FACILITIES
We
trace about 40% of infertility problems
to the female partner; another 40% to
the male; and the remaining 10% are
classified as unexplained. Both partners
are evaluated simultaneously, first
with a complete history and physical
examination and then with the more specific
testing appropriate to the complaints
presented and referred diagnosis performing
to the couple.
Complete couple oriented infertility
evaluation
Male evaluation
Male factor problems may be related
to:
» Inadequate or abnormal sperm
production and delivery
» Anatomical problems
» Previous testicular injuries,
or hormonal imbalances
» Sexual dysfunction and impotence
Our laboratory is fully equipped to
perform detailed semen analysis. Non
invasive Doppler examination is doe
to assess the presence of varicocele.
Female factor
Female infertility
is primarily due to ovulatory dysfunction,
fallopian tube dysfunction, uterine
or pelvic pathologies.
Ovulation and connected phenomenon can
be detected by Ultrasound Examination
including colour doppler study, this
clinical tool for imaging the dynamic
changes in the ovary and uterine endometrium.
Follicular sonography is best performed
with vaginal transducer and the follicular
details are clearly imaged.
Hysterosalpingogram (HSG)- an x-ray
of the uterine cavity and fallopian
tubes using a radiographic dye to detect
structural
abnormalities of the uterine cavity
and fallopian tubes. Also Sonosalpingography
is done to rule out tubular blocks.
Hysteroscopy- often done in conjunction
with laparoscopy or separately visualize
the interior of the uterine cavity for
scar tissue, adhesions, polyps, tumors,
and other abnormalities and to eliminate
endometriosis.
Diagnostic laparoscopy- a minimally
invasive surgical procedure typically
performed as an outpatient day surgery.
It permits direct visual assessment
of the uterus, fallopian tubes, ovaries,
and lower pelvic\s. it is particularly
useful in diagnosing endometriosis,
tubular disorders, or pelvic adhesions
and generally is performed at the end
of a work-up, but may be performed earlier
if deemed appropriate by the patients
history and referral diagnosis.
Hormonal
evaluation
Serum hormone testing- measures the levels
of luteinizing hormone, follicle stimulating
hormone (FSH), prolactin, progesterone,
and thyroid stimulating hormone (TSH).
Follicle stimulating hormone is produced
by the anterior pituitary gland and stimulates
the ovary to develop a follicle for ovulation.
Progesterone hormone is produced after
ovulation has occurred and prepares the
uterus for pregnancy.
Luteinizing hormone and follicle stimulating
hormone levels are checked for hypothalamic
pituitary dysfunction. It should be done
on the 2nd day of a naturally occurring
periods. Prolactin ( a hormone that stimulates
breast milk production) levels are checked
to see for it’s excess (hyoperprolactinemia)
a condition that interferes with ovulation.
Progesterone levels are performed to determine
if inadequate levels are interfering with
the development of the endometrium, the
lining of the uterus that prepares itself
for embryo implantation. FSH,T3, T4 is
checked to measure thyroid function.
OVERVIEW
OF IVF
For a pregnancy to occur, ovary has to
release an egg and it has to unite with
a sperm. Normally this union, called fertilization,
occurs within the fallopian tube which
joins the uterus (womb) to the ovary.
Howevery, in IVF the union occurs in a
laboratory after eggs and sperm are collected
and under congenial conditions, allowed
to unite. Embryos are then transferred
to the uterus to continue growth.
There
are five major steps in the IVF and embryo
transfer sequence
Monitor the development of ripening of
egg(s) in the ovaries.
Collect eggs
Obtain sperm
Put eggs and sperm together a petridish
in the laboratory, and provide correct
conditions for fertilization and early
embryo growth.
Transfer embryos into the uterus- the
woman is given hormones to produce multiple
follicles
To check
that egg development is satisfactory,
we utilize ultrasound exminations of the
ovaries (a painless method of seeing the
image of the enlaarging follicles containing
the eggs); hormone levels are also checked
by taking a series of blood and/or urine
samples. Using the above information we
determine when to administer an injection
to cause final ripening of the eggs and
when to schdule egg retrieval.
