On most occasions surrogacy is done with the intended parents own eggs and sperm. This usually happens when the lady does not have a uterus (genetic or surgical removal) or has a defective uterus (septum, bicornuate, arcuate, or due to infection like Tuberculosis). Another reason we use surrogacy is when the couple has had numerous failed IVF cycles.
The intended parents first decide to proceed with self-cycle surrogacy at our centre, they sign the contract and the tentative dates are decided. The lady is put on pills to be able to synchronize with the surrogate’s menstrual cycles. The surrogate is also prepared to build the endometrium. Once the intended parent (lady) periods start, hormones are injected to make multiple eggs. This usually goes on for 10-12 days. The lady needs to stay in the city for minimum of 7 days provided she takes a few of these injections at home. All this is discussed and explained to the couple beforehand. There is regular communication through e-mail and telephone.
The eggs are retrieved under anesthesia, they are fertilized with the husband’s sperm, it is to be noted here that if time does not permit the husband may leave his semen sample in his earlier visits and the same can be frozen.
After fertilization of the eggs and sperm, the embryos take 2-3 days to develop. We are doing both cleavage and blastocyst transfer depending on the total no. of eggs retrieved, no. of grade A embryos formed and previous history. The embryos are then transferred into the surrogate under the ultrasound guidance. The decision regarding the no. of embryos depends on the age of the intended lady and previous treatment history. We usually transfer 2-3 cleavage stage embryos or 1-2 Blastocysts.
Following embryo transfer the surrogate is given hormonal supplements like estrogen and progesterone. She is asked to take rest and the pregnancy test is done 2 weeks later. Both her co-ordinator and the centre co-ordinator pay regular visit to ensure that the instructions are being followed.
At this moment there are more than a million infertile couples in India trying for a conception.IVF (in vitro fertilization) or ‘test tube baby’ is the magic word for infertile couples desperately desirous of a child. Through this technology which is a boon to mankind, many who had no chance of having their own child, are now proud parents. Though by IVF a couple has up to a 60% chance of success, the success rate may vary from couple to couple and may not be the same for all couples.
This article attempts to answer some of the frequently asked questions about IVF clarify certain aspects of IVF- for example, which group of patients need IVF, what happens in an IVF treatment cycle and why all patients do not get pregnant after IVF treatment?
Which group of patients need IVF?
Infertility investigations usually start once the couple has had one year of unprotected regular intercourse. However, it is advisable to investigate and treat earlier if there are known predisposing factors such as age of female partner greater than 35 years, menstrual irregularities, known endometriosis, pelvic infections, undescended testis in the male partner, or when there are pre-existing causes of infertility (eg, previous tubal surgeries). Problems in conception can occur when there is a problem in either the male or female partner. Investigations therefore focus on evaluating the sperm, uterus, egg development and maturation, and fallopian tubes.
