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| Treatment
For
Assisted Reproduction Technologies (ART) |
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| Intrauterine
Insemination (IUI) |
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IUI
Intrauterine Insemination is also referred as Artificial Insemination
(AI), frequently used as a first line strategy in the treatment
of an infertile couple.
IUI
offers many variants depending on source of semen for insemination,
the type of ovarian stimulation and where in the reproductive
tract that the sperm is placed. Thus it is imperative to know
their differences to determine which one is best suited according
to your needs. |
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Source
of semen : semen utilized for the process of artificial
insemination depends on the semen quality or other clinical
condition of male factor. Depending
on the source of semen there a 2 types of IUI.
1. Semen
from Husband AIH. Artificial Insemination Husband
2. Semen from Donor AID. Artificial Insemination
Donor, where the Husband has no Sperms [ Donor
Insemination Programme]
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Ovarion
stimulation and artificial insemination :
In
normal cycle of menses which occurs 28 +or – 2 days, the ovulation
takes place some where around the 14 th day after the
bleeding starts , the LH surge occurs 2 days prior so an insemination
is planned accordingly.
Current
trend based on no medication that uses the above Natural phenomenon
is called as NON STIMULATED or "NATURAL CYCLE”. However
recent reports support the view that to achieve best results
it is suggested that AI coupled with ovulation induction by
fertility drugs. This works on principle that exogenous hormonal
stimulation of ovary to induce development and recruitment
of more than one follicle. This is often referred to “CONTROLLED
OVARIAN STIMULATION” or “SUPEROVULATION with IUI”. |
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Commonly
used “fertility drugs” for stimulation are :
1. Clomiphene citrate(Clomid
or Serophene)
2. Gonadotrophins(Humegon,Gonal-f,Pergnol)
The
choice between the methods is based on ovarian response to
drugs, age of patient and previous history. It is generally
recommended 2-3 cycles with clomiphene citrate & three
cycles with gonadotropins.
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| CLASSIFICATION
OF IUI BASED ON PLACING THE SPERMS IN THE REPRODUCTIVE TRACT
Intracervical
Insemination : (ICI)
This
involves placing a raw ejaculate directly into the cervix
with help of a plastic cap or sponge,syringe, cannula. The
cap or sponge prevents the regurgitation of semen into vagina.
The semen to be used for this procedure should be of good
Quality and the cervical environment must be appropriate for
sperms for this procedure to be useful.
Intra uterine
Insemination : (IUI)
This procedure involves
sperm preparation by using sperm enhancement media to harvest
a specimen of maximum motile, normal sperms. This washed specimen
is inseminated via a catheter directly into the uterine cavity.
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Procedure
of IUI & Ovarian Stimulation
The
use of drugs to stimulate ovary offers an increased probability
of success when combined with few risks and proper control
measure is mandatory to avoid the potential complications.
Ultrasound
monitoring with hormone blood testing is done during drug
therapy, this is to evaluate the ovarian response and to reduce
the risk of high order multiple pregnancy and any side effects
of treatment. Serial tracing the number & development
of follicles by ultrasound, with measuring the oestrogen levels
in blood is advised & helps to avoid complications.
Excessive
response to treatment is evidenced by high levels oestradiol
coupled with several follicles, in such an event the whole
cycle is cancelled to prevent complication. The aim of IUI
with stimulation is to induce a moderate response without
complication. The ideal expected size of the follicle when
achived the ovulation is induced by injection of
HCG approximately 36 hrs prior to procedure.
On
the day of the IUI 36hrs after the HCG injection a semen sample
is processed washed and insemination done using a fine catheter
into the uterine cavity.
This
is a painless procedure, no anaesthesia is required. A modified
protocol of two insemination in the same cycle one 24 hrs
after HCG followed by second insemination 42-48 hrs after
HCG is also done. Luteal support with progesterone
is prescribed to aid the implantation. Two weeks later a urine
sample or blood samples is drawn to monitor the BHCG level
which is repeated to document a rise in titre and establish
pregnancy followed in several weeks by ultrasound test to
witness the viability and the number of gestational sacs in
the uterine cavity. |
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IVF- In Vitro
Fertilization IVF
or In Vitro Vitro Fertilization and Embryo transfer
(IVF-ET) is the most popular treatment
of reproductive technology. Very commonly
known as “Test tube baby” technique, has helped
ingertile couples conceive and start a family.
Has been in existence since 1979 after the just
successful baby “Lousie Brown” was conceived &
given birth by this technology. IVF - Et technique
was originally developed for treatment of women
with tubal factor infertility. But now it is used
for a wide array of infertility problems due to
adhesions, endometriosis. Sperm antibodies, male
factor of moderate kind, unexplained infertility,
secondary infertility, failed GIFT cycles etc.
What
is IVF Process?
For a natural pregnancy to occur, the egg released
from the ovary must unite with the sperm to undergo
FERTILIZATION followed by development of an embryo.
This process starts in the fallopian tube, the
embryo during its development travels to eventually
implant in the uterine cavity.
