Intra-uterine insemination (IUI) also known as Artificial Insemination is a process in which the washed/processed semen is placed directly into the uterine cavity with the help of a thin sterile plastic tube (catheter) in and around the time of ovulation (release of egg from the ovary).
Fig. Diagrammatic representation of Intra Uterine Insemination (IUI)
It is one of the simplest techniques of assisted reproductive technique (A.R.T.). It forms the first basic and the least invasive treatment technique for infertility management.
The purpose of IUI (Artificial Insemination) is to introduce the best and the most motile sperms high up in the uterine cavity i.e. as close to the ovum as possible so that the distance that the sperms have to cover is the minimal and to overcome factors like cervical mucus opposition for its entry into the uterine cavity. Also as generally it is done with follicular monitoring, the egg is matured and released or about to be released. Hence we are sure that both the egg and sperm are timed properly for optimum fertilization and increased chances of pregnancy.
What are the indications of IUI
IUI (Artificial Insemination) is performed for both male and female cause of infertility as well as in unexplained infertility.
The main reasons where it is used are as follows:
Low sperm count and/ or less number of motile sperms
Anatomic defects of the penis (abnormal structure of penis) leading to failure of deposition of sperm correctly
Sexual or ejaculatory dysfunction (problems related to having sexual intercourse or release of sperms in the vagina)
The main reasons where it is used are as follows:
Low sperm count and/ or less number of motile sperms
Anatomic defects of the penis (abnormal structure of penis) leading to failure of deposition of sperm correctly
Sexual or ejaculatory dysfunction (problems related to having sexual intercourse or release of sperms in the vagina)
Retrograde ejaculation (occurs when semen, which would normally be ejaculated out via the urethra outside, is redirected back into the urinary bladder)
Immunological (presence of antibodies to sperm)
Increased viscosity (thick semen- does not liquefy easily to release the sperms)
Cervical factors- Thick cervical mucus preventing the sperms to reach the uterine cavity. There are also sometimes antisperm antibodies (a protein that attacks and destroys the sperm) in cervix which are harmful to the sperms and prevent fertilization.
Ovulatory dysfunction – No release or delayed or abnormal release of eggs (Oocytes) from the ovaries. Hence ovulation induction using drugs helps in increasing the conception rate.
Minimal endometriosis – Grade 1-2 (presence and growth of the tissue lining the uterus in places other than the uterus e.g., in ovaries, fallopian tubes, intestine)
Psychological and psychogenic sexual dysfunction (Sexual intercourse is not possible)
IUI (Artificial Insemination) has also shown good results in cases of unexplained infertility (No apparent cause found for inability to conceive on routine recommended medical testing) as well.
In some cases where husband is away for many days due to job like military or navy, their semen sample can be frozen and used later. Once the follicle is of appropriate size and has ruptured, IUI (Artificial Insemination) can be performed at the correct time even in his absence. Thus even if the husband is not able to be present on the day of ovulation, husband’s previously frozen semen sample can be processed and insemination can be done.
Is there any condition for which IUI (Artificial Insemination) not suitable?
Very low sperm count (less than 5 million) and poor motility
Abnormal or blocked Fallopian tubes. .
Abnormal or thin endometrial growth (Thin ET on USG).
Advanced age of the wife, husband or both.
How long does one IUI (Artificial Insemination)cycle treatment take?
It takes the same time as a normal menstrual cycle i.e. on an average of four to five weeks from the beginning of menses cycle till the pregnancy test.
First sonography is done on day 2 or day 3 of menses to rule out cyst or any other abnormality. Later on she is put on ovulation induction drugs for 5 to 6 days and called for USG on day 7 or 8. Her USGs are repeated (folliculometry) and the follicles are monitored for growth. Once rupture occurs, IUI (Artificial Insemination) procedure is done. This generally happens around 14 to 16 day of cycle. After IUI (Artificial Insemination) procedure some medicines are given for support for another 14 days.
Is there any risk in performing IUI (Artificial Insemination) procedure?
There is generally no risk in performing IUI procedure for both the husband and the wife. It is one of the safest procedures. There may be a small chance of multiple pregnancies as sometimes more than one follicle may develop when ovulation inducing drugs are used.
IUI – How to Proceed
IUI(Artificial Insemination)treatment can be done in natural unstimulated cycle or in a stimulated cycle (using oral drugs/injections).
Time of IUI (Artificial Insemination)
In a natural cycle, with menses coming every 28 days, ovulation, i.e., release of the egg after follicle rupture, happens around 14 days before the next menses. IUI (Artificial Insemination) in a natural cycle is done after the rupture of the follicle is confirmed by ultrasonography. In women with longer cycles, the days may vary.
When drugs or injections are given for follicular maturation (ovulation induction cycles), IUI (Artificial Insemination) is usually done 36 hours- 48hrs after HCG injection. This injection is given to facilitate release of the egg from the ovary (ovulation and release of ovum).
The egg is usually alive for 24-48 hrs. after ovulation. Sperms are alive for around 48-72 hrs. after they are released into the female genital tract. Thus, if processed / washed semen sample is deposited around this time, the chances of conception are very high.
Anesthesia in IUI (Artificial Insemination) Treatment
Will there be any pain while doing the IUI (Artificial Insemination) procedure? Is anesthesia required?
IUI (Artificial Insemination) procedure is the simplest of all procedures. It causes no pain or discomfort.
It is best performed when you are awake. Interacting with the Doctor/ Fertility physician performing the IUI (Artificial Insemination) procedure will not give you the time to realize as to when the IUI (Artificial Insemination) procedure got over.
So the need for Anesthesia in IUI (Artificial Insemination) procedure never arises.
In patients with severe anxiety or severe female sexual dysfunction sometimes there may be need of Anesthesia.
Do I require fasting on the night prior to IUI procedure (Artificial Insemination)?
IUI (Artificial Insemination) is a very basic procedure. No anesthesia or pre-medication is required. So, fasting is not required. In fact a light snack before the procedure may help.
What happens in Natural cycle IUI (Artificial Insemination)?
In a natural cycle, on the second day of menses, a sonography is done to rule out any ovarian cysts (FLUID FILLED swelling in the ovary). A repeat sonography is done on 8th/9th day of the cycle.
Depending on the size of the follicles in the ovary, further scans are done on daily basis or on alternate days. When the follicle in the ovary (which contains the female egg) reaches optimum size (around 18-20mm), sonography is done every day to identify the exact day of ovulation (release of egg) and the IUI(Artificial Insemination) procedure is done either on the same day or the next day.
Ovulation induction cycle
In a stimulated cycle, we induce ovulation by using medicines such as clomiphene citrate or N-clomiphene or injections such as gonadotropins (hMG, FSH).
It is generally given from 2nd/3rdday of menses for 5 days.
Fig. USG image of both ovaries on Day 2 and 3 of menses
A repeat sonography is done on 8th/9th day of the cycle. Depending on the size of the follicle in the ovary further scans are done on daily basis or on alternate days.
The monitoring of the cycle is done as above. When the follicle reaches around 18-20mm in size, hCG injection is given (hCG trigger). The IUI procedure (Artificial Insemination) is generally done 36 hrs after hCG injection and after confirmation of ovulation (release of the egg).
Below is the picture is of an ultrasound image of the follicle of 18 to 20 mm at which time hCG trigger (hCG injection) is given for rupture of follicle (ovulation).
Fig . Triple line endometrium of good thickness seen during rupture of follicle.
It has been found that stimulation protocols yield better results as compared to natural cycle. This could be related to the quality of oocyte available for fertilization and better endometrial development (inner lining of the uterus).
Ankoor clinic recommendations
Monitoring of patient is very important, as proper monitoring is the key to success. Preconceptional Folic Acid supplementation is started. On Day 2 of her periods a transvaginal ultrasonography (TVS) is done to rule out retention cyst. Ovulation Induction medication is generally given between Day 2- Day 6 of menses – Oral Clomiphene Citrate 50mg/ 100mg or Injectable gonadotropins. On Day 8 TVS is repeated to see the growth of the follicle and endometrial thickness.
This TVS may be repeated on alternate days to monitor growth of the follicle. Once the follicle reaches a size of 18 to 20mm, trigger (Injection HCG) is given for rupture of the follicle and release of egg (ovulation)
IUI procedure (Artificial Insemination) is generally performed 36 hrs.After this trigger after confirming ovulation.
Post IUI Luteal Phase Support is given in the form of Oral or vaginal Progesterone for around 15 days. Patient needs to stop her medications after that and wait for 7days. If there is no menses then she follows up with a serum b hCG to confirm pregnancy.
IUI procedure: How should the husband prepare?
There should be at least 2 days/48hrsof abstinence after intercourse or ejaculation of the semen. Too long an abstinence (more than 7 days) will increase the chances of dead sperms in the sample. Too short an abstinence interval (less than 2 days) will reduce the sperm count in the sample collected. Short abstinence generally does not affect the semen quality of those who had a normal sperm count and motility, but sometimes can affect those who have low sperm count.
Once we know the patient has ovulated, necessary instructions are given to the husband. He is asked to collect the semen sample in a sterile, wide-mouth, labeled, tissue culture graded container provided at our centre.
The female partner is now asked not to go to the wash room as a partially full bladder for IUI procedure is always preferred.
COLLECTION OF THE SEMEN SAMPLE
Semen collection facility is available at our centre. Adequate privacy is ensured at “ANKOOR Fertility Clinic” and private rooms are provided for the same.
For those who are not comfortable collecting the sample here at our place, collection can be done at home but should reach the centre in the container provided by the centre (within 30-45mins).
SEMEN COLLECTION ROOM
Precaution like avoiding contamination of the semen container and keeping the temperature around the sample as close as possible to room temperature should be followed by the patient.
Instructions while collecting semen sample:
Wash your hands with soap and water.
Refrain from using lubricant, saliva or any product that may contain spermicidal agents.
Ejaculate directly into the provided sterile sample container. Try to capture the first part of the ejaculate and do not attempt to collect any spilled semen.
If by chance there is any spillage of the sample, please inform the concerned lab person.
Cap the container as soon as you have finished.
Make sure your name (both husband and wife) and the time and date of your sample is clearly mentioned on the container.
If at all the male partner faces difficulty in collecting the sample, the doctor/lab person should be informed prior.
Assistance in the form of medications or magazines, audio-visual aid etc can be provided.
WHY IS SPERM PROCESSING NECESSARY
Normally during intercourse the semen that gets deposited in the vagina contains seminal fluid (which helps to keep the sperms alive even in the acidic environment of the vagina) along with sperms. The cervix then adds as a barrier to this seminal fluid and allows only the motile sperms to enter in
to the uterus. The fluid that comes out after intercourse is the seminal fluid.
Only processed semen sample is used during IUI procedure (Artificial Insemination). Processing helps to separate the active motile sperms from the seminal fluid. This seminal fluid can be irritating to the uterine lining as it contains chemicals called Prostaglandins. Thus when the semen (unprocessed) is inserted directly into uterus, it could cause severe pain and cramping.
SEMEN PROCESSING ROOM
In the process, the most active, motile sperm are concentrated and separated from dead sperm, cellular debris, mucous and bacteria and thus only the active motile sperms are inseminated in the uterus.
SPERM PREPARATION TECHNIQUES
There are different techniques available for sperm preparation:
Swim –Up Wash
Density Gradient Wash
At Ankoor fertility clinic, we do the SWIM UP method for semen processing.
Evidence suggests that there is no significant difference in the success rate for a particular method of semen processing.
(Cochrane Database Syst Rev. 2007 Oct 17 ;( 4):CD004507. )
Principle: Get the progressive motile spermatozoa into the sperm washing medium.
High number of sperm with progressive motility available.
Effective separation from bacteria & cellular debris which are trapped in the settled pellet.
Sperm washing/Swim-up Technique is the only method to achieve any success when numbers & motility of sperm are very low.
IUI Procedure (Artificial Insemination)
Before the IUIprocedure (Artificial Insemination), the semen processing media is removed from 2-8°C and is kept on the heating block at 37°C for atleast 20-30 mins so that the temperature of the media and the semen sample is almost the same. After collection, the sample is kept in the laminar flow over the heating block for liquefaction in sterile air with 37*C.( This generally takes 20 minutes).
The count and motility is then checked under the microscope &a live image is stored where in the couple is informed about the sample (We have special video & snap system).
The raw semen sample is then taken in a sterile test tube &an equal volume of the sperm preparation medium is added. After thorough mixing, this tube is then placed in the spermifuge for a desired time and speed (depending on the sample).
After centrifugation, the supernatant is discarded but a small volume is left behind.
