1. What is infertility?

When a couple fails to conceive after one year of unprotected intercourse, they are said to be infertile or rather subfertile.

2. What is a trial transfer?

Embryo transfer plays an important role in the success of an IVF cycle. Up to 30% of all failures can be attributed to difficult or improper embryo transfer. If there is a difficulty to negotiate the cervical canal and internal os, it usually results in bleeding and stimulation of uterine contractions which can expell the embryos. To avoid that we do a mock embryo transfer without the embryos, either one month prior or during the early part of the cycle. If difficulty is encountered it is corrected much before the embryo transfer.

3. What to expect on the day of IVF oocyte retrieval?

Oocyte retrieval is a transvaginal procedure under scan guidance. It is done under IV sedation. Typically the procedure lasts for about 20 minutes. Post procedure there is very minimal pain or discomfort which can be managed with medicines.

4. How many embryos do you transfer during an IVF cycle?

In a good prognosis and young patient we can restrict to transfer of a single blastocyst. But generally in others we transfer up to three day 3 embryos and up to two or blastocysts.

5. What to expect on the day of embryo transfer? What are the restrictions after the transfer?

Embryo transfer is done in most of the patients without anaesthesia. It is generally painless. Embryos are loaded into a small catheter and then transferred to the appropriate position in the uterus under ultrasound guidance through the vagina.

6. What type of over the counter medications can I take during the fertility treatment cycle? Are there restrictions on diet, caffeine, and alcohol during the cycle and pregnancy?

Avoid pain killers during the treatment cycle. For pain relief safest medication is paracetamol.

7. What is PGD and is it recommended?

PGD (preimplantation genetic diagnosis) is a procedure in which the embryos are biopsied and few cells are taken out typically on day 5 (blastocyst stage) which are then analysed for chromosomes. About 30 - 40% of blastocysts can have chromosomal abnormalities. Such embryos do not implant and thus are excluded from transfer. Only euploid or normal embryos are selected for transfer. PGD is reserved for patients with repeated implantation failure and also can be considered when we are doing a single embryo transfer. PGD can also be used to detect specific genetis diseases which can be transmitted from the parents.

8. What is assisted hatching?

The embryos have a thick protective covering called zona pellucida until the blastocyst stage after which the layer thins out and the embryo hatches out, ready for implantation. In assisted hatching a laser shot is used to thin the zona pellucida so that it assists the embryo in hatching and implantation. This procedure is used for patients with recurrent implantation failure, frozen embryo transfers, in IVM embryos and in patients with unusually thick Zona.

9. What are the symptoms of OHSS? What can I do to prevent it? How is it treated?

OHSS or ovarian hyperstimulation syndrome is a dreaded complication of IVF where we use drugs to stimulate multiple follicles in the ovary. It usually results from excessive leakage from the blood vessels stimulated by the chemicals released from the hyperstimulated ovaries. This results in excessive fluid accumulation in the abdomen andsometimes in the lungs. Patients usually present with bloating of the abdomen , breathing difficulties and in severe cases it can cause hypotension , renal failure or thrombosis. OHSS can be easily prevented if risk factors are identified on time. The amount of hormonal stimulation should be controlled according to the patient profile . In case of hyperresponse we avoid HCG injection for the final maturation of oocytes and instead give either decapeptidyl or luprolideacetate . We also follow the stategy of freeze all embryos and transfer in a frozen cycle at a later date. With these measures OHSS can almost be completely avoided. OHSS is self limiting. It resolves in about 7-10 days until the effect of HCG lasts. Till then the treatment is symptomatic with adequate hydration and to maintain the renal function. Rarely the abdominal fluid needs to be aspirated to relieve the symptoms of compression. It can be difficult to manage if there is simultaneous occurence of pregnancy.

10. Can I have intercourse during fertility treatment? Can I have intercourse after the egg retrieval?

It is ok to have intercourse during IUI treatment. In IVF cycles the ovaries are excessively enlarged and it is better to avoid intercourse during and after egg retrieval (for about 2 weeks) till the ovaries shrink to normal size.

