What is infertility?

Infertility is the inability to conceive after a year of unprotected intercourse in women under 35, or after six months in women over 35, or the inability to carry a pregnancy to term. Couples who have known barriers to fertility, such as endometriosis, polycystic ovarian syndrome, male infertility, irregular cycles, etc., do not need to sit out the traditional "waiting period" to seek expert care for infertility. With IVF developing and advancing in India, these couples have in their hand treatment for infertility.

Why should I seek treatment from a Reproductive Endocrinologist rather than from my OB/GYN?
  • Picking a doctor is so very important. Reproductive medicine specialist  treat Reproductive Disorders that affect women & men in more specialized & scientific manner  . It is important to find a doctor who is responsive and well matched to your needs and diagnosis.
How one can make out what is the fertile period ?
  • Follicular monitoring through Transvaginal ultrasound scan is more reliable method to check for fertile period and ovulation status  of an individual.
  • Regular menstrual cycles does not indicate that patient is forming and releasing egg on time.
How do you determine the first day of your cycle?
  • CD1 is the first day you see a red flow, not just intermittent spotting. There Is no universal rule for the cutoff time for that date. Some doctors use midnight as cut off, but  usually CD1 is considered the first day of full flow.
How does blood test FSH and AMH helps in checking for ovarian reserve or capacity to produce egg ?
  • FSH is more of an indirect measurement of an ovarian reserve. Usually it should be <10. If it is more then it indicates poor ovarian reserve .
  •  Better indicator to check for ovarian reserve is Anti mullerian hormone which is preferred and can be done on any day of the cycle. It should be mor than 2ng/ml .

These two parameters changes with age or with conditions like endometriosis, PCOD , PID , premature ovarian failure .

How long do sperm live after timed intercourse or after IUI?
  • Normal, healthy sperm live approximately 48-72 hours. (Abnormal sperm may have a shorter life, which may vary according to sperm health.)
What is life of ovulated egg ?
  • Life span of an egg is 12-24 hrs  and  are able to be fertilized for about 4-8 hrs after ovulation. The older the woman, the shorter this time becomes.
How long does it take for fertilization to occur?
  • Fertilization occurs within 24 hours after ovulation.
How long does it take for implantation to occur?
  • Implantation occurs about 5-7 days after ovulation.
How soon can I take my Pregnancy Test (Beta HCG or Home Pregnancy Test)?
  • The earliest that a sensitive blood test can pick up any HCG at all is 12 - 14 days after ovulation. Extremely sensitive home pregnancy tests might in some cases be reliable as soon as 14-16 days of ovulation.
How progesterone hormone is important and What should be the progesterone level ?
  • Progesterone hormone is important to sustain the pregnancy  which is  deficient in some infertile cases . it peaks about 5 to 7 days after ovulation, when it reaches 15 Ng/ml or more. Additionally, you may get very high progesterone levels after IVF because so many follicles were created. (Progesterone is made by the corpus luteum, which is the site on the ovary from which the egg is released).
  •  Good progesterone level does not that indicates pregnancy.
What should be the blood E2 level during mid cycle ?
  • It should be 150-200 pg/ml per mature follicle.
What should my uterine lining be at ovulation and at implantation?
  • As you approach your LH surge, it should be above 6 mm, ideally between 8 and 12 mm. if its less then 6 or greater then 12 than chances reduces.
How do we know if the sperm count is adequate for IUI?
  • Besides the number of sperm, the percentage with rapid forward-progressive motility and with normal morphology at the time of insemination are important to know. If the functional sperm count (number with normal morphology and rapid forward-progressive motility) exceeds 10 million; chances for pregnancy with well-timed IUI are excellent.
  • As per few studies functional motile sperm count should be more than 5 million.
I am concerned about the size of my follicles, and the timing of my HCG shot. How big should my lead follicle be before I take my HCG shot?
  • A lead follicle should be at least 16 – 18  mm on an HMG cycle , and should be about 22 mm on Clomid, but the size of the follicle is the not only criteria to decide for the HCG shot. Besides follicile size , endometrium thickness and its character is also important . Measurements of  E2  and LH  hormones should be used to check for maturity of the egg developing inside the follicle and decide for the timing of injection HCG especially in stimulated cycles.
How much do follicles grow each day?
  • Follicles grow 1 to 2 mm a day  while taking ovulatory stimulants.
I have left over cysts in my ovaries. Will they go away?
  • A corpus luteum, or functional cyst, is simply a leftover follicle of the previous cycle. Some continue to produce progesterone and estrogen, which may delay the arrival of the next period.
  • Usually these kind of cysts disappear on their own.
How big the cyst size to be to reduce chances of pregnancy?
  • It is observed that anything under 10 mm shouldn't be cause for concern as long as your baseline hormone levels are in range.
How long should I use Clomiphene citrate before I move to Injectables/IUI?
  • The vast majority of Clomiphene  pregnancies occur during the first 4-5 ovulatory cycles. Some physicians also indicate that of those pregnancies, the majority occur during the first 3 attempts. The average number of cycles on Clomiphene  before moving on is three to six depending upon the age of the patient and its response.
  • Clomiphene citrate should not be taken for more than 6 cycles.
How many times should I try IUI before moving on to IVF?
  • Once a patient has had 3-6 IUI cycles , they might consider moving to IVF as the chance of a successful IUI cycle is reduced.
What is the maximum recommended dosage for Clomiphene citrate ?

