As NATIONAL FERTILITY RESEARCH FOUNDATION, SURAT. The center is staffed by specially trained personnel including gynaecologists, embryologists, laboratory technologists and nurses. As an established GUJARAT INSTITUTE FOR RESEARCH IN REPRODUCTIN, it has to its credit the first IVF, first egg donation, first embryo donation babies of Gujarat.

TREATEMNT AVAILABLE AT THE IVF CENTRE: -

1. In Vitro Fertilization and Embryo Transfer (IVF-ET)
2. Gift (Gamete Intrafallopian Transfer) - A procedure where sperm & eggs are mixed and directly transferred into intact functioning fallopian tubes.
3. ZIFT (Zygote Intrafallopian Transfer) - A procedure where embryo is transferred into functioning, patent fallopian tubes.
4. Egg donation program particularly for elderly women and women whose ovaries are not functioning.
5. Artificial insemination - In particular intrauterine insemination (IUI) where washed live motile sperms are deposited in the womb to facilitate their passage into the fallopian tubes. The use of donor sperm may be considered in some instances.
6. Fertility evaluation and counseling regarding all aspects of infertility treatment inclusive of hormonal, seminal and laparoscopic assessment.
7. Sperm and embryo freezing. (Cryopreservation)
8. Micro manipulation - Directly injecting single sperm into an egg.

With proven track - record of success, this is the most experienced unit in Gujarat with highest number of conception. With over 350 test tube babies by IVF-ICSI, over 1500 babies with IUI itself in last 5 years.

PREGNANCY IN NATURAL CYCLES:
In the middle of menstrual cycle an egg is released from the ovary. The egg is captured by the fallopian tube. If sexual intercourse occurs, sperms may penetrate egg. The fertilized egg, now becomes an embryo, travel down the fallopian tube towards the uterus and implants into the wall of the uterus thus initiating a pregnancy.

IN VITRO FERTILIZATION / EMBRYO TRANSFER (IVF/ET)
IVF is a technological process where several eggs are retrieved from a woman's ovaries and then fertilized by the husband's sperm outside of the body in the controlled environment of the laboratory. The fertilized egg then develops into embryos, which are redeposit into the woman's uterus, by the procedure of embryo transfer.

COUPLES WHO CAN BENEFIT THROUGH IVF:

1. Both fallopian tubes are absent, blocked or irreparably diseased.
2. The husband has a reduced sperm count (oligo-asthenoteratoozospermia).
3. Sperm antibodies in the wife's and/or husband's serum.
4. Endometriosis, which is the presence of the lining of the womb outside the uterus.
5. Unexplained infertility when couples in whom no obvious pathology is found but who still cannot conceive.
6. IVF also helps women who either lack ovaries or have no eggs in the ovaries, provided any young member of the family with proven fertility is willing to donate her oocytes.

ELIGIBILITY:

1. The couple must be legally married.
2. The wife must be between the age of 18 and 40 years in a conventional IVF program.

IVF/ET PROGRAM (STEP-BY-STEP)

Initial Consultation & Evaluation:

The couple should bring along their previous records of infertility workup such as hysterosalpingogram films, semen analysis reports, basal body temperature chart, previous laparoscopy test results. The IVF team physician will counsel the couple about the program and some further investigation may be necessary to establish the chances of success. The woman may have to be scheduled for a screening laparoscopy, hysterocopy and ultrasonography, if needed to assess the pelvic anatomy and accessibility of the ovaries for egg retrieval.

1. Hormonal Stimulation:
The woman is taken into the program on the 20th day of her previous cycle. Medication is given to the patient during the early phase of her next cycle to increase the likelihood of developing more than one egg to increase the chances of her getting pregnant sine not all eggs make babies.

2. Monitoring The Maturity of Eggs:
Blood tests are drawn frequently towards the middle of the patients cycle to determine the progress of the stimulated ovaries. Ultrasound examinations are conducted several times to visualize the developing follicles. The size of the follicles, development of lining of womb and result of the blood tests will determine the time of egg collection.

3. Egg Collection:
Eggs are retrieved transvaginally by needle aspiration, guided by ultrasonic imaging. This requires local/general anesthesia. The eggs thus obtained are placed immediately into the culture dish that contains a special nourishing fluid The patient can leave the IVF laboratory within 4 hours of egg retrieval.

4. Semen Specimen Collection:
Semen specimen is collected by masturbation within a couple of hours of collection of the eggs. The live sperm cells are separated from the seminal fluid, mixed with the eggs and are then placed in an incubator till such time, as the eggs are ready to be fertilized.