11. What are you looking for during the pregnancy ultrasound?

In the early pregnancy scan during the first trimester, we look for the location of the pregnancy, rule out ectopic or tubal pregnancy, date the pregnancy and look for the number of sacs and their viability.

12. What should I do if I start spotting while pregnant?

Any bleeding in pregnancy is abnormal and it could be a sign of threatened abortion. See your doctor immediately.

13. Can I travel during the fertility treatment or while I am pregnant?

There is no restriction to travel during fertility treatment or after pregnancy unless you have some complications associated with pregnancy.

14. What medications are used?

Medicines are generally used to induce ovulation. They can be oral drugs like clomiphene citrate, Letrozole, Tamoxifen or Anastrozole. Injectables like urinary / highly purified/ recombinant - FSH/ HMG/ HCG are used in various stages of ovulation induction.

15. Can my OB/GYN treat me?

First line investigations and treatment like ovulation induction can be carried out at an OB/GYN clinic. For advanced treatment like IUI and IVF, it is better to approach an infertility specialist or an expert in reproductive medicine.

16. Is infertility a common problem?

One in eight of married couple suffer from infertility due to various reasons.

17. Is infertility just a woman's problem?

Both men and women contribute to infertility equally and sometimes there could be combined causes.

18. What causes infertility in men?

Infertility in men could be due to genetic defects , developmental due to undescended testis or congenitally small testes, due to vaicocele, infections or due to blockage of the vasor the seminal duct. Smoking can also cause decrease in the sperm count.

19. What causes infertility in women?

Infertility in women could be because of ovulatoty disturbances / PCOD, tubal block, endometriosis, uterine defects like fibroids, intrauterine adhesions(Asherman's Syndrome), uterine septum, polyps etc.

20. How does age affect a woman's ability to have children?

As the age advances the quality of the eggs decreases and also there is a higher chance of miscarriage with advanced age mainly because of the increased chances of chromosomal abnormalities.

21. How long should women try to get pregnant before calling their doctors?

For young women, they should consult if they have not conceived after one year of unprotected intercourse. For women more than 35 years of age, investigations should begin as early as 6 months

22. How will doctors find out if a woman and her partner have fertility problems?

The basic tests for infertility include a pelvic scan, tests for ovulation , semen analysis and test for tubal patency (HSG). Some patients may also need a hysterolaparoscopy.

23. How do doctors treat infertility?

Treatment of infertility depends on the cause for the same. For PCOD and ovulatory disturbances, ovulation induction is done either with oral or injectable drugs. For decreased sperm counts Intrauterine insemination (IUI) or Invitro fertilization (IVF) is indicated depending on the severity. If the fallopian tubes are blocked, IVF is required. In case of mild endometriosis, IUI can be tried but in severe cases IVF is needed. In case of unexplained infertility again, IUI or IVF can be an option.

24. What is assisted reproductive technology (ART)?

Assisted reproductive techniques(ART) involve the manipulation of the gamates outside the body. This includes the IVF - ET (In Vitro fertilization and Embryo transfer) , ICSI- Intracytoplasmic sperm injection , FET - Frozen embryo transfer, IVF-ICSI with donor oocyte and donor sperm and embryo donation.

25. How often is assisted reproductive technology (ART) successful?

The success rate of ART depends on multiple factors but mainly on the age of the female partner and the sperm quality. Overall success rate for both fresh and frozen embryo transfer ranges from 45-55%. With the use of donor eggs it can be as high as 60-80%. After 35 years the success rate of ART decreases exponentially and after 40 years it is less than 15 %. The miscarriage rates also increase proportionately.

26. What are the different types of assisted reproductive technology (ART)?

Assisted reproductive techniques(ART) involve the manipulation of the gamates outside the body. This includes the IVF - ET (In Vitro fertilization and Embryo transfer) , ICSI- Intracytoplasmic sperm injection , FET - Frozen embryo transfer, IVF-ICSI with donor oocyte and donor sperm and embryo donation.

27. Can You Find Out Earlier If You Have Fertility Issues?

Evaluation for infertility is indicated if you have not conceived even after one year of unprotected intercourse. Earlier testing is needed if the woman is over 35 years of age or if there is a suspected cause for infertility like endometriosis, pelvic tuberculosis or history of mumps orchitis / undescended testis in the childhood for the husband. The basic tests include a semen analysis, a pelvic ultrasound and test for tubal patency (HSG) if required.

