What is infertility?
Infertility is when a couple is unable to conceive after one year of unprotected intercourse. It affects approximately 15% of couples worldwide (in Armenia 17-18 %). Women with certain symptoms such as irregular menses or no menses, and women who are 35 years of age or older should also seek care with a specialist sooner. Approximately 40% of infertility is attributed to the male partner, 50% to the female partner and in 10% of cases, the cause is unknown.
The good news is that most will succeed in achieving parenthood with the appropriate management.
What causes infertility in men?
A man’s sperm count can be influenced by numerous factors. Lifestyle, including the excessive use of nicotine, alcohol and marijuana could have a strong impact on semen parameters. Certain medical conditions, such as diabetes, and medications could also impact sperm production. Congenital or anatomic abnormalities either from birth or as a result of surgery (hernia repair), hormonal imbalances, genetic conditions (cystic fibrosis), infections (mumps), testicular damage or trauma have all been known to impact sperm production. Inability to ejaculate normally can also prevent conception and can be caused by many factors including surgery of the prostate gland or urethra, diabetes, high blood pressure, medication or impotence. It should be noted that the cause of many cases of male factor infertility are unknown. The good news is that we are able to achieve successful outcomes in most male factor couples.
What causes infertility in women?
Common causes of infertility in women include abnormalities in ovulation, blockage or disease of the fallopian tubes, and ovarian failure or diminished ovarian reserve. Uterine conditions, such as uterine adhesions and fibroids are conditions that rarely cause infertility. Lifestyle factors such as stress, extreme dieting or athletic training can affect a woman’s hormonal axis and hence result in infertility.
Certain medical conditions, such as thyroid gland abnormalities and pituitary gland tumors can also impact the reproductive system and hence resulting in infertility. Other conditions including endometriosis (the abnormal presence of uterine lining cells in other pelvic organs) and pelvic adhesions have been associated with infertility.
How is infertility tested?
The first step for a woman is to determine if she is regularly ovulating each month. This can be done by charting changes in morning body temperature, by using an home ovulation test kit (available over the counter), or by a blood test for hormone levels or an ultrasound of the ovaries. Other common female tests to evaluate female infertility include:
- Hormonal Testing: This may include assessment of ovarian reserve, thyroid function and prolactin levels.
- Hysterosalpingogram: This procedure involves an X-ray to investigate the shape of the uterine cavity and the fallopian tubes after they are injected with dye.
- Laparoscopy: A miniature light-transmitting tube, also known as laparoscope, exams the tubes and other female organs for disease. Usually under general anesthesia, the tube is inserted into the abdomen through a small incision below the navel.
- Hysteroscopy: A miniature light-transmitting camera is inserted into the uterine cavity to evaluate for the presence of polyps, adhesions or fibroids, which can interfere with fertility.
How is infertility treated?
Treatment of infertility varies for all couples depending on the information gathered from the consultation and the diagnostic testing. Common treatments include ovulation induction, which could be done with clomid, a medication taken orally for five days in the beginning of a woman’s cycle. If appropriate, ovulation induction could also be done with gonadotropins, which are hormonal medications delivered through small injection shots. An intrauterine insemination (IUI) may also be recommended depending on the semen parameters.
If ovulation induction and IUI is not an option due to female and/or male factors or has previously not been effective, the next option for treatment would be in-vitro fertilization (IVF). IVF offers the highest percentage of success rate and every protocol is customized to address the specific needs of the patient.
Conditions that are amendable to surgical correction are approached through surgery. Surgeries that are involved with a woman¡¯s ovaries, fallopian tubes, or uterus are recommended only if there is a good chance of restoring fertility.
What is in vitro fertilization (IVF)?
IVF is what is known as a “test tube baby.” It is a technology where medications are given to stimulate the ovaries to produce multiple mature oocytes (eggs). Once the follicles containing these oocytes are at a certain size, the eggs are removed from a woman’s body using a small needle. The eggs are then assessed for maturity and quality and then fertilized with the partner’s sperm in the embryology lab. The resulting embryos are grown for 3 to 5 days and then returned back to the woman’s uterus. A pregnancy test is performed approximately 10 days later.
