It is preferred that you bring along all available previous tests that you and your husband have undergone and the medicines you have takes. The doctors will review your menstrual history, past tests and treatments and then examine you. A general as well as gynae . Check up will be done and certain investigations will be ordered as required in your case. After the basic tests are done, your doctor will discuss the various treatments. Options and a plan of treatment will be decided. You are free to ask any questions and get your doubts cleared.
If the treatment is IVF/ ICSI, the plan would include blood tests , counselling, ovarian stimulation, egg collection, embryo transfer, luteal phase support and test for pregnancy.
An appointment is given at a later date to review the result of tests ordered and modify the treatment plan where appropriate.
It would be useful if you can arrange for your blood to be tested for FSH level on day 2 of the menses in your home country. You and your husband should arrive in India just after your menses have stopped. This would allow you time for preliminary consultation,Counselling and tests. The treatment of IVF takes about 6-8 weeks, during which you will be required to visit the center 6-8 times. If your husband can not afford this time he can come for about 5-7days. This visit can be scheduled around the expected time of egg retrieval which will be told by the IVF specialist. If however he is busy on those dates, he can come earlier for a few days when his sperms can be frozen and subsequently used for IVF or ICSI as required.
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The chance of pregnancy is influenced by your age and your basal FSH level. In general, the younger you are the better the outcome.The chance of pregnancy is dependent on the number of embryos transferred and the condition of the lining of the uterus. Although more embryos transferred increase the chance of pregnancy it also results in a higher chance of multiple pregnancy with its associates problem of premature births. In practice, two or three embryos are transferred.
Intra Cytoplasmin Sperm Injection (ICSI) is modification of IVF. ICSI is a procedure in which one immobilized sperm is sucked into a very narrow pipette and then injected inside the egg, allowing fertilization to take place. It is usually employed when sperms are unable to enter eggs by their own power. Most forms of male infertility can be solved by use of ICSI and sperm donation is less necessary.
Some women have egg shells (zona pellucida) which are hard and which may prevent the developing embryo from hatching and implanting in the uterus. In order to assist in hatching an opening is made in the shell of the egg. This can be done either mechanically, optically (laser) or chemically (acid). In ICSI cases, the egg shell has already been weakened by the insertion of the sperm injecting pipette. In theory, this would allow hatching to occur more easily.
This is the process in which embryo formed after fertilization of eggs & sperms are placed inside your uterus using a flexible catheter. This procedure is painless. Insertion and removal of the catheter are done slowly with ultrasound guidance. After the catheter is removed, it is checked under the microscope to ensure that all the embryos have been placed in the uterus.
Usually two embryos are placed inside your uterus at a time. This is because the chance of pregnancy is low when only one embryo is transferred. On the other hand, there is the possibility of a triplet pregnancy with three embryos are transferred. Triplet pregnancy carries a higher chance of premature delivery and should be avoided. The actual decision in each case would depend on various factors. The transfer of three embryos is considered if you are about the age 37, have a raised basal FSH level, embryos are not of very good quality or have been unsuccessful in pervious attempts at IVF.
There does not appear to be any difference in the chance of pregnancy whether there is best rest or not. However, it is preferred that you do not engage in strenuous activities.
Coitus during the two weeks after embryo transfer does not have a adverse impact on the chance of pregnancy. However if your ovaries are big in size, your doctor may advise you to abstain from sexual relations.
This is the process by which the embryo attaches itself to the internal lining of your uterus and starts to take nutrition and oxygen from you. This takes place a few days after embryo transfer.
Blood test for detection of pregnancy is done fourteen days after the embryo transfer. Doing it earlier may produce a negative result even if you are actually pregnant because the level of HCG very early pregnancy is very low. On the other hand, if you are given implantation (Luteal) phase support in the form of injections of HCG (Profasi) you may get a positive result even if you are actually not pregnant. Hence, it can be misleading to do the pregnancy test too early.
A raised basal FSH level means that the number of eggs remaining in the ovary is reduced. A higher dose of ovarian stimulation medicine would be required to produce ripe eggs. Even so, some of the eggs may be sub optimal in quality. If the level is very high and in the menopausal range, this indicates that there are no eggs left in the ovary which are capable of ripening. Using eggs from an egg donor may be a more effective approach.
Ovulation induction means giving medicines (tablets or injections) for egg formation. Tablets are given from D3- D5 of menses while injections may be added later on by your doctor. Ovulation induction is a must for all patients who are not forming eggs naturally e.g. patients of polycystic ovaries or those who have sub optimal egg formation. Ovulation induction which leads to formation of more then 1 egg (about 2-4 in number ) is also utilized for increased pregnancy rates in cases of unexplained infertility or donor insemination. The results of IUI are much better if done along with injections of HMG/FSH.
When two or more of your leading follicles are 18mm or more in average diameter your eggs are mature enough to have the HCG trigger injection. Usually there will be clear mucus from your vagina and the ultrasound scan would show an endometrial thickness in excess of 8 mm.
You will not have food or drink for six hours before the procedure. You will empty your bladder and be placed under a short general anesthesia for usually less then fifteen minutes. A needle will be inserted under vaginal probe ultrasound scanning. The follicles will be emptied systmatically and aspirated fluid will be examined under a dissecting microscope for the cumulus oocyte complex.. Antibiotics will be given After a five hour rest, you can go home. You may experience a little lower abdominal discomfort for a short while which is relieved on taking a pain killer.
