Intrauterine insemination (IUI)

The highly motile and morphologically normal sperm are harvested by density gradient separation technique from the semen which is usually a mixture of pus cells and abnormal sperm. The separated good sperm is enriched with special medium using highly sterile technique. We also prepare sperm sample for other clinics so that they can perform IUI independently at their centre and improve the success rate of intrauterine insemination. Woman with ovulatory dysfunction, treated endometriosis with patent tubes, luteal phase defects, cervical factor incompatibility, polycystic ovarian disease , can try IUI first before trying more advanced techniques of Assisted Reproduction. Men with slightly compromised semen parameters can also benefit from IUI. A cozy room specially designed for semen collection is available for the male partner. The room provides absolute privacy. The cumulative pregnancy rates after 6 cycle of IUI is about 70 - 80%.

Intrauterine insemination (IUI) - chance of success:

It is difficult to assess success rates for intrauterine insemination (IUI) because success depends upon the cause of infertility and whether fertility drugs are used to stimulate egg production.
Discuss with your clinician whether fertility drugs are suitable for you. Usually, it would be reasonable to try three to six IUI treatments. Your clinician will advise what is best for you.

• 15.8% (237/1497) for women aged under 35
• 11.0% (154/1394) for women aged between 35-39
• 4.7% (23/492) for women aged between 40-42
• 1.2% (2/172) for women aged between 43-44
• ** (0/46) for women aged over 44

Figures given in brackets are (IUI cycles resulting in a live birth / IUI cycles started).
If IUI fails after several attempts, depending on your age, your doctor may suggest you try another treatment such as in vitro fertilisation (IVF).

BLASTOCYST CULTURE

In the past most embryos produced with IVF were transferred on day three of development, known as cleavage stage. When an embryo reaches five days of development it is called a blastocyst. Currently, with advances in understanding of the needs of developing embryos, the ability to produce blastocysts in the laboratory has increased. This extended culture time allows nature to help select those embryos with the highest capacity to produce a pregnancy. Culturing and transferring blastocysts on day five of development allows the transfer of fewer embryos while still maintaining a high pregnancy rate. Normally only two blastocyst stage embryos are transferred, thus reducing the risk of multiple pregnancies higher than twins.

Why Blastocyst Transfer ?

Selection of embryos

We know that at least 50% (or higher in women over 40) of embryos are not viable, and many of these arrest their development before the blastocyst stage. A large proportion of these embryos have a chromosome or genetic defect and it is believed that those embryos that failed to develop to the blastocyst would not, in any event, have established a pregnancy. Where there are large numbers of good quality embryos available at the blastocyst stage these can be frozen. CARE Fertility has seen excellent post thaw survival and pregnancy rates with frozen blastocysts.

Embryos are transferred to the right place at the right time

Some researchers believe that the conditions in the womb may be more optimal for a blastocyst than a day 2/3 embryo as there are slightly differing conditions in the fallopian tube and the womb on day 2/3.

Higher pregnancy rate in women having Blastocyst Transfer

Data suggests that blastocyst transfer can increase the chances of a live birth but it needs to be remembered that each couple must be considered independently.

Confirmation of development to the blastocyst stage

Some specialists believe that for those patients who have recurrent failure of implantation, extended culture gives an opportunity to examine the embryo quality over a longer period. If the embryos arrest or become fragmented this may help to clarify a potential problem.

Specific situations where blastocyst transfer is applicable

Where single embryo transfer is specifically indicated (eg. previous history of multiple pregnancy, patient preference, uterine anomaly etc) blastocyst transfer may be a particularly useful option.

Extended culture and Blastocys Transfer with Frozen Embryos

Some patients have large numbers of frozen embryos and it can difficult to know which have the best potential for pregnancy. An option in these cases is to thaw all embryos and culture through to the blastocyst stage to allow the best 1 or 2 embryos to be replaced based on development.

The main benefit of the blastocyst transfer approach is in the ability to discriminate between different embryos in terms of their quality and implantation potential. It is essential to understand that the extended culture process doesn't enhance an embryos quality per se, it is principally a method for choosing the 'front runner' or 'runners' from a group of embryos.

CARE doctors and embryologists will advise on whether blastocyst transfer is possible this will depend on the number and quality of embryos available on day 3.

Donor Oocyte Programme

Welcome to the donor egg programme, which has been functioning since 2002.  the donor oocyte (egg) programme is a boon for women who are unable to produce healthy oocytes or who have chromosomal abnormalities or who have had repeated IVF failures.  The selection criteria for donors abide by strict guidelines laid down by Human Fertilization and Embryology act and by the guidelines laid down by American Society of Reproductive medicine.  PFRC has a large donor bank with over 150 donors.