Is in vitro fertilization expensive?
The average cost of an IVF cycle in Armenia 3000-3500$ (in Europe 4000Euro, in the United States is $12,400). IVF involves highly trained professionals with sophisticated laboratories and equipment.
Does in vitro fertilization work?
Yes. IVF was introduced in the United States in 1981. Since 1985, through the end of 2006, nearly 500,000 babies have been born in the United States as a result of reported Assisted Reproductive Technology procedures (IVF, GIFT, ZIFT, and combination procedures). IVF currently accounts for more than 99% of ART procedures with GIFT, ZIFT and combination procedures making up the remainder. The average live delivery rate for IVF in 2005 was 31.6% per retrieval.
That’s better than 20% chance in any given month that a reproductively healthy couple has achieving a pregnancy and carrying it to term. In 2002, approximately 1 in 100 babies born in the United States and 4 in 100 in Denmark was conceived using ART and that trend still continues today.
What factors increase a man’s risk of infertility?
The number and quality of a man’s sperm can be affected by his overall health and lifestyle. Factors that may affect sperm count and quality include:
- Tobacco use
- Environmental toxins, including pesticides & lead
- Medical conditions
- Radiation treatment & chemotherapy for cancer
What factors increase a woman’s risk of infertility?
Many things can affect a woman’s ability to have a baby. These include:
- Tobacco use
- Poor diet
- Athletic training
- Being overweight or underweight
- Sexually transmitted diseases (STDs)
- Health problems that cause hormonal changes
How does aging decrease a woman’s chance of having a baby?
Aging affects a woman’s ability of achieving pregnancy in the following ways:
- The ability of a woman’s ovaries to release eggs ready for fertilization declines with age.
- The quantity and quality of a woman’s eggs decline with age.
- As a woman ages she is more likely to have health problems that can interfere with fertility.
- As a women ages, her risk of having a miscarriage increases.
Am I infertile?
About 85% of young, healthy heterosexual couples conceive after one year of trying and about 93% are successful after two years. The standard definition of infertility is the inability to conceive after 12 months of unprotected sexual intercourse. Today this has been modified to take into account age, and now women over 35 may be considered infertile if they have failed to conceive after trying for six months. Some specialists half that number to three months for women over 40. If you suspect you are infertile or are at risk of being infertile, speak with a medical professional to discuss your options.
What is the difference between ‘sterility’ and ‘infertility’?
Sterility means that it is impossible for a couple to conceive a child. A diagnosis of sterility is given after a thorough examination concludes that there is no sperm production and ovulation cannot occur.
Infertility means that a couple is not sterile but for some reason they have not been able to conceive a child. There are three conditions that need to be met for conception to be possible: sperm must be present, the fallopian tubes must be open, and ovulation must occur. If one or more of these conditions is not met, the couple suffers from “true infertility”. If all three conditions are met but the couple has failed to conceive, the diagnosis is “sub-fertility”.
Once couples are diagnosed as infertile, the doctor will perform tests to determine the cause or causes. Then treatment can begin. With todays technological advances even truly infertile couples conceive a child, sometimes with the assistance of a third party donor or surragate.
Should I consider seeking professional treatment for infertility?
People who consider undergoing IVF or other assisted reproductive techniques (ART) often do so after they have failed to conceive for 12 months. Others who have known risk factors for infertility seek treatment sooner. Reasons for this include;
- the female partner is over 35 years old
- either partner has received injuries or has been diagnosed with conditions that affect fertility (endometriosis, pelvic infection, polycystic ovarian syndrome, undescended testicles)
- either partner has a family history of genetic disorders (Tay-Sachs disease, thalassemia)
- the couple has not been helped by ovulation induction or infertility treatments
- the female partner has had multiple unsuccessful pregnancies for other reasons
Single women and lesbian couples may also obtain professional assistance when attempting to conceive a child.
I have been diagnosed as infertile, will I need IVF?
