TREATMENT OPTIONS

Available Treatment Options

Evaluation of Couple

  • Thorough History taking and Examination of both the partners are fundamental for any infertility case.
  • We evaluate both the partners with equal importance .
  • Semen Analysis is very Basic investigation for male partener for infertility workup.
  • Properly carried out Semen Examination tells us about many aspects .
  • We carry out all basic as well as advanced andrology work up like Sperm Morphology assessment, DNA Fragmentation testing, Sperm viability test and Semen Culture.

ANDROLOGY

We offer comprehensive Andrology services through our in-house Andrologists and andrology laboratory, including evaluation and treatment for male infertility, male sexual problems, and andropause.

Facilities include:

  • Semen analysis
  • Sperm function tests – DNA fragmentation
  • Clinical evaluation and medical treatment for male infertility
  • Doppler ultrasound evaluation for varicocele
  • Treatment of anejaculation by vibrator or electro-ejaculator
  • Surgical sperm retrieval by PESA/TESA/TESE.

Semenology

  • Semen analysis is the most important test for assessing male fertility.
  • The count, motility (activity) and morphology (structure) of the sperm in the semen give valuable information on whether a man has impaired fertility.
  • However, the semen test is very subjective and needs to be done by a well-trained person. It is a must to follow sexual abstinence for at least three days after which the semen sample should be provided.
  • The sample is best collected by masturbation in the laboratory, but if there is difficulty in collecting the sample then alternative methods are available.
  • IUI is intra uterine insemination of processed, highly motile and viable sperms directly inside uterine cavity with soft catheter under all aseptic precautions at time of ovulation in Natural or Stimulated cycle .
  • Ours success rate is around 18-19% per cycle depending upon cause of infertility

Steps of IUI Step 1 :

  • Semen Analyis
  • Ovulatory drug starts.
  • It may be in tablet form
  • It may be in injection form (on 2nd/3rd day of menses)

Step 2a:

  • Follicular Monitoring
  • Follow up visit after 7days, for vaginal sonography to see the follicle size in ovary.

Step 2b:

  • When follicle size reaches 18-20mm triggering of hCG injection is done to make the ovulation.

Step 3:

  • After 36 hrs of triggering injection, husband will give the semen sample in the lab, after two days of abstinence.

Step 4:

Semen is prepared, good sperms are collected & deposited in the uterine cavity of the partner without anesthesia
It is a simple procedure

  • No Rest
  • No food restriction
  • No lifestyle deviation

Step 5:

  • After procedure female has to take prescribed medications.
  • After 15 days follow up visit can confirm the pregnancy.
  • Results >20%.
  • Trials max 3.

IVF

What is IVF?

  • IVF means In Vitro (Greek Word means outside body) Fertilization.
  • It is often called as test tube baby treatment as well.

What are the indications For IVF?

In Females, following factors indicate the need for IVF:

  • Bi-lateral Tubal Block
  • Long Standing infertility with 3 IUI failures
  • Pre-mature ovarian failures where ovary is not functioning
  • Certain cases of PCO (Poly Cystic Ovary) where IUI has failed to give results
  • Multiple abortions with associated genetic disease

In Males, following factors indicate the need of IVF:

  • Long Standing infertility with normal semen analysis
  • Less than 10 million count and less than 10% motility in semen analysis

What is right age to enter IVF?

  • In today’s scenario, with respect to female, the AMH levels depicts the fertility power which is more important than age.
  • If the AMH levels are less than 2.0, than it suggest that individualized approach is required to treat the infertility in such cases.
  • However, off late I have noticed that many a times the AMH levels is interpreted in a wrong manner and therefore the clinical diagnosis with 2nd-3rd day Transvaginal Sonogram should be co-related with the results.
  • It can be summarized that in cases of age above 35 years or/and marriage life of 10 years with infertility should be considered for IVF.

What do you mean by success rate in IVF?

  • Success rate in IVF suggests the positive pregnancy rates after transferring 2-3 Grade-1 embryos in the uterus in each attempt.
  • As per my experience, transferring embryos in the same cycle immediately after pick-up will never increase the success rate of IVF on continuous basis. It varies from batch to batch and it is anywhere between 35 to 45%.
  • However, freezing the embryo and transferring in the natural cycle two months after the ovum pick-up can have more than 60% results in the same cycle.

Steps of IVF:

Step 1:

  • Thorough history of the patient
  • Basic counselling about IVF
  • Lab tour
  • Consultation with IVF specialist doctor

Includes

  • Trans-Vaginal Sonography
  • Protocol Selection – For making eggs
  • Success rate consulting
  • For each couple, at AKASH IVF CENTER we are always explaining the transparency regarding the take home baby plan.

