Introduction to IVF
In vitro fertilization is effective in overcoming a variety of infertility problems, particularly tubal problems or marked sperm problems. In this procedure the ova are fertilized outside the body using partners sperms & then the fertilized embryos are placed back into the uterus transvaginally.
IVF is a four-stage procedure:
Stage One: Hormonal injections are given to stimulate the development of multiple follicles.
Stage Two: Once mature, the eggs are removed (or retrieved) from the woman’s ovaries using a fine needle.
Stage Three: The eggs are transferred to a laboratory dish where they are fertilized by sperm collected from the male partner.
Stage Four:Several days later, the fertilized embryo is inserted back into the uterus.
Infertility Treatment
Main Infertility Treatment are: ( Depending on type of infertility)
- Superovulation with IUI (intrauterine insemination of processed sperms)
- Operative Endoscopy
- Microsurgical tubo tubal & vaso epididymal anastomosis for blocked tubes & blocked Vas deference
- ART (Assisted Reproductive Technologies) which include IVF-ET (Test Tube Baby), GIFT, ICSI etc.
- Donor Insemination
- Adoption & Surrogacy
Gamete Intrafallopian Transfer (GIFT), developed in 1984.
This is a treatment of choice in unexplained infertility and patients having cervical factors and immunological factors. In this procedure mixture of sperm and eggs is placed directly into one of the woman’s fallopian tubes during a laparoscopy. Conception occurs in the fallopian tube. Once fertilized, the embryo then travels into the uterus, just as in a natural cycle.
As with other ART procedures, GIFT requires that the woman’s ovaries first be stimulated with hormonal medication to encourage the development of multiple oocytes. This enhances the possibility of fertilization. With GIFT, fertilization takes place inside the woman’s body. However, GIFT can only be used in patients with healthy fallopian tubes ( atleast one).
Zygote Intrafallopian Transfer (ZIFT) combines aspects of both IVF and GIFT. Protocols for ovarian stimulation are similar to those used for IVF and GIFT. Eggs are collected and fertilized by the partner’s sperm in the laboratory. What makes ZIFT different from IVF is that the embryo is placed into the woman’s fallopian tube via laparoscopy instead of the uterus.
ICSI (micromanupulation)
This is the treatment of choice for male factor infertility in which the sperm count is less than 5 millions/ml, sperm defects, dead, immotile, abnormal sperms, unexplained infertility and failed IVF. ICSI is a micromanipulation procedure whereby a single sperm is injected into the single egg with the help of small micro needle with the help of robotic machine called micromanipulator. Super ovulation, follicular monitoring, ovum pick up is done like that in IVF. This technique may provide men who have very small amounts of weak sperm (too small for routine IVF) a chance to fertilize individual eggs. If the egg is fertilized, the embryo is inserted into the uterus.
ICSI is Intra Cytoplasmic Sperm Injection. In this, a single sperm is injected into the oocyte using an robotic micro manipulator. Other steps are same as IVF.
Indication of ICSI include:
In fact ICSI has revolutionized treatment of male factor infertility.
This is the treatment of choice for male factor infertility in which the sperm count is less than 5 millions/ml, sperm defects, dead, immotile, abnormal sperms, unexplained infertility and failed IVF. ICSI is a micromanipulation procedure whereby a single sperm is injected into the single egg with the help of small micro needle with the help of robotic machine called micromanipulator. Super ovulation, follicular monitoring, ovum pick up is done like that in IVF. This technique may provide men who have very small amounts of weak sperm (too small for routine IVF) a chance to fertilize individual eggs. If the egg is fertilized, the embryo is inserted into the uterus.
