When facing infertility, dwelling on causes often leads to blame and guilt, taking away some of the strength a couple needs to face their situation together. Although it is important to know the factors impeding their goal of conceiving, it is also important for them to take positive action together, by exploring options and forms of treatment that are available.
For some couples, all that is needed is advice or a simple approach such as Ovulation Induction or IUI. For others high-level technology, such as In Vitro Fertilisation (IVF), may be needed.
If you have been trying to conceive for 12 months or more (6 months if you are 35 years and over), we encourage you to seek advice from a fertility specialist rather than a gynecologist.
How to Start Fertility Treatment
Before commencing fertility treatment at Gargash IVF there are several preliminary steps that you should undertake in preparation.
1. Initial Fertility Specialist Appointment
The first step is to organize an appointment with a Gargash IVF Fertility Specialist who will review your medical history, organize initial investigations and discuss treatment options with you.
Routine Investigations:
Depending on the level of testing performed by your referring GP or gynaecologist/obstetrician, your fertility specialist may order further tests for evaluation including:
For Wife:
· Rubella immunity (German measles)
· HIV Status
· Hepatitis B and C
· Pap smear (within last 2 years)
· Base line Hormonal Profile – Day 3 FSH, LH, Prolactin, TSH and if needed AMH
· Base line Pelvic Ultrasound
For Husband
· HIV Status
· Hepatitis B and C
· Semen analysis at specialist andrology laboratory (within 12 months)
Your Fertility Specialist may also require that you attend a follow up appointment to review the results of these tests and explain in detail your recommend treatment plan.
New Patient Initial Appointments
Commencing Investigations
At your initial appointment with a Fertility Specialist, your medical history and any preliminary tests that have been carried out with your GP or referring gynecologist/physician will be reviewed. Further investigations may or may not be necessary. Your fertility specialist will recommend a treatment plan based on the outcomes of these tests if they are sufficient enough for your future treatment.
Infertility is a shared concern, but most often it is forgotten and concentration will be completely focused on the female partner only. Wherever the problem may reside, so it is always mandatory that both partners attend this appointment together and undergo routine screening blood tests and investigations together. For male partner, the first line of investigation is a semen analysis. For female partner, the first step is to check ovulation through a blood test,(although further investigations may be necessary to evaluate the tubes, ovaries and uterus).
The cause of infertility may be attributed to "female factors" such as tubal disease, ovulatory dysfunctions, or endometriosis, in approximately 40% of cases and to sperm problems, so called male factor in another 40% of cases. Or it can be "unexplained" in 15-20% of cases. In about 33% of couples with infertility, there will be more than one problem may be present or multiple problems can be in both partners.
Investigations for Male Partner
The semen analysis is the most important test in the evaluation of the male. The test gives an accurate measurement of the number of sperm (stated in millions per ml), the motility (swimming capacity)of the sperm cells,the morphology ( the size and shape of the sperm cells), the volume and consistency of the ejaculate. The examination should be performed on a fresh specimen within two hours of collection in a sterile container. It is obtained by masturbation and the entire ejaculate should be collected. We prefer to relay on a semen analysis done in a specialist andrology laboratory according to the WHO guidelines. This is very important because the decision for specific treatment will be decided based on the semen parameters and will in turn decide the success of your treatment.
It is important for IVF purposes to have the percentage of normal morphology (shape) accurately assessed by experienced andrology scientist who is specialised in sperm analysis. It is desirable wherever possible for these tests to be performed at Gargash IVF andrology laboratory, where more extensive testing of semen for sperm antibodies or for penetration defects and sperm preparation along with the assessment of total motile count (number of total sperm with swimming capacity)may also be performed which is needed for the further evaluation of semen and these extensive testing is not usually not performed in the ordinary laboratories.
Whenever abnormalities are found on semen analysis, repeat tests are often required to assess the type and degree of the problem found, and if it is a persistent feature.
Diagnosis of causes of male factor infertility may require blood tests for the hormones like FSH, LH and testosterone, which play a role in the development and maturation of sperm, and a referral to an Andrologist (a specialist in male reproductive disorders), may be made if certain male problems are found. A karyotype (chromosome analysis) and other tests like assessment of Y chromosome microdeletions may be ordered if the sperm count is very low or zero. Also evaluation of the hormonal profile including the thyroid function& serum prolactin also may be required whenever the sperm counts are very low or completely absent.
Investigations for Female Partner
Initial Investigations
The first step in investigating a woman’s fertility is to establish whether or not she is ovulating (producing an egg) every month regularly. This can be determined through a variety of tests including blood tests, ultrasounds and urine testing kits, but blood tests are more commonly used because of ease of perfoming the tests & reliability of blood tests. Ultrasound scanning can be used to check the condition of the endometrium (the lining of the womb) and help diagnose any polyps and fibroids (growth inside & outside the uterus). Ultrasound scan is very reliable in assessing the abnormalities of the ovaries as well. Conditions like Functional Ovarian Cysts (fluid collection inside the ovary), endometriotic cysts and hydrosalpinx (dilated damaged tube with fluid secondary to pelvic infections). To a certain degree ultrasound can also tell us about the adhesions inside the pelvis.