Step 2:

  • Financial Consultation to make sure transparency about treatment & cost

Step 3:

  • Counselling + Explanation for injections.
  • Our injection team will explain patients about how to take injections & at what time to take injections.
  • If there is any query among patient for injections telephone support is available.

Step 4:

  • Follicular monitoring
  • Treatment start on 2nd/3rd day of menses.
  • Injections will start on this day, as prescribed patients have to take injections.

1st follow up:

  • 7th day of menses vaginal sonography will be prepared & will assess the size of follicles in both the ovaries.
  • If there is 4 follicles in both side size will be more than 13mm.
  • Another injection will be started in the evening for taking control over the rupture
  • 10th day – 3rd follow up for the maturation size if 4-4 follicles in both ovaries reach >18mm than triggering injection is given.

Step 5:

  • Ovum pickup / egg collection.
  • Always after 36 hrs. of triggering injection.
  • Pre requisite- Meal by mouth for atleast>6 hrs.
  • OPU after 36 hrs. under short GA protocol.
  • It is very easy procedure takes maximum 15 minutes.
  • Discharge on same day. No food restriction after 2 hrs of the procedure.

Step 6:

  • Embryo formation
  • After collection of eggs, eggs are washed.
  • Sperm will be selected by IMSI & inserted by ICSI technique.

Step 7:Embryo transfer

  • If age is <30 years
  • AMH is > 3
  • Egg collection is less than <20
  • Short protocol in P4< 1.5 on triggering day
  • If no previous failure
  • If embryo quantity is between 5 to 9
  • If endometrium is > 7mm

Step 8:

  • Will be counsel for rest & diet
  • Assistant will explain how to take medicines
  • Follow up after 15 days

ICSI

  • Intra-Cytoplasmic Sperm Injection (ICSI) is a process where a single sperm is injected directly into the egg using a fine glass needle.
  • The main objective of ICSI is to ensure that the spermatozoa fertilize the egg membrane.
  • The woman is stimulated with medications and then an egg retrieval procedure is performed so that several eggs can be obtained to attempt an ICSI procedure.

Steps to follow in an ICSI treatment

  • A very fine delicate needle is carefully inserted through the zona (the shell of the egg) and into the center (cytoplasm) of the egg.
  • The sperm is injected into the cytoplasm and the needle is removed.The eggs are checked the next morning for evidence of normal fertilization.

Intricacies involved in an ICSI treatment

  • There is evidence that the babies conceived through ICSI may have an increased risk of chromosomal abnormality.
  • The possibility that a boy conceived as a result of ICSI may inherit his father’s infertility.
  • An increased risk of miscarriage because the technique uses sperm that would not otherwise have been able to fertilize an egg.
  • A low sperm count caused by genetic problems could be passed on to a male child, so you may want to undergo genetic tests before going ahead with ICSI.

Precautions to take after an ICSI treatment

  • Heavy exercise like aerobics, jogging, and weight lifting are prohibited.
  • Smoking or consumption of alcohol should also be avoided.
  • Please consult your doctor before taking any medication.

Precautions to take after an ICSI treatment

  • Heavy exercise like aerobics, jogging, and weight lifting are prohibited.
  • Smoking or consumption of alcohol should also be avoided.
  • Please consult your doctor before taking any medication.

THIRD PARTY DONATION

Sperm, Egg, and Embryo donation and surrogacy

The phrase “third-party reproduction” refers to the use of eggs, sperm, or embryos that have been donated by a third person (donor) to enable an infertile individual or couple (intended recipient) to become parents.

  • Donors may be known or anonymous to the intended recipient. “Third-party reproduction” also includes traditional surrogacy and gestational carrier arrangements.
  • Traditional surrogacy refers to a treatment in which a woman is inseminated with sperm for the purpose of conceiving for an intended recipient.
  • The surrogate in this scenario has a genetic and biological link to the pregnancy she might carry. In contrast, a gestational surrogate (also called a gestational carrier [GC] or uterine carrier) is an individual in which embryos created by the intended parents are transferred into the surrogate’s uterus, which has been prepared hormonally to carry a pregnancy.
  • The gestational surrogate has no genetic link to the fetus she is carrying.

Traditional surrogacy arrangements often are perceived as controversial with the potential to be complicated both legally and psychologically.