Sperm Retreival Techniques(TESA,MESA,PESA,TESE)
When sperm cannot move through the male genital tract due to an uncorrectable blockage, sperm can be extracted directly from the epididymis or the testicle by microsurgical techniques. Congenital absence of the vas deferens or seminal vesicles, failed vasovasostomy or epididymovasostomy are all conditions where MESA might be used. Usually performed as an outpatient procedure, MESA can provide sperm for in vitro fertilization cycles. Epididymal sperm are usually not fully motile and, therefore, cannot be inseminated into the uterus or cervix successfully without sophisticated techniques that place the egg and sperm in direct contact so fertilization can occur. If MESA is done in conjunction with an IVF cycle, it will be performed around the same time as egg retrieval from the female partner. Sperm obtained from the epididymis are usually placed directly into the egg.
Embryo Reduction
Nadkarni Hospital & 21st Century Hospital practice sequential transfer, that means 2 embryos transferred on day 2/3 and 1 Blastocyst transfer on day 5-6. This leads to 20-30% multiple pregnancies-Twins, Triplets, Quadruplets etc. This is known as HOMP-High Order Multiple Pregnancies. This may lead to more chances of abortion, preterm deliveries, preeclampsia, bleeding off and on. So we prefer to have single or twins. To do that under ultrasound control 1-2 fetus can be reduced with injection diluted KLL in the heart. So that only singles or twins pregnancies. This procedure is known as Embryo Reduction and done in 10th week of pregnancy with 99% success.
Genetic Councelling
Under Construction
Embryo Freezing
Embryos which are not used in a particular ART cycle are preserved for future use. Once embryos are frozen and stored, they remain viable for long periods of time. About half of frozen embryos will survive thawing and can be transferred. Cryopreservation enables some embryos to be used in the ART cycle and some to be stored for future use in a natural cycle (a cycle without hormonal stimulation). Cryopreservation may also lower the cost of subsequent ART procedures because the first few stages (ovarian stimulation, egg retrieval) do not have to be repeated when the frozen embryos are used.
Surrogacy
Surrogacy is a legal and ethical arrangement in which a woman (the surrogate mother) carries the baby of another couple (the genetic parents or commissioning couple – the egg and sperm belong to them). The commonest form of surrogacy is gestational surrogacy wherein the female partner of the infertile couple is treated with hormones to yield more eggs which are retrieved and fertilized with her husband's sperm in vitro (in the laboratory). The embryos thus formed are then transferred to the uterus of a surrogate mother who gets pregnant and hands over the baby to the infertile couple after delivery. Sometimes, if the female partner is of advanced age or has poor quality eggs it might be necessary to have an egg donor to improve the chances of pregnancy. The child thus born would be genetically related to both (husband and wife) or one parent (egg donor and husband).
Surrogacy is indicated in patients with repeated implantation failures at IVF, recurrent miscarriages owing to insufficiency or birth defects in the womb (absent uterus, some cases of bicornute uterus, intrauterine adhesion, cases of hysterectomy where the uterus has been surgically removed for cancer or other disorders such as severe hemorrhage and bleeding after delivery) or in cases where the mother suffers from some medical disorder such as hypertension or severe diabetes making it risky for both mother and child (increased maternal and perinatal morbidity and mortality).
Screening Criteria for Surrogates – We prefer to recruit young surrogates in the age group of 21-35. They may be single, married, widowed or divorced. Legal proof of their marital status is ensured. They are screened for any medical or health problems. A detailed history is taken for medical illnesses, past pregnancies, ease of normal or cesarean delivery, health of children born and previous attempts at surrogacy. We also subject them to a complete cardiologist screen with 2-D echocardiography to avoid unpleasant surprises during the pregnancy. Once they are certified fit by the cardiologist they are subjected to the complete pathology work up including: Hemoglobin, sugar, clotting profile, HIV, Hepatitis B and C, VDRL for syphilis, Hb electrophoresis for thalassemia and other special tests if requested by the couple. This is followed by a social and home screen (surprise visits by our social worker) to rule out homes which are unhygienic, signs of physical or domestic violence, alcoholism in the husband, etc. Also, detailed evaluation is done for alcohol, drug or nicotine abuse. Only after all the above criteria are fulfilled the surrogate is placed on a waiting list.