The maximum dosage is 150mg, we do not prefer to give more then 100mg , as the risk of antiestrogenic side effects of Clomiphene  increase sharply as the dosage goes up .

How long should my partner abstain before the IUI? His semen analysis is normal?
  • we don't advice any abstinence during fertile period even if IUI is planned as it is not going to compromise the sperm count and motility.
How should my IUIs be timed?
  • In most cases, doctors who do two IUI's do the first about 24 hours after the HCG shot and the second about 48 hours after the shot. Some studies have shown that doing one IUI about 36 hours after the HCG is equally effective.
What are normal ranges in a semen analysis?

As per WHO  Criteria

Volume

>1.5ml

Colour

Greyish Opalescent

Liquefaction

Complete

Viscosity

Normal

Ph

>7.2

Concentration

>15x10^6 per ml

Motility

30-35%

Normal Morphology

atleast 4%

Fast Progressive Sperms

20%

Semen Culture

Sterile

What is Sperm DNA Fragmentation Test and what are its utilities?
  • Sperm DNA Fragmentation (SDF) is an important piece of information about seminal quality. An SDF value that exceeds a threshold value of 30% suggests sub-par sperm quality. The SDF value confers clinicians the power to make informed decisions in their daily practice and take action based on quantitative results. It is an established fact that the quantitative results it is an established fact that the probability of pregnancy is more if fragmentation is low.

 

-Applications:

  • -Unknown etiology or  fertility failure
  • -Embryo loss.
  • -Repetitive miscarriage
  • -To distinguish which couple are suitable for treatment by IUI.
  • -To assess the efficacy of medical interventions or treatment of antioxidants and varicocele.
What constitutes early or late ovulation? Does late ovulation decrease fertility?
  • There is not complete agreement on this. You might consider "too early" to be cycle day 10 and "too late" to be cycle day 20. There are two problems with late ovulation. The first point is that  obviously you have fewer chances (less ovulation) over a given time period. Second is the fact that with late ovulation you may be releasing eggs that have not been matured properly. It is also possible that the other parts of the reproductive system (hormone levels) and the lining of the uterus  may  not  sync with the egg. That is not to say you cannot conceive if you ovulate late--. It is just that your chances are somewhat reduced.
My doctor says I am not ovulating regularly. How could I get my period if I do not ovulate?
  • Menstruation only requires development and shedding of the endometrium i.e lining of uterus in response to alternating levels of estrogen then progesterone in the blood stream. These hormones can be produced by the ovary even when an egg does not mature or release.
  • Cycles can get delayed if egg formation is very late or absent in the cycle.
What causes chemical pregnancies or early pregnancy loss ?
  • Many early pregnancy failures are due to genetic abnormalities.. Some studies says , the earlier the failure occurs after implantation, the more likely it is to be genetic. You can also have implantation problems that would cause chemical pregnancies such as hypercoagulation, failure to form the needed blood vessels, or autoimmune issues.
I have questions about special precautions during treatment. Should I avoid exercise after ovulation?
  • There is no such special precaution. Avoid eating junk foods, papaya & pineapple. Normal routine activities can be followed.
Who is the Candidate for IVF (In-Vitro Fertilization) and ART?

Assisted reproductive technology in India includes IVF, which is the technique of fertilizing a woman's egg in the laboratory. While it was designed originally for women with tubal diseases, IVF has been extended with equal success as treatment of infertility due to endometriosis,  unexplained factors and male infertility.