Not necessarily. Most couples find that they can successfully conceive with the help of medications, fertility drugs, or occasionally surgery. Only a small percentage of infertile couples – about 5% – require advanced treatments such as IVF, GIFT (gamete intrafallopian transfer), ZIFT (zygote intrafallopian transfer), ICSI (intracytoplasmic sperm injection) and egg donation.
What exactly is a Hysterosalpingogram? What does it involve and does it involve pain?
Hysterosalpingogram (HSG) is an x-ray study of the uterus that uses a special dye visible on x-rays. A series of x-ray images are taken as the dye flows into the uterus and through the fallopian tubes which helps the doctors evaluate the size and shape of the uterine cavity and determine whether the fallopian tubes are open, and sometimes even if there are adhesions near the tubes.
HSG is best scheduled 2 to 3 days after the last day of menstrual flow. It is important to ensure that you are not pregnant at the time this study is performed, if there is any doubt about whether you are pregnant, of if the flow is light, a pregnancy test should be performed beforehand. You may be prescribed a dose of antibiotics to reduce the risk of infection and a non-steroidal antiinflammatory agent such as Ibuprofen (advil or brufen) or Naproxen (aleve) to minimize cramping.
The doctor begins by inserting a speculum into the vagina. The cervix is wiped with an antiseptic, and a catheter (narrow tube) is inserted into the uterine cavity. There may be mild cramp at this point. The speculum will be removed, and you will be repositioned on the x-ray table. The radiologist will place tension on the uterus to straighten the bend and give a better picture of the uterine cavity. The dye is then injected into the uterus via the catheter. This again may cause cramping. If you can try and relax it should help with the cramping. If the dye does not flow through the fallopian tubes, additional pressure may be necessary to see if the tubes are really blocked. This can cause more intense discomfort.
After the x-ray, you will be asked to remain lying down for another 5 – 10 minutes to allow any cramping to subside. If you experience increased pain, fever or heavy bleeding after the procedure you should contact your doctor.
What are the tests I need to have done prior to treatment?
Before a recipient can be matched with an egg donor, the following tests must be carried out:
- Hepatitis B HIV Syphillis
- Blood Type
- Baseline scan or HSG
- Hepatitis B
- Hepatitis C
- Semen Analysis
- Blood Type
NB: These tests must be less than 12 months old at the time of treatment.
Who are the donors?
Donors are women of 18 – 30 years of age. Most of them are 21 – 28 years old and often students or graduates. They will have normal body weight, healthy medical and genetic history and will have tested negative for all the infectious disease screening performed. Donors cannot donate more than three times.
How will the egg donor be selected?
You complete a donor characteristic form in which we document the characteristics you would like the donor to have. We use this information to supply you with a list of donors that match your criteria and blood groups. You select your first choice and a reserve donor. This will allow flexibility and avoids delays in case the first choice donor does not produce enough number of eggs or for any reason, decides to withdraw from the programme.
How can I be sure the donation will be safe?
All egg donors are fully screened prior to being accepted. Baseline ultrasounds and blood work are carried out to determine hormone levels, absence of substance abuse, sexually transmitted or other diseases, and her physical eligibility to undergo follicle stimulation and egg retrieval. Genetic screening, when indicated, to test whether the individuals carry a genetically transmitted disease is carried out.
The criteria for donor selection includes:
- Age less than 30 years old
- Two ovaries
- FSH level not more than 8IU/L
- BMI not more than 25
- No previous ovarian surgery
- No previous history or family history of genetic of familial illness
- No history of infertility
In addition, all donors are screened and must be completely clear with respect to:
- Cystic Fibrosis Gene
- Hepatitis B and C
- Kıdney function
- Liver function
- Normal Chromosome Analysis
- Total Blood count
Will the donation be anonymous?
Yes. The rules on anonymity are strict and are in the best interests of all concerned. No identifying information will be given to you about the donor. Likewise, the donor will not receive any information about you.
Will I be given any information about the donor?