Diagnosis of Ovulation
Two hormones which are produced from the pituitary gland responsible for the development of eggs within the ovary: Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH). The cells in the follicle (growing egg within the ovary) also produce oestrogen and progesterone hormones. The rise and fall of these hormones depend on the stage of a woman’s cycle.
Ovulation can normally be confirmed by blood tests (either LH or Progesterone hormone) that measure the levels at certain specific stages of your menstrual cycle. Also, a transvaginal ultrasound scan can be used to visualise the follicles within the ovary and measure their size. This way, the stage of follicle development can be assessed. Serial ultrasound monitoring of growing follicles and its rupture with disappearance of follicle and collection of fluid inside the tummy can also predict ovulation.
Depending on the each patient's individual circumstances, other investigations that may be recommended to assess the fertility status include:
Sonosalpigogram (SSG) and hysterosalpingogram(HSG)
This is a non-invasive test, which gives some valuable information about the anatomy of the uterine cavity and the patency of the tubes. This involves an ultrasound with the concurrent speculum examination, and insertion of a tiny tube into the cervix to pass dye through the uterine cavity and tubes.
A similar technique using Xray technology may also be used to assess the uterus & tubes. It is called a hysterosalpingogram (HSG). These techniques are often performed as alternative to a laparoscopy and hysteroscopy which are invasive and costly investigation. This also will tell us about the anatomy of uterus and tubes with patency of tubes.
Diagnostic laparoscopy and hysteroscopy
These tests are very important part of the evaluation of many couples. It is generally reserved for the end of the evaluation process as it is a more invasive procedure because it needs anesthesia and one day admission to the hospital.
Laparoscopy is done under general anaesthesia with small incisions made at the umbilicus and sides of the pubic hairline. A laparoscope (a fibreoptic telescope with a light source) is passed through the umbilical incision and the ovaries, fallopian tubes, uterus and pelvic cavity can be visualized for any abnormal findings. Tubal patency can be checked by injecting dye through the uterus and observing it spill through the fimbrial lateral ends of the fallopian tubes. If any abnormalities are noted during the evaluation that can be corrected in the same sitting.
Hysteroscopy may also be performed, either along with laparoscopy or sometimes alone using another fibreoptic device called a hysteroscope. It provides direct visualization of the uterine cavity for growths, adhesions and abnormal anatomy and abnormal appearance or damage of womb lining. Hysteroscopy can be a diagnostic one if we are just observing and coming back without any interventions inside the uterus, but any kind of intervention or surgery is done inside the uterus then it is called operative hysteroscopy. Almost all inner abnormalities of uterus can be corrected using a hysteroscope. Usually hysteroscopy & laparoscopy are day care procedures and after few hours of surgery you will be able to leave the hospital.
Laparoscopy can be avoided in couples where the need for IVF is obvious from the history or analysis of test results. Your fertility specialist will explain to you in detail regarding the necessity of each investigation they have asked for and how it is going to improve the success of your treatment.
IVF Counselor & Counseling Sessions:
As part of the preparation for IVF treatment, it is better a couple to meet with a counselor to discuss treatment options and various aspects of IVF before their first cycle. Most couples find these sessions useful and informative. Consent forms must be signed with the counselor before starting treatment. Counselor will also clarify your doubts regarding the cost of the treatment, treatment protocols, complications, adverse effects if any and also outcome of the treatment.
Couples with infertility problems and those who are undergoing treatment may have faced many frustrations, disappointments and investigations before, during and after IVF treatment. Once started, IVF treatment can also be physically and emotionally challenging, and certainly waiting for results can be too stressful. Each and every couple has difficulty coping with this stress from time to time, so you can contact our counselor if you need to discuss your situation or explore ways of coping that particular situation. This will certainly help you to ease out the stress and a low level of stress and relaxed mind will help you in achieving success in your treatment. Our counselor is available throughout the different stages of your treatment. Counseling sessions can be attended with prior appointment, but in case of emergency you can make a walk in appointment with counselor if slots are available for sessions. Let us know if we can help, even if it is at short notice we will try our level best because here we believe in making relations and long term bonding along with helping the couple to achieve pregnancy.
New Patient Session with Reproductive Care Nurse
An initial appointment with the reproductive care nurse is also required and we recommend that you make this visit for session with reproductive care nurse about a week before you expect your period. During this session, an IVF cycle (with any specific treatment protocol decided by the fertility specialist) will be explained in detail, like about medications & their duration of intake , injection techniques will be taught, medications discussed and given to you to take home if needed. Patients who are wishing to make an appointment to see the nurses and the counselor on the same day before the start of the treatment cycle can do that but both appointments will be provided only if it is feasible during the busy clinic schedule.