The palette formed is then gently re-suspended in this supernatant.
The sperm preparation medium is then layered slowly from the side wall of the tube without the pellet being disturbed. At this time, there are 2 clearly distinct layers formed, the top being of the medium and the lower layer being the re-suspended pellet. The tube is then incubated in the heating block at 37°C for 45-60 minutes.
Post incubation, the top most layers now containing the active sperms is aspirated for insemination &the post wash count is checked.
Both, the pre-wash and post wash count are checked and the image/video of the same is shown to the couple along with a detailed report of the same.
The required consent form is signed and we then proceed for insemination.
The female partner is then made to lie down on the bed and with her legs parted.
An instrument called speculum is inserted in the vagina to see the cervix. The vagina is then cleaned with sterile gauze piece to remove the debris and discharge.
A thin tube called the IUI catheter is introduced in the uterus via the cervix (The lower part of the uterus) and the washed semen sample is slowly released in the uterus.
Then the female partner has to lie down on the bed for 15-20min.
SEMEN PROCESSING SWIM-UP TECHNIQUE
IUI (Artificial Insemination): Media
Medium should maintain sperm integrity, and promote acrosome reaction and capacitation.
Commonly used media are as follows:
Bicarbonate buffer media equilibrated with 5% carbon dioxide, 5% Oxygen and 90%Nitrogen at 37ºC with 95% humidity for 8 days.
10% heat inactivated serum or HAS or synthetic serum can be added as protein supplement.
Additions of methyxanthene derivatives like pentoxyphylline& caffeine can be added.
It is a tabletop centrifuge with a temperature controlled chamber specially made for semen sample preparation. It is intended to be used in Andrology (preparation in IUI and IVF labs). It has a graphic LCD display and a dial encoder. The function of a temperature controlled chamber makes this equipment unique the lab. The entire emphasis is to maintain the specimen temperature at 37 *C (to keep the temperature as close to body temperature) and to eliminate any thermal shocks. This advantage prevents any kind of damage to the sperms, thus maintain the quality and motility of the sperms to produce very good result.
Laminar air flow
The laminar air flow is capable of maintaining a sterile work area even when operated even in an uncontrolled environment. This is achieved by the total removal of the airborne droplet nuclei & dust – borne bacteria uni- directional oriented streamlines of clean air at velocities designed to flush the contaminating particles. This also creates a sterile pressure against the intrusion of external contaminants, & sweeps out particulates produced by the work process not allowing them to deviate, let alone settle down. It is used in IUI lab for air flow that air flow passed throw hepa filter. The air flow passed through hepa filter is clear of dust, microorganisms and thus transferring only the sterile air in which we can perform processing.
The microscope is attached with LCD,to show the prewash &postwash semen count to the couple.
This is used for warming the test tube, sample & medium to maintain the temperature as close as possible to body temperature.
What is Intrauterine Insemination Catheter?
Various types of catheter have been used for IUI (Artificial Insemination). These are known as IUI (Artificial Insemination) catheters. They are easy to use. They were semi-rigid devices that fit the curvature of the uterus & minimize trauma to the cervical crypts, endometrium and uterine walls. They are made of non-toxic material. They carry a small volume from their intrauterine tips with minimal dead space (to minimize backflow). Care is taken so that the tip of the catheter does not touch the fundus of the uterus as it may cause contractions.
Instruments used for IUI (Artificial Insemination) procedure:
A well timed IUI (Artificial Insemination) is the critical key to success of the procedure.
After documenting ovulation, the husband has to give semen sample for IUI (Artificial Insemination). This semen sample is then processed. The processed and washed semen is used for insemination.
The patient is told to lie comfortably in supine position with flexion at her hips. The mouth of uterus (Cervix) is visualized with the help of a speculum (instrument). Irrigate the ectocervix and endocervix with buffer. Place the catheter fully assembled, negotiate the internal os gently and deliver it 1.5-2 cm from the internal os. The semen sample is then injected slowly into the uterine cavity with the help of IUI (Artificial Insemination) catheter over period of 1-2 mins. Remove the catheter slowly after 30 seconds.
After the insemination, the woman is told to remain in the dorsal position for around 10 -15 minutes.
There is no need of prolonged bed rest, head low, pain killers, antispasmodics or antibiotics.
Studies have shown that catheterizing distance of 2 cm from the fundus with infused semen volume of 0.3 ml can significantly improve pregnancy rate in patients undergoing IUI (Artificial Insemination) with the husband’s semen.
Ankoor clinic recommendations:
There is no restriction on any kind of diet.
There is no restriction on traveling, exercise, climbing stairs, swimming etc.
Intercourse after IUI (Artificial Insemination) in fact has shown better pregnancy rates.
What is Difficult IUI (Artificial Insemination)?
Sometimes there may be problem in visualizing the cervix and doing IUI. In these cases, one should use a tenaculum (long vaginal instrument) and give traction to manipulate the Utero-Cervix angle and also to stabilize the cervix. Maklers or metal catheter (standard) also help in these cases.
VIDEO: Endometrial contractions seen in USG. These may be seen in cases of difficult IUI (Artificial insemination) and may hamper the result.
Various positions of the uterus during Difficult IUI (Artificial Insemination):
Empty Bladder and Acutely Anteverted Uterus
In these cases it is better to have a Full Bladder and or use Allis (instrument) Traction in the opposite direction as shown in the figure below.
Full Bladder and Acutely Retroverted Uterus.
In these cases, patient should empty her bladder and traction should be applied using Allis forceps or tenaculum in the opposite direction as shown in the figure below.
Ankoor clinic recommendations
In cases of Difficult IUI (Artificial Insemination), one must consider cervical dilatation with smallest dilator (helps to identify the direction and also to negotiate the stenosis). Also it is very important to make a note on the paper and consider for Cervical dilatation on the 1st or 2nd day of next menses.
Is Ultrasound-guided IUI (Artificial insemination)better ?
Studies have shown that Ultrasound-guided IUI (Artificial insemination) does not produce better results than blind insemination, because the pregnancy rate per cycle is similar. (Reference: Hum Reprod. 2009 May;24(5):1080-4. Epub 2009 Feb 5 )
What is the Advantage of Having Semen Processing and Insemniation under One Roof?
Some centers have folliculometry (USG monitoring) facilities but may not have Semen processing facilities or IUI facilities; while a few may not have folliculometry (USG monitoring) facilities too. Thereby, the wife has to go to a radiologist or some other center for doing the follicular study (serial USGs) for 5 to 7 days depending on the growth of her follicle. Once the follicular rupture has been confirmed, the husband needs to give sample and it has to be processed (washed). If this centre does not have facility for the same, then the couple has to go to another center for getting the semen washed.
The processed and washed sample has to be carried back to the clinic doing the IUI (Artificial Insemination). Thus all this leads to confusion for the patients as well is precious time is wasted in travelling and communicating at various centers. As a result of which there is tremendous stress and exhaustion for the couple. Also there may be reduced sperm motility, thereby decreasing the chances of conceiving.
At our centre, we provide everything from consultation to follicular monitoring, semen collection, preparation and insemination under one roof. This help us to attain better pregnancy and live birth rates.
Studies have shown that techniques for channelizing the positive energy and reducing stress increases success of IUI (Artificial Insmeination) .Once such technique is “Accupuncture”. At Ankoor clinic we also have facilities for Accupuncture by qualified specialist too under the same roof. This can further boost your success changes.
Advantages of IUI (Artificial Insemination)
High concentration of highly motile, best quality sperms are placed very close to the egg. This increases the chances of conception manifold.
Very simple procedure. No need of anaesthesia.
Patient can go home or to work soon after the procedure.
Extremely useful for couples with sexual dysfunction like dyspareunia, vaginismus, erectile dysfunction, non consummation of marriage, mild male factor infertility, grade I & II Endometriosis, unexplained infertility etc.
Usually husband is not required at all visits.
The pregnancy rates are lower in case of IUI (Artificial Insemination) , approximately 10-15%. During folliculometry we document the release of the egg from the ovary. In the IUI (Artificial Insemination)procedure, we inseminate the active motile sperms into the uterus of the women, however we have no control over the fusion of the egg and the sperm. This explains the low pregnancy rates in case of IUI (Artificial Insemination) .
Apart from the time spent on visiting the doctor, there are no disadvantages of the procedure. IUI (Artificial Insemination)is one of the most basic procedures done to enhance fertility. We try and reduce the number of your visits to the clinic, so as to that the work burden on you doesn’t build up.
In most cases, 5-6 visits is all that is required. This includes the day we start ovulation induction, 3-4 follow up visits for follicular growth and a visit on the day of IUI (Artificial Insemination).
IUI (Artificial Insemination) with normal semen parameters
It does make sense to try IUI (Artificial Insemination) if you haven’t had success with intercourse with a normal sperm count.
IUI (Artificial Insemination) increases the chance of success with injectable Gonadotrophins no matter what the sperm count is.
With intercourse, only few sperms make it through the cervical mucus and up into the uterus and fallopian tubes. With IUI (Artificial Insemination), significantly more number of sperm will be available for fertilization.
IUI with abnormal semen parameters
Video of Semen Sample with Normal Parameters, Pre & Post Wash
IUI(Artificial Insemination) with abnormal semen parameters
Research has shown that an IUI done just prior to ovulation and repeated again after ovulation increases the conception rate specially in cases of sample with abnormal semen parameters.Therefore, we at Ankoor Fertility clinic, do “double insemination” in such specific cases.
Video of Semen sample with abnormal parameters
Precautions after IUI (Artificial Insemination)
No precaution is the “Best Precaution”.
However, complete mental relaxation is what we want.
Apart from 10 – 15 minutes of lying down immediately after IUI (Artificial Insemination), no additional bed rest is required.
There are no restrictions on travelling as also on mode of travel. You can safely travel by autos, 2 wheelers, local trains, metro etc…etc… It will not change your success rate.
You can safely go to work from the following day.
No restrictions on the food that you eat. One can definitely have papaya, mangoes, veg, non-veg, etc..without changing the success rate.
Medication after IUI(Artificial Insemination)
IUI (Artificial Insemination) is a very simple procedure. To enhance your conception rate, very few medicines need to be taken.
The medications given are generally various progesterone preparations used to support the pregnancy in the luteal phase (the phase of implantation of embryo and continuation of pregnancy after ovulation).
The progesterone preparations may be given in the form of oral drugs or vaginal preparations for insertion in the vagina or a combination of both oral and vaginal preparations.
These medicines are usually started a day after the IUI (Artificial Insemination) procedure.
The vaginal preparations are found to be superior to oral ones as they work locally (in the vicinity) without undergoing the systemic metabolism (absorption into the blood) and also giving higher pregnancy rates.
At Ankoor Fertility Clinic we evaluate the endometrium on Day2 or Day3 and the endometrial blood flow on Day 10 of the cycle. If the blood flow is found adequate and the endometrial lining is good, the likelihood of conception is higher. In cases of deficient endometrial blood flow, medications like Ecosprin, Sildenafil and Arginine are added. Studies have shown these drugs improve the implantation and conception rate. Such a holistic approach gives good results for our patients.
Pain during IUI(Artificial Insemination)
IUI (Artificial Insemination) procedure is usually painless per se. Most women feel a little discomfort similar to internal examination. The actual pain is generally not felt.
It’s more of fear of the procedure that results in pain/discomfort rather than IUI (Artificial Insemination) itself
In 1-2% of patients, there could be abdominal cramps or back pain after IUI (Artificial Insemination), the severity of which is not more than the pain during periods.
Many women also experience ovulation pain which may contribute to the discomfort during IUI (Artificial Insemination) because IUI (Artificial Insemination) is done at the time of ovualtion.
Adequate information regarding the procedure and counseling will reduce the discomfort of the procedure.
Discharge/Semen coming out after IUI(Artificial Insemination)
Before IUI (Artificial Insemination) we clean the vagina with sterile gauze piece to remove the debris and the natural discharge.
Then we use a sterile medium solution to wash out the vagina before IUI (Artificial Insemination) and make it more receptive to the sperms. This fluid might trickle down to give you a sensation that sperms are coming out.
Also the motile sperms are injected directly into the uterine cavity which is higher up than the vagina and they will swim up as soon as they are injected into the uterus towards the fallopian tubes and not in the vagina. The semen sample is already into the uterine cavity once the catheter is removed. Thus it is normal to have some fluid discharge after the procedure but this does not contain the motile sperms.
Bleeding after IUI(Artificial Insemination)
IUI (Artificial Insemination) is a simple, atraumatic procedure taking a few minutes.