28. At what time of the month is a woman fertile?

In a regularly cycling woman the midcycle , ranging from Day 11 to Day 18 of periods is the most fertile period as it coincides with the time of ovulation. After ovulation the egg is fertilizable for about 12-24 hours. Hence couples should start having intercourse atleast on alternate days during this period.

29. How can a woman tell if she ovulates?

A woman who gets a regular menstrual cycle once in 28-30 days will usually be ovulating. The other tests for ovulation detection include a serum Progesterone on day 21 of periods (in a regularly cycling woman), urinary LH kits and ovulation can also be detected by using serial follicular scans.

30. Is pregnancy possible after (menopause)?

Menopause is a state where the ovaries are exhausted of their oocyte reserve but the uterus can still be healthy to hold the pregnancy. Even after menopause pregnancy is still possible using third party donor oocytes.

31. How long does this whole process take?

The process of IVF/ICSI and embryo transfer takes about 15 days when we use the short stimulation protocols. With the long protocols it takes about 3-4 weeks. Long protocols are rarely used and are restricted to a certain subset of patients. After the embryo transfer, pregnancy check can be done after 2 weeks.

32. What are your success rates?

The success rate of IUI varies between 20-25%. The success rate of IVF / ICSI varies between 45-55%. The success rate for frozen embryo transfer cycles varies between 48-55 %.

33. Are urine pregnancy tests as reliable as blood tests?

Urine pregnancy test can detect the pregnancy hormone - beta hcg , when the levels are beyond a certain threshold. Normally that threshold is around 100 mIU/ml. So when the urine test is strongly positive, it is reliable. But if it is weekly positive or if it is negative, the test needs to be confirmed by doing a blood test for beta hcg.

34. Who gets it?

It affects upto 1 in 6 couples trying to conceive.

35. What can cause infertility?

The various causes of infertility include: • Problem with the production or quality of sperm or eggs. • Structural or functional issues with the female or male reproductive systems. • Hormone or immune conditions in men, women or both.

36. What happens during my initial consultation?

There will be a thorough assessment of both partners, including a detailed medical history and physical examination. Routine tests will be adviced. This will form the basis for further treatment plan.

37. What kind of blood work is generally ordered?

Blood work to assess the hormonal profile such as TSH, prolactin , AMH and Day 2/3 FSH, LH, estradiol will be ordered.

38. What are you testing for on day 2 or 3 blood work?

On a Day 2 /3 blood work which includes FSH, LH, estradiol, we will be able to test the ovarian reserve of the female partner along with AMH and transvaginal pelvic scan findings.

39. What is being analysed in a semen analysis?

o The number of sperm, volume and consistency of the sample. o The size and shape (morphology) and ability to move (mobility) of the sperm, both of which can interfere with penetration and fertilization of an egg.

40. What is the doctor looking for on the trans-vaginal ultrasound?

Transvaginal scan is required to look at the condition of the uterus for the presence of issues like fibroids,adenomyosis and ovaries for ovarian reserve, cysts or Polycystic Ovarian Syndrome (PCOS).

41. What is an HSG? What is a saline sonosalpingogram?

HSG stands for hysterosalpingogram. It is a non-invasive, x ray examination of the uterus and fallopian tubes to find out the patency of the tubes after injection of a contrast agent into the uterus. Saline sonosalpingogram is another procedure to find out the patency of the tubes where saline in injected into the uterus. Simultaneouly, a transvaginal ultrasound is carried out to assess the spill from tubes.

42. What should I expect after the initial consultation?

The cause for infertility is usually found out after the initial consultation and treatment which is most suitable for the partners is discussed.

43. In general, what are the fertility treatments available to me?

It depends on the cause of infertility. You may be advised to take some medications for stimulating the ovary to produce eggs with or without IUI, IVF or ICSI.

44. What is intrauterine insemination (IUI or artificial insemination)?

IUI is the process of inseminating processed semen into the uterus around the time of ovulation to ensure adequate sperms of good quality are available in the female genital tract for fertlizing the released egg.