Panoramic View of Infertility Treatment
After the initial evaluation, your fertility specialist will recommend, based on your medical history and results of initial testing, a treatment plan to that will provide the best outcome to suit your individual problems. Whenever possible, Gargash IVF aim to begin with the least invasive and least costly option first, before moving onto more advanced treatments such as IVF or ICSI. But certain couples we may suggest IVF or ICSI as the first line of treatment because though invasive & costly this will optimize their success of becoming pregnant and sticking on to other less invasive treatments will be futile and waste of time and money for them.
The usual types of treatment offered at Gargash IVF is outlined below.
Initial Simple Treatment Protocol
Ovulation Induction (OI):
Ovulation induction is used when a woman is either producing her eggs very irregularly, or is not ovulating at all. Treatment involves taking hormone stimulating medication (normally oral) or hormonal injections in very low dose or a combined approach using oral medications and injections from the initial days of a new cycle and then monitoring the growth of eggs in the ovary using a vaginal ultrasound tracking. Once the egg reaches proper size you may be given injection to rupture the follicle and to aid ovulation at a proper time. Then following few days you will be advised to have sexual intercourse to maximise the chance of conception. You may also be prescribed the pregnancy support medications in the later part of the cycle till pregnancy test.
Intrauterine insemination (IUI):
IUI is commonly used to treat women who have normal healthy Fallopian tubes and when more complex treatments are not yet indicated. Usually IUI is advised for patients with mild male factor problems, ovulatory dysfunction not responded to OI treatment, Mild endometriosis, un explained infertility, cervical factor infertility and sexual dysfuncions. Treatment involves placing partner's concentrated sperm inside the womb near the time of ovulation after stimulating the ovaries with hormonal medications followed by follicular tracking. It can also be performed in a natural cycle with monitoring of follicular growth. Usually you can try 3-4 cycles of IUI treatment and a maximum of 6 attempts, if not working out should change over to IVF or ICSI tratement.
Advanced Techniques
In Vitro Fertilisation (IVF):
Mature eggs are collected from the ovary through vagina under ultrasound guidance after ovarian stimulation, mixed with sperm collected from the male partner in the incubator in the laboratory, and later two or three of the resulting embryos are transferred
to the uterus after 2 days, 3 days or 5 days of incubation inside the laboratory.
Intracytoplasmic Sperm Injection (ICSI):
The treatment process is the same as IVF but a little bit more complicated. With ICSI, a single sperm is injected directly into the egg to achieve fertilization under the microscope manually by embryologist. ICSI is the treatment option when the number of sperm and eggs are less. With advent of ICSI even azoospermic men (total absence of sperm in the ejaculate) can father the pregnancy after collecting sperm through PESA/TESA
Surgical Treatment of Infertility
After initial assessment, surgery may be recommended to either investigate the cause of infertility for either partner, or to overcome factors influencing their ability to conceive.
FEMALE FERTILITY SURGERY
Diagnostic laparoscopy and hysteroscopy
These tests are very important part of the evaluation of many couples. It is generally reserved for the end of the evaluation process as it is a more invasive procedure because it needs anesthesia and one day admission to the hospital.
Laparoscopy is done under general anaesthesia with small incisions made at the umbilicus and sides of the pubic hairline. A laparoscope (a fibreoptic telescope with a light source) is passed through the umbilical incision and the ovaries, fallopian tubes, uterus and pelvic cavity can be visualized for any abnormal findings. Tubal patency can be checked by injecting dye through the uterus and observing it spill through the fimbrial lateral ends of the fallopian tubes. If any abnormalities are noted during the evaluation that can be corrected in the same sitting.
Hysteroscopy may also be performed, either along with laparoscopy or sometimes alone using another fibreoptic device called a hysteroscope. It provides direct visualization of the uterine cavity for growths, adhesions and abnormal anatomy and abnormal appearance or damage of womb lining. Hysteroscopy can be a diagnostic one if we are just observing and coming back without any interventions inside the uterus, but any kind of intervention or surgery is done inside the uterus then it is called operative hysteroscopy. Almost all inner abnormalities of uterus can be corrected using a hysteroscope. Usually hysteroscopy & laparoscopy are day care procedures and after few hours of surgery you will be able to leave the hospital.
Laparoscopy can be avoided in couples where the need for IVF is obvious from the history or analysis of test results. Your fertility specialist will explain to you in detail regarding the necessity of each investigation they have asked for and how it is going to improve the success of your treatment.
But in this era of ART the importance of laparoscopy is becoming less in the field of fertility treatment. But still laparoscopy has a role in the management of fertility problems. In certain cases of tubal problems and post sterilization cases laparoscopic surgery can be used to reverse the fertility capacity. Laparoscopy will help in removal of fibroids also.
Endometriosis
Endometriosis is a condition in which endometrial cells (those lining the uterus) grow in places outside the uterus. It may cause symptoms such as painful periods, pain during intercourse, premenstrual spotting and/or infertility.
If your fertility specialist suspects you to have endometriosis, a laparoscopy may be recommended to confirm this diagnosis. Treatment depends, in part, on the extent of the disease, and may involve surgical removal of the endometriosis and associated scar tissue at the time of laparoscopy, or hormone treatment to suppress the menstrual cycle and inhibit the growth of endometriosis.