The retrieval procedure to obtain the
eggs is performed under anaesthetic transvaginally
using a hollow needle guided by the ultrasound
image(this is comfortable under adequate
sedation and local anesthesia_. Eggs are
gently removed from the ovaries using
the needle. This is called “follicular
aspiration”.
The eggs are immediately identified by
our embryologists in the adjacent IVF
laboratory. They are placed with sperm.
The sperm and eggs are then placed in
incubators to allow fertilization
to take place. The eggs are examined carefully
at intervals to ensure that fertilization
and cell division have taken place; the
fertilized eggs are now called embryos.
Embryos
are usually placed in the wife’s
uterus 2 or 3 days after egg retrieval.
A speculum is inserted into the vagina
to expose the neck of the womb (cervix).
The embryos are suspended in a tiny drop
of fluid nd then very gently introduced
through a catheter into the womb, often
under ultrasound guidance. The transfer
is followed by some rest, and then blood
tests and possibly ultrasound examinations
are carried out to see if pregnancy has
been established.
IVF is of demonstrated value for patients
with absence of both falopian tubes or
irreversible tubal blockage (where corrective
surgery has either failed or is inadvisable).
Intra
cytoplasmic sperm injection (ICSI)
A tiny pipette is used to inject a single
sperm into the awaiting egg in a revolutionary
new procedure, Intracytoplasmic Sperm
Injection.
A series
of functional capabilities is required
for a sperm cell to reach, and ultimately
penetrate and active, the egg. Recent
estimates suggest that only about 10%
of male infertility is attributed to underproduction
of sperm due to maturation arrest or germinal
aplasia, and that only 10% more can be
attributed to pure motility disorders.
This means that approximately 80% of infertile
men have disorders ranging from profound
oligospermia to failure of the sperm to
acrosome reaction.
The acrosome reaction allows the sperm
to penetrate through the sona pellucida,
to enter into the perivitelline space,
and ultimately bind to the egg membrane
or oolemma and penetrate into the egg.
IN 1992, a “seminal” paper
in a July issue of Lancet (15) described
a powerful new method that has revolutionized
the treatment of male infertility. That
method is intracytoplasmic sperm injection(ICSI).
ICSI allows fertility experts and embryologists
to effectively treat the large number
of couples where the sperm cannot penetreate
into the egg to initiate fertilization.
ICSI involves microinjection of a single
sperm cell into each egg. This means that
if as few as one viable sperm per available
egg can be obtained from the semen, epididymis,
or testes, then otherwise infertile men
can now father children. ICSI is also
performed on failed IVF patients.
ICSI can also benefit the additional group
of post-vasectomy males for whom after
vasectomy reversal often have diminished
sperm quality, or who can avoid vasectomy
reversal entirely through NSA ( non-surgical
sperm aspiration) and ICSI. ICSI can be
utilised for unexplained infertility couple.
Percutaneous
Epididymal Sperm Aspiration (PESA)
PESA is indicated for men with irreparable
obstruction resulting in azoospermia (lack
of or no sperm), congenital absence of
the vas deferens or failed vasectomy reversal.
The procedure takes approximately 10 to
20 Minutes and does not require a surgical
incision-a small needle is passed dirctly
into the head of the spididymis and fluid
is aspirated. Subsequently, the IVF labortory
team retrieves the sperm cells from the
fluid and prepares them for ICSI because
of the limited amount secured. The Fertility
Centre team in New England was the first
to offer PESA.
Testicular
Epidydinal Sperm Aspiration
Surgical removal of a portion of the testical
tissue for patients who are not good candidates
for PESA. In the andrology laboratory,
tissue is homogenized (minced) and individual
sperm is collected for ICSI.
Equipments
Ultraspimd
Aloka and L&T
Video Endoscopy
Karl Storz-Germany
IVF
Zeiss Microscope
Co2 Incubator
Galaxy and Hereus
ICSI
Narishige manipulator With Nikon Microscope