  • Despite the requirement for in vitro fertilization (IVF) to create embryos, the utilization of a gestational surrogate, legally, is a lower-risk procedure and is the more common approach conducted in the United States.
  • Third-party reproduction is a complex process requiring consideration of social, ethical, and legal issues. The increased use of egg donation has required a reconsideration of the social and ethical impact this technology has had on prospective parents, their offspring, and the egg donors themselves.
  • The surrogate in this scenario has a genetic and biological link to the pregnancy she might carry. In contrast, a gestational surrogate (also called a gestational carrier [GC] or uterine carrier) is an individual in which embryos created by the intended parents are transferred into the surrogate’s uterus, which has been prepared hormonally to carry a pregnancy.
  • The gestational surrogate has no genetic link to the fetus she is carrying.

EGG DONATION

The first pregnancy achieved with egg donation was reported in 1984.

  • Since that time, there has been increasing use of egg donation to help infertile couples/individuals conceive.
  • Egg donors are identified, and, through the process of IVF, eggs are obtained from the donor’s ovaries and donated to the intended recipient. Sperm obtained from the recipient’s partner (or a sperm donor) is used to fertilize these eggs, and embryos are transferred into the recipient’s uterus. If pregnancy occurs, the recipient will have a biological but not genetic relationship to the child; her partner (if he provided the sperm) will be both biologically and genetically related.

Indications for Egg Donation

  • Typically, women were prematurely menopausal as a result of disease, chemotherapy, radiation therapy, or surgical removal of their ovaries.
  • Egg donation is appropriate for women who were born without ovaries. Due to the success of the procedure, as well as the improvements in IVF technology, these indications have been expanded.
  • Egg donation may be offered to women who are known to be affected by or be the carrier of a significant genetic disease who would prefer not to pass this disease on to her offspring. This indication includes women who have a significant family condition where their carrier status cannot be determined.
  • Normal-ovulatory women who appear to have an egg factor as the cause of their infertility often are candidates for egg donation. In many instances, this includes women with multiple failures to conceive after IVF, women of advanced reproductive age, and women with inadequate response to ovulation induction.

Who are Egg Donors?

Anonymous donors:

Women who are not known to the recipient. Donors may be recruited through established egg donation programs or may be identified through agencies.

Known or directed donors:

Women who are known to the recipient. The donor is generally a close relative or friend.

IVF programs:

Women undergoing IVF may agree to donate their excess eggs to infertile patients. This source of donors is limited, probably because of the perceived coercive nature of the donation, particularly if the women are offered a financial discount on their own IVF cycle.

Evaluation of the Egg Donor

All donors, both anonymous and known, should be screened according to the most recent guidelines recommended by the ASRM.

  • Donors should have attained their state’s age of legal majority and preferably should be between the ages of 21 and 34. The rationale for the lower age limit is to ensure that the donor is mature enough to provide true informed consent.
  • The rationale for the age of less than 34 is that younger women typically respond favorably to ovulation induction, produce more eggs and high-quality embryos with high implantation, and have subsequent higher pregnancy rates than older women. If the donor is over the age of 34, recipients should be informed as to the cytogenetic risk of having a child with a chromosomal abnormality such as Down syndrome and the impact of donor age on pregnancy rates.
  • The gestational surrogate has no genetic link to the fetus she is carrying.

Both anonymous and known donors should complete an extensive medical questionnaire that details their personal and family medical history.

  • Included in this questionnaire should be a detailed sexual history, substance abuse history, history of family disease, and psychological history. In the United States, the Food and Drug Administration (FDA) requires that all egg donors be screened for risk factors for, and clinical evidence of, communicable infections and diseases. A donor is ineligible if either screening or testing indicates the presence of a risk factor for, or clinical evidence of, a communicable infection or disease. For anonymous donors, the questionnaire should assess the donor’s motivation for donating her eggs and provide insight into the donor personality, her hobbies, educational background, and life goals.
  • This document ultimately will be shared with the recipient and provides her with insight into a donor she will never meet. A medical professional reviews this history with the donor and conducts a comprehensive physical examination.

Evaluation of the Recipient Couple

  • The physician should obtain a comprehensive medical history from both partners. In addition, the female assessment will include a comprehensive gynecologic history and complete physical exam. From a laboratory perspective, the female should have an assessment of ovarian reserve, when appropriate, blood type and Rh, and rubella and cytomegalovirus (CMV) testing. A Pap smear and cultures for Neisseria gonorrhoeae and Chlamydia trachomatis should be obtained.
  • The female partner should have an evaluation of her uterine cavity with a hysterosalpingogram (HSG), sonohysterogram (SHG), or hysteroscopy.
  • If the female recipient is over the age of 45 years, a more thorough evaluation with assessment of cardiac function, risk for pregnancy-induced hypertension, and gestational diabetes should be considered.
  • A high-risk obstetrical consultation is recommended to discuss the impact of advanced maternal age on pregnancy, as well as any medical conditions that may impact a pregnancy. The male assessment will include a semen analysis, blood type and RH factor, and genetic testing as indicated. The intended recipient couple should be screened for syphilis, hepatitis B and C, HIV-1, and HIV-2.