Egg Donation:
The programme is one of the largest in India and provides quality service at affordable cost.  Worldwide couples have benefited by this programme and are immensely happy with the professional service offered by the center.

Egg Donation and you:
Our egg donation program at Conceptual Options allows Intended parents to choose a donor with the physical and mental characteristics that match their own.  The eggs from this donor are then fertilized with the sperm provided by the partner or a donor and transferred into either a surrogate or the intended mother.

Selection criteria include for the Donor:

    Age less than 27

    Must have had children earlier

    Should undergo all medical tests for general health

    Normal hormone values and normal uterus and ovaries

    No history of genetic or medical problems.

   Donors are not allowed to donate no more than 6 times.  The donors are counseled regarding the procedure and the importance of daily visits to the clinic.  They are subjected to psychological assessment and we ensure that they stick to unit protocols to ensure smooth functioning of the programme.

 

For the children:

The children also undergo medical and psychological IQ assessment to ensure quality care.  A database of physical characteristic, medical screening and all assessments made is maintained and the donor is matched as per the requirement of the recipient. www.pfrcivf.com Consent forms are signed by the donor, her husband and the recipient couples to avoid legal problems.
We have a programme for oocyte donation for women with premature ovarian failure, surgical or induced menopause and those in the perimenopausal group.  Some women with repeated poor recruitment of follicles at the time of IVF, women with extensive endometriosis, severe pelvic adhesions and in accessible ovaries might also qualify for this programme.  A total of 506 babies have been delivered till date.  The success rate of the donor oocyte program is 65 – 69%.  Their babies are as normal as other babies born through IVF programs using own oocytes.

Egg Donation Program:

Clinical Pregnancy rate per Embryo Transfer                67%
Clinical Pregnancies                                                      55%

Donor Egg Cycle:

In this cycle you do not undergo ovarian stimulation. www.pfrcivf.com The eggs are taken from a donor who undergoes ovarian stimulation after down regulation as explained in the long protocol.  You will be asked to take T. Ovral G from a specific day and stop on a specific date.  Injection suprefact is started before Ovral G is stopped for down regulating your body hormones.  You have to come daily for the injections.  On Day 3 of the period you have to undergo an ultrasound to measure the Endometrial thickness, if it has been sufficiently suppressed, tab.  Progynova is started from D3 to stimulate Endometrial growth.  The Endometrial thickness is measured on frequent scans and when the lining is about 1 cm and eggs have been collected from the donor your husband is asked to give a semen sample (on the day of egg collection from the donor).  Fertilization is done.  You will be asked to stop suprefact injection and start inj.  Gestone 100 mg.  daily from that day.  You should call the unit the next day to find out about the day of embryo transfer.
Regarding the donor, we select a healthy person in the age group of 20-25.  We screen them for major infections like VDRL, Hbs Ag & HIV.  Detailed family history, medical history & surgical history is enquired into.  We select people who already have healthy children so that we can rule out major familial diseases.  Confidentiality is maintained.  The 2-3% risk of congenital anomalies found in the general population is applicable here also.

Semen collection

Semen collection

Semen collection refers to the process of obtaining semen from male humans or other animals with the use of various methods, for the purposes of artificial insemination, or medical study (usually in fertility clinics). Semen can be collected via masturbation (e. g., from male wolves,dogs and foxes), prostate massage, artificial vagina, penile vibratory stimulation (vibroejaculation) and electroejaculation.

Humans
Methods of semen collection from humans include:

Masturbation, directing the sample into a clean cup.This is the most common way to collect a semen sample.
Sexual intercourse in a special type of condom known as a collection condom.Collection condoms are made from silicone or polyurethane, as latex is somewhat harmful to sperm. Many men prefer collection condoms to masturbation, and some religions prohibit masturbation entirely. Adherents of religions that prohibit contraception may use collection condoms with holes pricked in them.However, such samples are inferior to the ones collected by masturbation in clean cup.
Coitus interruptus (withdrawal). With this technique, the man removes his penis from his partner near the end of intercourse and ejaculates into a wide-necked cup or bottle.http://www.pfrcivf.com

Surgical extraction, if for example a blockage in the vas deferens is suspected to impede fertility, semen can be taken directly from the epididymis. Such a collection is called per cutaneous epididymal sperm aspiration (PESA). Alternatively, the testicular tissue itself, instead of the sperm produced can be investigated. Then, the collecting method is called testicular sperm extraction (TESE). A Cochrane review found insufficient evidence to recommend any specific surgical sperm retrieval technique for men with azoospermia undergoing intracytoplasmic sperm injection (ICSI).
Penile vibratory stimulation (PVS) and electroejaculation are two other alternatives for men with anejaculation due to spinal cord injury.The penile vibratory stimulator is a plier-like device that is placed around the glans penis to stimulate it by vibration, and provides the first-line method for sperm retrieval in spinal cord injury patients with anejaculation.http://www.pfrcivf.com/andrology-services/semen-collection.html

The best specimen is produced when a short period of 3–5 days of abstinence is observed. More prolonged period does not yield better results.