45. What is IVF (In Vitro Fertilization)?

IVF (In-vitro fertilization) or test tube baby as it is commonly called is a procedure in which the eggs and the sperms are fertilized outside the body and then transferred back to the womb after 2-5 days.

46. What is ICSI?

ICSI – Intracytoplasmic sperm injection, is an IVF procedure in which a single sperm is injected directly into an egg whereas in IVF, about 50,000 to 1,00,000 sperms are inseminated around the eggs and one of them penetrates the egg on its own. ICSI increases the fertilization rates especially in male factor infertility and cases of previous fertilization failure.

47. Can I exercise during my fertility treatment cycle?

Low impact exercises such as walking, yoga is a OK. Keep the exercise to less than four hours a week. A 2006 study, published in Obstetrics and Gynecology, reviewed IVF results for more than 2200 women over a nine year period. They concluded that, “Women who reported exercising 4 hours or more per week for 1-9 years were 40% less likely to have a live birth and were almost three times more likely to experience cycle cancellation and twice as likely to have an implantation failure or pregnancy loss than women who did not report exercise.” Avoid streneous activity around the week of egg retrieval as the side effects of drugs you are taking may cause abdominal bloating, fatigue which will prevent you from exercising. Also there may be a risk of ovarian torsion during streneous activity.

48. Can I dye my hair during fertility treatment? Get a pedicure? Massage?

Limited evidence available suggest that it is safe to dye the hair during fertility treatment as only small quantity of chemicals are absorbed. These are detoxified in the liver. Non toxic, organic options such as henna can be tried which also acts as a conditioner and nourishing agent for the hair. Similarly pedicure and manicure can be opted for during fertility treatment, provided it is carried out in well ventilated areas. Non toxic, chemical free nail polish and remover for the same can be opted for. However due to the unknown chemical exposure, it is best to avoid elective treatments until the end of first trimester(12 weeks)

49. If I spot before my period, is that considered cycle day 1?

NO, if it just spotting for a day or two, it is not considered a menstrual flow. The other causes for spotting before periods include implantation bleed, hormonal imbalance, in women with PCOS, in women on oral contraceptives. Presence of pathology in the genital tract such as infections – Pelvic inflamatory disease or a sexually transmitted disease, uterine fibroid or polyp or an ectopic pregnancy must be ruled out. Visit your physician to explore the cause of spotting.

50. Why do I need a scan on day 2/3 of my period while I am still bleeding?

Scan on day 2/3 of period is the best time to assess the antral follicle count – the ovarian reserve, look for any cysts which may interfere with your response during ovarian stimulation. The endometrial thickness is also looked for, if increased you must undergo further evaluation to rule out intracavitory lesion such as polyp.

51. I am having a lot of cervical mucous, does this mean I am ovulating before the retrieval or IUI?

Drugs taken furing fertility treatment is associated with increased estradiol levels which is the cause for copius cervical mucous.

52. What are the side effects of the medication?

Side effect depends on the drug which is used. Clomiphene, the commonest drug used for ovarian stimulation may cause dizziness, hot flashes, headache, rarely visual distubances. Gonadotropins may cause injection site reactions such as redness or burning sensation which generally resolves in a few minutes to hours. If it persists, you must consult your physician. The other common side effects include ovarian hyperstimulation and multiple pregnancy. The necessary precautions to avoid these side effects will be taken with regular monitoring by your fertility specialist.

53. Are there physical restrictions after an intrauterine insemination (IUI)? What should I expect on the day of the IUI? Can I go back to work? Do I have to take any medications after IUI?

You will have a scan to look for ovulation. The male partner should give the semen sample for processing which generally takes 30-60 minutes. In case of frozen sample, it is thawed and sample preperation done. IUI involves placing this processed sample inside the uterus. You will be asked to lie down for 15-20 minutes after the procedure. You can resume normal activity after this. A few oral/vaginal medication will be prescribed for 2 weeks to aid in implantation of the embryo.

54. Why do you use birth control pills before an IVF cycle?

It is used for 2 reasons: • To time the cycle to the convenience of both patient and physican availability. • To ensure even recruitment and growth of a group of follicles in the IVF cycle.