F & Q

F.A.Q's- Steps of ART

	Steps of IUI 1. Ovarian stimulation

	•	To stimulate 2-3 follicles to mature.
	•	Clomiphine or gonadotropins given to stimulate the growth of follicles

	2. Monitoring of treatment

	•	To measure the growth and number of follicles, individualize drug doses and prevent higher stimulation.
	•	By transvaginal ultrasound scanning (2-3 times during a cycle)

	3. Ovulation trigger

	Injection - h CG 5000 I.U. should be administered taking following criteria into account :
	•	Follicular size should be more than 17 mm.
	•	Endometrium should be more than 9 mm.

	4. Timing of IUI

	•	Usual IUI recommended time is 36 hours post hCG injection
	•	Two IUI's per cycle, one between 18 to 24 hours post hCG and second IUI 36-50 hours after hCG injection is advised

	5. Sperm Collection

	•	Provided by masturbation or coitus interruptus on the day of IUI

	6. Semen Preparation

	•	To stimulate 2-3 follicles to mature.
	•	Clomiphine or gonadotropins given to stimulate the growth of follicles

	7. Insemination

	•	0.5 - 1 ml of sperm preparation is injected through the catheter 0.5 cm below the fundus

	8. Follow up

	•	Luteal support in the form of progesterone passaries or hCG may given. Pregnancy test is advised after 15 days of last IUI

	FAQ about IUI
	1.What is I.U.I?

	•	I.U.I. stands for "Intra Uterine Insemination", a fairy new form of assisted fertilization. I.U.I involves the placing of freshly prepared seprm (from your husband) high in the uterine cavity at a selected time in your menstrual cycle. Conception is then allowed to occur naturally. These procedures are carried out on a outpatient basis and you will not need to be admitted to hospital.

	2. Who needs I.U.I?

	•	Ideally, couples who have unexplained sub ferility and in woman there is no evidence of damaged falloppian tubes. It may alo help those who have minimal endometriosis or some male factor.

	3. How is I.U.I performed?

	•	I.U.I can be divided into five stages:- 1. Stimulation of the ovaries 2. Monitoring egg development 3. Egg release 4. Insemination 5. Follow up
		Stimulation of ovaries Stimulation of the ovaries in a normal menstrual cycle, several follicles which are (little sacs of fluid each containing one egg) begin to grow in each ovary and in absence of pregnancy normally die. With I.U.I. We try to make certain that no more than 2 eggs are released by very careful control of the cycle using fertility drugs.
		Monitoring Egg Development This is performed by and by ultrasound scans which are safe, simple and fast. An instrument called an ultrasound probe is placed in the vagina. The probe then transmits a picture on to a small television screen so that ovarian follicles can be seen and measured. The vaginal probe is less than the tickness of two fingers and does not hurt you, ( a full bladdder is not required). The growth of the follicles is monitored from the 8th day after your period begins and on alternate days after that. When the biggest follicles reaches 18mm -36 mm with two other follicles of over 14 mm in diameter then a different hormone ijection is given to indufe the final stage of egg matration. Sometimes follicles are more than 10mm in diameter at the time of the first ultrasound scan on the 3rd day after your period, if this is the case treatment is withheld in that cycle . Sometimes the ovaries respond inadquately to the drugs and therefore the treatment cycle is cancelled. A further attempt would then be arranged and the amoutn of drug used to stimulate the ovaries increased or another treatment plan organized using different drugs.
		Egg Release
		This follows within 36-48 hours of the injection given for egg release and some women know when it has happened because they experience a lower abdominal cramp like discomfort.
		Insemination
		Your partner will be asked to produce a semen sample which can be taken to the laboratory within half an hour of being produced so that it can be prepared immediately. It is not uncommon for the man to be anxious about having to produce a sample in the hospital a sample in the hospital to order. If you foresee a problem with this, please let us know well in advance. The sperms are carefully prepared by washing them and the healthy sperms are seprated. Approximately 5-30 million in 3 ml will be used for the insemination. A second insemination may be given the next day at the same time. There is of course no need to avoid sexual intercourse while you are undergoing treatment. Your partner should however, abstain for 48 hours( no more) before producing the semen sample which will be prepared for insemination. Apart from this, you can continue your normal sexual relationship.
		Follow up
		If you have not had any bleeding five days after your next period is due, collect an early morning sample of urine and bring it to the hospital. We ought to be able to do a pregnancy test and have result within minutes. Unfortunately folloing normal conception, 1 in 4 pregnancies are lost because of miscarriage. Ectopic pregnancy ( a pregnancy outside the womb). Therefor , we would like everyone to have two scans two weeks and three weeks after their missed period to confrim that the pregnancy is in the womb and that the pregnancy is progressing normally.