Ovulation Induction (OI)

 One of the three common reasons why couples do not conceive is when the female partner is not ovulating. Although this can often be remedied using fertility tablets (clomiphene citrate), there are some women who need to use hormone injections and this is called "Ovulation Induction" (OI).

The hormone that stimulates production of eggs (oocytes) in the ovary is secreted from a small part of the brain (called pituitary gland) is Follicle Stimulating Hormone (FSH) http://www.pfrcivf.com/andrology-services/ovulation-induction.html. It is FSH that is administered on a daily basis by using an injection pen into the fatty tissue in the abdominal wall when OI is used. The response to the hormone is the development of follicle or follicles in the ovary that contain the developing eggs. The progress of the developing follicles is monitored by measuring the oestrogen hormone they produce by blood tests, and by watching them grow on ultrasound examination. The dose of the FSH is then adjusted with a small increase every seven to ten days, in line with the response. 

The aim is to stimulate preferably one or two and a maximum of three ripe follicles. When the size of the follicle and the oestrogen level suggests that the follicle is ripe, another hormone, Human Chorionic Gonadotrophin (HCG) is administered which releases the egg. All the couple have to do usually is to have intercourse around the time of ovulation.

We usually obtain about 20% pregnancy rate per cycle, with a small risk of multiple pregnancy (usually only twins) of about 20%. http://www.pfrcivf.com/andrology-services/ovulation-induction.html
The risks are that too many follicles may be produced, and then the cycle is cancelled (the HCG hormone is not administered) and intercourse is avoided. It is very rare for the symptoms of sore swollen ovaries with abdominal fluid (ascites) to develop after OI.


After the first cycle if there was ovulation but no conception, the cycle is repeated. If too many follicles were produced, the dose of FSH is kept lower for longer.

Over 80% of women who undergo OI have a successful pregnancy within six cycles. Occasionally there are other fertility abnormalities that require progressing to IVF.

SURROGACY

Surrogacy is when another woman carries and gives birth to a baby for the couple who want to have a child.The HFEA does not regulate surrogacy.Surrogacy may be appropriate if you have a medical condition that makes it impossible or dangerous to get pregnant and to give birth.

Intended parents may seek a surrogacy arrangement when either pregnancy is medically impossible, pregnancy risks present an unacceptable danger to the mother's health or is a same sex couples preferred method of procreation. Monetary compensation may or may not be involved in these arrangements. If the surrogate receives compensation beyond reimbursement of medical and other reasonable expenses, the arrangement is considered commercial surrogacy; otherwise, it is referred to as altruistic. The legality and costs of surrogacy vary widely between jurisdictions, sometimes resulting in interstate or international surrogacy arrangements.

Types of surrogacy            

•  Gestational surrogacy (GS)
• Gestational surrogacy with embryo from both intended parents (GS/IP)
• Gestational surrogacy and egg donation (GS/ED)
• Gestational surrogacy and donor sperm (GS/DS)
•  Gestational surrogacy and donor embryo (GS/DE)
•  Traditional surrogacy (TS)
•  Traditional surrogacy and donor sperm (TS/DS)

The type of medical conditions that might make surrogacy necessary for you include:

• absence or malformation of the womb
• recurrent pregnancy loss
• repeated in vitro fertilisation (IVF) implantation failures

Full surrogacy (also known as Host or Gestational) - Full surrogacy involves the implantation of an embryo created using either:

• the eggs and sperm of the intended parents
• a donated egg fertilised with sperm from the intended father
• an embryo created using donor eggs and sperm.

Partial surrogacy (also known Straight or Traditional) - Partial surrogacy involves sperm from the intended father and an egg from the surrogate. Here fertilisation is (usually) done by artificial insemination or intrauterine insemination (IUI).