Preparation of the Donor for Egg Retrieval

  • In order to retrieve multiple eggs from the donor’s ovaries, the donor must be given a combination of hormonal medications to stimulate the development of multiple eggs within the ovary. This technique is called ovulation induction. The medications may include a gonadotropin-releasing hormone agonist (GnRH-a) or gonadotropin-releasing hormone antagonist (GnRH-ant) to prevent the donor from spontaneously ovulating, and either human menopausal gonadotropin (hMG) or recombinant follicle-stimulating hormone (r-FSH), both of which are able to induce egg development. Development of eggs is monitored by ultrasound and measurement of hormones in blood. When the egg development is at the appropriate size, ovulation is triggered by an injection of human chorionic gonadotropin (hCG).
  • The eggs are harvested from the ovary approximately 34-36 hours after hCG administration through a process called transvaginal ultrasound aspiration . This is done by placing a transvaginal ultrasound probe, which has a needle guide, into the vagina. A needle is placed into this guide, through the vaginal wall, and into the ovary. The eggs are obtained, evaluated for maturity, and then are inseminated with the male partner’s sperm (donor sperm also may be used), which has been processed in the laboratory. For further details regarding the types of ovulation induction medications and the IVF procedure, please refer to the ASRM patient information booklet titled Assisted Reproductive Technologies.

Preparation of the Recipient for Embryo Transfer

  • In order for embryos to implant into the recipient’s uterus, the endometrium (uterine lining) must be prepared and synchronized with the donor reproductive cycle.
  • Numerous methods of endometrial preparation have been described; however, the principle of hormonal preparation is similar. Women who have ovarian function are given a GnRH-a to temporarily suppress their menstrual cycle. When the donor starts her hormonal medications to stimulate her ovaries, the recipient is given estradiol to stimulate the endometrium to develop. Estradiol may be given in the form of an oral pill, transdermal patch, or injection. Ultrasound assessment of the endometrium and blood tests may occur during this time.
  • The recipient begins progesterone on the day after the donor receives hCG. Progesterone causes specific maturational changes within the endometrium that enable the embryo to implant. Progesterone may be given by intramuscular injection, vaginal gel, or tablet.
  • Embryos are transferred into the recipient’s uterus, usually within three to five days after the eggs are fertilized in the laboratory. The embryo transfer is performed by placing a small catheter with the embryos through the cervix and into the uterus. If the recipient couple has extra embryos, these embryos may be cryopreserved (frozen) for use at a later time in additional attempts to achieve a pregnancy.
  • The hormonal replacement regimen of estradiol and progesterone is continued until the recipient achieves a positive pregnancy test.
  • If the pregnancy test is positive, estradiol and progesterone are continued through the first trimester to support the early pregnancy.

Pregnancy Rates with Egg Donation

  • The pregnancy rate with egg donation depends on many factors but is generally independent of the age of the recipient.
  • Success rates compiled by the Centers for Disease Control (CDC) for the year 2009 show the average live-birth rate per fresh embryo transfer is 55.1% for all egg-donor programs.
  • The major risk for egg-donor programs is multiple gestations. . The current trend is to reduce the number of embryos transferred in an effort to reduce the risk of multiple gestations. Most programs will limit the number of embryos transferred to two if the donor is between the ages of 21 and 34.

SPERM DONATION

  • Over the past 10 years, the use of donor sperm has decreased as the use of intracytoplasmic sperm injection (ICSI) for the treatment of male infertility has become widespread. Since the late 1980s, with the emergence of acquired immunodeficiency syndrome (AIDS), artificial donor insemination has been performed exclusively with frozen and quarantined sperm.
  • Current FDA and ASRM guidelines recommend that sperm be quarantined for at least six months before being released for use.

Indications for Sperm Donation

  • Currently, therapeutic-donor insemination (DI or TDI) is appropriate when the male partner has severe abnormalities in the semen parameters and/or reproductive system. These abnormalities include both obstructive (caused by a blockage of the ejaculatory ducts) and nonobstructive (due to testicular failure) azoospermia (absence of sperm), which may be congenital or acquired. Examples of obstructive azoospermia include congenital absence of the vas deferens or previous vasectomy. Examples of nonobstructive azoospermia include primary testicular failure or secondary testicular failure due to previous radiation treatment or chemotherapy. Severe oligospermia (decreased sperm count) or other significant sperm or seminal fluid abnormalities also are indications for DI. DI also is indicated if the male has ejaculatory dysfunction or if he is a carrier or affected with a significant genetic defect and would prefer not to pass this gene on to his children. DI may be used if the female is Rh-sensitized and the male partner is Rh-positive. DI often is used in the treatment for a single woman who desires a pregnancy but who lacks a male partner.

