What To Expect In An Infertility Workup

1.COMMON TESTS IN INFERTILITY

1. Semen Analysis
2. The only major test done in male partners.
3. Should be collected in a clean container.
4. Avoid any form of ejaculation 3 days prior to testing
5. Do not collect semen in condoms.
6. Deliever the sample within half an hour to the laboratory
   
   

Sperm Motility

A motility rate of atleast 50% is normal

Sperm Count

A count below 20 millions say indicate decreased fertility

Sperm Shape

Normal sperm has oval shape and long tail enabling them to penetrate the egg.

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2. HORMONAL TESTING :

Among the tests which will be advised to the couple seeking treatment will be a set of hormonal tests which would be ideally done by the female on day 2/3 of her periods.These are follicle stimulating hormone ( FSH ), luteinizing hormone (LH), prolactin( PRL ), thyroid stimulating hormone( TSH ), which could give an idea about any hormonal imbalances within the body, which in turn may cause an ovulation, leading to the difficulty to conceive. Besides these there may be other tests which may have to be studied in certain cases.

The male may also require to get these hormone levels done in case his semen report shows some problem of sperm production.

3. FOLLICULAR STUDIES :

Follicular studies has become the cornerstone of all fertility treatment around the world and has made detection for ovulation much easier. The female is called for serial sonography from the eighth day of her periods and the size of the follicle and the thickness of the endometrium (thickness of the uterine lining ) is measured at each session. The sequential study provides the doctor with detailed information about the growth of the eggs and any problems thereof which can be corrected by medicines if necessary. At the appropriate time when the growth of the eggs is adequate, injections may be given to ensure rupture of the eggs .Also it is ensured that sperms are present during this period within the female's genital tract which may improve the chances of fertilization of the eggs and therefore lead to a pregnancy. The couple may be asked to have planned intercourse more frequently during the time of anticipated rupture or an intrauterine insemination may be done if required.

Before the advent of sonography, ovulation was documented by studying the cervical mucus of the female or by keeping a record of basal body temperature and documenting the changes which ovulation brought about in these parameters but nowadays these tests are hardly used. Cervical mucus studies may be done by the doctors to do a “post coital test”.

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4. POST COITAL TEST :

This test is usually done around the time of ovulation in the female partner. The couple is asked to report to the clinic within 5 hours of having unprotected vaginal intercourse. The vagina is inspected and a small sample of cervical mucus and vaginal fluid is collected on a slide and inspected under a microscope. If the mucus is favorable, the sample should show a good amount of sperm swimming rapidly in the fluid. Sometimes however if the cervical mucus is hostile to the sperm or if there antisperm antibodies, the mucus may show only dead sperm ,in which case it may be interpreted as a negative PCT report. Such couples may require intrauterine insemination for achieving a pregnancy.

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5. DIAGNOSTIC HYSTEROLAPAROSCOPY :

Hysterolaparoscopy is one of the most important tools for investigating the female. It gives us a eye witness picture of the internal genital organs, thereby allowing accurate diagnosis of any anatomical problems, and also allows testing for the continuity within the genital tract.

The procedure basically involves introducing a fiber optic endoscope within the uterine cavity (hysteroscopy) and the abdominal cavity(laparoscopy) and visualizing the structures within. This is done under general anesthesia and takes about 30 min, and requires an indoor stay for half a day, followed by rest at home for 2 days.Hysteroscopy tells us about the lining of the uterus (endometrium), the opening of the tubes in the uterus( ostia), as also about any pathology within the uterus which otherwise is very difficult to detect (septum , polyps , adhesions etc ).Our centre is fully equipped to do any corrective surgery if any of the above mentioned problems are encountered during the scopy , thereby saving the patient time , money and the stress of another surgery subsequently.

A curettage (scraping of the lining of the uterus) done at the end is sent for histopathological testing to the lab for study.
The second part of the procedure involves laparoscopy, wherein a small incision is made below the umbilicus (navel) and the endoscope is introduced into the abdominal cavity. The abdomen is inflated using carbon dioxide to allow proper visualization of the pelvic organs. The uterus, ovaries, fallopian tubes are inspected for any anatomical defects or pathology and then patency of the tubes is checked by pushing methylene blue dye through the vaginal end of the uterus. Tuberculosis and endometriosis is also looked for during the procedure. Various surgical procedures can also be carried out if indicated during the same session if required (adhesiolysis, fibroid removal, ovarian cysts, tubo ovarian masses..).

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6. ENDOMETRIOSIS :

This is one of the most painful and most chronic conditions to afflict women. Basically it is believed that the cause of endomtriosis is a partial backflow of menstrual blood through the fallopian tubes into the abdominal cavity.This blood is highly irritant and leads to all the genital and other abdominal organs getting adherent to each other over a periods of time. Also the lining of uterus(endometrium) is deposited outside the uterus and the menstrual blood gets collected as cysts into which further bleeding occurs during each menstrual cycle leading to severe painful menses (dysmenorrheal ) as also fertility problems. Although now many good drugs are available for treating this condition there is no complete cure for this condition except permanent stoppage of menstruation ( natural or induced ).Even fertility treatment for this condition gives very poor results and severe endometriosis usually requires extensive surgical intervention (laparoscopic adhesiolysis ideally ) followed by IVF .Even with these treatments results can be disappointing. It is usually better to go in for aggressive treatment of endometriosis for enhancing fertility treatment results.