In
the IVF process the eggs are retrieved transvaginally
when mature and sperms are processed and united
in the Laboratory to produce an embryo. This embryo
is then transferred back to the uterus for implantation
& further development of the embryo. |
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This
is a sequential process. Requiring the harvest of oocytes
from the woman's ovary, receiving ovarian stimulation,
achieved through use of different fertility or ovulation
induction medication. Mature eggs on a predictable schedule
are retrived from the ovary, inseminated with the prepared
semen sample, harvesting the most robust sperm in the
laboratory. The eggs and sperms are incubated together,
18 hrs later the fertilization is observed. These fertilized
oocytes are cultured further into early embryos. These
are monitored for few days prior to their transfer into
the uterus for initiation of pregnancy. The basic technique
of transferring the embryo's can either be
 Day
3 : At 6-8 cell stage Embryo. This is universally accepted
stage of Embryo Transfer(ET)
Day
5 : Blastocyst stage transfer-day 5 Embryo Transfer. |
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| Intracytoplasmic
Sperm Injection (ICSI) / Micromanipulation
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Certain couples with severe male factor infertility
cannot be helped, with conventional IVF. In order to
tackle this problems procedure based on Micromanipulation
of oocytes and spermatozoa have been established. ICSI
is one of the most technically advanced procedure where
a single spermatozoon is directly injected into the
ooplasm (Cytoplasm) of the oocyte. This procedure is
done using an inverted microscope equipped with micromanipulators
and microinjectors where the prepared sperm is injected
using a microinjecting pipette which is 60 times thinner
than human hair, into the ooplasm which is held by a
microholding pipette which is 20 times thinner than
the human hair. The microinjected egg is returned to
the incubator for further culture and checked for fertilization
about 16-18 hours after ICSI, following another 24 hours
of In Vitro culture. The Embryo's thus obtained from
ICSI programme are taken for Embryo transfer following
a similar policy of conventional IVF.
ICSI is indicated for the following:
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Extremely
low count i.e.Oligospermia. ICSI recommended if
<5 million sperm count is seen. |
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Abnormal
or poor sperm morphology Teretozoospermia esp
Globozoospermic ejaculates. |
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Impaired
sperm motility. Asthenozoospermia |
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Man
with ejaculatory disorders. |
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Woman
with advanced age |
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Infertility
due to immunologic cause. |
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Unexplained
Infertility. |
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Endometriosis. |
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| Blastocyst
Culture and Transfer: |
| The ultimate
aim of every ART program is a normal single intrauterine
pregnancy which ends with an uneventful delivery of a
normal healthy infant. It is a normal practice among the
reproductive specialists to transfer more than one embryo
at each transfer to increase the likelihood of establishing
a pregnancy. |
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this practice of more embryo’s results in multiple
pregnancy for a given couple. High order multiple pregnancies
present significant ethical & economic problems.
Commonly encountered are Prematurity and associated
neonatal morbidity, these adverse outcomes are not routinely
reported by assisted reproductive technology programs
or the society of ART.Under standard IVF culture conditions
only 10-40% of fertilized eggs will undergo implantation
to give pregnancy. Which embryo is most likely to result
in normal pregnancy is a very challenging job faced
by In Vitro fertilization group. Proper & accurate
selection of these embryo’s enables the IVF team
to transfer as few as possible best graded embryo’s,
leading to fewer multiple order pregnancy rate.
In the past few years, with the recent development of
sequential media embryo culture upto day 5 is possible
by then the embryo’s have reached a stage of development
described as “ BLASTOCYST STAGE “ - Proper
& accurate selection of these embryo’s enables
the IVF team to transfer as few as possible best graded
embryo’s, leading to fewer multiple order pregnancy
rate.
The process
of extended culture allows nature select those embryo’s
with the highest capacity to produce a pregnancy which
will result in live birth eventually. Thus the
ongoing refinement and recent development add to the
greater opportunities & hopes for infertile couples.
The advent of extended culture i.e. BLASTOCYST CULTURE
is the latest important breakthrough. We at Pune fertility
Centre are able to offer our patients this promising,
technique, thereby increasing the successful pregnancy
chances in their favor.
A Blatocyst Culture or Extended Culture is an embryo
which has developed for at least five days after fertilization
and has divided into two different cell types viz. the
surface cells called the trophoectoderm which will eventually
become the “placenta.” The inner cell mass
which will become the “FETUS”. A healthy
blastocyst should hatch from the Zona pellucida shell
by the end of day six and within the next 24 hrs hours
the hatched embryo should begin to implant within the
lining of the uterus. Embryo’s by this stage have
undergone a natural selective process whereby the weaker,
unfit embryo’s are selected out & the best
one progress to the eventual blastocyst stage. The studies
have revealed that Blastocyst stage embryo’s have
a higher pregnancies rate than Day 2 or Day 3 old embryo
transfers. There by 5th day transfers of Blastocyst
requires less embryo per transfer, which dramatically
reduces the probability of multiple pregnancies. Also
in quite a few cases day 5 transfers offer higher pregnancy
rates, as the uterine lining is more receptive to the
advanced embryo’s.