The clinic provides a comprehensive package for care of the surrogate mother during the tenure of the pregnancy and one month after delivery to ensure that all precautions and measures are in place for optimal safety of both the surrogate mother and the baby in equal priority. All medical check-ups, ultrasounds, admissions, delivery are monitored by an agency member who is totally dedicated to third party reproduction with help from her competent team members. We provide the following options for stay:
1. At her own home if patient and clinic is satisfied with the cleanliness and hygiene
2. At a surrogacy home if desired by patient (not recommended by clinic)
3. At a nursing home – one in western and one in central suburbs – as a superior option as patient can be admitted for the latter and crucial part of the pregnancy with complete and intensive monitoring of pregnancy, mother and child welfare.
4. At the patient's home – if they should so desire.
LEGAL ISSUES IN SURROGACY
The following are covered in the legal papers which are drawn up between the patient and the surrogate mother with a dedicated lawyer (different for domestic and international clients):
• Surrogacy Agreement as per ICMR guidelines
• Affidavit of Surrogate Mother's Husband relinquishing rights on the child
• Terms & Conditions of the Surrogacy as per ICMR guidelines
• Declaration of Intent
• Endorsement by the ART Clinic, details of IVF procedure, confirmation of gametes used by the IVF doctor (own eggs / donor eggs, husband's sperm / donor sperm)
The said agreements are signed by the respective parties and notorized Personal information required for the agreements includes name, age, address of the surrogate mother, her husband and their parents if mother is single, name, age, address of the genetic parents (infertile couples), name and address of the doctor and IVF clinic, name, age, address of the third party coordinator, witnesses and the lawyer.
As soon as the child is born, the records of the birth are sent by the Hospital to the Birth Certificate Issuing authority. The birth certificate is prepared in the name of the genetic parents (as per ICMR guidelines.
In case of foreign nationals, after the Birth Certificate is received, an Application is filed for Citizenship and issue of Passport at the respective Embassy along with required documents.
After the issuance of Passport, an Application is filed with Ministry of Home affairs (MHA) for Exit Visa and then with Foreign Regional Registration Office (FRRO) for exit clearance.
Finally after obtaining the Exit Visa, the Intended Parents can leave India for their respective country with their child(ren).
Sperm Bank
Under Construction
OOCYTE DONATION & EMBRYO DONATION (OD-ED)
Human Egg donation, first introduced in 1983, has evolved in a relatively short time into a common procedure that addresses a variety of reproductive problems. This method has provided key insights into the physiology and patho-physiology of reproduction and, like other ART, has engendered its share of controversy. The popularity of egg and embryo donation is evidenced by the rapidly increasing demand for services. In the USA, 10389 procedures involving fresh or frozen embyros procured through oocyte donation were reported to the CDC in 2000, nearly double from that reported in 1996. At our own centre, which performs close to 2400 ART cycles per year, almost 1000 were those of oocyte and embryo donation. This increase is largely due to the rising percentage of women who remain childless past the age of 37, a number that has increased sharply over the past 20 years. Many women are marrying later, or are pursuing education and vocation and deliberately delaying childbearing. This section will highlight the various indications for oocyte donation, recruitment of oocyte donors, preparation of the recipient, success rates and obstetrical outcome of these pregnancies. Egg sharing between one professional egg donor and several recipients is a novel way of reducing the cost of treatment. The next frontier in oocyte donation may include use of enucleated donor oocytes which would allow recipients to use their own genetic material. Improvements in oocyte freezing may soon permit "egg banks" to be set up, reducing the need to synchronize patients while allowing for quarantine.
WHO NEEDS EGG DONATION??