Where treatment for endometriosis has not resulted in successful pregnancy, IVF may be an appropriate treatment option.
Tubal Surgery
The diagnosis of tubal damage will usually have been made at laparoscopy.
The presence of tubal pathology may reduce the success rate with IVF treatment and your doctor may recommend you have it treated prior to starting treatment.
In some cases, surgery to remove scar tissue (adhesiolysis) or to correct tubal damage (eg tubal anastomosis) will be recommended. Some types of tubal surgery may be performed through the laparoscope (adhesiolysis, salpingolysis), while other procedures (such as tubal anastomosis) may require an "open" operation using the operating microscope, known as microsurgery.
Where surgery has not resulted in successful pregnancy, or where damage to the tubes and other pelvic organs has been so severe as to make surgery unlikely to be successful, IVF becomes the treatment option with the best chance of success.
Surgical Sperm Retrieval Techniques
PESA (PER CUTANEOUS EPIDIDYMAL SPERM ASPIRATION)
This procedure is performed when there is a block in or above both sides of the epididymis (the part of male genital tract where sperm are stored). PESA is a day care procedure and can be done under IV sedation or local anesthesia. If the male infertility is due to blockade at or above the level of epididymis there is high chance of getting good quality mature sperm after this procedure. Sperm obtained can be used for ICSI treatment and excess amount of sperm can stored by freezing and can be utilized later also.
TESA (TESTICULAR SPERM ASPIRATION)
This method of sperm collection is used for patients who have impaired sperm production from the testis without any block in the genital tract. It is also a day care procedure and can be performed either under IV sedation or local anesthesia. Chance of getting good quality sperm after TESA will depend on the extend of impairment of sperm production in the testes. Good quality sperm obtained can be used for ICSI and excess sperm can be stored by freezing to use it for later treatment.
TESE (TESTICULAR SPERM EXTRACTION)
TESE is more invasive procedure compared to TESA and PESA. This requires an open incision and then removing a chunk of testicular tissue (testicular biopsy). Usually performed when TESA is failed to give adequate amount of viable normal sperm. The complications associated with this procedure are bleeding and haematoma formation. This usually performed under IV sedation or GA. Usually this procedure also a day care procedure and patient can go home on the same day after few hours of procedure if there are no complications. Here also if excess amount of sperm retrieved can be stored by freezing for later use.
Ovulation Induction
Clomiphene citrate (Clomid) or Letrozole (femara) and hormone preparations of follicle stimulating hormone (FSH) may be used to encourage the development of one or more follicles and thus more than one egg, during the woman's cycle. This process is known as Ovulation Induction if the woman is not ovulating or irregularly ovulating, or super-ovulation or ovarian hyperstimulation if she is already ovulating without treatment.
Clomiphene or Letrozole tablets may be used in conjunction with timed intercourse, or artificial insemination, to ensure that the sperm are introduced at the right time inside the female genital tract. The cycle is monitored more closely than a natural cycle with vaginal ultrasounds and/or urine tests to check follicle development and observe hormone levels. Human chorionic gonadotropin, known as hCG is the hormone may be used in injection form to trigger the process of ovulation.
Fertility drugs are generally used for women who have an ovulation disorder due to hormonal imbalances. There is little scientific evidence that they increase fertility rates in women who are already ovulating.
Intra-Uterine Insemination (IUI-AIH)
IUI treatment involves inserting the male partner’s concentrated semen through the neck of the womb and into the uterus close to the time of ovulation. This procedure can be performed during a natural cycle or with artificial hormonal stimulation.
Usually an injection of hCG is given when follicle development has reached a certain stage. The partner’s fresh semen sample is usually prepared by scientists to separate sperm from the semen, wash and suspend it in a salt solution. This preparation is then injected into the cervical mucus or directly into the uterine cavity (intra-uterine insemination - IUI).
Artificial insemination may be recommended by your doctor in cases of unexplained infertility, hostile cervical mucus, minor sperm abnormalities, coital difficulty and male sexual disorders.
Advanced Assisted Fertility Treatments
INVITRO FERTILIZATION (IVF)
For many couples Assisted Reproductive Technology (ART) is the treatment option that offers the best opportunity of achieving a pregnancy. With In Vitro Fertilisation (IVF) the eggs are fertilised by the sperm in the laboratory instead of fertilization happening inside the woman's fallopian tubes. The process was initially developed to overcome blocked or damaged tubes or absent tubes due surgery, where fertilization will not occur due to the hindrance between the egg and sperm. As of now IVF/ICSI is a common form of treatment used to overcome other factors affecting fertility, including sperm problems, endometriosis, and unexplained infertility.
IVF treatment involves the collection of eggs from the woman, sperm from the man, placing the egg with the sperm in a culture dish in a controlled environment in the laboratory which mimics the tubal and uterine environment, to create an embryo outside the body. The resulting embryo is then placed back into the woman’s uterus by a simple procedure called the embryo transfer. Embryo transfer is routinely not done under anesthesia.