Ovulation status is assessed by noting the menstrual cycle length and regularity. If you have a cycle length shorter than 26 days, it is useful to do basal follicle stimulating hormone (FSH) test on the second day of your menstrual cycle to see your egg reserve.
If you have intervals between menses of longer than 34 days, poly cystic ovarian diseases (PCOD) is suspected. This is confirmed be finding a ring of small follicles in your ovaries on ultrasound scanning.
If you have an irregular menstrual cycle and problem with ovulation is suspected, you will be given an appointment to return on day 2 of your next menses for your blood to be taken for testing hormones : Follicle stimulating hormone, luteinizing hormone, Estradiol, Thyroid stimulating hormone and prolactin.
The eggs develope within a fluid filled structure called follicle. Usually some fourteen days after the first day of the menses, this follicle bursts open (ovulation) to release the egg (oocyte). The remaining follicle wall develops into a yellow body (corpus luteum) which produce a hormone called progesterone. This prepares the internal lining (endometrium) of the uterus for implantation of the fertilized egg (embryo). A raised progesterone level some seven days before the expected next menses indicates that ovulation has taken place.
Progesterone also raises the basal body temperature (BBT). BBT is your body temperature taken on the first waking up in the morning. When charted over a menstrual cycle, a shift to a higher temperature is seen at about mid-cycle denoting ovulation.
The developing follicle can be seen by use of a vaginal probe ultrasound scan. In unstimulated cycle only one of the many small follicles would grow and ovulate. This can be tracked by using the trans vaginal probe ultra sound scan. In unstimulated cycle, ovulation is imminent when the leading follicle is more than the 16 mm in average diameter. However, when you have received medicines to stimulate egg production, ovulation usually occurs after the leading follicle reaches 20mm in average diameter.
The endometrium can show the influence of progesterone. A biopsy specimen of endometrium can be used to indicates that ovulation has occurred. However, the biopsy procedure can be uncomfortable.
Most of the test show ovulation only after it has occurred and is not useful in predicting imminent ovulation for the purpose of timing coitus or insemination.
The urine luteinizing hormone test can predict ovulation within 24 to 36 hrs. This is a do it yourself urine test on the first morning urine specimen during the five days when ovulation is anticipated.
For tracking of ovulation and timing of coitus or intra uterine insemination, the preference is to use the vaginal probe ultrasound scan to assess the follicle size. Since the follicle grows at about 2 mm per day, the time it reaches 20mm can be predicted. The urine LH test is the used at around the predicted time to anticipate the day of ovulation more precisely.
Your fallopian tubes will be checked for blockages.
The initial preference is to perform an X-ray examination called Hysterosalpingogram (HSG). This involves coming on day 7 or day 8 of your menstrual cycle. You will be brought to X-ray department. Are radio-opaque liquid will be flushed into your uterus and fallopian tubes. An X-ray is taken to show the liquid spilling out from your tubes.
Another way to assess whether your fallopian tubes are blocked is to perform an operation called video laparoscopy and hydrotubation. This is an invasive procedure involving the insertion of instruments through the abdominal wall to see your uterus, ovaries and fallopian tubes. It will be performed painlessly under general anesthesia.
Methylene blue is added to sterile water and flushed into the uterus and out through the tubes to test the blockage. A major advantage of this procedure is that various problems which may be the cause of your failure to conceive can also be corrected at the same time. These are Endometriosis, ovarian cyst and pelvic adhesions. Even some blocked fallopian tubes can be opened. The laparoscopic procedure can be used for diagnosis as well as treatment.
Since ovulation induction treatment can help some couples get pregnant with minimal discomfort, and since the majority of laparoscopic examinations fallopian tubes show no blockage, the initial preference is to try few cycles of ovulation induction before proceeding to the operation.
Hysteroscopy is a procedure of inspecting the inside of the uterus with an optical instrument (hysteroscope) inserted through the cervix from below. This allows abnormalities in the uterine cavity to be seen and dealt with. Hysteroscopy performed before IVF is useful because it permits polyps and other problems within the uterus to be seen and corrected. It also enlarges and smoothens the canal leading from the neck of the uterus (cervix) to the uterine cavity proper. This ensures ease of replacement of the embryo and improves the chances of pregnancy. Hysteroscopy is usually done as a day surgery procedure.
This is minimally invasive operation performed under general anesthesia where small incisions in the abdomen allow instrumental access to view the pelvic organs and to correct problems in the pelvis. Laparoscopy is used for assessing the state of health of the fallopian tubes. The fallopian tubes are not blocked if there is spillage of methylene-blue tinted water flushed into the uterus from below.
Laparoscopic surgery can permit the removal of ovarian cyst and myoma, separation of adhesions and destruction of deposits of endometriosis. The objective is to restore the pelvis into a healthy state.
The best time to perform laparoscopy is after the menses. The day before the procedure, medicine is taken to clear the intestines.
At the umbilicus a 1cm incision is made for the laparoscope. The pelvic organs are inspected and another two or three 0.5 cm incisions are made in the lower abdomen for specialized instruments to perform the required surgery. The duration of surgery varies according to task at hand and varies between half an hour to two hours.
After the procedure you will feel minimal discomfort and should be able to go home the next day and be able to go back to work within a week.
If laparoscopy is done for fertility assessment, it is preferred to also have a hysteroscopic examination at the same time.
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