What should I expect to know about IVF?
  • IVF  process consist  of several steps. First, fertility drugs are given to stimulate the ripening of several eggs. Blood test and ultrasound examination allow for precise monitoring of egg development. At the appropriate time, the eggs are retrieved under light sedation or anesthesia. The sperm is then added to the eggs in the laboratory where the fertilized eggs develop for 2-3 days. In case of micromanipulation for male infertility a single sperm is injected into egg ICSI (Intra cytoplasmic sperm injection). Finally, the embryos (fertilized dividing egg) are placed in the womb by a simple non-surgical procedure similar to a pelvic examination. A mock embryo transfer is done before the  actual IVF prior to starting the cycle to ensure that we do not encounter any unexpected problem on the day of the actual embryo transfer. Two weeks after embryo transfer, a pregnancy test is done.
How many times in a cycle will I have to come to the clinic?

 we do not encourage unnecessary travel to the clinic. However, this varies from patient to patient and also with the stage for treatment. In a DI or IUI (H) cycle, for example,the likely number of out-patient visits for monitoring is 2-4. For IVF or  ICSI 4-5 visits. During these visits eggs  and endometrial development are checked.

 Some blood tests may be advised to assess egg maturity and decide on the drug dosage.

  • The first visit is on day 2/3 of the cycle. At this visit an ultrasound is done at to rule out any residual ovarian cysts and to check for endometrial thickness. Drug administration is withheld in case these parameters are not within the required limits. 
  • Egg recovery is generally carried out under anesthesia which requires you to be in hospital for half a day. For embryo transfer you are required to come in  with a full bladder and you will be asked to rest for couple of hours  after the transfer.
What are the risks of ART?
  • The associated reproduction procedures have so far proven remarkably safe for both -–'would be' mother and her child. The Spontaneous abortion rate is slightly higher than in the general population. This is not related to the procedure, it is due to inherent problems with the patient that led to infertility in the first place . There is an increased chance of multiple births, which can be limited by the number of embryos transferred. There is no difference in the delivery - vaginal /caesarian section, if all routine parameters are normal.
What are the risks for assisted conception pregnancies?
  • The risk of abnormalities does not appear to be significantly greater than with natural conception. With procedures like ICSI there is an increased risk of sex chromosomes related anomalies. The reason for this is that in patients with severe male factor infertility the abnormality existing in the male partner is carries forward , But detailed follow up data is not yet available.
Is there an increased risk of malignancy?
  • Current knowledge does not show any definite increase in malignancy. The scientific committees' worldwide are constantly looking into this and we will keep updated as to the results. Women in whom there is a family history of ovarian malignancy should limit the exposure to ovarian stimulation drugs.
I heard that multiple cycles with fertility drugs increase the chance of getting ovarian cancer. Is this true?
  • No. There is no evidence that shows a statistically significant increase in the ovarian cancer risk.
Do your chances increase with each consecutive cycle?
  • Yes, each cycle is independent. Chances increase with each cycle but after three failed cycles, the chances of concieving reduces and the doctor has to look at other options.
How many attempts should we have?
  • Every couple is different and the answer to the question will inevitably depend on the specific treatment you have had and the result of preceding treatment cycles. It is believed that IVF success optimizes in three cycles. Decision on how to proceed will be discussed indetails with you during your consultation with the doctor in person.
What happens if treatment is not successful?
  • we shall make every endeavor to care for you and to help you cope with the distress.
  • . ART has made tremendous progress in the last few decades and there will certainly be a treatment, which would benefit you.
I am concerned about the nature of my discharge during treatment cycles?
  • Usually fertile mucous is clear and very stretchy -- similar to egg whites seen during very ovulatory period. Often women are not even aware of it, as most of it tends to stay up by the opening of the cervix.
  • Also, progesterone vaginal suppositories prescribed after ovulation can create discolored  or brown discharge in normal situations. However, any unusual spotting or discharge needs to be checked by your physician.
I am afraid that I might have ovarian hyperstimulation. What should I know ?
  • First, if you are concerned about the possibility of OHSS you should call your clinic as soon as reasonably possible. OHSS (Ovarian HyperStimulation Syndrome) is when you have an unusually large number of mature follicles that release. and the ovaries are generally enlarged far beyond their usual plum size - in some cases, they can swell to softball size
  • In milder cases, women experience bloating and some pain from the oversized ovaries. The treatment then is just a matter of rest and staying well hydrated with high protein diet. .
  •  In more severe cases, excess fluid in the abdomen causes marked discomfort and bloating, and can cause difficulty breathing due to pressure on the diaphragm. In the most severe cases, the leaking of the fluid will lead to hypovolemic shock and organ damage because of a lack of perfusion.
  • The best pre-ovulation predictor of hyperstimulation is the E2 level, number of follicles  and the size of ovaries . If you experience symptoms of OHSS, you should always play it safe and check with your doctor.
I have spotted, and it is not the time for my period. Was it implantation spotting?
  • Implantation spotting is the exception rather than the rule. At the time of implantation Sometimes  blood vessels may get eroded  resulting in  little bit of spotting. Light spotting can be normal, but contact your physician with any concerns.
Should I avoid air travel or ground travel after my Embryo transfer?
  •  we don't prohibit travel but just advise not to overdo it. No restriction of physical activity as such.