If more embryos are available, the remaining or surplus embryos can be stored by freezing for transfer in the forthcoming cycles if lady fails to conceive in the fresh cycle. Replacing thawed embryos in subsequent cycles, therefore, is a much less demanding treatment. Advantage of the cycles are it will not have injections for ovarian stimulation and hence totally devoid of risk of OHSS. But in UAE, according to the federal law freezing of embryos are banned. So here we have facility for freezing the eggs when they in surplus amount and later ICSI can be performed and can be transferred into the uterus without the risk of OHSS.
At Gargash IVF it is our aim to offer a service, which optimizes the outcome of treatment with reduction ofdisruption to our patients' lives including the stress level during, before and after the treatment. To achieve these goals, we have adopted a minimal monitoring approach to treatment that is minimally invasive to the woman and leads to the least disruption in a couple's life during a stressful time of treatment till pregnancy test. At Garagsh IVF total treatment cycle is completely on OP basis care. No treatment during IVF in Gargash IVF require admission in the hospital. Our results have proved this is a safe and effective form of treatment without compromising the outcome.
CO INCUBATION DURING IVF - VIDEO
INTRACYTOPLASMIC SPERM INJECTION (ICSI)
Conventional IVF involves placing the egg from the female partner together with many thousands of sperm prepared from a semen sample provided by the male partner, and allowing the process of fertilization to take place over a number of hours in the culture dish kept in the incubator which maintains the body temperature all the time. However, for many couples this technique will be unlikely to result in fertilization, rather can result in total fertilization failure either because the number of sperm available is insufficient or because there is reason to believe that the sperm will be unable to penetrate the egg. In such cases the technique of Intra Cytoplasmic Sperm Injection (ICSI) is usually is the answer with which a man with completely absent sperm in the ejaculate also can father a normal pregnancy.
Together with IVF, ICSI is one of the most common techniques used in Assisted Reproductive Technology, and many thousands of babies have been born worldwide till daye since it was introduced routinely into clinical practice. It involves the direct injection of a single sperm into each egg using very fine micromanipulation equipment which contains fine glass injection pipettes. Given that the human egg is one tenth of a millimetre in diameter, this is a very delicate procedure performed by highly skilled embryologists. The technique can also be used along with sperm which has been obtained surgically from the male reproductive tract (from vas deferens or epididymis or testes) when sperm are not present in the semen.
ICSI – VIDEO
STEP BY STEP APPROACH FOR IVF TREATMENT
Step 1: Fertility Specialist Appointment - At your consultation with your fertility specialist, your medical history will be reviewed, any initial tests ordered, and advice regarding further management will be provided. Based on the results of the initial investigations, a final treatment plan will be recommended for you and it will be the best option for your fertility problem. If your doctor has advised you for IVF, the following points narrates the main steps involved in a typical IVF treatment.
Step 2: New Patient Appointments - These appointments can be organized over the phone or face to face, but we will not encourage walk in appointments as far as possible because fertility appointments and meeting will take long duration which will affect the routine working of our clinic. Apart from that we will not be able to spend enough time for assessing and planning your optimal treatment option. The initial appointment includes
Counselling and evaluation appointment with fertility specialist
New patient appointment with areproductive care nurse
Step 3: Mandatory Counselling Session - Attend a mandatory counselling session with both partners, to assist in considering any issues that may arise throughout upcoming treatment and to sign mandatory consent forms. This can be clubbed with the initial fertility specialist appointment if possible.
Step 4: New patient information session with a nurse - Attend a new patient information session with a nurse who will explain about the the different types of treatment including the Ovulation Induction, Artificial Insemination and the IVF cycle/ICSI cycle. During this session injections techniques will be taught and usual medications used during different treatments will be discussed.
Step 5: New Patient Appointment Session with the Administrator - During the appointment with the Administrator, patients will be explained about the costs structure associated with your treatment and answer any questions that may arise.
Step 6: Treatment Begins - The Reproductive Care Nurse will start your treatment according to the prescribed protocol by our fertility specialist
Step 7: Monitoring of IVF cycle - Throughout treatment we monitor how you are responding to medication with blood tests and ultrasound scans, to measure the endometrial thickness, size and number of follicles on both ovaries. Based on this we will determine when you are ready for egg collection.
Step 8: Final Trigger for Complete Maturation of Eggs - Once you have the optimum number and size of developed follicles you are ready for the final trigger injection which allows complete maturation of eggs inside the follicle. The nurses advise you two days before your egg collection of the exact time that you are required to administer the trigger injection. This is usually 35 hours before egg collection. This injection most often you may have to come back to the clinic and take. Because if not administered properly the chance of your pregnancy completely loses due to un availability of mature eggs.