Many couples are directly referred for IVF once these investigations are complete. These are patients with either tubal block on both sides or those with severe male factor infertility (< 5 million/ml sperm count). In other cases there are many treatment options available for eg, ovulation induction, intrauterine insemination and surgical treatment of infertility. Many couples conceive after such treatment, but some don’t. After a reasonable duration of trying such treatment these couples should be referred for IVF. The results of IVF are best when the lady is less than 35 years of age. Often much to our frustration, we are unable to help such couples either because of late referral or because the couples have waited too long to start IVF treatment. What happens in an IVF treatment cycle? Typically an IVF cycle consists of ovarian stimulation, egg collection, fertilization, embryo culture and embryo transfer. Ovarian stimulation consists of daily injection of hormones to the female partner with frequent clinical and ultrasonographic monitoring. This usually continues for 10-15 days. Egg retrieval is performed under anaesthesia through the internal route. There are no incisions or scars. The egg and sperm are either mixed (IVF) (Figure 1) or the sperm is injected into the egg (ICSI-intracytoplasmic sperm injection) (Figure 2). The fertilized egg forms the embryo. The embryo is cultured in the laboratory for 2-3 days (Figure 3). Two-three best embryos are selected and transferred into the womb (uterus) on the second or the third day. The pregnancy test is done 14 days after the day of embryo transfer. What is the success rate of this process? It all sounds so logical and definitive that one would expect success in every case! But unfortunately this is not the reality. One must understand that in the entire process of IVF each step is a hurdle that has to be negotiated successfully. For example, not all women respond to ovarian stimulation, not all eggs are mature, not all eggs fertilize to make good embryos and not all embryos implant. Therefore, there is an attrition or drop out at each stage. It is at the stage of implantation that there is a huge scope for further research. Implantation is the process where the uterus accepts the embryo which then develops to form the baby. Much work has been done on this aspect of IVF and medications such as steroids, aspirin, heparin, sildenafil are being tried to improve implantation rates. The overall success rate of IVF is about 35% per treatment cycle. In order words 4 out 10 , who otherwise had given up all hopes of parenting a child would conceive after attempting IVF. World over the success rate is highest in younger women where it can reach up to 60% per treatment cycle. In case of failure, IVF may be tried again and the cumulative pregnancy rate over 3 cycles may go as high as 70%. In order to give the optimum benefit to the patient it is essential that the infertile couple is offered the right treatment at the right time. It is also essential that patients understand the entire process of IVF. We are in an era of transparency and constant dialogue with patients. They should be involved in decision making. They must understand the strong points and drawbacks of the entire IVF process. Once there is complete understanding of the process a lot of stress associated with such intensive treatment will automatically be allayed.
Assisted Reproductive Technologies (ART)
Assisted Reproductive Technology (ART) is evolving at great pace, breaking new grounds and providing couples with number of treatment options. The reproductive technology not only refers to IVF but also to several variations tailored to patients’ unique conditions. These procedures are usually paired with more conventional therapies, such as fertility drugs, to increase success rates. If your initial treatment do not bring results, we can provide latest assisted reproductive technologies and techniques. Various treatment options may include:
The age of woman has a major impact on IVF success rates, if age of woman is less than 35 years, the success rate is higher. The possibility of success falls dramatically after 40 years. Other factors that determine success rate are:
Eggs and sperm quality
Condition of endometrium
Ease of embryo transfer
The major complication is risk of multiple births, this may lead to:
Potential for long term damage
The other major complication is ovarian hyperstimulation syndrome. In this condition fluid accumulates inside the abdomen and lungs. Usually it settles on its own with proper fluid management. In rare cases hospital admission and intensive care is required.
How to find best fertility clinic
Seeking fertility care is a decision of lifetime. It is expensive, time-consuming, as well as physically and emotionally draining. In order to achieve dream parenthood, it is important to find the best care possible from the very beginning. To find the best fertility clinic you must consider the following factors :
Location: Institute where couple wants to take treatment should be easy to locate.
Stay: Fertility institute should offer a good comfortable room in institute or can make arrangements in nearby good
On-line consultation: Fertility institute should give advice or arrange pretreatment for national or international couples to cut down their stay.
Mode of payment: Fertility institute should have facility to accept credit card, bank transfer & wire transfer for payment.
Information of procedure: Couple undergoing fertility treatment should know about their treatment procedure.
Facilities of the centre: The centre should have all the facilities like hormone lab, pathological lab, ultrasound scan, operation theater to conduct minor to major infertility correction procedures, IVF lab, IUI, etc.
Working environment: Fertility center should have co-operative environment.
Experience & expertise: Knowledge and expertise of fertility centre matters a lot .
Emergency services: Fertility center should offer 24/7 contacts or any emergency services.
Success rate: Success rate of fertility center is a major part to consider that centre for treatment.
There should be easy access to primary fertility specialist.
In simple words infertility is defined as the inability to conceive. And this is the reason, it requires thorough diagnosis of both the partners. Once, this malady is diagnosed, there is every possibility that it could be treated successfully.