Generally there is no bleeding after IUI. However, bleeding can happen if the catheter does not enter the cervix (the lower part of uterus) and hence the need to hold the cervix with an instrument called tenaculum arises.
This is called as mild spotting and it stops in 24 hrs. In some patients ovulation itself could be associated with some spotting.
Intercourse after IUI(Artificial Insemination)
It is absolutely safe to have intercourse soon after IUI (Artificial Insemination).
Infact, we recommend intercourse soon after IUI so as to make sure that the fertile period is completely taken advantage of.
Husband not available at time of IUI (Artificial Insemination)
One can freeze the semen sample before an IUI (Artificial Insemination) procedure if they are physically away at the time of procedure.
Once semen sample is given to the lab; a complete semen analysis is performed which includes, volume, liquefaction and viscosity, sperm count, motility, forward progression and morphology.
This semen is then subjected to freeze and can be revived on IUI (Artificial Insemination) day (Freezing can sometimes reduce the motility of the sperms).
Outcome of IUI(Artificial Insemination)with frozen semen
Freezing process tends to kill off weaker sperms, and may thus lead to survival of the best sperms.
It does not change the success rate.
It has been documented in the literature that pregnancy has occurred using semen frozen for 21 years.
Implantation after IUI(Artificial Insemination)
In normal conditions, the sperm meets the ovum in the fallopian tube around ovulation, the fertilized embryo then travels the entire length of tube and implants in the uterus after around 5-6 days.
The same thing happens after IUI (Artificial Insemination). Hence bed rest following IUI (Artificial Insemination) is not required.
This is the time required for fertilized egg to travel from your fallopian tubes to the uterus. This is also the time when lining of uterus will be ready to accept your fertilized egg.
At our centre, we do Color Doppler assessment of the Endometrial blood flow. If the blood flow is good, the receptivity of the endometrium for fertilized embryo is good. If the blood flow is inadequate, we at our centre, provide necessary treatment to improve the blood flow of the endometrium either in the same cycle or the next to increase the pregnancy rates.
VIDEO SHOWING GOOD ENDOMETRIAL BLOOD FLOW ON USG COLOUR DOPPLER
Good Endometrial blood flow at the time of ovulation
Post ovulatory good endometrial blood flow
What happens after IUI(Artificial Insemination)?
Post IUI (Artificial Insemination) the medication for luteal support (2nd half of the cycle)is given for 14 days.
After stopping the medications, you need to wait for 5 days.
If you don’t get your periods after that then you have to come for a checkup to “Ankoor Fertility center, Mumbai” to confirm pregnancy.
If within 5 days after stopping the medicines you get your periods, you have to come and see us on the second or third day of periods.
Detecting Pregnancy after IUI(Artificial Insemination)
If pregnancy occurs, there is release of hormone β HCG from the developing embryo. Serum levels of this hormone are measured to detect pregnancy. This hormone is also secreted in urine.
Pregnancy can be detected earliest around 14 days after IUI (Artificial Insemination).
A simple urine pregnancy test done at home will tell you about your pregnancy.
If in doubt, blood test for hormone βHCG levels can confirm the same.
Method of delivery after IUI(Artificial Insemination)
Mode of delivery i.e. normal delivery or cesarean section is not decided by the way you achieve pregnancy. In the absence of any risk factors, you can safely have a normal delivery.
Success rate in IUI (Artificial Insemination)
The success rate of IUI (Artificial Insemination) depends on a multitude of factors like women’s age, ovarian reserve, previous obstetric history and semen parameters and most importantly on stimulation protocol used.
IUI (Artificial Insemination) done in natural cycles has a success rate of 8-10%.
Stimulation done with oral medications (Clomiphene Citrate) increases the success rate to 14 – 15%.
Use of injectable Gonadotrophins increases the rate of success to 18 – 20%.
Using highly potent recombinant Gonadotrophinsfurther increases the success rate.
Addition of GnRh antagonist increases the pregnancy rates further by 26-30%
Overall, at Ankoor Fertility centre, the success rate following 3 IUI(Artificial Insemination)has been 18-25%.
How to further enhance the success rate in IUI (Artificial Insemination)?
At Ankoor fertility centre, we do a various unique things, so as to help you become pregnant faster and in a healthier way.
Trial cycle – Before commencing, we often do a trial cycle in which we observe the growth of your follicles, their rupture, the timing of rupture, whether spontaneous rupture occurs or not and most importantly evaluation of the endometrium.
Endometrial evaluation – Gametes are like seeds and the endometrium (lining of uterus) is like the soil. Just as for proper implantation of seeds, good soil is necessary, so is the endometrium for the embryo. We routinely evaluate the thickness and pattern of endometrium so as to prepare optimum endometrium and enhance the results.
This is done by serial Ultrasound at our clinic.
If found necessary, certain medications are given to increase the thickness and also Color Doppler for blood flow to endometrium is done. If the blood flow if found deficient, a medical treatment is initiated along with constant evaluation of the same to increase the live birth rates and decrease the abortion rates.
Video 2: Post ovulatory good endometrial blood flow
Evaluation of male partner – We do semen analysis in our Lab, so as to pick up any subtle abnormalities which might be present inspite of normal count and motility.
Certain specialized tests like Sperm Function Test, DNA fragmentation rate and Mitochondrial assay are done in specialized circumstances so as to enhance the result.
Sperm function test gives an idea of the capacity of sperm to fertilise an egg.
DNA fragmentation rate gives an idea of genetically normal sperms. High fragmentation rate is associated with higher rates of abortion.
What are the predictive factors influencing pregnancy rates after intrauterine insemination?
The predictive factors after IUI (Artificial Insemination) are as follows:
Female partner’s age (less than 35 years of age have better results),
Body mass index (BMI) (BMI <26 have better results),
Duration of infertility (Longer the duration of infertility, poorer are the results),
Type of infertility (primary versus secondary),
Follicle stimulating hormone (FSH) level and estradiol (E2) on third day of the cycle (If the Estradiol levels are 1000 to 1200 for 3 mature follicles, then the response is better),
Number of preovulatory follicles (More the number of follicles, better the response),
Endometrial thickness (If endometrial thickness is 9 to 12 mm around the time of IUI, then the response is better),
Total motile sperm (TMS) count (more than 5 million, better response) and ratio of progressive motile sperm.
Reasons for failure in IUI(Artificial Insemination)
The success of IUI (Artificial Insemination) depends on multiple factors like age of women, ovarian reserve, semen parameters, cause of infertility, duration of infertility etc.
Even in a natural cycle with couple having no abnormality, the success rate in a cycle is only 8-10%.
Failure can be due to poor quality egg, abnormal semen parameters or just due to probability of success.
Even if 2-3 IUIs (Artificial Insemination) have failed, you should not get disappointed as we have seen success after 6 cycles of IUI (Artificial Insemination) too.
Working women/couple and the number of visits to the clinic
IUI (Artificial Insemination) is an outpatient procedure, so leaves from office are not required during the monitoring phase.
Moreover, at Ankoor fertility Clinic, most procedures are done in the evening after your office hours.
Only on the day of procedure, half a day leave may be required, since the time from giving semen sample to processing the semen sample and doing the IUI procedure (Artificial Insemination) takes about an hour and a half to two hours.
If done during the morning hours, the busy schedule of the husband can be easily handled by allowing him to leave for his job after giving the semen sample and the initial semen count been checked. The wife could stay back till the procedure is over and resume duty after that.
Also, during the monitoring phase, husband is not required at all visits. However, if time permits he can accompany you.
Number of IUIs to be done in a cycle?
Generally at “Ankoor Fertility Center, Mumbai”, we perform one IUI (Artificial Insemination) after confirming the rupture of follicle (release of egg). Usually the follicle ruptures after 36 hrs.of administration of HCG injection. Sometimes two IUIs (Artificial Insemination) are done in a cycle in selected group of patients like previously repeatedly failed IUI’s (Artificial Insemination), male factor infertility, unexplained infertility and when time is a constraint (e.g. The husband is working abroad and has come to India for limited time period) etc.
In our experience by doing two IUI(Artificial Insemination) for male factor infertility like low sperm count or motility would give a higher pregnancy rates than one IUI(Artificial Insemination) in a cycle.
These IUIs (Artificial Insemination) are done generally at 24 hours and 48 hours after the HCG injection.
Failure in IUI (Artificial Insemination)
Usually for a perfectly healthy couple trying for pregnancy without any intervention, success rate in any given cycle is only 8 – 10%.
By doing IUI (Artificial Insemination), success rate can be increased upto12%.
In case of failure to conceive in one cycle of IUI, the same treatment and procedure is usually carried ahead by most of the Gynecologists. But we at Ankoor Fertility Clinic go beyond this. Not only is a detailed counseling assured, but also a change in the ovulation induction protocol, a better endometrial evaluation and an approach to increase the male sperm count, improvement in the endometrial blood flow and a better support of the luteal phase, i.e. after ovulation to enhance the success of the treatment in the next cycle.
If oral medications were used for ovulation induction, we use Injectable Gonadotrophins can increase the success rate next cycle.
What is included in the IUI(Artificial Insemination)treatment cost?
Preparation of the Semen sample.
Insemination of the processed semen in the uterus of his wife
What is not included in the IUI(Artificial Insemination)treatment cost?
Monitoring Ultrasound scan
Cost of fertility drugs or injections
Fee for freezing sperm (if required)
Fee for donor sperm (if required)
Cost for IUI procedure (Artificial Insemination)?
Cost of IUI (Artificial Insemination) depends on the medications used as well as the whether the consultation and folliculometry was also done with us. It also increases if a donor sample is used for IUI(Artificial Insemination) . The cost at Ankoor Fertility Clinic is around Rs. 5000/-, but it varies between Rs. 2000/- to 10,000/- depending on the above mentioned factors.
Number of IUIs before moving to IVF / next line of treatment?
This depends on factors like age of the couple, cause for infertility, semen count of the male partner, number of years of infertility, any other associated factors involved etc.
In a young couple, at least 6 cycles of IUI (Artificial Insemination) with ovulation induction are advised whereas in an elderly couple (age > 35 yrs) 3 cycles of IUI are advised. Also in cases with mild to moderate Endometriosis, it is better to restrict to 3 cycles and then move to higher treatment. Individualization of the cases is done and same parameters cannot be used for all the patients.
A study conducted at Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Centre, Room H4-213, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands stated that as many as 9 IUI (Artificial Insemination) cycles can be performed but at our centre “Ankoor Fertility Centre, Mumbai” we restrict to 6 cycles as we found that patient returning for further trial and pregnancy rates dropped after initial 6 cycles.Bottom of Form
What is Donor IUI(Artificial Insemination)?
At Ankoor fertility clinic, we also do Donor IUI. Donor semen is required in cases of severe male infertility with very poor sperm count or very poor motility. It is also done in cases of no sperms in the semen (azoospermia).
We screen the donor for infectious diseases like HIV, HbsAg, HCV (jaundice), VDRL (sexually transmitted diseases) and also the blood group. The donor is also matched physically as per the husband.
Endoscopic surgery is a surgery in which long telescope like instruments are used through small incisions or natural body openings in order to diagnose and treat disease. Another popular term is minimally invasive surgery (MIS), which emphasizes that diagnosis and treatments can be done with reduced body cavity invasion.
Commonly performed endoscopic surgeries in infertility management are laparoscopy (instrument introduced through the abdomen to visualize the womb and its surroundings like the fallopian tube and ovaries from above) and hysteroscopy (instrument introduced through vagina and cervix to visualize the inside of the womb). Both of these can be either diagnostic (to diagnose the cause leading to infertility) or operative (to treat the condition leading to infertility ).
At Ankoor fertility clinic we offer all kind of endoscopic surgeries, both diagnostic and operative under one roof. In certain cases while doing diagnostic surgeries if some disease or condition is diagnosed which requires operative intervention, then the same is also done (only after the consent of the couple) in the same sitting.
For example, if on doing a diagnostic laparoscopy, we find that there is some endometriosis (discussed in details later), we fulgurate (cauterize or burn the unhealthy and abnormal tissue) .
This helps to reduce the burden of undergoing another operative procedure to the patient, which in turn reduces the risk of another anaesthesia, cost of surgery and also fewer days for recovery .
Some of the common indications for using endoscopic surgeries in infertility
Tubal cannulation is a procedure by which proximal end of fallopian tube can be opened with the help of cannulation wire by hysteroscopy and laparoscopy simultaneously.
Hysteroscopy is done initially and uterine cavity, both tubal opening are observed.
Laparoscope is introduced through abdomen and methylene blue dye is pushed, free spill from either of the tubes is observed.
This is called as selective tubal cannulation.