We will provide you with information on:
- Hair colour
- Body build
- Eye Colour
- Number of children of their own if applicable
- Country of origin (ethnicity)
How many egg/embryos will I receive?
You will receive between 10 and 16 oocytes (eggs) from your allocated donor.
What is the drug regimen?
There are two drug regimens
- Patients who are menopausal (ie with no periods) Oral Oestradiol Valerate (Progynova) is given for 10-12 days to thicken the uterus lining(endometrium). An ultrasound scan will be performed to check the endometrial thickness. Progesterone support will commence 3-4 days before the embryo transfer.
- Patients with naturally occurring periods (ie not thought to be menopausal). In order to control your cycle, you will first need to take oral contraceptive before starting with oral Oestradiol Valerate to thicken the lining of the uterus and progesterone support as above.
In order to sychronise both recipient and donor cycles for fresh embryo transfer it is essential to “switch off” the recipients cycle using a long protocol. The recipient will need to take Nafarelin (Synarel) nasal spray daily, from day 2 or 21 of the menstrual cycle, until the day before the donors egg collection. The endometrium is prepared by giving oral oestradiol valerate (Progynova) and progesterone support as above.
For both sets of clients , the drug regime is continued until a pregnancy test is performed.
Are there any side effects of the medication used during my IVF treatment cycle?
During down regulation you may experience headaches, hot flushes or mood swings. When you start your stimulating injections these side effects should subside, but you may experience “twinges” in your ovaries and feel bloated.
Can I stop my down-regulation eg Buserelin, when I start my stimulating injections eg Menopur, Gonal F?
You must continue using your Buserelin throughout your cycle of IVF treatment. A member of the medical or nursing team will advise you when to stop.
Can I mix the Buserelin and my stimulating injection together?
No you cannot mix your Buserelin and stimulating hormone together in the same syringe, but they can be injected at the same time as single injections.
Can I mix my Menopur/Gonal F the night before use and store in the fridge?
NO. Your menopur/gonal F must be injected immediately after you have mixed it.
Will the drugs make me put on weight?
You will not increase in weight, but once you commence your stimulating injection eg menopur/gonal, you may feel a little bloated and experience lower abdominal swelling.
What can I take for my period pains during down-regulation?
Do I have to have my stimulating injections at the same time each day?
It is advisable to administer your Menopur/Gonal F at approximately the same time each day. As you may need to attend the clinic for a scan, do not have your stimulating injection before the scan as your injection dose may be changed.
Can I still have intercourse whilst on my drugs?
Intercourse is unrestricted until day nine of your stimulating injections
Why do I have to use barrier form of contraception once I have commenced treatment?
If you should become pregnant naturally, the down regulation drugs may increase the chances of miscarriage.
Following embryo transfer do you recommend I use my cyclogest pessaries rectally or vaginally?
It is your personal choice whether you administer your pessaries rectally or vaginally. When using the pessaries vaginally you may experience a white discharge.
Can I do a pregnancy test earlier than 2 weeks following embryo transfer?
It is advisable to perform a pregnancy test 2 weeks after embryo transfer to avoid false results. We also recommend you test using an early morning sample of urine.
I am due to have a dental filling, can I have this done during treatment?
Yes, but it is advisable to inform your dentist of the possibility of your being pregnant. He will then decide whether dental treatment needs to be postponed or cancelled.
Can I drink alcohol during treatment?
There is evidence that alcohol reduces fertility in both men and women. It is advisable to keep alcohol intake to below the recommended limits eg up to 5 units per week.
Can I dye my hair/use spray tans while having treatment?
Ask your hairdressers advice about using certain hair products in early pregnancy. A reputable tanning establishment should also be able to advise you.
My doctor has given me antibiotics, can I take them during my treatment?
If your doctor is aware you are having IVF treatment he/she will prescribe antibiotics that are safe to take during pregnancy. If you doctor is not aware inform him/her that you may be pregnant.
Can I have my flu jab during treatment?
No, it is not advisable to have a flu vaccination during treatment.
Can I go swimming during/after treatment?