5. Fertilization and Cleavage:
Fertilization is the process of a sperm penetrating the egg. The eggs once fertilized are called embryos. These are observed further to be certain that they are dividing (cleaving) normally.

6. Embryo Transfer:
This is done 48 hours after following egg collection. The embryos are placed into the uterus by means of a thin tube (catheter) through the mouth of the womb. The procedure is done on an outpatient basis. The patient leaves the IVF centre 4-6 hours following the transfer procedure. Patients are advised to take Progesterone injections and some rest for a week after embryo transfer.

7. Blood Tests:
Blood tests are performed for evidence of pregnancy approximately 11 days & 16 days following embryo replacement.

8. Causes for cancellation in a treatment cycle prior to operation:
The aim of the intensive monitoring programme is to obtain healthy, mature eggs at sonography. Thus if the cycle is unsatisfactory, if may be cancelled at any stage. The reasons for this are:

(i) The follicles are developing in a inaccessible ovary.
(ii) Too few follicles are developing which would decrease the chance of obtaining at lest once mature egg.
(iii) There are no follicles developing at all. This is rare but may occur.
(iv) The blood oestrogen levels are abnormal. These may be too low for the development of healthy eggs or according to the patterns seen over the last 18 months, unlikely to lead to pregnancy.
(v) The follicles may have ovulated prior to sonography. Occasionally some women ovulate earlier than expected or ovulate without our being able to detect the time when ovulation commenced. Thus it is impossible to accurately predict when operation should be performed.
(vi) Sometimes ovarian cysts develop in response to the drugs. These are not serious or harmful. They usually resolve within one month or may require to be aspirated before starting the stimulation.

CENTER FOR REPRODUCTIVIE MEDICINE

In the normal situation sperm are produced in the testes and then pass through a series of tubules called the epididymis where they collect and are concentrated before ejaculation. As they travel to this point the sperm mature and gain their ability to swim and fertilise an egg.

Why is sperm recovery necessary?

Some men are able to produce sperm in their testicles but for a number of reasons these sperm are notpresent in the ejaculate. This may be because a blockage is stopping the sperm from passing through the tubules. It may also be because sperm are produced in such low numbers in the testes that they are lost within the tubules before they are ejaculated. A blockage in the tubules may have been caused naturally or may have been surgically, e.g., vasectomy.

For these men sperm can be recovered from the tubules behind the blockage or from the testes themselves.

Are recovered sperm normal?

Sperm recovered from the epididymis will be very similar to those that are ejaculated, except that they will be immature and therefore unlikely to be able to fertilise an egg at IVF. Sperm recovered from the testes will be even less mature than those recovered from the epididymis and so will also not be capable of fertilising an egg at IVF.

What is the best way to use these sperm for treatment?

Intracytoplasmic Sperm Injection (ICSI) offers the best chance of gaining fertilisation with these immature sperm. Please see the relevant ICSI information sheets.

How will I know if I need sperm recovery?

A semen analysis showing the presence of no sperm at all (Azoospermia) will indicate that further tests should be carried out to determine whether sperm recovery is an option. These tests will include a blood test to check your hormone levels, an examination of your testes and a blood test to see if you have any genetic problems. If these tests are inconclusive you may also require a testicular biopsy which would determine whether sperm production is occurring in your testes.

What dose sperm recovery involve?

There are a number of sperm recovery techniques available:

Microepididymal Sperm Aspiration (MESA)
Percutaneous Epididymal Sperm Aspiration (PESA)
Testicular Sperm Aspiration (TESA)
Testicular Sperm Extraction (TESE)

The treatment most suitable for you will depend on your medical history and this will be disussed with you during your consultation.

MESA - This technique involves the recovery of sperm from epididymis. The scrotal sac is opened to expose the epididymis. A fine needle is then passed into the epididymis to collect sperm. Once sperm have been recovered the opening in the scrotal sac is closed. This method is not used frequently because of the need to open up the scrotal sac.

PESA - This technique involves the recovery of sperm from the epididymis. A fine needle is passed through the skin of the scrotum and into th eepididymis to collect sperm. This method is preferred to MESA as it does not involve opening the scrotal sac.

TESA - IF PESA is unsuccessful or not possible sperm recovery will be attempted from the testes. This technique involves a fine needle being passed throug the skin of the scrotum into the testicular tissue. A small piece of testicular tissue is then aspirated. This procedure may be repeated at a number of different sites on the testis to ensure enough sperm are recovered.

TESE - If sperm cannot be recovered by PESA or TESA this technique will be used. This involves a small incision in the scrotal sac to expose the testicular tissue. A small piece of this tissue will be removed and sperm extracted from it. Once the sperm collection is complete the incision in the skin is closed with absorbable stitches.