This procedure is done only in case of proximal tubal block. Whenever there are pathologies on the distal end of the tubes such as, fimbrial agglutination, adhesions to the ovaries, pelvic inflammatory disease, endometriosis, tubal cannulation might lead to implantation of the pregnancy outside the uterus (ectopic pregnancy).
So it is done only when distal tubal end is normal devoid of any above pathologies and normal semen parameters.
Cannulation catheter with guide wire (instrument to open the block) is passed from the uterine cavity towards the tubal opening, just a centimeter forward.
What is Laparoscopy ?
Laparoscopy is a procedure that involves insertion of a narrow telescope-like instrument through a small incision in or near the belly button. This allows visualization of the abdominal and pelvic organs including the uterus, fallopian tubes and ovaries. Laparoscopy is sometimes referred to as ‘band-aid’ surgery since the incisions are very small and usually covered with a band-aid (Steri-strip). Some people refer to it as a key- hole surgery or minimally invasive surgery.
Normal Uterus with bilateral tubes and ovaries on diagnostic laparoscopy
Do all women with infertility need to undergo this surgery?
Laparoscopy is not indicated as a routine investigation in all women who have difficulty in conceiving.
There are specific indications for undergoing laparoscopy and the decision for the same is taken in consultation with your infertility specialist.
What are the indications for laparoscopy?
Laparoscopy is indicated whenever the history of the patient, clinical examination or other investigations such as Ultrasonography (USG) or Hysterosalpingography (HSG) indicate an abnormality in pelvic region. Hysteroscopy usually goes hand in hand with laparoscopy.
Common indications being:
Diagnostic laparoscopy – It is generally done to visualize check whether the uterus and its surrounding structures are normal. A blue coloured dye can be injected from the cervix (mouth of the uterus) by an assistant and the dye is seen coming out through the fallopian tubes via the telescope, thus confirming that the tubes are open (chromopertubation).
Endometrioma (Cyst in ovary containing blood)
Hydrosalpinx or pyosalpinx (Infective fluid or pus in uterine tubes)
Pelvic adhesions (sticky bands similar to what is seen when there is fevicol smeared in between our fingers ) with or without tubo ovarian mass (Usually these occur following infection in pelvic region)
Bulky polycystic ovaries (PCOS) not responding to medical line of management
Fibroids of uterus
Failure of IUI (Intrauterine insemination) – When more than 6 consecutive cycles have not been able to achieve pregnancy.
Prior to IVF (if needed) – Sometimes the history of the couple and previous investigations lead to the conclusion that IVF (test tube baby) may be needed. In these cases endoscopic surgery may be needed to visualize the uterine cavity, particularly its lining on hysteroscopy and uterus or ovaries on laparoscopy for any abnormality which can be corrected prior to the procedure.
In women with long term unexplained infertility (where all other standard or routine investigations are normal). In these cases endoscopic surgery (Laparoscopy or hysteroscopy) may be needed to search for any factor which may have been missed by routine non invasive tests like USG ( ultra sonography) or HSG (Hysterosalpingography)
Endometrioma is also called as endometriotic cyst, which is found in ovary.
It can be unilateral (only in one sided ovary) or bilateral (in both ovaries)
How to operate on endometriotic cyst?
1) Locate endometrioma and its realtion to the rest of the ovary and part of the uterus
2) Incision (cut) taken on surface of the endometrioma
3) Separating the endometriotic cyst with its cyst wall from the rest of the healthy ovary
Separating the endometrioma with its cyst wall avoids chances of recurrence of endometrioma Ankoor fertility clinic prefers the same method
4) One should assure that there are no bleeding points in the surgical field. Minimal use of electrical energy (bipolar) or couple of sutures can be taken to stop the bleeding in case
( Staging done by laparoscopy – as a gold standard )
Adhesions – These are the pathological connections formed between different reproductive organs or within one organ
It can be due to previous infections or previous surgeries
For example – adhesions formed between fallopian tubes and ovary will disturb tubo-ovarian relationship and affect the pickup of oocyte by fimbria
Adhesions formed inside uterus will affect the chances of pregnancy getting implanted inside the uterus
That is why adhesiolyis (breaking these adhesions ) improves the rate of fertility in future times
How to diagnose fibroids –
1. Transvaginal 2D/3D sonography
2. Fluid contrast sonography – (sonohysterogram) – to establish relationship between fibroid with the uterine cavity in case of submucous fibroid
If the size of submucous fibroid is bigger we give medical therapy f or 3-6 months and size is reduced. such fibroids are easy to take out in one surgery which otherwise might have taken one or more surgeries
3. MRI – used when there are more numbers of fibroids ( more than 5-7 ) to get information about exact location of fibroids from the endometrium and outer surface. This is called as “fibroid mapping “ – for surgical accuracy (image
Plan of surgery is decided pre operatively after one of these investigations
Depending on location of fibroid
It’s distance from serosa ( outermost layer of uterus )
It’s distance from mucosa ( innermost layer of uterus )
Number and site of incision
How we operate on fibroid :
Step 1 – locate fibroid and inject inj. Vasopressin in particular dilution with saline . This injection helps in reducing blood flow to fibroid ( by constricting the vessels supplying fibroid ). This is needed as fibroid is very vascular organ .
Step 2 – taking incision on fibroid depending on type of fibroid
Step 3 – inserting a screw like device ( myoma screw ) in fibroid to take out the fibroid from its capsule inside the uterus
Step 4 – suturing of uterus at the site from where myoma is removed ( myoma bed ) with absorbable suture material in 2 -3 layers
Step 5 – removing the myoma outside the abdomen by use of special instrument called as morcellator. It uses mechanical energy to make small pieces of fibroids in the form of strips an then taken out of the abdomen through same incision
What do you mean by diagnostic laparoscopy and operative laparoscopy?
Diagnostic laparoscopy is performed as a part of investigation for infertility in cases where no abnormality is detected on non invasive tests like USG (ultrasound) or HSG (hysterosalpingography). It is usually performed in women with unexplained infertility, following failure of repeated IUIs or along with operative hysteroscopy. The pelvic anatomy is visualized with a telescope like instrument. The uterus, tubes, ovaries and there surrounding structures are systematically checked. A blue coloured dye is injected from the cervix (mouth of the uterus) by an assistant and the dye is seen coming out through the fallopian tubes via the telescope, thus confirming that the tubes are open. This is known as chromopertubation.
Diagnostic Laparoscopy Video
Video Bilateral Tubo Ovarian Mass
Diagnostic or operative hysteroscopy usually accompanies this procedure.
A review of literature shows that even among women whose tubes were found to be unobstructed or patent (open) using HSG (which shows the inside image of the fallopian tubes), 18% were found to have tubal obstruction or peritubal adhesions (outer side of the fallopian tubes) using laparoscopy and a further 34% were found to have endometriosis or fibroids (again outer side of the fallopian tube is involved or compressed). These conditions remain silent and cannot be diagnosed on non invasive tests (USG or HSG).
If there is any abnormality like fibroids, endometriosis, pelvic adhesions or blocked tubes, these can be tackled at the same time.
Many a times a diagnostic laparoscopy is done along with operative hysteroscopy in cases like hysteroscopic fibroid removal and septum resection for extra seafety of the patients, to know the end point and to prevent complications like uterine perforation.
Whenever some surgery is performed in addition to chromopertubation, like removal of fibroid, endometrioma removal, fulguration (burning) of endometriosis, adhesiolysis(separation of adhesions in pelvis) or delinking of hydrosalpinx or pyosalpinx, is called operative laparoscopy.
How is laparoscopy performed?
Laparoscopy procedure is usually done as a day care surgery (you can get admitted, undergo surgery and discharged on the very same day or the next day but generally within 24 hours) under general anaesthesia. It usually takes about few minutes to less than an hour.
During this procedure a small cut is made on or near the belly button (this leaves a minute scar which is almost invisibles). A telescope (laparoscope) is then inserted through the umbilicus and gas (carbon dioxide) is pumped into the abdomen to push the intestine away. A powerful light is then shone down through the laparoscope.
The endoscopic surgeon then inspects the inside of the abdomen and pelvis including the outside of the womb / uterus, the tubes and ovaries as seen on the video monitor.
A second incision (1-1.5cm) is also made on the left or right lateral side of the lower abdomen so that another probe can be inserted in order to move pelvic organs such as the ovaries or bowels to get a clear view. A blue coloured dye (methylene blue) is then injected through the cervix (mouth of uterus). If the tubes are not blocked the dye should pass along them and spill into the abdomen.
If an abnormality is found during laparoscopy, this may be dealt with at the same time thus avoiding another operation. When performing operative laparoscopy such as opening of blocked tubes, cutting of adhesions and freeing of the tubes etc. additional instrument such as micro-scissors and forceps are placed in the abdomen through additional cuts generally on the lateral side of the abdomen.
When the surgery is completed, the gas is removed and a stitch is taken to close the incisions.
Is it a big procedure? How much work would I miss?
Diagnostic laparoscopy is a day care procedure and generally takes about 30 minutes. If on doing the laparoscopy any abnormality is seen like adhesions, cyst etc and operative work is required, the procedure might take a little longer. The woman is generally discharged home from the hospital on the same evening or the next day morning.
The woman will usually need to take off an additional 1-2 days from work following the procedure. Mild discomfort in the form of mild abdominal pain or shoulder tip pain, should be expected to last for up to 7 days or so after the procedure.
What are the complications of laparoscopy?
After the laparoscopy procedure the in about 3% of patients there may be some nausea, discomfort and shoulder tip pain, due to the gas that was injected into the abdomen. The discomfort usually lasts not more than 24-48 hours.
Major complications associated with operative laparoscopy include the possibility of damage to other structures in the pelvis such as the bladder, ureter, bowel and blood vessels. Unexpected open surgery (larger incision) is always a possibility, but is very uncommon.
Any surgery can have an anesthesia-related complication or be associated with post-operative infection, such as a skin infection at an incision site.
However when such surgeries are performed by experts with utmost care the possibility of complications is very rare.
The word surrogate originates from Latin word surrogatus (substitution), which means “to act in the place of”.
The term surrogacy is used when a woman who is unable to carry her child during the nine months of pregnancy and give birth to her baby, takes the help of another woman and hires her womb (uterus) to carry her child and deliver it.
Surrogacy is gaining popularity as this may be the only method for a couple to have their own genetic child. Also sometimes the procedure of adopting a baby may be very long and drawn out, because of which some couples use surrogacy as an option of treatment.
What is the history of surrogacy?
IVF / Gestational surrogacy – This is more common form of surrogacy. This is where a woman carries a pregnancy created by the egg and sperm of the genetic couple. The egg of the wife is fertilized in vitro by husband’s sperms by IVF/ICSI procedure. The embryo formed is the genetic child of the infertile couple. This is then transferred into the surrogate’s uterus. The surrogate carries the pregnancy for nine months and delivers the baby. On birth of the baby, the child is handed over to the legal parents (genetic parents).
The child is not genetically linked to the surrogate.
Traditional / Natural surrogate – This is where the surrogate is inseminated or IVF/ICSI procedure is performed with sperms from the male partner of an infertile couple and using eggs of the surogate. The child that results is genetically related to the surrogate and to the male partner but not to the infertile female partner (who is the legal mother).
Traditional or Natural surrogacy is banned by the Indian Council of Medical Research (ICMR).Gestational Surrogacy is legal in India as the surrogate is not genetically related to the unborn baby and is just a carrier for the legal infertile mother.
To whom surrogacy is advised?
IVF or Gestational Surrogacy is advised in the following conditions:
Most commonly it is indicated in women whose ovaries are producing eggs but they do not have a uterus. Some of the common reasons are as follows:
Congenital absence of uterus (Mullerian ageneris)
Surgical removal of uterus (hysterectomy) due to cancer, severe hemorrhage in previous Cesarean section or Rupture uterus.
A woman whose uterus is malformed (unicornuate uterus, T shaped uterus, bicornuate uterus with rudimentary horn) or damaged uterus (Tuberculosis of the endometrium leading to severe adhesions and loss of normal endometrium, severe Asherman’s Syndrome).
Women at a high risk of rupture of uterus due to previous uterine surgeries for rupture uterus or fibroid uterus and hence is unable to carry pregnancy to term.
Women who have repeated miscarriages or have repeated failed IVF cycles may be advised IVF surrogacy in view of unexplained factors which could be responsible for failed implantation and early pregnancy wastage.
Women who suffer from medical problems like diabetes, heart or kidney diseases like chronic nephritis, whose long term prospect for health is good but pregnancy would be life threatening.
Woman with Rh incompatibility (One partner may have a positive blood rhesus factor/ blood group and the other negative, leading to repeated miscarriages).