During treatment it is a good way to keep fit. After treatment we would advise you not to go swimming for at least a week following your egg collection to prevent the chance of infection occurring.
Can I use complementary therapies during treatment?
We have no evidence to say it is harmful, but we would advise you tell your therapist that you may be pregnant as the use of certain aromatherapy oils is NOT advisable during pregnancy.
Do I need to take time off work during treatment?
It is not necessary to take time off work during your treatment.
What is your success rate?
We regularly achieve high pregnancy rates due to a combination of high quality oocytes and the expertise of our team of highly experienced physicians, nurses, embryologists and other laboratory staff. The programme is achieving excellent results. Please see up to date pregnancy rates on the results page of our website.
What is IVF (Test Tube Baby)?
In intractable infertility when medical or surgical treatment fails to achieve pregnancy, IVF is suggested. BY IVF we mean-
- Extraction of female egg.
- Mixing the egg with husband’s sperm in the laboratory.
- After fertilization (egg and sperm) in the embryo is replaced back in the mother’s uterus.
Is single egg enough or multiple eggs are necessary?
In IVF we collect multiple egg. For production and collection of multiple eggs patient is given some injections (hormone starting form day 2 of the menstrual cycle. Before starting the specific hormone injection are increasing the number of eggs. Another hormone injection (Suprefact) is usually started from 21st day of the previous menstrual cycle. This procedure reduces the chances of cancellation during the treatment cycle and increases the pregnancy rate. These injections are very costly. Approximately 30 to 40 injections are required for multiple egg maturation in each menstrual cycle.
How to known when the eggs are getting matured?
This is know by periodic examination of blood for hormones and ultra-sound examination of the ovary. So every patient has to report to the clinic from day 2 of the treatment cycle. During treatment cycle, the patient has to report every day or every alternate day from day 2 of menstrual cycle till the eggs are aspirated and the embryos are replaced. Blood for hormone test is collected in the morning and the report is available in the afternoon. The number of injections to be given on each day of treatment cycle will depend on the blood report. Blood Examination is costly Approximately Rs. 300.00 has to be spent for examination of each test.
When the eggs are collected?
By periodic blood and ultrasound examination the correct tie for egg collection is determined when the eggs have become mature. Approximate time usually between day 11 to day 14 of the menstrual cycle. Then the patient is admitted for egg collection.
How the egg is collected?
Either by laparoscope or ultrasound. We are doing ultrasound guided collection.
What is done after collection?
Husband’s semen is collected. The sperms are specially prepared and each egg is mixed with husband’s sperm and kept in (when the temperature, pH etc. are maintained at optimum level).
How do you know when the sperm has entered into the egg and the egg is fertilized?
Egg which was a single cell will divide into two and into four and so on. This will indicate that the egg is fertilized and the embryo (unborn baby) is developing.
When this embryo is replaced inside the mother’s uterus?
About 48 hours after mixing the egg with semen.
How many embryo are usually replaced inside the mother’s uterus?
3 to 4 embryos.
Is there any increased chance of twins or triplets?
There is chance but does not happen very frequently.
Q. Can a couple straight way go for treatment?
No before the treatment by IVF a few investigations are performed. Investigation of the wife has to be planned on specific days of menstrual cycle i.e. Some blood examination is to be done on second day. Husbands investigation can be done on any day.
Are all infertile couples acceptable for treatment by IVF?
No. specific indications are:
- Damage of the fallopian tube.
- Disease known as Endometriosis.
- Defect of husband’s semen-defect in count but not in motility.
- Unexplained infertility i.e. Where husband and wife though normal on all available investigations have failed to achieve pregnancy.
Big tumours of uterus and ovary are unsuitable conditions for IVF. They are to be treated surgically and then failed to achieve pregnancy.
What is the duration of stay near IVF centre (for couples coming from outside)?