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7. OVULATION INDUCTION :

Almost invariably, the female partner is given stimulation by means of drugs to enhance ovulation and to increase the number of eggs available for fertilization. The commonest drug used and which remains the gold standard for all infertility treatment worldwide is Clomiphene citrate which is given in dosages varying from 50 – 100 mg , depending on the requirement of that particular patient. Most patients would show follicular growth with this drug. At the appropriate size of the follicle , as measured by sonography, an injection (HCG) may be given to induce rupture of the follicle .
In some cases, besides clomiphene citrate, other drugs may be given additionally, like injections of FSH / LH etc, either to improve the response of the ovaries or to induce superovulation (if needed) .

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8.ASSISTED REPRODUCTIVE TECHNIQUES

After trying everything else it is good to know you still have a chance.

1. INTRAUTERINE INSEMINATION (IUI):

IUI

Done if :

• there is low sperm count &
• cervical mucus deficiency,
• cervical antibodies.
• unexplained infertility.

This procedure involves the instillation of washed and processed sperm within the uterine cavity of the female around the time of ovulation.

IUI may improve the chances of conception by about 10 -15 %. In this process the semen sample, collected by masturbation is processed after washing with certain chemicals to remove impurities and to concentrate the sperm in the semen sample.After the wash, the sperm are incubated with other chemicals under CO2 which improves the motility and quality of the sperm .This processed sperm is then transferred into the uterus using a very thin bore plastic catheter under strict aseptic care. After the procedure , the lady is made to lie down for a period of an hour

IUI LAB

with a slight head low posture to prevent any outflow of the injected sample , and then sent home . The procedure is an OPD procedure and can be repeated if the ovulation is not as per schedule. While most semen samples can be processed using different methods to get adequate quantity of sperms for IUI , sometimes one does encounter cases where the quality of semen is either too poor or the semen has no sperm . In such cases donor insemination is a possibility which can be explored , since this can give the desired results at a reasonably low cost. It is important to emphasise that couples opting for donor samples need not worry about the quality of the sperm nor fear about getting any infectious diseases from the sample , as these samples are collected from thoroughly screened donors and are tested for hepatitis B and HIV viruses. Sperms are placed inside the uretrus using thin catheter

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2. IVF AND ICSI :

The womens eggs are removed with a thin needle from ovary. Sperms are combined with the eggs in a dish in labratory.Embryos are insereted in to the ureturus after 2-3 days

Since the first IVF baby was born more than twenty years ago, the progress in the field of fertility has ben tremendous and nothing short of miraculous. Nowadays IVF has become a highly specialized branch by itself and is improving day by day. Basically IVF involves replicating the fertilization process (which occurs naturally ) outside the female's body. Though medical science has progressed a lot , we are still to understand a lot of the physiological processes involved in fertilization and conception and the best centers worldwide offer a success rate between 25 – 30 %.To prepare the body for the assisted reproductive technologies ( IVF & ICSI ), various hormonal medications are used alone or in conjunction to stimulate the development of ovarian follicles. This is known as “superovulation” or “ controlled ovarian stimulation”.

These medications are administered for two reasons:

1. To enhance the growth and maturation of as many follicles as possible,thereby improving the chances of fertilization and development and
2. To control the timing of ovulation so eggs can be retrieved before they are spontaneously released.

Before the actual injections for egg growth are administered ,one set of injections are started a few days prior to the expected menses to bring down the body levels of the hormones which are present normally within the female ( downregulation ).Subsequently after the onset of menses,hormonal injections are administered for 7 -10 days;doses may be adjusted during the cycle depending on follicle growth.The patient is carefully monitored using lab tests ,ultrasound and physical examination.When in the physicians opinion follicular development has reached the stage where an optimum no of eggs will be produced with minimal side effects ,an injection (HCG ) is given to trigger ovulation.Egg retrieval is scheduled within 34 -36 hours of the injection administration. As with any other medication, side effects are a possibility which has to be discussed prior to entering an IVF program. Ocasionally overstimulation of the ovaries may occur. Ovarian Hyper Stimulation Syndrome generally causes enlargement of the ovaries accompanied by by abdominal discomfort and/or pain. In severe cases, other additional symptoms may require hospitalization of the patient. There appears to be no increased incidence of birth defects, congenital abnormalities or spontaneous miscarriage associated with these medications.Thereis however an increased possibility of multiple births when more than one egg is transferred.

Oocyte recovery is generally effected by ultrasound directed procedure under general anesthesia.The ultrasound probe is placed in the vagina. An aspiration needle is inserted along the transducer and through the upper part of the vagina directly into the ovary.The ultrasound image allows the physician to accurately guide the needle into each follicle for aspiration.

The next stage involves the fertilization of the collected eggs,which takes place in the laboratory. Retrieved eggs are placed in a special medium and allowed to remain there undisturbed for a couple of hours. A semen sample of the husband is obtained and processed using different lab techniques with the goal of obtaining a more vigourous motile sperm from the ejaculate.The final preparation is then introduced into the medium containing the eggs.

Approximately 48 hours after oocyte retrieval, if the eggs have fertilized and are developing normally, embryo transfer will take place. Embryo transfer is a relatively easier procedure not requiring any anesthesia. A catheter is introduced into the uterus through the cervix and embryos are placed into the uterine cavity.

ICSI differs from IVF only in the step of fertilization ,wherein in a ICSI procedure each individual egg retrieved is held under a microscope and a sperm is injected into the cytoplasm using a microinjection pipette. This is a highly technical procedure and still available in a few selected centres. Fertilization rates are higher with this procedure and this procedure is a boon for those couples having a male factor infertility since it can be done even when husband semen is of very poor quality or the semen count is very poor.

Success rates with these procedures range from 25 %-30%.

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