Surrogacy with donor eggs
Women who have no functioning ovaries due to premature ovarian failure or streaky ovaries due to some congenital anamolies. Here egg donation also can be an option.
Sometimes the ovaries may have been removed due to cancer or severe endometriosis etc
A woman who is at risk of passing a genetic disease to her offspring.
There are a few combinations in which surrogacy is used as discussed below:
Wife’s egg + Husband’s semen = Embryo transferred in the surrogate
Wife’s egg + Donor’s semen = Embryo transferred in the surrogate
Donor’s egg + Husband’s semen = Embryo transferred in the surrogate
Donor’s egg + Donor’s semen = Donor Embryo transferred in the surrogate
Is Surrogacy right for you?
For some couples opting for surrogacy is a very straight forward decision but for others there are lots of things to be considered and thought about before taking the decision about surrogacy. There are lots of complex issues involved.
It is an emotional roller coaster ride for the couple, the families and friends.
It is a decision where the ‘right’ and the ‘wrong’ are very individual things.
An infertility specialist or a counselor can help the couple seeing things in perspective.
Other options to surrogacy like adoption or further infertility treatment can be considered.
What is the success rate of surrogacy?
The success rate of surrogacy is very good with a carry home baby rate of around 60%..
What are the screening criteria for surrogate? How is a surrogate chosen?
We at Ankoor fertility clinic, have a very meticulous and stringent criteria for choosing a surrogate.
The surrogates are between 21-35 years of age.
They are married with previous normal deliveries and healthy babies.
Detailed medical history, surgical history, personal history, family history is looked into.
History of blood transfusion and addiction is also taken. It is made sure that the surrogate has an uneventful obstetric history (like no repeated miscarriages, no antenatal, intranatal and postnatal complications in previous pregnancies).
The surrogate and her partner are screened for infectious diseases like sexually transmitted diseases, Hepatitis B, Hepatitis C, HIV, VDRL.
Thalassemia screening is also done.
Detailed pelvic sonography is done and other tests for uterine receptivity are done to ensure maximum chances of success.
A detailed financial and legal agreement is then made between the surrogate and the commissioning couple.
What is the procedure involved?
For IVF surrogacy matching of cycles of the genetic mother and the surrogate is done by adjusting menstruation dates by oral contraceptive pills.
When the cycle starts, the surrogate is put on estrogen tablets to prime the uterus.
Protocol used for genetic mother is day 2 protocol or day 21 protocol depending on the age of the genetic mother and other test results.
For the day 2 protocol called the ‘Antagonist protocol’, oral contraceptive pills are given in the previous month. On 2nd day of the periods gonadotropin injections are started. USG monitoring is done daily. When the size of the follicle reaches 14 mm the genetic mother is given antagonist injection to prevent surge of endogenous hormones.
For the day 21 protocol called the ‘Long protocol’, GnRH analogues are started on day 21 of the previous cycle. Once the genetic mother gets her periods, gonadotropin injections are started.
In both the cases the patients are monitored daily.
When the follicle reaches 18 mm size hCG trigger is given. The surrogate is started on progesterone tablets on the day of hCG injection to the genetic mother.
Oocyte retrieval is done 36 hours later which is generally day 12/13 of the cycle. On the same day the genetic father gives his semen sample. The eggs of the genetic mother are fertilized with sperms of the genetic father in the laboratory by IVF / ICSI procedure.
The embryo which has resulted from the above mentioned procedure is transferred into the womb of the surrogate under ultrasound guidance. The surrogate is then put on luteal support using progesterone tablets / injections and pregnancy is confirmed using a simple blood test done 15 days later.
How is the nine months journey like with surrogate?
The surrogate is treated as a high risk pregnancy and is cared for by two consultant gynecologists / obstetricians in our hospital. Appointments are scheduled with the consultants every three weeks for the first 6 months, then every 15 days for the next 2 months and then weekly / biweekly in the last month. Blood tests and ultra sound are done as and when required. Routine blood tests like hemoglobin, blood group, VDRL, HbsAg & HIV are done prior to the embryo transfer also.
Special care and tests are done to pick up any obstetric or medical complications like hypertension, diabetes etc. at the earliest. Two doses of Inj. Tetanus toxoid are given during pregnancy. The baby’s growth is monitored stringently. Ultrasound is done at 6 weeks to confirm pregnancy and the viability of the baby, then at 12 weeks to assess growth and certain parameters like nuchal thickness.
At 18 -20 weeks a detailed level III ultrasound is done to detect any abnormalities in the baby. At 16 weeks amniocentesis is performed if the genetic mother’s age is more than 35 years after counseling and in consultation with the genetic parents.
At 28 weeks and 34 weeks colour Doppler is performed to assess the growth of the baby and rule out intra uterine growth retardation.
Fetal well being tests like non stress tests are done as and when required.
Detailed information is given to the surrogates about diet during pregnancy. They are regularly provided with supplements from the hospital.
Thus it is taken care that adequate nutrition reaches the baby and baby’s growth is maintained.
We keep the couple posted on the progress of the baby and send them ultrasound pictures and blood reports as and when they are done.
We have an LDRP (Labour Delivery Recovery Puerperium) room for delivery which is equipped to handle any obstetric emergency. Our NICU setup is also completely equipped to handle any neonatal complications, with a neonatologist who is available round the clock.
What are the different ways children born through surrogacy may receive breast milk?
Just because baby is born through surrogacy does not mean he or she cannot receive breast milk and the many health benefits it provides.
Benefits of Breast feeding: Breast fed babies have been found to have higher IQs, more protected from leukemia and less likely to have problems with obesity. Breast milk protects babies from getting diarrhea, ear infections and respiratory problems such as asthma. Premature babies who receive breast milk are more protected from infections and high blood pressure later in life. Breast milk contains the protein CD14 which works to develop B cells which are immunity cells that are needed in the production of antibodies in an infant to build the babies immunity system. The babies may drink breast milk acquired through milk bank, breast milk donor may be located or the intended mother may induce lactation before birth of the baby. Induced lactation has been embraced by the nursing community as a welcome method to enhance the bonding relationship between a new mother and baby born through surrogacy.
How Inducing Lactation Works?
Lactation involves two hormones: Prolactin is considered the milk-making hormone while oxytocin is the hormone responsible for releasing breast milk. Both of these hormones are controlled by the pituitary gland and are therefore not ovarian hormones. This means that even in a woman who has undergone a hysterectomy lactation can be induced.
The hormones involved in inducing lactation both respond to nipple stimulation, and thus respond to manual stimulation such as:
sucking by baby
sucking by a hospital grade electric breast pump
While manual stimulation alone should be sufficient in inducing lactation, hormonal therapy to induce lactation is also available. This typically involves administering high levels of estrogen hormones in order to simulate pregnancy. This is followed by an abrupt withdrawal of estrogen to mimic the hormonal environment in a woman’s body after birth.
Medication to enhance prolactin levels will then be administered, and sucking – whether by baby or a pump – will begin at this point.
Inducing lactation can take anywhere from 5 days to 4 months, so expecting mothers often begin to induce lactation during the third trimester of a surrogate pregnancy. Inducing lactation should only be attempted with the guidance of a pediatrician, lactation consultant and/or doctor.
What are the advantages of surrogacy?
This may be the only chance for some couples to have a child which is biologically completely their own (IVF surrogacy using husband’s sperm and wife’s egg ) or partly their own (using either Husband’s sperm with Donor eggs) OR (Wife’s egg and Donor’s sperm).
The genetic / legal mother can bond with the baby better than in situations like adoption.
What are the disadvantages of surrogacy?
It is highly controversial topic and can involve many legal complexities.
The surrogates may face medical / obstetric complications during pregnancy which puts extra financial burden on the commissioning couple.
Some surrogates have a problem parting with the baby.
In some cases the surrogacy technique may be ‘misused’ like career oriented women, figure conscious woman, models etc. may just ‘hire’ women on ‘rent’ to carry their biological child. Of course, this is strictly not ethical, should be vehemently banned and prohibited.
In short surrogacy is an existing and innovative, yet complex and a little adventurous way to achieve parenthood.
Donor egg program includes oocyte retrieval from healthy young donors after controlled ovarian hyper stimulation followed by IVF and embryo transfer in recipient’s uterus.
What is Donar Egg Program?
Who are the Reciepients?
Who are the Donars?
How to Select the Right Donar?
DETAILED CASE HISTORY OF DONOR
Menstrual&Obstetric history (how many pregnancies she has had, when was the last pregnancy, any history of recurrent abortions etc. to determine fertility potential)
Family history (history of any genetic / congenital abnormalities in any family member)
Personal history(habits like using tobacco, smoking, drinking, what is the contraceptive being used)
PRESELECTION ULTRASOUND ASSESSMENT
To look for donor’s ovarian reserve and presumption of ovum retrieval after hormonal ovarian stimulation
Investigations done before choosing Donar
At Ankoor Clinic , once donor’s profile is found to be appropriate after meeting our criteria, blood tests are carried out to screen for any hormonal abnormality in the donor, any major blood disorder and infections that can be transmitted to the baby. We also do blood tests of donor’s husband to screen for any infectious diseases that may be transmitted to the baby if not screened early. Tests for genetic disorders may be done in certain circumstances on recipient couple’s request.
Thus, at Ankoor clinic, utmost care is taken in screening the donors, and only health , fertile and disease free donors are chosen. When we have a patient in need of a donor egg/ oocyte, we chose a suitable one from our Donor bank after matching the profile of the lady in need of the donor eggs with the donor.
If there are special requirements of a couple, about the donor, then we try to meet these specific requirements also.
For example: A Brahmin couple may want only an educated, graduate Brahmin donor
Steps involved in Donar Egg Program
Matching with donor
Synchronization of menses of donor and recipient
Controlled ovarian hyperstimulation of donor
Recipient’s treatment to prepare endometrium for implantation Oocyte retrieval from donor
In vitro Fertilization of retrieved oocytes with recipient’s husband’s sperm /Donor sperm obtained from Sperm bank
Culture of embryos
Embryo transfer in recipient’s uterus and luteal phase support
Serum beta HCG level on day 14
Once the investigations are done and are normal and inclusion criteria are met with, the menstrual cycle of the donor and recipient are matched using oral contraceptive pills so that synchronization of cycles happens
We start with tab estrogen after stopping the oral contraceptive pills to maintain the supression and to start preparing the endometrium for implantation.
A dummy embryo transfer is done for the recipient at this stage to rule out cervical stenosis. If there is cervical stenosis, cervical dilatation is done on day 2 of periods in the next cycle. This helps the actual embryo transfer to be easy and atraumatic. (Atraumatic transfer increases the success rate of pregnancy in IVF cycle.)
The donor is simultaneously started on injection lupride in the late luteal phase to shut down her natural hormones.
Once the donor gets her periods she is started on injections for ovulation induction.
The estrogen dose in the recipient is progressively increased so that the endometrial thickness is in the range of 9-11 mm.
Once the donor’s eggs are ready hCG injection is given for maturation of the eggs and ovum pick-up is done between 34-36 hours after hCG injection. On the day of hCG injection for the donor, a progesterone preparation is started for the recipient
The donor’s eggs are fertilized with the recipient’s husband’s sperms. The resultant embryo is transferred in the adequately prepared uterus (estrogen & progesterone primed uterus) of the recipient between the 15th & 20th day of periods i.e. between the 6th & 9th day of starting progestrone. Specific tablets / injections / vaginal preparations are given to the recipient in the luteal phase of the cycle to support the pregnancy.
A blood test (serum beta hCG) to confirm the outcome of the cycle is done on the 14th day after embryo transfer. If the blood test results are positive, the luteal phase support is continued and further instructions are given.
For couples not staying in Mumbai, the trip to Mumbai can be planned around the time of onset of periods for egg donation in Mumbai. Thus they will need to spend around 3 weeks in Mumbai. The total number of hospital visits will be around 8-10.
What are the outcomes of oocyte donation IVF cycle?
Success rates with conventional IVF decline steadily as the age increases, mostly beyond 35 years of age.
In contrast, live birth rate in oocyte donation cycle varies little across all age groups.
There are no unique problems associated with pregnancy after oocyte donation.
Multiple pregnancies are common with well known associated high risks.
Therefore, at our clinic, only two embryos are transferred in a cycle to prevent multiple pregnancy and complications associated with it.
Best and effective low sperm motility treatment only at Ankoor Fertility Clinic!
Sperm motility refers to the movement of sperm. Poor sperm motility means that the sperm do not swim properly, which can lead to male infertility. Poor sperm motility is also known as asthenozoospermia.