	4. what is the Success rate of IUI?

	•	Success Rate Predicting the cahance of succss in any one couple who undergo assisted conception procedures in difficult but generally speaking, an increasing age in the women reduces a successful outome. I.U.I has been claimed to give pregnanay rates up to 35%. I.U.I is however, a recent development and as such has to be evaluated carefully. Its attraction rests on its relative simplicity.

	5. What is the Frequency of Treatment of IUI?

	•	Any sub fertility treatment is stressful for patients. It is advised to follow a treatment cycle by a rest.

	1.Drug treatment

	•	To stimulate several eggs to mature
	•	GnRH agonists to suppress all other hormone activity (jnjections/nasal spray for usually two weeks before gonadotropins and then a further , 10-14 days depending on response)
	•	Gonadotropins to stimulate the growth of follicles and cause ovulation.

	2. Monitoring of treatment

	•	To measure the growth of follicles, individualize drug doses, and prevent serious side effects
	•	By transvaginal ultrasound scanning (two or three times during a treatment cycle)
	•	Sometimes by measuring hormones in blood samples.

	3. Egg collection

	•	usually done under anaesthesia, lasts between 10 - 20 minutes
	•	Guided by transvaginal ultrasound
	•	Collected (32-36 hours after final hormone injection).

	4. Sperm sample provided on the same day as egg collection

	5. Fertilization

	•	Eggs and sperm prepared and cultured together overnight
	•	Eggs examined next day under microscope to see whether fertilization has occurred.

	6. Embryo transfer (usually two or three days after fertilization)

	•	Transvaginal transfer of no more than three embryos
	•	Embryos placed in the womb
	•	Spare embryos usually frozen

	7. Pregnancy testing/monitoring

	•	Pregnancy test is done 12 - 14 days after embryo transfer and ultrasound is done 2 weeks after that.

	Definitions of the terms

	•	Ovum or egg: It is the female gamete or the cell, which develops baby after union with sperm. These are present in ovaries.
	•	Sperm: It is the male gamete, which after fertilization (union) with ovum develops into baby. These are produced in testes.
	•	Uterus: The female organ in which the baby grows.
	•	Fallopian tubes: These are two in number, one on each side of the uterus and these transport ova from ovaries to the uterus.
	•	Ovaries: These are two in number, situated along the side of uterus and have all the ova a women is supposed to have in her lifetime. One ovum matures per month.
	•	Fertilization: The process of union of the ovum and the sperm. Normally, it takes place in the fallopian tube and then the embryo is transported to uterus where it implants.
	•	Implantation: Attachment of the developing embryo in the uterus. Embryo: The early developmental stage after fertilization and before the organs of the baby are formed.

	What do IVF, ICSI, ET and ovum donation mean?

	•	IVF: In-vitro-fertilization (IVF), i.e. the union of egg and sperm is achieved in the laboratory by placing the eggs and sperms, together in a dish in the special media in an incubator under controlled environmental conditions.
	•	ICSI Intracytoplasmic Sperm Injection means fertilization of an egg in the laboratory by injecting a single sperm inside it with the help of a sophisticated machine called micromanipulator.
	•	Ovum donation: When the wife has lost the capacity to produce her own eggs, the eggs then have to be borrowed from another healthy young woman.
	•	ET: Embryo Transfer means the process of transferring the embryos, which have developed after IVF/ICSI/Ovum donation into the uterus for implantation

	Who are the suitable candidates for these procedures? IVF:

	•	Women with tubal block- an absolute indication for IVF.
	•	Infertility of more than 5 years due to any cause.
	•	Women with endometriosis (chocolate cysts)
	•	Previous ectopic pregnancies
	•	More than 6 cycles of unsuccessful IUI (Intra uterine Insemination).
	•	Women with problems of follicular rupture.
	•	Prolonged unexplained infertility.