1. Patients with repeated IVF failures owing to poor egg quality / vacuolated eggs/eggs with thick or dark zona, embryos with moderate to severe fragmentation (these are terms which might have been used in the discharge summary of your previous IVF cycles)
2. Patients above the age of 37 with decreased ovarian / egg reserve
3. Patients with decreased ovarian / egg reserve at any age indicated by low serum AMH levels, elevated serum FSH levels or decreased antral follicle counts on ultrasound
4. Patients with premature menopause
5. Patients with premature ovarian failure
6. Patients whose one or both ovaries have been removed with poor ovarian stimulation with FSH injections
SELECTION OF EGG DONORS
Fortunately, most ART banks have a large pool of young, healthy, fertile egg donors from all backgrounds and all walks of life. There are options to select from Indian, African, Caucasian, Georgian, Russian, Turkish, Chinese, Asian, South east asian and so on as per your requirements Egg donors are screened as per international standards .
Egg donors are screened as per international standards
Adoption
Under Construction
Microsurgery
Under Construction
USG/3D Colour Doppler
This painless test is by applying a probe to the outside of the abdomen, or by inserting a diagnostic instrument into the vagina. High-frequency sound waves produce pictures that reveal information. The pelvic organs (uterus and ovaries) can be examined in detail and both normal and or problem pregnancies can be monitored. Abnormalities including cysts, tumors and infections seen, cyclical development of the ovarian follicles and uterine lining can be monitored.
3-D ultrasound can furnish us with a 3 dimensional image of what we are scanning. The transducer takes a series of images, thin slices, of the subject, and the computer processes these images and presents them as a 3 dimensional image. Using computer controls, the operator can obtain views that might not be available using ordinary 2-D ultrasound scan. 3-dimensional ultrasound is quickly moving out of the research and development stages and is now widely employed in a clinical setting. It too, is very much in the News. Faster and more advanced commercial models are coming into the market. The scans requires special probes and software to accumulate and render the images, and the rendering time has been reduced from minutes to fractions of a seconds.
A good 3-D image is often very impressive to the parents. Further 2-D scans may be extracted from 3-D blocks of scanned information. Volumetric measurements are more accurate and both doctors and parents can better appreciate a certain abnormality or the absence of a certain abnormality in a 3-D scan than a 2-D one and there is the possibility of increasing psychological bonding between the parents and the baby
Video Endoscopy
Diagnostic & SOS therapeutic hysterosaparoscopy is a small operation ( Procedure ) done under anesthesia ( CA ). It is a day care procedure and patients is discharged on the same day. In this operation a laparoscope is introduced. In the abdomen the uterus, tubes, ovaries, pouch of douglas and bowel is visualized. Tubal potency is confirmed by injection of dye. Small corrective operations are also done through laparoscope such as ovarian drilling, adhesionolysis excision of myomas, endometriomas, cauterisation etc. Through hysteroscope the uterine cavity is visualised. Polyps, fibroids, septum etc is diagnosed & treated. Tubal osteas can be visualized and can be treated if necessary. At the end of a hysteroslaparoscopy the diagnosis of infertility is definitely established and a treatment plan is made. It is better to do a hysteroslaparoscopy in all cases of infertility before strong treatment. However it may be differed or delayed in some cases such as :
Young patients just married with no obvious disease who may be given trial by direct Treatment Cycle.
Cost Consideration: If patient refuses to spend for it then alternative methods of determining tubal potency such as HSG or sonosalpingography may be performed.
If patient has undergone laparoscopy earlier.
If patient is unfit to undergo operation.
A good diagnostic hysteroslaparoscopy is the gold standard basic investigation in infertility work up.