Counseling of Gestational Carrier and the Intended Parents

Counseling of GCs is intended to provide the GC with a clear understanding of the psychological issues related to pregnancy. With the assistance of a MHP, the gestational surrogate and her partner should explore issues such as managing a relationship with the intended parents, coping with attachment issues to the fetus, and the impact of a GC arrangement on her children and her relationships with her partner, friends, and employers. The intended parents should be counseled regarding their ability to maintain a respectful relationship with the surrogate. The surrogate, the intended parents, and the MHP also should meet to discuss the type of relationship they would like to have. In addition, expectations they have regarding a potential pregnancy should be discussed. This includes a discussion of the number of embryos for transfer, prenatal diagnostic interventions, fetal reduction, and therapeutic abortion, as well as managing the relationship while respecting the carrier’s right to privacy.

LEGAL ISSUES

There are a number of legal issues that concern third-party reproduction. Written consent should be obtained for any procedure. In situations of known sperm or egg donors, both donors, as well as intended parents, are advised to have separate legal counsel and sign a legal contract that defines the financial obligations and rights of the donor with respect to the donated gametes. With embryo donation, in view of the absence of any statute defining the rights and responsibilities of any party involved, it has been suggested that a pre-donation agreement be obtained and a judicial determination of parentage be obtained prior to the donation taking place. With GC arrangements, legal contracts, in addition to delineating financial obligations, may include details regarding the expected behavior of the GC to ensure a healthy pregnancy, prenatal diagnostic tests, and agreements regarding fetal reduction or abortion in the event of multiple pregnancies or the presence of fetal anomalies. Finally, many states allow for a declaration of parentage prior to the child’s birth obviating the need for adoption proceedings. The laws regarding third-party reproduction are either non-existent or different from one state to another. Thus, all couples are advised to consult with an attorney knowledgeable in the area of reproductive law within their individual states.

CONCLUSION

The options available through third-party reproduction provide many couples the opportunity to make their dream of parenthood a reality. The comprehensive nature of the screening and counseling of intended parents and their donors or surrogates ensures that the process meets the needs of all involved. Finally, as third-party reproduction is more widely used, there continues to be a broader understanding of the ethical, moral, and legal issues involved. The ultimate goal of physicians, MHPs, and attorneys specializing in reproductive law is to enable this process to move forward as smoothly as possible and bring joy and satisfaction to all parties involved in ensuring the conception and delivery of a healthy chil.

EGG DONATION

Egg donation & IVF is required in female, who are unable to produce egg, or produces bad quality of eggs. Where anonymous egg donor is selected & sperm of husband is inserted & embryo is created, which will be transfer in female (wife) for pregnancy

Egg donation & IVF is required in female, who are unable to produce egg, or produces bad quality of eggs. Where anonymous egg donor is selected & sperm of husband is inserted & embryo is created, which will be transfer in female (wife) for pregnancy

Who require egg donation?

  • Premature ovarian failure
  • Women who is having multiple abortion with any known genetic disease where egg donation is the only option
  • Multiple IVF Failure with exhausting ovary.
  • After removing of ovary in certain cancer treatment

Steps of Egg Donation

Step1: Consultation & Counselling:

  • Explanation will be given regarding the reason for egg donation, if no option is available.
  • Sonography: to assess the uterus & to assess the uterine lining should be >7mm, ideal is 8 to 10mm.

Donor Selection:

  • According to ICMR guideline option will be given
  • We are proud to say that, we are having high end donor program at our clinic with all detailed transparency
  • After donor is selected – financial part will be explained.
  • Blood tests of husband & wife will be done
  • One semen sample of husband will be freeze.

Step 2: Egg collection

  • Explanation will be given regarding the reason for egg donation, if no option is available.
  • Sonography: to assess the uterus & to assess the uterine lining should be >7mm, ideal is 8 to 10mm.

Step 3: Collection of husband sperm& selection of sperm

  • According to ICMR guideline option will be given
  • We are proud to say that, we are having high end donor program at our clinic with all detailed transparency
  • After donor is selected – financial part will be explained.
  • Blood tests of husband & wife will be done
  • One semen sample of husband will be freeze.

Step 3: Collection of husband sperm& selection of sperm

  • On the day of egg collection of egg donor, Sperm will be collected from husband, then one sperm will be injected in the donor egg