Step 9: Vaginal Egg Collection - The vaginal egg collection is undertaken in the morning on a day surgery under a intravenous sedation and takes around 30 to 45 minutes. You will be at the hospital for around 4 hours and will need someone to drive or escort you home afterwards and please don’t plan to work that day because you can have minimal lower abdominal pain and hang over of sedative medication. The procedure is performed using an ultrasound guided probe attached to the ultrasound probe through which the fine needle passes through the vaginal wall into the ovary and draws the fluid from the follicle which contains the egg. The tube containing the follicular fluid is then immediately passed to the IVF laboratory and checked to ascertain whether it contains an egg.
On the morning of your egg collection your husband will need to provide a fresh semen (sperm) sample (unless using frozen sperm) so we can inseminate/microinject your eggs after collection. If the husband is absent on the day of egg collection or he can produce a sample under stress, he can make an appointment previously for freezing the sperm.
Step10: Freezing of Collected Oocytes - At this point of time if you have surplus amount of eggs we can do egg freezing which will help you to attempt a repeat cycle without stimulation. Yet another occasion we encounter often is the hyperstimulation in which the response of the ovary is too much to these hormonal injections. During these situations also we can freeze the eggs to avoid dreaded complication of OHSS later.
Step 11: Fertilisation of Collected Oocytes - Following egg collection, if you are planned to give IVF, the egg and sperm will be placed in a dish allowing fertilisation to occur naturally. If you are having ICSI, an embryologist will insert one single sperm directly into the egg, allowing fertilisation to occur.
Step 12: Embryo Development - The day after egg collection a nurse will contact you to let you know the time for embryo transfer the following day. The embryos will grow under the care of the embryologists for normally two days.
Step 13: Embryo Transfer - The embryos are returned to the woman’s uterus in a simple procedure called an Embryo Transfer, a simple procedure similar to a pap smear, performed by a fertility specialist under ultrasound guidance. No anaesthetic is usually used for the procedure, which involves a speculum being inserted into the vagina, and a narrow (about 2-3mm diameter) soft tube called a catheter, gently passed through the opening of the cervix and embryos are placed at an ideal place inside the uterus under USG guidance. Embryo transfer can be on 2 days, 3 days or 5 days after the egg collection which will be decided by the embryologist depending upon the growth number and quality of available embryos. We routinely aim for day 5 transfer, otherwise known as blastocyst transfer which gives maximum implantation rate.
Step 14: Pregnancy blood test - A pregnancy blood test will be organised for two weeks following embryo transfer. A blood test is the only reliable pregnancy test, as urinary pregnancy test kits can provide a false reading due to the hormone medication used in IVF treatment. Should the pregnancy test be positive, the nurses will organise an appointment with your Fertility Specialist for an ultrasound scan normally at around 6 weeks.
Advantages of Fertility Treatment at Gargash IVF
Gargash IVF assures you that we will provide you with the highest standard of fertility care available - every step of the way - throughout your treatment with us, and encourage you to call us should you have any questions or concerns.
We understand that commencing treatment can be haunting, that there are complicated medical regimes to absorb and that you may not remember everything your fertility specialist or nurse explained in your initial appointments.
Outlined in this section we have detailed the most common Gargash IVF treatments in a step-by-step guide to help reinforce the most important stages of your treatment. If you are about to start treatment, or have just started treatment, this section aims to answer some of the common questions that arise throughout this time.
We emphasise the importance of patient support throughout the care we provide. We encourage you to access the range of patient support services in a way that suits your individual needs. The main areas of patient support focused on in this section include counselling, support groups, workshops and the provision of additional resources.
Encountering Problems during IVF Cycle
Unfortunately not all IVF cycles are successful. At Gargash IVF, we believe it is important that you are aware of the possible disappointments as well as the joys that IVF can bring. The following is a brief outline of where problems may arise.
Treatment Cycle Cancellation:
A treatment cycle may need to be cancelled due to poor response to fertility drugs. In some cases, the ovaries do not respond well to the drugs and an insufficient number of eggs grow. This is detected by low, or a slow rise in hormone levels or follicle growth as measured by blood tests and ultrasound. Setbacks at this stage teach us more about the hormone patterns and we may be able to amend the treatment plan for subsequent attempts. Cycles cancelled at this stage do not incur the full costs of IVF.
No Egg Recovery After Egg Collection:
In a normal IVF cycle most, but not all follicles, will yield an egg at the time of your egg collection. The usual proportion is that approximately 70% of your follicles will produce an egg. Some follicles will not produce an egg at all. Small follicles may produce an egg but it will not usually be a mature egg. Immature, Post mature and Atretic eggs cannot be used for IVF/ICSI The number of follicles seen on your stimulation cycle scan is not, therefore, the same as the number of eggs expected at your egg collection, particularly if small follicles are included in the count.
Failed Fertilization and Cleavage of Embryos:
In a very small proportion of cycles (1-3%), none of the eggs will fertilize. On average, around 65% of eggs fertilize, as not all eggs collected at the time of egg collection will successfully fertilize and develop into an embryo suitable for transfer or freezing, nor will all eggs fertilize normally. Sometimes this is due to poor sperm quality or poor egg quality. Usually a special technique to inject the sperm directly into the egg (ICSI) can overcome the problem in a future cycle. However it is important to remember that, even when ICSI is used, fertilization and further division of the egg does not always occur.