However, there are other factors as well like age, general health etc., that may affect the success of treatment.
At the same time, with technological advancements in the field of surgery and/or assisted reproductive technologies (ART), such as in vitro fertilization (IVF), majority of infertility cases can be treated successfully.
Infertility in women
The common cause of Infertility in women is disruption of ovulation symphony by disturbances in menstrual cycle. Instead of a regular cycle, the women suffering from infertility undergo irregular cycles. In the wake of this, menstrual history is considered to be the first instance of infertility, which one should seriously take care of and immediately consult the doctor.
The Menstrual Pattern is the simplest screening test to guide medical investigations.
The regular menstrual period: In this category, the periods are regular from month to month, beginning like clockwork every twenty-five days or every thirty-five days. The consistently irregular menstrual cycle, where one month you begin menstruating after twenty-five days, the next month after thirty-four, and the next in thirty, may indicate that you have fertility problem.
Irregular menstrual periods or Amenorrhea for six or more months: Irregular periods aren’t unusual, they affect about 30% of women in their reproductive years. The woman’s menstrual periods occur infrequently and at unpredictable intervals. Even in some of the cases, the menstruation at a period of time, may suddenly stop altogether.
Nonexistence of the menstrual period: If a women does not have menstruate even after the age of 16 years, which is considered to be the maximum limit to start menstruating, it is considered to be a serious condition. The cause of such conditions may include genetic abnormalities, congenitally deformed reproductive organs, delayed puberty, or a pituitary malfunction.
What is Ovulation?
Ovulation is the process in the menstrual cycle by which a mature ovarian follicle ruptures and discharges an ovum (also known as an oocyte, female gamete, or casually, an egg) that participates in reproduction. The entire process of ovulation is controlled by the hypothalamus of the brain and through the release of hormones secreted in the anterior lobe of the pituitary gland, Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH). A spike in the amount of FSH triggers ovulation and LH is released from the pituitary gland.
Causes of Infertility
There are various conditions that may cause infertility in the women. These conditions include the following:
It is a common medical condition in which the endometrial tissue, the tissue that normally lines the uterus, grows outside the uterus and attaches to other organs in the abdominal cavity such as the ovaries and fallopian tubes. Endometriosis is a progressive disease that tends to get worse over time and can reoccur after treatment.
The most common symptom of endometriosis is pelvic pain. The pain often correlates to the menstrual cycle, but a woman with endometriosis may also experience pain that doesn’t correlate to her cycle. The other symptoms include abnormal menstrual bleeding and pain during or after sexual intercourse. Endometriosis can also cause scar tissue and adhesions to develop, that can distort a woman’s internal anatomy.
A laparoscopy, an outpatient surgical procedure, is necessary to confirm a diagnosis of endometriosis after a medical history review and pelvic exam. After the diagnosis, our physician will classify your condition as stage 1 (minimal), stage 2 (mild), stage 3 (moderate) or stage 4 (extensive). Based on the stage of the Endometriosis, the physician may decide the best treatment plan.
Polycystic ovary syndrome (PCOS)
Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality that affects six to ten percent of women, who are in the reproductive age group. PCOS is a leading cause of infertility and also affects the woman’s cardiovascular health. The causes of PCOS are unknown. Researchers believe that the causes of PCOS may be insulin resistance and an imbalance of female hormones (estrogens and progestins, those important for the menstrual cycle) contribute to the development of this condition.
The symptoms of the disorder include acne, difficulty becoming pregnant (infertility), irregular menstrual periods, obesity, skin discolorations and unwanted hair growth or loss.
New medical researches have revealed different methods of treatment including insulin-reducing ovulation medication (clomiphene, glucophage, metformin), dietary changes (low glycemic diet) and surgery (ovarian drilling). Women who undergo treatment for PCOS, but are still unable to conceive naturally, often turn to assisted reproductive technologies such as IVF.