While the most well-known reason for male factor fertility is low sperm count, a few men are infertile on account of low sperm motility. Ordinarily, at least 50% of a man’s sperm ought to have great quality dynamic motility.
How motility is analyzed?
Sperm testing is performed with a semen examination which includes utilizing a particular counting chamber or a microscope slide with a grid.
The rate of sperm that has forward movement is important. This implies not just that they are moving – they are advancing continuously.
Treatment options for male to improve low sperm motility
In the present time, couples unable to conceive is an increasingly common scenario compared to two decades ago. So, we recommend medication or other treatment to increase the sperm numbers or the percentage of motile sperm, etc. here is some approaches that have been very effective for improving sperm motility.
Clomid (clomiphene) prescription for the male
If the man has a varicocele then Varicocele surgery is preferable
Various combinations of vitamins and minerals
How can you boost male fertility and increase sperm count naturally, and understand lifestyle factors which can impact male fertility
Reduce chemical exposure
Take nutritional supplements
Try herbal helpers to boost male fertility
Prevent yourself from smoking tobacco
Stop usage of marijuana
Avoid drinking alcohol
Stop using any anabolic steroids including any testosterone supplements
IVF with ICSI is a profoundly fruitful treatment for male infertility
Most IVF programs see that about 70-85% of eggs injected with ICSI become fertilized. We call this the fertilization rate, which is diverse from the pregnancy success rate.
IVF with ICSI achievement rates varies according to the details of the human being, the ICSI method used, the skill of the individual performing the process, the overall excellence of the laboratory, the quality of the eggs, and the embryo transfer skills of the fertility specialist physician.
Achieve successful results with us!
Dr. Kedar Ganla founded Ankoor Fertility Clinic in Mumbai. His infertility management which not only includes medical management and ART procedures but also counseling for stress management and lifestyle modification. Many patients have benefited with this different approach to their problem.
He has worked with thousands of infertile patients over the last decade using a combination of attentive personal care and advanced medical technology.
Today millions of men face infertility. In the event, that your partner is experiencing difficulty in getting pregnant, you are not the only one. The good news is that numerous men with fertility issues become fathers.
Whether you are suffering from low sperm count issue or are concerned companion, or relative, then you may have many questions regarding it. All your questions are answered only at Dr. Kedar Ganla’s Ankoor Fertility Clinic in Mumbai.
Low sperm count causes and effective treatment options:
To solve your queries let understand about low sperm count problem.
Low sperm count is a condition which is called as oligospermia. This is the term used to depict the condition when the sperm check is low, under 15 million sperm/ml. If there are no sperm at all in the semen test, the condition is named as azoospermia.
When you are attempting to have your children, the quantity of sperm you discharge is very vital. In case of low sperm or no sperm, we suggest book an appointment with Dr. Kedar Ganla for examining low sperm count and medical history.
In order to determine the best low sperm count treatment options, we will ask you whether there were any operations in the groin region, undescended testicles in adolescence or whether there has been any significant harm or disease in the genital zone. Be open, and take the benefit of effective treatment options.
What are the causes of low sperm count?
Men with heavy weight can also get to be distinctly sterile because that the sagging layers of fat can overheat the testicles.
Men whose occupations include extend hours of sitting, e.g. long separation lorry-drivers may have infertility because of the expanded warmth to the genital zone.
Very frequent intercourse lead to the demand exceeding the supply. There are a significant number of infertile men whose sex drive is the end goal that they should discharge 2-3 times each day consequently results into lower sperm tally.
Smoking more than 20 cigarettes a day has been appeared to lessen both the sperm count and sperm motility.
Different types of treatment for low sperm count
Successful surgery can help: A varicocele may be surgically corrected or an obstructed vas deferens repaired. But before that vasectomies can be reversed. In cases when there is no sperm count in the ejaculate, then sperm can often be retrieved directly from the testicles or epididymis using sperm retrieval techniques.
Treating Infections with antibiotics: Firstly the infections should be treated with the help of antibiotics as it helps to cure infections of the reproductive tract, this not always helps.
Healing for sexual intercourse troubles: Effective Medication or counseling from us can be helpful for you to improve fertility in conditions such as erectile dysfunction or premature ejaculation.
Treatments and medications for hormone issues: In the case of low sperm count we may suggest you for hormone replacement or medications where infertility is caused by high or low levels of certain hormones.
Assisted conceptive innovation (ART). This type of medication includes acquiring sperm through ordinary ejaculation, surgical extraction or from donor people, dependent upon your particular case and wishes. The sperm is then embedded into the female genital tract, or utilized for In Vitro preparation or intracytoplasmic sperm infusion.
IVF stands for in vitro fertilization. It refers to the process by which a woman’s eggs are collected and then fertilized outside her womb in the laboratory.
This is done in a Petri dish (“in vitro” is Latin for “in glass”) where the collected eggs are kept and the washed semen containing sperms is added to it so that one of the sperms fertilizes the egg.
The fertilized eggs (embryos) are cultivated and grown in the laboratory and after appropriate growth; they are transferred back to the uterine cavity.
What is IVF Treatment or test tube baby?
IVF stands for in vitro fertilization. It refers to the process by which a woman’s eggs are collected and then fertilized outside her womb in the laboratory.
This is done in a Petri dish (“in vitro” is Latin for “in glass”) where the collected eggs are kept and the washed semen containing sperms is added to it so that one of the sperms fertilizes the egg.
The fertilized eggs (embryos) are cultivated and grown in the laboratory and after appropriate growth; they are transferred back to the uterine cavity.
What is ICSI?
ICSI is a form of gamete (sperm and egg) micromanipulation that involves the direct injection of a single sperm into the cytoplasm (inside portion) of an oocyte (egg).
ICSI is an acronym for “Intra Cytoplasmic Sperm Injection” – which is a long, fancy way of saying “inject sperm into the middle of the egg”.
ICSI is a very effective method to get fertilization of eggs in the IVF treatment lab after they have been retrieved from the female partner.
IVF treatment with ICSI involves the use of specialized micromanipulation tools and equipment and inverted microscopes that enable embryologists to select and then pick up individual sperms in a tiny specially designed hollow ICSI needle. The sperms are first inactivated by breaking their tails. (Hence ICSI is mostly used in males with severe motility disorder, severe asthenozoospermia)
Then the needle is carefully advanced through the outer shell of the egg and egg membrane and the sperm is then injected into the inner part (cytoplasm) of the egg. This will usually result in normal fertilization in approximately 70-85% of eggs injected with viable sperm.
Fig. Intracytoplasmic sperm injection (ICSI)
Who requires IVF Treatment ?
Couples who require IVF treatment include:
Women with tubal diseases like blocked tubes, hydrosalpinx, and previous tubectomy done.
Patent tubes but non functional like in previous pelvic inflammatory disease or tubal tuberculosis.
Infertility due to endometriosis.
Infertility due to male factor likeoligospermia ( low count), asthenozoospermia (less motility), teratozoospermia (abnormal sperms) or a combination of abnormalities like oligoasthenoteratozoospermia.
Different Kind of Sperm Morphologies
Pictures showing different kind of sperm morphologies Click Below link .
Tapered sperm head
Round headed sperm
Amorphous sperm head
Elongated sperm head & sperm with double head.
Pictures showing different kind of sperm morphologies:
Tapered sperm head:
Round headed sperm:
Amorphous sperm head
Elongated sperm head & sperm with double head
Sperm with thick tail
Sperm with short tail
Pin head sperm
Semen sample showing plenty of pus cells in the sample, suggestive of infection. This will require treatment with antibiotics.
Semen sample showing leucocytes with ingested sperm head
Semen sample showing RBCs/ blood in semen sample
Who Requires ICSI?
ICSI Treatment has proved to be very useful in couples who had Failed IVF Treatment earlier in achieving fertilization or had very poor fertilization where the male partner has abnormal sperm parameters like severe oligospermia (very low count), severe asthenozoospermia (very less motility), severe teratozoospermia (high percentage of abnormal sperms) or a combination of abnormalities like oligoasthenoteratozoospermia (very low count, poor motility, abnormal sperms).
ICSI also can be performed in azoospermic men (where semen sample contains no sperms).
In such cases the testis are producing sperms but due to block in the tubules or in the path through which the sperms come out from the testis, the sperms produced in the testis cannot come out.
ICSI has proved to be very useful in couples who have failed to achieve fertilization or had very poor fertilization following standard IVF treatment & in couples where the male partner has abnormal sperm parameters like severe oligospermia (very low count), severe asthenozoospermia (very less motility), severe teratozoospermia (high percentage of abnormal sperms) or a combination of abnormalities like oligoasthenoteratozoospermia (very low count, poor motility, abnormal sperms).
ICSI also can be performed in azoospermic men (where semen sample contains no sperms). In such cases the testis are producing sperms but due to block in the tubules or in the path through which the sperms come out from the testis, the sperms produced in the testis cannot come out.Here the sperms are obtained micro surgically from testis or epidydymis (PESA, TESA, and TESE)*. In few cases when there is severe abnormality in the semen, testicular extraction by microsurgical approach (PESA, TESA & TESE) has given normal sperms.
*PESA- Percutaneous Epididymal Sperm Aspiration
TESA – Trans Epididymal Sperm Aspiration
TESE – Testicular Sperm Extraction
What is TESA / TESE /PESA?
TESA or testicular sperm aspiration (also known as TESE, or testicular sperm extraction) is one of the surgical sperm harvesting techniques used for retrieving sperm in patients with azoospermia. A number of surgical sperm retrieval or recovery methods have been devised to recover sperm from the male reproductive tract.
In men with obstructive azoospermia,(because of duct blockage or absence of the vas deferens) , sperm are usually recovered from the epididymis. The original technique was devised by a urologist, Dr Sherman Silber, who is a specialist in microsurgery. It is a very simple and easy method to recover sperm from the blocked epidiymis. Since the surgeon can feel the turgid epididymis, swollen with sperm, he will blindly puncture the epididymis using a simple butterfly needle – a technique which was very similar to drawing blood from a blood vessel! This simple technique is called PESA (percutaneous epididymal sperm aspiration), in which the sperm is sucked out from the epididymis by puncturing it with a fine needle.
For patients with obstructive azoopsermia in whom sperm cannot be found in the epididymis, it is always possible to find sperm in the testis. The easiest way to retrieve this is through TESA or testicular sperm aspiration, in which the testicular tissue is sucked out through a fine needle, under local anesthesia. The testicular tissue is placed in culture media and sent to the lab, where it is processed. The sperm are liberated from within the seminiferous tubules (where they are produced) and are then dissected free from the surrounding testicular tissue.
What is the Purpose of IVF Treatment?
The purpose of IVF treatment is to:
By pass the fallopian tube where fertilization normally occurs, so that we can overcome tubal factor if it is one of the factors causing infertility.
IVF / ICSI can also bypass mechanical factors, sperm defects like acrosome defect or oocyte defects like zona pellucida being too thick. With IVF treatment/ICSI, subtle hormonal defects get corrected and endometrial receptivity improves. Unexplained infertility may be due to one of the above factors and may get corrected by IVF treatment/ICSI treatment cycle.
This is a microscopic process & cannot be documented by sonography or any other tests. This process of fertilization in IVF treatment is done in the laboratory and it is ensured that fertilization happens.
By removing the eggs we can know the quality of eggs which otherwise cannot be judged.
In male factor infertility, there might be an inherent weakness in even the normal looking sperms. These sperms cannot fertilize the egg. By doing ICSI, it is made sure that the sperm reaches inside the egg and chances of fertilization are maximized. By, ICSI it is ensured that fertilization of egg happens with the best quality sperm
What is the success rate of IVF Treatment/ICSI?
The carry home baby rate is around 30-35%, depending on various factors, which is quite high as compared to almost no hope without IVF Treatment/ICSI.
Age of women
Pre IVF evaluation & treatment
Quality of gametes (eggs and sperms) & embryos
Number of embryos transferred.
The higher success rates are achieved by meticulous pre IVF evaluation & counseling the couple for the treatment available to them.
Pre IVF treatment Preparation
In the month prior to the IVF Treatment stimulation cycle, medications/injections are given to suppress the body’s natural hormones so that the subsequent stimulation of ovaries is better controlled.
You may be put on birth control pills in this cycle. This may seem strange – you are trying to get pregnant and we are putting you on birth control pills. Actually, though, using birth control pills before a treatment cycle has been shown to decrease your risk of ovarian hyperstimulation syndrome (OHSS) and ovarian cysts and hence may improve the chances of success.
In the month prior to the IVF treatment stimulation cycle, medications/injections are given to suppress the body’s natural hormones so that the subsequent stimulation of ovaries is better controlled.