Is blatocyst
culture & transfer suitable to all infertility couple?
There are many
unresolved issues regarding blastocyst transfers. Blastocysts
transfer have a number of risks and hence is not a suitable
option for each and every couple. There are percentage
of patients, in whom none of their embryo’s develop
to the blastocyst stage and gradually degenerate &
thus result in a complete wastage of all embryo’s.
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| Assisted
Hatching |
Assisted hatching is a procedure whereby the embryo
is
subjected to enzymatic softening or total removal
of Zona Pellucida (ZP). Subsequently these enzymatically
treated embryo's either with a faint or no zona is
transferred in the uterine cavity. Thereby allowing
a better cell-to-cell anchorage between the trophoectoderm
and endometrium.
Thus improving implantations and pregnancy rates.
Assisted hatching is useful in older woman, in whom
the zona tends to be thickened. It is also beneficial
to couples who have tried I.V.F. unsuccessfully previously.
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| Semen
and Embryo Cryopreservation |
Cryopreservation
of Spermatozoa is well-established for Assisted Reproduction
technique for many years. Sperm cryopreservation and Banking
is now routinely practiced in Assisted Reproduction technology
and Andrology for a range of reasons including the quarantine
of donor sperm for transmissible diseases eg. HIV, Hepatitis
B etc. long term storage for men who will be absent during
their partner's assisted reproductive treatment. Our cryopreservation
facilities are also routinely used to cryopreserve testicular
and epididymal sperm, so that repeated attempts at obtaining
fresh epididymal & testicular sperm are avoided. At our
centre the donor semen cryopreservation programme is in accordance
with the Guideline established by the ICMR National Guideline
for Accreditation supervision and regulation of ART clinics
in India. We follow a stringent screening process before a
male is selected in our Semen donor programme. We have established
successful pregnancies, live births using previously cryopreserved
spermatozoa for our patient's in their various treatment protocols. |
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| Oocyte
Donor Program |
Oocyte (egg) donation involves the
deliberate use of oocytes (eggs) provided by a donor for
In vitro fertilization and Subsequent Embryo transfer to
a matched and synchronized recipient.
Our center has an ongoing oocyte donor programme, with subsequent
successful pregnancies. PFC has recently started oocyte
donor registry , if any female less than 35yrs of
her age is eligible to register. Secrecy and reward is assured.
The indication for using donar oocyte
includes premature ovarian failure (Hypergonadotropic hypogonadism),
Perimenopausal women with a diminished ovarian reserve,
women with advanced reproductive age who have already experienced
natural menopausal, young woman, not benefited from repetitive
attempts at In vitro fertilization or who have performed
poorly with respect to oocyte (poor responder) or Embryo
quality, woman with extensive endometriosis often consider
oocyte donation. Finally oocyte donor programme is chosen
to avoid the possibility of transmitting of significant
genetic illness for which the female recipient is known
to be a carrier.
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| Oocyte
donor program |
Oocyte
(egg) donation involves the deliberate use of oocytes
(eggs) provided by a donor for In vitro fertilization
and Subsequent Embryo transfer to a matched and synchronized
recipient. |
Our
center has an ongoing oocyte donor programme, with subsequent
successful pregnancies. |
The
indication for donation includes premature ovarian failure
(Hypergonadotropic hypogonadism), Perimenopausal women
with a diminished ovarian reserve, women with advanced
reproductive age who have already experienced natural
menopausal, young woman, not benefited from repetitive
attempts at In vitro fertilization or who have performed
poorly with respect to oocyte (poor responder) or Embryo
quality, woman with extensive endometriosis often consider
oocyte donation. Finally oocyte donor programme is chosen
to avoid the possibility of transmitting of significant
genetic illness for which the female recipient is known
to be a carrier. |
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| Embryo
Donor Programme |
For couples undergoing assisted
conception treatment, where both partners are infertile,
the embryo donation programme is well established
and proved to be successful. Menopausal or Perimenopausal
woman and infertile partner, recurrent IVF failure
especially older partners and couples who are carrier
of genetic diseases or chromosomal abnormalities are
the candidates who benefit from embryo donation.
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Andrology
Laboratory for diagnostic and therapeutic tests |
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| Testicular Epididymal
Sperm Aspiration (TESA) & (PESA) |
| TESA (Testicular Sperm
Aspiration ) : |
| This is like an aspiration
cytology procedure . A 22 G scalp vein needle is jabbed
around the testicular substance while applying suction
with a 10 or 20 ml syringe. The aspirate is examined for
sperm. Once the sperms
have been aspirated these sperms are injected to the
cytoplasm of the oocyte (ICSI)
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| MESA (Microsurgical
Epididymal Sperm Aspiration): |
| The epididymal is
exposed and the tunica is opened to expose an epididymal
ductile. The ductile is opened microsurgically. The spermatic
fluid that flows out is aspirated and the ductile is then
closed with microsutures. It is hoped that with such a
microsurgical procedure the ductile would be preserved
for future repeat aspiration, if required. |
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