under general anaesthesia. This procedure takes 15-20 minutes. The vaginal ultrasound probe is inserted in the vagina and a hollow needle is pierced in each follicle to suck out the fluid which contains the egg.
- Sperm preparation: The semen is washed and prepared to separate the good quality sperms. Usually the husband is asked to have prior abstinence of two to five days.
- Insemination of eggs: The eggs are kept in a culture medium in a dish or test tube to provide nutrition. Then each egg is mixed with about 50,000 to 100,000 actively motile sperms. These are then kept in special incubators under strict environmental control. The next day, they are checked for fertilization and on the following day for embryo formation.
- Embryo transfer: The very best embryos are selected and two or three are transferred inside the uterine cavity. This is a painless and very simple procedure which takes only a few minutes. To achieve better pregnancy rates, some hormonal drugs are prescribed in the form of tablets, vaginal pessaries and injections. A pregnancy test is performed after 15 days. If the test is positive, an ultrasound scan is ordered after two weeks. The success rate is usually 30-35%. This increases with number of cycles attempted and multiple cycles have a better success rate. The rate decreases as the age of the female increases as the quality of eggs decreases after the age of 35 years. In males, the sperms show DNA fragmentation and poor fertilization after the age of 45 years.
Intra Cytoplasmic Sperm Injection (ICSI)
This is the only answer for male factor infertility. It is an advanced technology for males who have only a few normal sperms. A single sperm is picked and injected directly inside an egg. This procedure is performed by a highly trained scientist under a very fine microscope equipped with a micromanipulator. The whole cycle is run in the same way as IVF. It is the laboratory work which is more sophisticated.
Surgical Sperm Collection
This is for those men who have no sperm in their semen. In this technique, sperm is collected directly from the testicles. This simple technique is to insert a needle in the epididymus and aspirate some fluid to check for the presence of mature sperm. This is called Per Cutaneous Sperm Aspiration (PESA). If sperm cannot be obtained using this technique then a small piece is removed from the testis under general anaesthesia, a process called Testicular Sperm Extraction (TESE). This small piece is checked in the laboratory and mature sperms are extracted. Sperms collected through SSC are used for ICSI and thus pregnancy can be achieved.
Cyro Preservation and Vitrification
This is the freezing of sperms and embryos for future use for the same couple. When embryos are available in a large number after ET, the remaining good quality ones are frozen in liquid nitrogen so they can be stored for many years. Whenever the couple wants to have them transferred, they can be thawed and returned back to the uterus.
Pre Implantation Genetic Diagnosis (PGD) (in the near future)
This is a technique in which the embryo’s genetic make-up is determined before transferring it to the uterus. Embryo biopsy is performed and genetic testing is done to identify possible chromosomal defects such as Down’s syndrome (Trisomy 21). The sex of the embryo can also be determined using this technique.