	•	Women with pelvic TB
	•	Women with previous operations.
	•	Women with previous sterilization operation.
	•	Failed Tuboplasty.
	•	No pregnancy even after repeated cycles of ovulation induction injections despite ovulation.

		Ovum donation
		Who cannot get IVF, ICSI and Ovum donation?

	•	Badly damaged or absent uterus due to operations, tumours or TB.
	•	Severe medical diseases.

	What is the age limit?

	•	IVF & ICSI Chances of success are best with IVF & ICSI if the age of the woman is less than 35 years. Above 40 years, the chances of success decrease markedly. Also the chance of abortion and abnormal babies increase with age.
	•	Ovum donation: There is no age limit for this procedure but the chances decrease with age.. The oldest woman recorded to bear a child is 63 years. However pregnancies above 50 years of age should be undertaken with careful evalution of health risks

	Which tests are required before undergoing these procedures?

	•	Both the husband and the wife need to be investigated thoroughly for the cause of infertility, physical fitness to undertake pregnancy and the IVF procedure and the assessment of the successrate. The egg donor also needs to undergo general examination, ultrasound and basic tests toassess the general health. Medical diseases such as hypertension, diabetes etc need to be diagnosed and treated or controlled before starting the cycle.

	How much time the couple has to spend at the clinic?

	•	One treatment cycle is spread over nearly two menstrual cycles during which many visits to the clinic are required.

	Is admission required?

	•	Woman is required to be admitted for ovum pickup and ET for one day each. Presence of the husband is compulsory only on the day of ovum pick-up for providing the semen sample.

	When is semen required? How much abstinence is required?

	•	Semen is required after ovum pick up. Couple may abstain from sex for 3-4 days before the procedure. Prolonged abstinence should be avoided.

	Whose sperms are taken?

	•	Normally the husband provides the sperms. Donor sperms can be used if the husbands sperms are not suitable for IVF or ICSI. Finally informed consent of both the husband and the wife is essential for this purpose.

	Does the women require extra rest?

	•	No, normal activity may be undertaken after ET. However exertion should be avoided.

	When does one come to know about pregnancy?

	•	Blood test for pregnancy is done 14 days after embryo transfer.

	What is the success rate?

	•	The success rates have improved considerably in the last few years. In women less than 35 years of age about 50% success can be expected at good centres. At times the success rates are better than even 50%. But, the overall average all over the world is about 50% or less. Unfortunately the success cannot be guaranteed. Those centres, which claim guarantee are only misguiding the people.

	What are the major reasons for failures?

	•	Increased age of the female partner, implantation problems and some other unexplained factors can cause failures.

	Are there increased chances of abortion?

	•	No. There is 15-20 % loss even in normally conceived pregnancies. The same risk is there for the IVF & ICSI pregnancies too.

	What are the major problems?

	•	Increased emotional stress because of the high costs; time consuming treatment and success rate of about 50%. Risks of multiple pregnancies and hyperstimulation syndrome are also increased.

	Does the mother have to take complete bed rest during pregnancy?

	•	No. However, being a high risk pregnancy, extra care is required.

	Can the sex of the baby be selected?

	•	No. Biopsy taken from an embryo can detect certain genetic diseases with very sophisticated techniques in selected laboratories of the world. Again the sex selection claims are misleading, unscientific and also illegal.
	•	Sometimes by measuring hormones in blood samples.

	What is the cost of one cycle?

	•	The hospital cost of one cycle are about Rs. 80,000 at present. Further Rs. 50-60,000 more are required for purchase of medicine. The costs have direct relationship with Dollar-Rupee exchange value.

	How many cycles can be tried?

	•	The costs cover only one cycle. Three four cycles can be undertaken if the ovarian response is satisfactory. However each additional cycle costs the same as the first.

	Is IUI also called test tube baby?

	•	No. Strictly speaking in medical language, only the IVF & ICSI babies are called test tube babies