You may be put on birth control pills in this cycle. This may seem strange – you are trying to get pregnant and we are putting you on birth control pills. Actually, though, using birth control pills before a treatment cycle has been shown to decrease your risk of ovarian hyperstimulation syndrome (OHSS) and ovarian cysts and hence may improve the chances of success. It also causes suppression of LH hormone and suppression of the entire cohort of follicles so that all the follicles are in the same phase and will grow simultaneously.
Another possible option is that we monitor your follicular growth and ovulation and give you estradiol valerate tablets till you get your periods. This is to suppress the FSH hormone in your body which helps in follicle recruitment. If the body’s FSH is suppressed, we can recruit more number of follicles by giving injections. Suppression of FSH does not allow the natural selection of the follicle by the body, thereby uniform recruitment of the follicles and we will get more number of follicles.
Sometimes we monitor your follicular growth and ovulation and start Injection Lupride. This is used in the long protocol of IVF treatment and the basic aim is the same – to suppress the body’s natural hormones so that all the follicles (cohort) are maintained at the same size and can grow equally.
The type of protocol differs from patient to patient, depending on their age, previous response, endometrial lining etc.
Generally the husband is told to give one semen sample before the start of the cycle. This sample will be frozen till the day of actual oocyte retrieval. This is because the stress of the day and anxiety can make it difficult for some to give the semen sample on the day of oocyte retrieval. So just in case that happens, at our IVF center in Mumbai/test tube baby center we will have a backup sample.
Oocyte retrieval as well as embryo transfer takes place through the vaginal route. Therefore if there is any vaginal infection, it may be transmitted to the ovaries or the uterus. This may hamper the results of IVF treatment. Even infection in the male genital tract can affect the results and more important, can be a source of transmission to the female partner. Treating genital tract infection is very important. Therefore, at our IVF center in Mumbai/ test tube baby center we give a course of oral antibiotics to both the husband and wife in order to clear the genital tract of any infection. In addition,vaginal pessaries (combination of antibiotic and antifungal preparation) are given to clear the vaginal tract of any infection.
Ovarian stimulation in IVF Treatment cycle
This is when we at our IVF center in Mumbai/ test tube baby center actually start the IVF treatment/ICSI cycle. You will need to come on day1/day2 of periods. A baseline ultrasound is performed to rule out ovarian cysts. If a cyst is present, the cycle may be postponed to next month or the cyst can be aspirated and the cycle can be started.
If required, baseline hormone levels like Serum E2 and LH are tested. This is to make sure your ovaries are “sleeping” or are suppressed so that the stimulation of ovaries with (Gonadotrophins) HMG /FSH injections will happen correctly.
Should the results be favorable the ovarian stimulation is started.
PRINCIPLE – In a natural cycle, a woman’s ovaries will generally produce one egg. But when we are doing an invasive procedure like IVF treatment/ICSI it is better to have more eggs which will maximize the chances of success. Also, not all stimulated follicles are mature and give eggs. In addition there is a limited rate of fertilization (all the eggs that are obtained do not fertilize). What would we do if a single egg we obtain does not fertilize? If we have more eggs, we can make more embryos and select the best embryos for transfer.
Hence injections are given to obtain controlled ovarian stimulation (COS).
At our IVF center in Mumbai/ test tube baby center,ovarian stimulation is achieved by daily injections of gonadotropins, which are given subcutaneously and can be self-administered. At our IVF center in Mumbai/ test tube baby center,we teach you how to take injections and 99% patients take them on their own without any problems. This helps you to cut down on hospital visits or running to your family doctor daily just to take the injections which wastes lots of time and creates unnecessary anxiety.
The stimulation process is monitored by serial ultrasounds and blood tests, which are done as and when required. The first ultrasound is generally done on the 4th /5th day of stimulation. This helps us to monitor the growth of your follicles and assess whether the dose of the injections needs to be increased, decreased or remain the same. The next ultrasound is 2 days later and then it is generally on alternate days or daily till the follicles are ready (approximately 18 to 20mm in size on USG). Transvaginal ultrasound not only helps to monitor the follicular growth but also helps to monitor the endometrial thickness.
These injections generally continue till the follicles are ready which is usually for 8 or 9 days. This comes to around 9th -11th day of periods.
When the follicles in the ovaries are ready (18-20mm) HCG injection is given for oocyte maturation. Timing this injection is vital. If it is given too early, the eggs will not have mature enough. If given too late, the eggs may be “too old” and won’t fertilize properly. The frequent ultrasounds are meant to time this trigger shot just right. At our IVF center in Mumbai/ test tube baby center we usually give the HCG injection is when three or more follicles have grown to 17 to 19mm in size.
This is a minor surgical procedure that is performed on day care basis.
The egg retrieval takes place between 34 to 36 hours after you receive the HCG shot. It’s normal to be nervous about the procedure, but most women go through it without much trouble or pain.
You have to be fasting from midnight of the previous day of oocyte retrieval. On the day of oocyte retrieval, you have to come fasting (no tea, water etc). However, if you are taking any regular medications like that for thyroid, blood pressure, diabetes etc. you will take them in the morning with a sip of water (after confirming with us). When you come in, you will be taken in the ultrasound room for a sonography and your husband will be sent to make admission papers. After the sonography, you will be taken to the recovery room where you will be given a OT changes (operation theatre gown). An IV line will be inserted and that is the only pain you will get! You and your husband will be given consent forms to sign. You will be taken to the operation theatre.
The oocyte retrieval is done under general anesthesia with ultrasound guidance. Before the retrieval, an anesthesiologist will give you some medication intravenously to help you feel relaxed and pain free. You are given general anesthesia so that you will sleep completely for the entire procedure and will come to know nothing about the procedure. There is no intubation required. The whole procedure of oocyte retrieval usually takes about 15 to 20 minutes. The entire procedure is absolutely pain free.
Once the medications take their effect, a transvaginal ultrasound is used to guide a needle through the back wall of your vagina, up to your ovaries. The needle is used to aspirate the follicle, and gently suck the fluid and oocyte from the follicle in to the needle. One follicle generally contains one egg. But all the follicles do not contain an egg. On an average when we aspirate, we get one egg for every 2 follicles we aspirate. These oocytes once aspirated will be transferred to the embryology lab for confirmation of the number of eggs retrieved and further fertilization.
Video of ovum pick up
The number of oocytes retrieved varies but can usually be estimated before retrieval via ultrasound. The average number of oocytes is 5 to 10.
After the retrieval procedure, you’ll be taken to the recovery room where you will sleep off under the effect of anesthesia for a couple of hours. Light spotting is common, as well as lower abdominal cramping, but most feel comfortable by the same evening. Once you get up you will be given a light snack. We will give you further instructions and you are ready to go home. Usually the procedure is done in the morning and you are ready to go home by afternoon or evening.
The follicles that were aspirated will be searched for oocytes, or eggs. Not every follicle will contain an oocyte.
Fig:Unfertilized immature eggs
Once the oocytes are found, they’ll be evaluated by the embryologist. If the eggs are overly mature, fertilization may not be successful. If they are not mature enough, the embryology lab may be able to stimulate them to maturity in the lab. This is called in vitro maturation which takes around 24 hours.
Fig Mature egg
Fig Vacuolated oocyte
All the oocytes which are retrieved are carefully identified and kept in the CO2 incubator. During this period the semen sample is obtained from the husband and semen processing is done which isolates the healthiest sperms. The union of male gamete (sperm) and female gamete(ovum) is known as fertilization. In an IVF laboratory, fertilization is done either through IVF treatment or ICSI.
In an IVF treatment, the embryologist places about 10,000 sperms in a culture dish with one oocyte.
With ICSI, which we generally prefer, the embryologist will choose a healthy-looking sperm and inseminate the oocyte with the sperm using a special thin needle.
Fig of ICSI procedure:
The culture dishes are kept in a special incubator under special conditions (specified temperature and CO2 concentration) and after 24 hours, they are inspected for signs of fertilization.
The fertilization rate with ICSI is higher than IVF treatment. With ICSI, around 75 – 80% of the oocytes will get fertilized.
VIDEO OF EMBRYO DEVELOPMENT AFTER ICSI PROCEDURE.
The above video shows the procedure of ICSI , wherein a sperm is injected into the egg. This is followed by fertilization and formation of the embryo. It further shows the development of the embryo from one cell to 2 cell, 4 cell, morula stage and later delevoping into a Blastocyst (Day 5 Embryo)
Fig . Normal fertilization, 2 pronulclei (PN) seen
Fig. Abnormal Fertilization , 3 Pronuclei (PN) seen after 17 -18 hours
Fig . Day 2 embryo, 2 cells seen (between 36 -48 hours)
Fig . Day 2 embryos, 4 cell seen after completion of 48 hours
About three to five days after the retrieval, the fertilized eggs will be transferred. The embryo transfer is a simple procedure just like an IUI procedure. When the embryos are transferred on day 3, the embryo is said to be 8 cell stage.
Video of USG guided Embryo transfer
Above video shows the procedure of transfer of Embryo under USG guidance.
Fig9. Day 3 embryos, after completion of 72 hours
Fig 10. Day 4 embryos, cluster of 16 cells called as morula
When the embryos are transferred on day 5, it is at blastocyst stage. This is the highest form of human life that can be sustained in the laboratory.
Fig 11. Day 5 embryo, Blastocyst stage
Fig 12. Day 7 embryo, Hatched blastocyst
The number of embryos transferred will depend on the quality of the embryos and your previous discussion with the doctor.
Poor quality fragmented Embryos:
Depending on your age, anywhere from one to three embryos may be transferred. Recent studies have shown success with just one embryo transferred. The transfer will be done on a full bladder in the operation theatre. No fasting or special preparation is required for embryo transfer.
Embryo transfer does not require anesthesia and is done on a day care basis. When you come to our IVF center in Mumbai/ test tube baby center in the morning, a routine vaginal scan is done to assess the endometrium. Then you will proceed to the recovery room, where the nurse will give you a progesterone injection. This will help in relaxing the uterus as well as maintaining good progesterone levels. You will lie down in the recovery room till your bladder is full. When the bladder is full, we take you to the operation theatre. There is soothing music which will help you to relax and be in a more positive frame of mind. At the time of transfer, the private parts will be cleaned with warm water and then the external catheter will be passed just beyond the internal os.
The embryologist will then bring the internal catheter loaded with embryos. The selected embryos are transferred into the uterus by a specially designed catheter under ultrasound guidance, which helps to transfer the embryos in correct place in the uterus i.e. 1-1.5 cms below the fundus which in turn increases pregnancy rates by up to 5-10%. After the transfer, you will lie down in the operation theatre for 10-15 minutes after which you will get up and go walking to the washroom and then lie down in the recovery room.
Video of Embryo Transfer Under USG Guidance
You may stay in our recovery room for a couple of hours (bring a book or your i-pad) and then head home. In the meantime we will give you final instructions.
If there are “extra” good quality embryos left over, you may be able to freeze them. This is called “embryo cryopreservation.” They can be used later or destroyed or donated.
At our IVF center in Mumbai/ test tube baby center on or after the day of your retrieval, and before the embryo transfer progesterone preparations / other medications are given to enhance implantation (the process by which the embryo adheres to the uterus) and to support early pregnancy (Luteal Support). Progesterone preparations can be in the form of injections/oral tablets/vaginal tablets/vaginal gel. Generally the dreaded painful injections (oil based progesterone injections) are not given unless absolutely required. The vaginal tablets/gel and oral tablets have given equivalent or better results. These medications are continued for 14 days after the embryo transfer.
Disadvantages of injectable progestrone –
The principle disadvantage is that of a need for daily intramuscular injection.
Also intramuscular progesterone administration may lead to redness, inflammation, tender wheals at the injection site and even sterile abscess formation can occur. This is the result of the long half life of the oil vehicle.
Allergic reactions also have been noted with use of intramuscular progesterone injections.
Advantages of vaginal progestrone
Vaginal route of administration provides targeted delivery. The active ingredients are transported directly from the vagina to the uterus, thus increasing the concentration of progesterone in the uterus and bypassing the systemic circulation. This increases the concentration in the target organ and reduces the risk of side effects via the “first uterine pass effect”.
The gel produces an endometrial response that is equal to or advanced in comparison with that demonstrated by the IM route.
The vaginal route is convenient and more acceptable to the patients since it does not hurt nor requires special equipment’s. It is rarely allergenic.
It has been noted that low plasma & high uterine levels following vaginal administration makes it unnecessary to monitor serum progesterone levels, thus providing substantial cost savings.