DONOR INSEMINATION

Donor insemination (DI) uses sperm from a donor to help the woman become pregnant.
Sperm donors are screened for sexually transmitted diseases and some genetic disorders. In DI, sperm from the donor is placed into the neck of the womb (cervix) at the time when the woman ovulates.
DI - IUI uses intrauterine insemination with donor sperm.
Donor sperm can also be used for in vitro fertilisation (IVF).

• In vitro fertilisation (IVF)
• Intrauterine insemination (IUI)

A clinic is likely to recommend donor conception if:

• you are not producing eggs or sperm of your own
• your own sperm or eggs are unlikely to result in conception
• you have a high risk of passing on an inherited disease
• you are in a same sex relationship, or
• you are single.

If you are considering using donated sperm, eggs or embryos, you will need to think about some complex issues before starting treatment. For this reason, you will be offered counselling; many clinics regard it as essential and will not offer donor conception treatment without it. Try to also talk to people who already have donor-conceived children.

How does DI work?

Using donated eggs

Donated eggs can be used in either in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI). Read more about these treatments in the previous sections.
The procedure for using donated eggs varies depending on your clinic and the fertility treatment you are undergoing. A typical procedure may involve the following steps:

 

For women:

1. You and your donor will be given medication to synchronise your menstrual cycles. You will also be given medication to prepare the endometrium lining of your womb for embryo transfer.
2. The donated eggs will be fertilised using IVF or ICSI. 
3. When the embryos begin to develop, they will be transferred to your womb as in conventional IVF. As the eggs will be from donors aged 35 or younger, no more than two embryos will be transferred.

Alternatively, the embryos may be frozen after they have been fertilised. This avoids the need to synchronise your menstrual cycle with that of the donor and may reduce the stress of the treatment.

For men:

1. Unless you are using donor sperm, before treatment takes place you will give a sperm sample to check that your sperm are healthy and active.
2. On the day that the eggs are collected, you will give another sperm sample.
3. The sperm sample is mixed with the donor eggs in vitro to fertilise them, or fertilised by ICSI and then transferred to the womb.

Using your eggs in your partner’s treatment

If you are in a same sex female couple and you want to use your eggs and your partner carry the baby, the process for collecting your eggs will be as follows:

1. After being screened for sexually transmitted diseases and some genetic disorders, you will be given a series of hormone injections to help develop and mature the eggs within the ovaries.
2. Once the eggs are matured, they are collected while you are sedated by inserting a needle into the ovaries through the vagina.

The eggs will then be fertilised, usually using IVF.

Donor insemination (DI) - chance of success

Female fertility diminishes with age, so if you are using your own eggs, on average, the younger you are, the higher your chances of success.
Some women receive fertility drugs to boost egg production before the sperm is transferred. We now present the stimulated and unstimulated cycles seperately.
In 2010 (the year for which the most recent data is available) women receiving unstimulated donor insemination (DI) - including intrauterine insemination (IUI) and GIFT - the percentage of cycles started that resulted in a live birth was:

• 14.6% for women aged under 35
• 11.4% for women aged 35-37
• 9.4% for women agend 38-39 
• 4.7% for women aged 40 and over

In 2010 (the year for which the most recent data is available) women receiving stimulated donor insemination (DI) - including intrauterine insemination (IUI) and GIFT - the percentage of cycles started that resulted in a live birth was:

• 20.7% for women aged under 35
• 17.1% for women aged 35-37
• 11.9% for women agend 38-39
• 5.3% for women aged 40 and over

EMBRYO TRANSFER

So you've had an embryo transplant, but still do not conceive. It is normal to blame yourself for something you may or may not have done during this time. Therefore, try not to do anything for which you will blame yourself if you do not get pregnant. In general practice the following guidelines:
 

• No tub baths or swimming for 48 hours after embryo transfer.
• No douching or wearing tampons. 
• No intercourse or orgasms until the fetal heartbeat is seen on ultrasound, or the pregnancy test is negative.
• No excessive physical activity such as jogging, aerobics, or tennis.
• No non-prescription medications or other prescribed medications without the approval of your doctor.
• No heavy lifting.
• You may return to "work" after 24 hours of bed rest (getting up for bathroom and meals only) and one to two days of light activity.

Doctors used to advise "strict bed rest" after an embryo transfer. However, remember that physical activity does not affect your chances of getting pregnant. Resting when you are well can be very emotionally taxing, and we encourage patients to lead as normal a life as possible. 

After a transplant, there are numerous stages which must be reached and completed before conception.

• More than one egg should develop.
• Eggs should mature.
• Ovulation should not occur before the eggs can be collected.
• Eggs must be retrieved during the "pick-up".
• Sperm must fertilize at least one egg
• Fertilized eggs must divide and grow healthily.