If preliminary investigations have been done, the approximate duration will be 4 weeks. The patient should report to the IVF clinic on the 21st day of the menstrual cycle. On the other hand, if preliminary investigations have not been done, the approximate duration of stay will be 6 to 8 weeks. The patient should report on the 2nd day of the menstrual cycle. In the first menstrual cycle the investigation will be done and the subsequent menstrual cycle the treatment of IVF will be continued provided pretreatment investigation reports are normal.
What is the cost involved?
The cost involved is at present approximately 3000-3500$ per cycle treatment. This is due to the increase in price of hormones and materials used for I.V.F. Hormones and materials are imported. The break-up of the amount is given below:
- Medicines 30-40%
- Investigations 15%-20%
- Culture materials & institute 40-50%
The above amount is to be spent by the party him self in purchasing medicines and for paying charges for investigations etc. In young ovulating patient with block tubes or any other reason, the package can vary.
How many times IVF can be repeated?
IVF can be repeated as many time as a couple can afford but the cost each time will be the same or until unless they have their own frozen embryos.
Up to what age the IVF is possible?
IVF is possible preferably up to the age of 35 (wife). It may be up to the age of 40. After the age of 40 females are usually to produce good quality eggs and at that time IVF does not give any result. Result have been achieved in these cases by using donors eggs but there are ethical and legal problems.
In case there is pregnancy how many days she has to stay at the institute?
She need not stay at the institute. She will be treated just like any other pregnancy following treatment of infertility. She will stay at home.
Is there increased risk of pregnancy complications after IVF?
Risks are more in pregnancy occurred after any treatment modality of infertility including IVF. These risks are related primarily to the increased of the female partners.
Is there a risk of abnormal baby?
No, the incidence of abnormal baby following the procedure of IVF (test tube baby) is the same as in pregnancies occurring spontaneously.
What will be the nature of delivery? Always by Caesarean section?
Most of the pregnancies following treatment of infertility are delivered by Caesarean section. As test tube baby technique is done basically in infertile couples, there is always an increased incidence of Caesarean section in test tube baby pregnancies.
What is hysteroscopy?
Hysteroscopy is considered to be minimally invasive surgery that enables a complete assessment of the uterine cavity. For this surgery, general anesthesia is usually given, although it can be performed with IV sedation, spinal or local anesthesia. No incision is necessary since the procedure is performed by accessing the uterus transvaginally. First, the cervix is dilated. Next, the hysteroscope (a small telescope camera) is placed inside the uterus. Fluid is used to distend the uterus so that the entire endometrium can be clearly visualized with the hysteroscope.
A diagnostic hysteroscopy involves looking inside uterus only (and, therefore, does not require anesthesia). Operative hysteroscopy includes surgery to remove polyps, myomas (fibroids), a septum or adhesions from the uterus. Occasionally, the surgery cannot be safely performed without laparoscopic guidance. If that is the case, your doctor will tell you about this possibility in advance.
Risks from hysteroscopy are unlikely, but include: bleeding, infection, fluid overload and uterine perforation. Fluid overload involves absorption of the fluid being used to distend the uterus. Usually the procedure is stopped if 1000 ml of fluid is absorbed. The patient is then observed in the recovery room. The risk of uterine perforation is rare (approximately 1/1000). Typically no intervention is necessary, but the hysteroscopy procedure is stopped and the patient is observed.
This surgery usually takes thirty to sixty minutes, but may take longer depending on a woman’s anatomy and what pathology is found during hysteroscopy. After the surgery is completed, you should expect to rest in the recovery room for about one hour before being ready to be discharged to home. The day of the surgery you may not go to work.
You will need to fast from midnight onward on the day of the surgery. After surgery, you may eat normally once you are at home. Be sure to take the pain medication that you were prescribed so that you are comfortable. You should call the doctor if you are having a fever (temperature >37.0C), pain that is not relieved by your pain medication or heavy vaginal bleeding (saturating a maxi pad in one hour).
You will need to be seen in the office for follow-up in one to two weeks after surgery. During that visit, the doctor will review the surgical findings with you including any photographs that were taken and the pathology report from any tissue removed. After this visit, you may resume normal activities including exercise, sex and swimming.