Besides the progesterone, there really isn’t much going on for the next two weeks. In some ways, the two weeks after the transfer may be more difficult emotionally than the two weeks of treatment. During the previous steps, you will have visited your doctor perhaps every other day. Now, after transfer, there will be a sudden lull in activity. All you can do is wait the two weeks and see if pregnancy takes place. It can help to keep busy with your life during this wait time and avoid sitting and thinking about whether or not treatment will be successful.
After fourteen days, a blood test – serum beta hCG is done to know the outcome of the cycle. No fasting is required for the test. We will get the report by afternoon and we will call you with the report.
If the test is positive, the blood test will be repeated every 5th day. This will help us to monitor the progress of your pregnancy. You will need to keep taking the progesterone supplementation for another several weeks. A transvaginal ultrasound is done when the beta hCG values reach a particular level. This will help us to monitor the pregnancy. At our IVF center in Mumbai during every visit, your blood pressure and weight will be charted. Slowly the luteal phase support decreases and stops by 10-11 weeks. After this the pregnancy continues as a routine pregnancy.
At our IVF center in Mumbai we will also monitor whether or not the treatment led to a multiple pregnancy. If it’s a high-order pregnancy (3 or more), the option of reducing the number of fetuses may be discussed. This is a procedure called a “multifetal pregnancy reduction.” This is sometimes done to increase the chances of having a healthy and successful pregnancy.
Can an IVF cycle be cancelled? Why?
If there are not enough follicles grow or if you’re at risk for severe ovarian hyperstimulation syndrome, your treatment cycle may be cancelled and the hCG shot will not be given.
If treatment is cancelled because your ovaries didn’t respond well to the medications, we may recommend different medications to be tried on the next cycle. While not common, a cycle may also be cancelled if ovulation occurs before retrieval can take place.Once the eggs ovulate on their own, they can’t be retrieved.
If the cycle is cancelled due to the risk of OHSS, we try and adjust the dose of gonadotrophins in the next cycle.
Cancellation happens in around 5 -6% of IVF treatment cycles. The chance of cancellation rises with age, with those older than age 35 and patients with severe PCOS are more likely to experience treatment cancellation.
What do you do when IVF Treatment Fails?
If the pregnancy test is negative 12 to 14 days post-transfer, however, you will be asked to stop taking the progesterone, and you will wait for your periods to start. The next step will be decided the further course of treatment, after we review the entire history, the actual cycle, drugs given, response seen and the embryology details.
Having a treatment cycle fail is never easy. It’s heartbreaking. It is however important, to keep in mind that having one failed cycle doesn’t mean that you won’t be successful ever. The first cycle can sometimes be a learning curve.
The subsequent cycle always gives the best pregnancy rate.
“Every failure is a stepping stone towards success”is true in IVF treatment/ICSI cycles as in any other walk of life. So instead of crying on failure, one should understand the cause of failure in consultation with an IVF treatment specialist (quality of eggs, implantation failure etc.), try to find solutions and appropriate treatment should be started with a fresh and optimistic state of mind.
What are the risks of IVF treatment?
The assisted reproductive procedures have so far proven remarkably safe for both, the would be mother & her child. However, long term follow up studies are not yet available.
The main concern is ovarian hyper stimulation (OHSS) in response to fertility drugs. This is usually very rare because of proper evaluation, judicious use of drugs and its accurate dosage and adequate monitoring.
Anaesthesia risks are very low, same as any other minor surgical procedures.
Sometimes, oocyte retrieval process can result in pelvic infection or bleeding or injury to adjacent organs like bladder or bowel, but this is generally avoided because the procedure is done under ultrasound guidance.
As far as pregnancy is concerned, there is an increased chance of multiple pregnancies due to the transfer of two, three or sometimes more embryos. However, the risks for pregnancy i.e. complications per say during pregnancy due to IVF treatment/ICSI&during delivery are unchanged.
Are there any birth defects or abnormalities in the child born through IVF treatment / ICSI ?
Male infertility is known to be associated (in some cases) with chromosomal and other genetic anomalies. There is known to be an increase in gross chromosomal abnormalities such as balanced translocations in men with very low sperm counts. Also, about 5% of men with very low sperm counts have small areas of missing DNA on their Y chromosome (Y micro-deletion).Techniques such as ICSI will, in some cases, may lead to transmission of genetic problems that might cause infertility in male offspring, or could possibly be associated with other (at this time unknown) medical problems in the child.
As of now, there have now been many thousands of babies born after IVF treatment with ICSI with follow-up after birth. Thus far, there has not been demonstrated to be any clear increased risk for birth defects as compared to IVF treatment with conventional insemination. Most studies thus far have shown that the risk of birth defects after ICSI is the same as for babies conceived through IVF treatment without ICSI, and for those conceived naturally. However, some studies have suggested that having IVF treatment with or without ICSI might increase the risk for birth defects.
Some studies have shown that around 4% of babies born via assisted reproductive technology such as in vitro fertilization (IVF treatment) may have major birth defects, such as heart and urogenital tract malformations. But these risks are not much different from what would be expected in the general population. The major birth defects seen in babies born via IVF treatment and/or ICSI included heart defects and malformations of the urogenital tract, such as hypospadias (an abnormality in the position of the opening of the urethra in boys).
It is not fully understood whether these birth defects or genetic diseases are caused by the infertility treatment itself or the underlying reason for infertility.
SOME FREQUENTLY ASKED QUESTIONS RELATED TO IVF TREATMENT/ ICSI
How may visits to the fertility clinic are required?
A total of around 8-10 visits are required to the clinic. Overnight hospitalization is NOT required.
Are injections painful?
The injections, by & large are not painful.
The injections are selected in such a way that they are highly purified and can be given subcutaneously (like insulin injections).
They can be administered on the thigh or stomach with very thin & small needle (no.26).
They can be self administered or administered by the partner.
Self administration of injections gives you better control of the cycle, flexible schedule for taking injections and avoids daily visits to the doctor. Also it gives you a feeling of self empowerment and involvement in the whole process.
Will I gain weight with injections?
The injections will not cause any weight gain.
I am a working woman. Do I need to take leave? How many days?
A prolonged leave is generally not required.
You will require a leave of one day on the day of ovum pickup.
You may take a leave of around one week after embryo transfer to relax at home.
BED REST IS NOT REQUIRED.
All scientific studies have shown that bed rest does not in any improve the results in any way. In fact, bed rest is detrimental to your mental status. This may make the 2 weeks wait for the test a nightmare.
Is my husband required for all the visits?
At our IVF center in Mumbai, He is required just before starting IVF cycle for consultation & counseling.
Then he is required on the day of ovum pickup to give a semen sample.
But circumstances permitting, if he can accompany you for your visits, it is a great morale booster.
I have endometriosis. Does this affect my fertility & can it affect the success rate of IVF Treatment ?
Studies suggest that endometriosis probably does not interfere with IVF treatment success rates.
There are, however, some caveats. Repeated ovarian surgery, removal of an ovary, or removal of severe pelvic adhesions may compromise the ovaries’ ability to produce enough eggs to warrant retrieval. Also, eggs that arise from an ovary with a large Endometrioma (ovarian endometrial cyst) may have a reduced fertility potential.
Other researchers have suggested that antiphospholipid antibodies, more commonly seen in women who have endometriosis, may contribute to implantation failure unless treated.
However, conflicting data suggest that although these antibodies may be seen more frequently in women with endometriosis, the benefits of treatment are as yet unproven.
Can fibroids interfere with IVF treatment?
Fibroids are benign tumors consisting of fibrous tissue & muscle which grow in the uterus.
The significance of fibroids relates not only to their size but also their location.
Even small fibroids located inside the cavity of the uterus (submucosal fibroids), where embryos need to implant may interfere with success and need to be removed.
Fibroids that do not encroach on the cavity of the uterus are generally not significant unless they are larger than 4 cm in diameter and also if there are multiple fibroids causing significant uterine enlargement.
I have bilateral hydrosalpinx. I have been told to get operated before the IVF cycle. Does surgery change the outcome of the cycle?
There are two possible reasons that a hydrosalpinx may decrease success.
First, it may be a mechanical wash out of embryos from the fluid back flowing into the uterus around the time of implantation.
Since the distal end of the tube is blocked, this fluid may leak into the uterus and disrupt implantation.
It is well known that a very small amount of media must be used when embryos are transferred after IVF treatment
Increased fluid decreases success. A second reason is that the fluid itself has been shown to be embryo toxic.
Since most hydrosalpinges, arise from a previous infection, there may still be agents in this fluid that cause an inflammatory response that either alters the uterine environment, or the health of the conceptus (embryo)
Does acupuncture treatment help during IVF treatment cycle?
The theory is that acupuncture can affect the autonomic nervous system, which is involved in the control of muscles and glands, and could therefore make the lining of the uterus more receptive to receiving an embryo.
Acupuncture seems to help some women because it improves circulation to the ovaries, which makes healthier eggs and to the uterus, by increasing the chances that the lining will be strong enough to hold the embryos.
Acupuncture provides better circulation and better blood flow to the womb thus helps in continuation of pregnancy till term and avoid premature deliveries.
Acupuncture can be a stress-reliever during an emotional time.
At our IVF center in Mumbai we also provide the facility of acupuncture.
What can be done to improve sperm quality?
Sperm quality on the day of egg retrieval is often related to what happened in the male’s body 3 months ago. This is because sperm development takes 3 months. Listed below are guidelines to help ensure the semen specimen is of the best possible quality.
Keep the use of alcohol and cigarettes to a minimum before and during ART treatment. Do not use any “recreational” drugs.
If any prescription medication has been taken during the last 3 months, notify the ART CLINIC.
Do not sit in hot tubs, spas, Jacuzzis, or saunas frequently during or 3 months prior to the ART cycle.
Do not begin any new form of endurance exercise during or 3 months prior to the ART cycle. Physical activity at a moderate level is acceptable and encouraged.
Frequent ejaculation (every 2 to 3 days) is recommended.
Refrain from ejaculation for 2-3 days, but not more than 5 prior to collecting the semen sample for the ART cycle.
Am I depleting my store of eggs by undergoing an ART cycle?
A woman is born with a full complement of eggs.
There are far more eggs than will ever be used during a normal lifetime and ART procedures have no measurable “lowering” effects.
Can I exercise while I’m undergoing IVF treatment?
But, you should refrain from high-impact exercise and choose workouts such as walking, swimming, yoga or cycling.
How is Pre IVF treatment Evaluation at our IVF center in Mumbai done?
For Female Partners.
A transvaginal sonography is done to assess the ovarian reserve (how many follicles of 2-3 mm size on day 2/3 of cycle), endometrial thickness, subendometrial blood flow, to look for any other abnormalities that may be present like fibroid in the uterus, uterine septum uterine polyp adhesions.
Hormonal tests like serum FSH, LH, TSH, Prolactin and AMH.
Infectious disease tests like HBsAg, HCV, HIV
A hysteroscopy if required
In most centers pre IVF hysteroscopy is a norm. But at Ankoor fertility clinic, we do not advise hysteroscopy as a routine to all IVF / ICSI patients. We do a thorough evaluation of the endometrium and it’s receptivity using Trans vaginal ultrasonographies (TVS) and Doppler studies. During these USGs we look for the endometrial thickness, echotexture, volume and blood flow. If there is any abnormality in these studies, only then a hysteroscopy is advised.
Fig . USG image of good uterine blood flow
Video of USG Doppler showing endometrial blood flow
Weight and body fat percentage assessment
As per requirement, drugs are given to improve ovarian reserve, endometrial lining, endometrial blood flow etc.
Losing as much as 10% of body weight will improve the chances of success of our cycle.
For Male Partner:
A detailed semen analysis followed by other tests like sperm function tests, ultrasound of scrotum & andrology opinion if required.
Based on the above observations medications are given to improve semen quality.
One should proceed with IVF treatment/ICSI only after all the factors are optimized giving us the maximum chances of pregnancy.
What are the steps of IVF Treatment?
Starting IVF treatment can be an exciting experience.
Usually, IVF treatment is pursued once other treatments have failed, following months of trying to get pregnant unsuccessfully. For most couples, it seems the end of the road.
There are lots of myths related to IVF Treatment/ ICSI as sometimes the procedure is not understood correctly or has not been explained correctly.
It has its own financial, social and most important emotional implications.
But the fact is that IVF/ICSI is a very short procedure, relatively painless and not very demanding; but the fear of IVF Treatment/ICSI is more consuming.
Let us understand the procedure correctly to allay the fears and anxiety and undergo the procedure with a more positive mindset. The actual procedure is over even before you realize it. It is not as stressful as it sounds like