Diagnostic & SOS therapeutic hysterosaparoscopy is a small operation ( Procedure ) done under anesthesia ( CA ). It is a day care procedure and patients is discharged on the same day. In this operation a laparoscope is introduced. In the abdomen the uterus, tubes, ovaries, pouch of douglas and bowel is visualized. Tubal potency is confirmed by injection of dye. Small corrective operations are also done through laparoscope such as ovarian drilling, adhesionolysis excision of myomas, endometriomas, cauterisation etc. Through hysteroscope the uterine cavity is visualised. Polyps, fibroids, septum etc is diagnosed & treated. Tubal osteas can be visualized and can be treated if necessary. At the end of a hysteroslaparoscopy the diagnosis of infertility is definitely established and a treatment plan is made. It is better to do a hysteroslaparoscopy in all cases of infertility before strong treatment. However it may be differed or delayed in some cases such as :
Young patients just married with no obvious disease who may be given trial by direct Treatment Cycle
Cost Consideration: If patient refuses to spend for it then alternative methods of determining tubal potency such as HSG or sonosalpingography may be performed.
If patient has undergone laparoscopy earlier.
If patient is unfit to undergo operation.
A good diagnostic hysteroslaparoscopy is the gold standard basic investigation in infertility work up.
Diagnostic & SOS therapeutic hysterosaparoscopy is a small operation ( Procedure ) done under anesthesia ( CA ). It is a day care procedure and patients is discharged on the same day. In this operation a laparoscope is introduced. In the abdomen the uterus, tubes, ovaries, pouch of douglas and bowel is visualized. Tubal potency is confirmed by injection of dye. Small corrective operations are also done through laparoscope such as ovarian drilling, adhesionolysis excision of myomas, endometriomas, cauterisation etc. Through hysteroscope the uterine cavity is visualised. Polyps, fibroids, septum etc is diagnosed & treated. Tubal osteas can be visualized and can be treated if necessary. At the end of a hysteroslaparoscopy the diagnosis of infertility is definitely established and a treatment plan is made. It is better to do a hysteroslaparoscopy in all cases of infertility before strong treatment. However it may be differed or delayed in some cases such as :
Young patients just married with no obvious disease who may be given trial by direct Treatment Cycle.
Cost Consideration: If patient refuses to spend for it then alternative methods of determining tubal potency such as HSG or sonosalpingography may be performed.
f patient has undergone laparoscopy earlier.
f patient is unfit to undergo operation.
A good diagnostic hysteroslaparoscopy is the gold standard basic investigation in infertility work up.
Hysterolaparoscopy
Structural problems, blockages and other disorders of the uterus, the fallopian tubes and the pelvis may be diagnosed through a sophisticated x-ray study (or film). A small tube is inserted into the cervix and a dye is injected slowly. The flow of the dye into the uterus, out through the fallopian tubes and into the pelvis can then be viewed on a screen.
This test is performed after a menstrual period but before ovulation. During the injection of the dye, the woman may feel uterine cramping that may last several hours. After the test, there may be a sticky discharge for several hours as the dye is expelled from the uterus. A sanitary napkin is worn instead of a tampon to allow the fluid to escape. Whatever fluid remains in the pelvic cavity is absorbed by the body without harmful effects. One positive potential side effect of HSG testing is that the chance of conception appears to increase for several cycles after an oil dye is used. Because of this, some physicians may prefer to wait several cycles before proceeding to the next test, a diagnostic laparoscopy.
Advance Lap. Surgery
Following are performed at Nadkarni Hospitals and testube Centre
- Cornual Catheterisation
- Septum Removal
- Fibroid
- Endometriosis
- Ovarian Cysts
- Hysterectomy
- Laparoscopic Burch
- Adhesionolysis
- Vaginoplasty
- Genetic Counseling / Adoption
High Risk Pregnancy
Under Construction
Advance Neonatal Care
Under Construction
Help Line And Councelling
Under Construction
Internal Audit
Under Construction
ISO Implementation
Under Construction
Superrevolution with IUI
Intrauterine insemination (IUI) is a process by which a husband’s or a donor’s semen sample is processed and a concentrated preparation of sperms is directly injected into the uterus with the help of very thin flexible tubing. Is a treatment option for pts with minor semen abnormalities & in women whom post coital test is negative, have cervical hostility to sperms, & those couples having sexual dysfunction.