Successful Embryo Transfer without Pregnancy:
If the cycle is not going to be successful, embryo implantation is usually the point at which it will not work otherwise known as implantation failure if the quality of transferred embryos are good. Unfortunately, many embryos lack all the genes needed to develop fully and, despite a healthy appearance at the time of transfer, will not subsequently implant and develop.
Adverse Effects of the IVF treatment
Ovarian hyper-stimulation syndrome:
Ovarian Hyperstimulation Syndrome (OHSS) is one of the more serious complications of an IVF cycle. OHSS can occur when the ovaries have over responded to the Follicle Stimulating Hormone. In this instance, the ovaries produce an excessive number of follicles and become markedly enlarged.
The symptoms you should be aware of and report immediately to us are:
· Abdominal pain
· Severe nausea and vomiting
· Diarrhoea
· Shortness of breath
· Increasing thirst
· Decreasing urine output
If moderate or severe OHSS occurs, hospital admission for intravenous fluid therapy and pain relief for up to a few days may be necessary. It is important to stress that OHSS is not a permanent condition however, and over the following 10-14 days your body will return to normal. In its severest form it is a danger condition and there have been reports in the scientific literature of severe side effects and fatility.
Adverse Reactions to Injections:
The large majority of women having IVF treatment will be having a stimulated cycle. This will involve the use of two different groups of drugs. The first one stimulates the ovaries to produce multiple follicles, and the second prevents the premature release (ovulation) of the eggs in those follicles. The drugs used in IVF treatment are generally of low risk and it is unlikely that you will have any significant side effects. Occasionally side effects include headaches, local skin reaction, and flu-like symptoms.
Complications of Vaginal Egg Collection:
In order to perform the egg collection, a fine needle must be passed through the wall of the vagina, into the abdominal cavity, and into the structure of the ovary. There is a very small chance of developing pelvic infection, pelvic bleeding and damage to the bowel, bladder or other internal organs from this procedure.
Pelvic infection:
The chance of developing pelvic infection following the egg collection procedure, especially if there is a past history of pelvic infection, or endometriosis involving the ovaries. In most cases, the infection would be very mild and would rapidly be brought under control with antibiotic therapy.
Bleeding:
There is an extremely small risk of causing bleeding, either from the wall of the vagina, or from within the structure of the ovary. Very occasionally, structures surrounding the ovary, such as the large blood vessels, might also be damaged during the egg collection.
Damage to bowel and bladder:
It is also possible for damage to occur to other pelvic structures during an egg collection, such as the bladder or the bowel. This is also extremely rare however there is a possibility that it might require readmission to hospital and further surgical investigation and treatment. Possible adverse outcomes of your pregnancy and the health of your baby
Pregnancy Complications Associated with IVF/ICSI
Miscarriage:
The risk of miscarriage with IVF pregnancy is not any greater than in naturally conceived pregnancies. In IVF, miscarriage occurs in up to 25% of all pregnancies with the chance of miscarriage increasing markedly as the woman becomes older. For women who are over 40 years of age, the risk of miscarriage is as high as 40%.
Light bleeding (or spotting) occurs in up to 55% of ART pregnancies and should not cause undue concern unless associated with increasing abdominal pain.
Ectopic pregnancy:
An ectopic pregnancy is one that implants outside the uterus, usually in the Fallopian tube. The risk of tubal, or ectopic pregnancy is quite small but it may occur in up to 3% of IVF pregnancies. It is more common when there has been previous damage to the tube. The risk of ectopic pregnancy following IVF is no higher than with spontaneous conception.
Multiple pregnancy:
Multiple births from IVF are caused by the transfer of more than one embryo. In most cases we recommend transferring only one embryo as twin pregnancy carries a significantly increased risk of a number of different childbirth and newborn complications. In particular a multiple pregnancy has a five times increased risk of death or major disability.
The health of a baby conceived through IVF:
The risk of health problems at birth or in the first year of life in children conceived naturally is approximately 4%. However, research carried out all around the globe has suggested that, in children conceived after IVF, the risk of health problems at the time of birth is slightly higher at around 5-6%. This increase does not appear to affect any specific conditions. It is not clear why this small increase occurs. It may be related to the processes of creating a child through ICSI, or certain types of infertility problems may predispose towards an increased risk of fetal abnormality.
Health of the Parents following IVF
There has been concern about the potential effects of fertility drugs on a woman’s long-term health.
Cancer and IVF:
A major study from La Trobe University published in 2001, which aimed to address whether there was any increase in the numbers of cancers of the breast, ovary and uterus in women on IVF compared with the numbers expected among women of the same age followed up over the same period in the general population, and in the event that there were more of these cancers than predicted, how this might be explained. The study involved 29,700 women who had undergone treatment in Australia and the duration of follow-up after treatment ranged from one to 22 years, with the majority followed up for five to ten years.