The embryos might get implanted in the uterus.

Think of it as a series of hurdles, all of which have to be cleared, in order to win the race!

 

Maximizing Chances for Success

Women:

• Avoid all medications. If you are taking other prescription medications check with your doctor prior to beginning your treatment cycle. 
• No smoking or alcohol use. Studies show both can result in lower pregnancy rates and a greater risk of miscarriage. Why put yourself through this if you are not doing everything YOU can to insure your success.
• No more than two caffeinated beverages per day.
• Avoid change in diet or weight loss or fad diets during IVF cycle. A healthy well balanced diet works best.
• Refrain from intercourse three to four days prior to egg retrieval and following embryo replacement until the pregnancy test has been done. 
• Normal exercise may continue unless enlargement of your ovaries produces discomfort.
• Avoid hot tubs or saunas.

Men:

• Fever greater than 100.4o one to two months prior to IVF treatment may adversely affect sperm quality. Be sure to let your doctor know. If you are sick, please take your temperature and report any febrile illnesses. 
• Sitting in hot tubs and saunas is not recommended. Even a single episode in a hot tub can adversely affect sperm function. Please refrain from this for at least three months prior to treatment.
• Drugs, alcohol, and cigarette smoking should be avoided for three months prior to treatment and at all times during the ongoing IVF treatment cycle to get the best results.

Abstain from intercourse for at least three days, but not more than seven days prior to collection of semen for egg collection and during treatment.

Intra-cytoplasmic sperm injection (ICSI)

Intra-cytoplasmic sperm injection (ICSI) differs from conventional in vitro fertilisation (IVF) in that the embryologist selects a single sperm to be injected directly into an egg, instead of fertilisation taking place in a dish where many sperm are placed near an egg.  

ICSI enables fertilisation to happen when there are very few sperm available.

Your clinic may recommend ICSI if:

·         you have a very low sperm count

·         other problems with the sperm have been identified, such as poor morphology (abnormal shape) or poor motility (not moving normally)

·         during previous attempts at IVF there was failure of fertilisation or an unexpectedly low fertilisation rate

·         you need sperm to be collected surgically from the testicles or epididymis (a narrow tube inside the scrotum, where sperm are stored and matured); for example because you have had a vasectomy, you do not ejaculate sperm, or because you have extremely low sperm production

·         you are using frozen sperm in your treatment which is not of optimum quality

·         you are using embryo testing.

How does ICSI work?

Before your treatment starts you will need to complete various consent forms and you, and if applicable your partner, may need to have blood tests to screen for HIV, hepatitis B and C and human T cell lymphotropic virus (HTLV) I and II.

Treatment then typically involves the following:

For women

You take fertility drugs to stimulate your ovaries to produce more eggs, as for IVF, and your progress will be monitored through vaginal ultrasound scans and possibly blood tests.

The eggs are then collected using the same procedure as IVF and each egg is injected with a single sperm from your partner or donor. The rest of the process is also the same as IVF.

You are more likely to become pregnant with twins or triplets if more than one embryo is transferred so your clinic will recommend single embryo transfer (SET) if they feel it is the best option for you. An embryologist will examine your sperm under a microscope and decide whether ICSI could increase your chances of fathering a baby.

The next step depends on whether you are able to provide sperm without a medical procedure:

·         If you can, you produce a fresh sperm sample on the same day as your partner’s eggs are collected.

Or:

·         Sperm can be collected directly from the epididymis using a type of fine syringe. This is known as ‘percutaneous epididymal sperm aspiration’ or PESA.

·         Sperm can also be retrieved from the testicles, a process known as ‘testicular sperm aspiration’ or TESA.

·         It is also possible to remove tiny quantities of testicular tissue from which sperm can be extracted. This procedure is called ‘testicular sperm extraction’ or TESE. For more information about PESA, TESA and TESE, speak to your doctor.

·         If you have stored sperm, it will be removed from frozen storage, thawed and prepared for treatment.

A single sperm is then injected into each egg. ICSI provides the opportunity for fertilisation to happen, but it is not guaranteed to succeed.

Finally, if fertilisation does take place, the embryos will be cultured in the laboratory for up to six days and then between one and three of the best-quality embryos will be transferred to the womb.

Zero sperm count

If you have a zero sperm count (other than caused by vasectomy), the chances of retrieving sperm surgically by PESA, TESA or TESE may be very low.

In this situation, you might consider having a surgical retrieval as a ‘dummy run’ and storing any sperm that are obtained. If no sperm are retrieved, you may want to consider donor insemination (DI) or IVF with donor sperm instead.