How do I Prepare for the operation?

You will be asked to shave your testicles the night before the operation. You will also need to not eat anything from midnight and drink anything from 7 am on the day the operation.

What anaesthetic?

For PESA and TESA you will be given a local anesthetic and sedation during the procedure. For TESE a general anaesthetic is required.

Recovering after the operation.

If you have had a local anaesthetic with sedation you will be allowed home a couple of hours after the operation. You will not be allowed to drive or work for 24 hours, so you will need to arrange transport home after the operatin. You may have some bruising, minor swelling and discomfort for a few days after the operation.

When will the recovery occur in relation to the ICSI cycle?

Sperm recovery is usually carried out partner taking her drugs to get started on an ICSI cycle. This means that we can be sure we have sperm stored before the ICSI cycle is stated.

Occasionally the sperm recovery may be lined up to coincide with the day of the egg collection in the ICSI cycle. This may be the case if we think that the recovered sperm will not survive the storage process. This is unusual and you would be informed if this is to be the case.

Sperm storage.

Sperm are stored in Liquid at 196C until required. Please see the patient information sheet entitled. "Storage of Sperm after Recovery from the Epididymis or Testes". Prior to the day of sperm recovery you will be asked to come and be a member of the andrology staff to be informed with regard to sperm storage.

ITHE CHANCES OF SUCCESS IN IVF/ET

Currently the success rate per oocyte retrieval cycle is 25-27% at our center. The patients are advised to be mentally prepared to avoid bitter disappointments and depression in case the procedure fails. However the chance of pregnancy is 60-70% within 3-4 attempts of IVF. The patient can try another cycle of IVF after a break or immediately utilize the next cycle. As IVF/ET today is done for various indications, patient can conceive spontaneously after failed IVF cycle. If more than required embryos develop in an IVF cycle, I have facilities to freeze the embryos which can be used in subsequent cycle for successful outcome.

WILL YOU GET AN ABNORMAL BABY FROM IVF?

More than five lakhs fifty thousand IVF babies have been born to date. The congenital abnormality rate has proven to be the same, if not slightly lower than the normal population.

WHAT ARE THE OTHER RISKS IN IVF:

1. The stimulated cycle is very carefully monitored. However in any cycle there is a small risk of hyper stimulation, which may result in an enlargement of the ovaries. In this event, conservative treatment usually results in total resolution of the cysts.
2. Chances of multiple pregnancies are 30%, hence once should be prepared to accept twins and triplets.
3. Pregnancies following IVF-ET have higher miscarriage rate than normal.

EXPENSES:

At present the fees for controlled stimulation, monitoring the cycle, oocyte recovery, fertilization of oocytes in the IVF laboratory and embryo transfer is Rs.15,000/- in addition the couple has to spend approximately Rs.40,000/- to Rs.50,000/- as expenses for fertility drugs, blood assays, ultra sonography examination & anesthesia charges etc. The total cost of each patient varies depending upon the number of injections and cost of tests required.

TREATMENT TIME:

The patient is required to follow up in for 6 weeks and the husband is required for 2 days at the time of egg pickup provided the preliminary investigations for both husband and wife has been done. This time can be reduced to around 3 weeks in exceptional circumstances.

THE PRELIMINARY INVESTIGATIONS REQUIRED:

For Wife
1. Hysteroscopy/diagnostic laparoscopy and measurement of uterocervical length.
2. Ultrasound examination of uterus and ovaries. To exclude uterine pathology and cysts in ovaries.
3. Hormonal profiles (TSH, Prolactin, FSH & LH on 3rd day of the period)
4. CBC, ESR, Blood VDRL, Blood Sugar PP, Blood group RH factor, Australia Antigen/HIV, Bleeding time and Clotting time, X-Ray Chest.

For Husband:
1. Semen analysis
2. Semen culture and antibiotic sensitivity test.
3. Antisperm antibody test for husband and wife.
4. Sperm survival test, semen harvesting & sperm function test.
5. Blood for Australia Antigen & HIV Antibodies.

A WORD ABOUT PUBLICITY:

The ovulation and pregnancy process tend to be fickle and are easily disrupted by stresses of various kinds. Therefore from a medical point of view it seems appropriate that our patients be shielded from contact with news media during this period and we request that participants in the programme refrain from granting interviews till the baby is born. Also, while we welcome the dissemination of information to public on the subject of In Vitro Fertilization we feel that their information should be general and should not refer to the particular medical situation of individual patients who are undergoing therapy. Therapy while it is in process is generally considered a private matter between patient and physician and most patients themselves do not consider the details to be suitable for wider dissemination.