The findings provide reassurance that the incidence of breast and ovarian cancers in IVF patients is the same as that for women of the same age in the general population when considered over a five to ten year period. Notwithstanding future research, this study reinforces the importance for women of medical check-ups at regular intervals after fertility treatment.
The male partner is not free from concerns either. Testicular cancer is known t occur more commonly in men with low sperm counts and our fertility specialists advise all men with low sperm counts to have an ultrasound on their scrotum to check for any early signs of this.
Patient Support During Treatment
There may be times before or during treatment that you may feel emotional or stressed, or feel like there are times when there is nobody you can talk to who understands what you are going through.
Direct relationships between stress and infertility have not been established. Some people conceive at times of high stress in their lives, while others will respond with ovulation disorders or a decreased libido. However, improving your overall health and wellbeing, and trying to minimise stress in your life, can only help while undergoing treatment.
IVF and trying to achieve a pregnancy
Many patients have found the support of IVF counselors throughout treatment an invaluable source of strength. The teams of counsellors are experienced in helping individuals and couples deal with difficult emotions and situations and we encourage you to access this service at any stage throughout your treatment.
Supportive counseling
Supportive counselling can help by:
· Preparing for fertility treatments and exploring options/implications when making decisions about commencing, changing or stopping treatments
· Working on relationship issues that may arise as a result of treatment or may be impacting on treatment
· Dealing with the emotional impact of treatment
· Coping with unsuccessful treatment cycles and/or pregnancy losses
· Developing coping strategies for dealing with other people's pregnancies, births and children
· Discussing reactions of families, friends and work colleagues and developing strategies for dealing with these reactions
· Exploring strategies to help feel more in control
· Discussing the anxieties of pregnancy and preparation for parenthood
· Dealing with the specific issues related to donor treatment cycles
The counselling team also provides a range of lifestyle workshops and support groups to help you and your partner throughout treatment.
Genetic Counselling
Some people require IVF or donor gamete treatment because they, or members of their family, have a specific genetic disease. The counsellors are able to discuss the options available to the couple and the implications arising from each form of treatment. Those having PGD treatment are also required to see one of the genetic counsellors.
Pregnancy Loss Care at Gargash IVF
About 1 in 6 pregnancies miscarry, making this a common though distressing occurrence. A miscarriage is broadly defined as pregnancy loss before 20 weeks.
Some women will experience more than one consecutive miscarriage. When a woman experiences three or more consecutive early pregnancy losses, it is called recurrent miscarriage. About 1 in 200 women experience this.
Women undergoing fertility treatment are no more likely to have a miscarriage than those who conceive naturally.
Causes of Pregnancy Loss
Some of the causes of miscarriage include:
· Random chromosome abnormalities
· Parental or Maternal Chromosome abnormalities
· Abnormalities of the uterus
· Immunological causes
· Blood clotting abnormalities
· Associated medical conditions
· Hormonal imbalances
· Advanced Maternal Age
The chance of having a miscarriage is also related to the woman’s age. After the age of 43, more than 50% of pregnancies are expected to miscarry spontaneously.
Early Pregnancy Care Unit (EPU) at Gargash IVF
Gargash IVF has a dedicated Early Pregnancy Care Nurse responsible for managing the care of patients in the early stages of pregnancy, including women who have experienced a pregnancy loss, or who are at risk of experiencing a pregnancy loss. This involves repeating blood tests where necessary, monitoring the hormone levels, liaising with the patient’s fertility specialist and providing information, advice and further instructions. The Early Pregnancy Care Nurse will also liaise with patients around the time of their pregnancy scans or the time of a pregnancy loss.
Fertility Preservation
FREEZING OF EGGS
Freezing of eggs is rather the latest tool in fertility specialist’s armamentarium. After introduction of vitrification, otherwise known as the ultra rapid freezing technique it has become possible to freeze the eggs routinely in clinical practice with high recovery and success rates. We are also using vitrification for egg freezing and till now we had handful of pregnancies after vitrification. Now we are routinely incorporated egg vitirification in our clinical practice. Most coomon indication at our center for vitrification is risk of OHSS and to avoid OHSS we freeze eggs and do ICSI and transfer later in a hormonally manipulated cycle.
PICTURE EGG FREEZING
FREEZING OF SEMEN
Semen freezing is a simple method of fertility preservation. It can be used for patients whose partners are have difficulty in producing sample at the time of treatment. It can also be used for fertility preservation in cancer patients. Our success rates are excellent after using frozen sperm for fertility treatment. It can be used for patients who obtain sperm after surgical retrieval (PESA/TESA) for later use if we get excess number of sperm. In our set up we will go for TESA for patients with complete absence of sperm in the ejaculate as an initial procedure and if sperm are obtained we will freeze them and start ovarian stimulation later so that the treatment cycle will not be futile in cases of patients with problem of azoospermia.
FREEZING OF EMBRYO
As per federal law embryo freezing is banned in UAE and hence we are not doing frozen cycle embryo transfers presently. |