One of the more common causes of infertility is – blocked or damaged fallopian tubes. The fallopian tubes are necessary for picking up the egg, released from the ovary. It is in the inside of the fallopian tube that natural fertilization occurs. Scar tissue resulting from endometriosis or abdominal or gynecological surgery, such as bowel surgery, cesarean section or a ruptured appendix, can block an egg from entering or traveling down the fallopian tube to meet the sperm, preventing fertilization.
Such condition may cause infections including chlamydia, can damage the cilia, the tiny hairs lining the fallopian tubes that help transport the egg, often preventing the sperm and egg from meeting. One result of damaged cilia is an ectopic pregnancy, which occurs when an egg is fertilized but, due to the damaged cilia, it is unable to travel to the uterus, growing instead in the wall of the fallopian tube. This condition can result in rupture, internal bleeding and further tubal damage.
The physician reviews the complete history and does a complete pelvic exam to diagnose the tubal disorder. For the confirmatory diagnosis, additional tests such as hysterosalpingogram and laparoscopy are required and the exact course of treatment is decided on the basis of the condition.
In about one –third of the couples despite an extensive battery of tests, we are unable to find the cause. These couples are termed to be suffering from ‘unexplained ‘ infertility. Perhaps there is a problem with sperm –egg interaction. These couples may benefit from superovulation and IUI or IVF.
Infertility in men
In men, infertility generally is caused by a lack of sperm in the semen (azoospermia), deformed or structurally abnormal sperm, sperm that lack the ability to reach and fertilize a female egg (immotile sperm). Genetic, infection, testicular trauma, hormonal imbalance or exposure to radiation and certain medications are all causes of sperm production disorders.
Infertility normally occurs when there is a low sperm count, or problems with the motility (movement) or morphology (appearance or shape) of the sperm. Sperms that have poor motility, are often not able to reach the egg and therefore, fertilization does not occur. Abnormal sperms are sometimes unable to penetrate and fertilize the egg. Sperm DNA damage may interfere with conception as well as lead to a greater risk of miscarriage.
Any structural or anatomical problem that may block the path of sperm can cause infertility, by preventing fertilization to occur. Infertility related to structural and anatomical problems in the male anatomy may be caused by scar tissue, varicose veins or infection or, in some cases, the problems exist from birth.
In few cases, the immune system of the men develop antibodies that may attack the sperm and destroy their ability to fertilize the egg. Antibodies bind to specific parts of the sperm, such as the head or tail and, depending on the site of attachment and interfere with the movement of the sperm.
Q. If I conceive, will my baby be normal?
A. Studies have shown that there is no increased risk of abnormality in IVF conceived babies compared to those conceived naturally.
Q. What are the precautions I should take after the IVF procedure?
A. The procedure demands no special precautions, but avoid strenous activity. We advise the patients to be mentally & physically relaxed as much as possible. You can return to work if you wish, but fist prefer to have a few days rest.
Q. What if IVF fails the first time? How many times will I have to undergo the same procedure?
A. You can go through IVF as many times as you wish, but we advise up to five cycles at the most.
Q. Is IVF the last option?
A. IVF is the option, which has highest success rate and is also the most expensive. But, it is not “end of the road”. Many women have conceived naturally or with intrauterine insemination, even after IVF. However, for those with blocked tubes & very poor sperm counts, it is only option.
Q. Is IVF very expensive?
A. IVF is not as expensive as percieved in general. Generally, the cost of IVF cycle depends upon the dose of drugs that would be needed for ovarian stimulation. It is only as expensive as perhaps gall stone removal or removal of uterus surgery.
Q. Do we need to get admitted in the IVF process?
A. A patient undergoing IVF does not require admission. However, one should visit the center 3-5 times during monitoring cycle. On the day of egg collection, the patient would need to fast for 6 hours & come to clinic (the procedure takes about half an hour). Patients can go home after the effect of anaesthesia weans off which takes about 2-3 hours. The next scheduled visit is after 2-3 days for the embryo transfer, which again takes about half an hour and patients are free to go home after resting for one hour.