When to see an infertility expert?

A couple should seek an expert opinion if they have not been successful at conception after at least one year of regular attempt at the same. An early consultation with an expert may be warranted in case there is a known biological or hereditary reason for infertility.

 

Clinical approach for infertility

The key to appropriate infertility management is to understand the real underlying problem so that required corrective steps can be taken. The initial assessment of the couple is directed at studying the structure and functions of reproductive organs and at evaluating the hormonal balance and functions in both the partners.

 

Treatment options for infertile couples

Once the likley cause(s) of infertility in a couple is identified, all effort is made to address the abnormality, which could be hormonal imbalance in one/ both the partners, poor sperm count/ quality in the male partner, structural anomalies like fibroids/ uterine septum/ endometrial polyps in the female partner or any pre-existing infectious diseases. If the problem does not get fixed here, one may need advanced fertility treatment.

 

Intrauterine insemination (IUI)

 

Intrauterine insemination (IUI) is often the first treatment offered to couples facing difficulty in conception. It is a simple procedure wherein good quality prepared sperms are placed in the uterus by inserting a thin flexible catheter through cervix around the time of ovulation. It is a short procedure done in OPD setting without need for any anaesthesia and takes only couple of minutes to perform.


Candidates for IUI

Infertile couples can be advised IUI in following situations.

  • Unexplained Infertility

  • Anovulatory infertility - The eggs in the female partner do not mature in time. In these cases, the growth of eggs is induced with the help of medicines/injections.

  • Mild male factor infertility - Reduced sperm counts in the male partner.

  • Cryopreserved sperms - Done when the male partner is not available at the time of ovulation or if the sperms have been preserved prophylactically before some treatment that has negatively affected the sperm formation/ count in the male partner.

  • Azoospermia (absence of sperms in semen) - IUI is done with donor sperm. The donor sperms are obtained from a licenses sperm bank, which follows the medical and regulatory requirements for donor screening in order to eliminate the risk of transmission of infectious diseases. 

  • Sexual dysfunction in either partner - The couple is unable to have intercourse for a variety of reasons e.g. vaginismus (painful intercourse), ejaculatory dysfunction (absence of ejaculation in male partner).

Risks associated with IUI

IUI is a very simple and safe procedure. Use of medications in stimulated cycle IUI carries minor risks of ovarian hyper stimulation and multiple pregnancies. But in experienced hands and with appropriate use of medications, these risks are well within manageable range.


Success rate of IUI

The maximum pregnancy rate with IUI is reported to be in range of 10-15% with maximum chance of conception within first four IUI cycles. A critical success factor with IUI is availability of good andrology facilities at the treating centre.

 

In vitro fertilization (IVF)

 

In-vitro fertilization (IVF) is also sometimes referred to as “test tube baby”. IVF refers to the process of fertilization of egg with sperms outside the human body in a lab environment. This process allows the egg and sperm to interact in a more conducive environment of a specialised incubator, which gives them a better chance of fertilization. The embryo thus formed is transferred back into the mother’s womb for further growth. 

Candidates for IVF

Some of the most common conditions, in which the infertile couples can benefit from IVF are:

  • Fallopian tubal blockage

  • Ovulatory disorders

  • Endometriosis

  • Unexplained infertility

  • Age related infertility

  • Mild male factor infertility

Risks associated with IVF

IVF is a fairly safe procedure with rather few side effects. The most important side effects include:

  • OHSS (ovarian hyperstimulation syndrome), characterised by enlarged ovaries, fluid in abdomen (ascitis), fluid in chest (pleural effusion), coagulation anomalies and renal failure in severs case. OHSS is now fairly uncommon due to availability of safer stimulation protocols.

  • Infection following egg retrieval, especially in women with endometriosis or severe pelvic inflammatory disease (PID)

Success rate of IVF

Several factors affect the overall success rate of IVF treatment. The most important factors include: 

  • Age of the couple

  • Cause of infertility

  • Ovarian reserve of the female partner

  • Quality of IVF lab

  • Stimulation protocols used

In women under age of 35 years, the probability of pregnancy with single attempt of IVF ranges between 50 and 60%​.

 

Which stimulation protocol to use?

One of the more common questions we get asked by patients who are preparing to undergo IVF concerns is what would be the best stimulation protocol for them.


Here, it is important to understand that the ultimate outcome in a case depends upon a number of factors including patient’s age, women's ovarian reserve status and associated hormonal parameters. In general older women and women with associated diseases like endometriosis or history of ovarian surgery produce lesser eggs as compared to women without these factors.


Some of the most commonly used stimulation protocols are:

  • Antagonist protocol

  • Agonist (Long) protocol

  • Mild/ minimal stimulation protocol

Dr Parul Katiyar approaches each case individually and tailors the stimulation protocol per the needs of that specific patient in order to optimize the treatment outcome.

 

Intra-cytoplasmic sperms Injection (ICSI)

 

ICSI is a well-established microinjection technique, wherein sperm is injected into an egg under vision to enhance chances of fertilization. Presently more than 50% cycles in India and up to 63% cycles in USA are ICSI cycles.

Who are potential candidates for ICSI?

  • Men with low sperm count, poor sperm motility or morphology

  • Cases with surgically retrieved sperms like MESA, TESA, TESE, where ICSI is used to fertilise the egg

  • Patients with recurrent fertilisation failure with IVF

  • Patients undergoing preimplantation genetic diagnosis


What is the process of ICSI?

ICSI is mainly an embryological process. The process of ovarian stimulation, egg retrieval and embryo transfer is the same as in IVF. Technically the number of sperms required is only as many as the number of eggs that can be fertilised.

The male partner can provide the semen sample on the same day or previously cryopreserved sperms can also be used for ICSI. In case of obstructive/ un-obstructive azoospermia, the sperms can be retrieved surgically.


The eggs are processed for ICSI slightly differently, as they are first cleaned in order to remove the debris and outer cumulus cells. The eggs are screened for maturity under a microscope and the mature eggs are selected for micromanipulation or ICSI.


One carefully selected sperm is injected into each cleaned egg using a micromanipulator under high magnification microscope. The fertilised eggs are then placed in an incubator and allowed to grow.​

What is the risk associated with ICSI?

ICSI is a fairly safe procedure. But, some studies have indicated a marginal increase in risk of congenital malformations in the offspring (6 per thousand births compared to 2 per thousand births in general population). But it still remains to be proven if the real cause of the higher incidence of congenital malformations in such children is ICSI or just a transmission of genetic abnormalities from the male with severe sperm abnormalities.

 

Other treatment options