IVF-ET (IN VITRO FERTILIZATION)
IVF-ET is needed to be done is patients with blocked fallopian tubes. It may also be done in other forms of infertility where IUI super ovulation has failed. In this the woman is subjected to controlled ovarian hyperstimulation using hormonal injections. Many more injection are required because we want to retrieve as many eggs as possible. Once the follicles have reached an appropriate size, vaginal ovum aspiration is done and the ova are collected in a petridish with a media. Capacitated sperms are then mixed with oocytes and fertilisation is achieved into the uterus. Once embryos are formed then they (2-3 embryos) are transferred into the uteros on day 3 or day 5. Progesterone support is then given chemical pregnancy is diagnosed by B-HCG on day 30. Live pregnancy is confirmed by 5 weeks by seeing a live foetal heart on vaginal sonography.
This is mainly done for blocked tubes, unexplained infertility, PCO, Endometriosis grade 3-4, mild oligospermia in males. Hormonal injections given to woman to induce super ovulation, serial Transvaginal sonographies done to monitor follicles, HCG injections given to induce release of eggs, Ovum pick up done with trans vaginal sonography, eggs are inseminated with processed sperms of her husband. Fertilization of eggs takes place within a day followed by cleavage & then embryos thus formed are replaced into uterus on day 2, 3 or 5 (Blastocyst). Patient is given Luteal phase support with injectable vaginal progesterone pessaries.
IVF is a four-stage procedure:
Stage One: Hormonal injections are given to stimulate the development of multiple follicles.
Stage Two:Once mature, the eggs are removed (or retrieved) from the woman’s ovaries using a fine needle.
Stage Three:The eggs are transferred to a laboratory dish where they are fertilized by sperm collected from the male partner.
Stage Four:Several days later, the fertilized embryo is inserted back into the uterus.
Semen Laboratary
The semen analysis is the single most important test in the evaluation of a man's fertility. It provides information about a number of issues related to male fertility. Semen quality and quantity may impact the ability of sperm to successfully fertilize the egg. Sperm motility appears to be one of the most important factors in determining the fertilizing capability of sperm. Even with a low sperm count, many men with highly motile sperm may still be fertile
A semen analysis is the study of a freshly ejaculated semen sample. This analysis measures the number of sperm present in the ejaculate (sperm count) and checks the shape and size (morphology) of sperm and their motility. The semen analysis is not an absolute test for fertility because it does not test certain important aspects of sperm function, such as whether sperm can actually penetrate the egg; however, it is very useful in initially determining if the cause of infertility is an obvious male factor.
Semen testing is performed using a fresh semen specimen within 2 hours of collection. The specimen is obtained through masturbation and is collected in a container provided by the physician. Semen for this analysis should not be obtained by interrupted intercourse or by use of an ordinary condom. Ordinary condoms contain substances that are toxic to sperm. If religious or personal practices prohibit masturbation or if the patient feels uncomfortable, the physician may suggest using a special condom designed for specimen collection that does not damage sperm. Feeling anxious about producing a specimen is common. Any questions or concerns should be discussed with a physician.
The information gathered during the semen analysis depends on proper collection of the specimen, as well as the skill of the technician or physician performing the test. Before testing, a standard period of sexual abstinence is recommended. Often, this is 2 to 3 days or the "usual" number of days between intercourse for the couple. This helps the physician obtain an idea of what the normal seminal fluid exposure is for the female partner. Because sperm counts and quality can vary, at least two or three samples will usually be obtained to establish a baseline. Evaluation of semen is based on standards established for fertile males. When a patient has values below these limits, a male factor does not necessarily exist, but the probability is significantly increased. It is important to remember that, despite an overall low sperm count, men with high-quality sperm may still be fertile. High quality sperm is defined as having a high percentage of motile sperm with good forward movement. Sperm motility appears to be one of the most important factors in determining the fertilizing capability of sperm.