ASSISTED REPRODUCTIVE TECHNIQUES
It is the initial step for improving the fertility when the natural expulsion of the egg from the ovary is not taking place. The stimulation of the ovary by medication is desired and aims at increasing the number of eggs per cycle thereby increasing the chances of pregnancy. Tablets and injections are prescribed in the early few days (1-4) of the period and growth of the on- going egg sacs (follicles) is monitored by transvaginal scanning. Once the optimum size of follicles is achieved, medication (Inj. hCG.) is advised to trigger the release after maturation of egg (ovulation) from the ovarian follicle. This is the fertile period that is to be consumed naturally by timed intercourse
This is the first step to assist those couples who have been diagnosed as having unexplained infertility or having mild male factor infertility, i.e. low volume, count and motility while the wife’s fallopian tubes are patent. Also it is a bypass method for cervical mucus problems and immunological factors. For couples whose husband cannot be present during the fertile period, their frozen sample can be used for IUI but this method has its own limitations.
The ovaries are stimulated with tablets and injections and then monitored for the probable time of ovulation. The husband’s semen sample is prepared in the IVF lab and then gently placed into the uterus.
*Gender selection IUI can also be done for some selected cases.
IVF - IN VITRO FERTILIZATION:
This is an advanced step of assisted reproduction where the gametes (egg and sperm) are allowed to fertilize outside the body and is indicated when the women’s fallopian tubes are blocked or non-functional due to any reason, (e.g. previous pelvic infection or surgery), but the husband sample is within the normal limits. It is also indicated for cases of unexplained infertility for more than three years after marriage. It tests the ability of the husband’s sperm to fertilize his wife’s eggs.
Steps for IVF include ovarian stimulation after proper assessment and individualization of treatment. Once the follicles achieve the desired size, a hormonal injection (hCG.) is given and the eggs (oocytes) are collected under ultrasound guidance with analgesia and/ or mild aneasthesia. These eggs are kept with the prepared husband’s semen sample in the incubator in a suitable environment. Once the eggs are fertilized, the best embryos with growing potential are gently transferred back to the cavity of uterus on day 2, 3 or 5, under aseptic conditions and ultrasound guidance.
If the embryo implants in the lining of uterus, pregnancy is confirmed through the blood test after one week to ten days.
ICSI (Intra-Cytoplasmic Sperm Injection):
It is the best option in cases where the husband’s sample is of low quality or very low quantity, therefore predicting low chances of fertilizing the eggs on their own. It is also the option for cases of failure to fertilize in IVF. In this method sperm is injected inside the cytoplasm of the egg, and once the eggs are fertilized and the embryos cleave, embryos are transferred back to the uterus on day 2, day 3 or day5 as in IVF-ET.
ICSI is the last resort for severe male factors including obstructive azoospermia (absence of sperms in semen), in which sperm may also be retrieved surgically from either the epididymis (PESA) or from the testes (TESA/ TESE/MESA). An azoospermic man can father a child provided it is retrieved from his testes.
FROZEN EMBRYO TRANSFER (FET):
Good quality embryos can be frozen when either left over after IVF/ICSI, or when the medical condition of the patient does not permit fresh embryo transfer as in cases of ovarian hyperstimulation. This will not only help the couples who had failed in their first attempt but it offers a lower cost Embryo transfer in the future, a step which is less time consuming and less invasive, since it requires no hormonal stimulation or egg retrieval.
AH (ASSISTED EMBRYO HATCHING):
Embryos implant only when they hatch out from their shell and when the endometrium of the uterus is healthy enough to encourage implantation. In cases where the embryo’s shell or covering (zona) is hard, making an opening may help the embryo hatch out and implant. This technique may-be done mechanically or by using a laser beam.
This technique may help the patients who suffer from repeated failure of implantation and also those women whose age is above 38 years and in some cases of frozen embryo transfer.
BT (BLASTOCYST TRANSFER):
Embryos naturally reach the uterus after their trip through the fallopian tubes to implant at the stage of Blastocyst development around Day5 or Day6. In IVF/ICSI it improves the chances to get pregnant and also helps to decide and calculate the growing potential of embryos. This involves the culture of embryos for 5 days in the incubators in the IVF laboratory to a stage called the Blastocyst. This helps in the selection of embryos most likely to implant, Blastocyst transfer is done in cases where the number of good embryos exceeds three on Day2 of embryo culture.
SURGICAL SPERM RETRIEVAL TECHNIQUES:
These are used when no sperm is found in the semen. Two techniques exist:
PERCUTANEOUS EPIDIDYMAL SPERM ASPIRATION (PESA):
If a blockage in the epididymis or congenital absence of the vas deferens (the drainage tube of sperm from the testis to the penis) is the cause for Azoospsermia (no sperm in the semen), then this procedure is indicated for obtaining sperm.
A very fine needle is insured into the epididymis(the sperm collecting tube outside the testis) and sperms are aspirated. This procedure is performed under local anaesthesia, requires no incision, and the patient can get back to work the same day.
TESTICULAR SPERM ASPIRATION (TESA):
In some men the production of sperms in the testis is very low and no sperms are seen in the semen. TeSA is a way of obtaining the few sperms that are available in the testis. Using local anaesthesia, a needle is inserted into the testis to obtyain some tissue. This tissue is carefully dissected in the laboratory and the few sperms obtained may be used for ICSI or frozen for later use.