• Infertility cases are different for every couple, with many seeking assistive tech
• There is no surgery involved in the IVF treatment at any point as catheter is used
Couples struggling to get or stay pregnant are now seeking different forms of assisted reproductive treatment to get children.
In assisted reproductive treatment, the egg is fertilised by the sperm outside the body in a laboratory.
An example of such treatment is Invitro Fertilisation, where the eggs and sperms are left in a lab dish to fertilise on their own.
While IVF is becoming more common, fertility specialist Dr Rajesh Chaudhary said no one ever walks into a fertility clinic demanding to get IVF treatment.
Dr Chaudhary, based at Fertility Point in Upper Hill, said all couples usually walk in saying they want a baby.
He said infertility cases are different for every couple.
A couple may have been pregnant before but they are struggling to sire another.
There are couples that never had a child before and are struggling to conceive.
There are also couples with low sperm count or blocked fallopian tubes.
Dr Chaudhary said the first move is always to do fertility tests on both the man and the woman.
"That is how we know the fertility potential of the person," he said.
He says a fertility test for a man is always the easiest as all he needs to do is give his semen as specimen, while the main test is conducted on the woman.
Men give their sperm for analysis, during which the doctor checks the sperm count, the sperm morphology, which is its appearance and the motility of the sperm (movement of the sperm).
Dr Chaudhary said if there is a defect in the sperm, perhaps the sperm count is low, below 15 million, and the motility is also low, doctors try to correct the situation with simple medicine.
"But in some cases if the problem is very severe, like the count is too low, let's say at 5 million or 10 million, and the motility is also low, then we do some other tests, like an ultrasound, hormonal tests and a physical examination as well," he said.
Dr Chaudhary said if the ultrasound shows the man has a varicocele, the doctors decide how to deal with it either through surgery or treatment.
"This is a condition where the vein supplying blood to the testis got dilated, making the testis a bit heated up, thus compromising its ability to produce sperms," he said.
In case the issue happens to be hormonal, which can come about due to obesity, the man is advised to cut some weight to achieve hormonal balance.
If the condition is severe, Dr Chaudhary said the only solution is to go for Intracytoplasmic Sperm Injection (ICSI).
ICSI is an advanced form of IVF, where sperm is injected into the egg directly.
"We load the sperm in a fine needle then we inject the needle into the egg then we release the sperm . This makes the fertilisation rate higher than the IVF process," he said.
Dr Chaudhary said the ICSI procedure is mostly used when a man's sperm count is too low or motility is low.
For a woman, Dr Chaudhary said the fertility test involves hormonal tests, blood tests and serum AMH test (anti-müllerian hormone), which tells the ovary reserve.
"We check ovary reserve to know how many eggs we are likely to retrieve for an IVF, how many eggs are there in the ovary and the number of follicles present. Follicles are potential eggs in a woman," he said.
A woman also undergoes a pelvic ultrasound to check for any fibroids.
"We check how is the womb lining is. It is important to know the condition of the womb because that is where the embryo gets attached," Dr Chaudhary said.
Additionally, doctors check for any cysts in the ovary. Dr Chaudhary said conditions such as cysts and fibroids can compromise the procedure, thus, they are treated before IVF treatment commences.
"Like, if she has fibroids affecting the womb lining, we ask her to go get the fibroids removed," he said.
"If there is any polyp in the womb lining, we ask them to go for hysteroscopy to remove the polyps."
Dr Chaudhary said some women have fluid in the fallopian tube, which must also be removed before the IVF procedure. IVF treatment may commence once the compromising conditions are dealt with.
After the fertility tests, the doctor consults with the couple again and informs them of their fertility situation and the best treatment option.
If it is decided that IVF be used, the woman is put on pre-IVF medication to boost her egg production for retrieval. At this point, the doctor has already decided how many eggs will be retrieved, but generally, 10 eggs are required for a good success rate.
The IVF treatment starts from the second day of one's periods.
"We call them on the second day of their period, then we do a scan to see how many follicles are there. We might do a hormone test," Dr Chaudhary said.
However, sometimes the ovarian reserve may be low, making it impossible to get 10 eggs. In such a situation, doctors increase the dose of the IVF injections.
The IVF injections are started from the second day of one's periods for 10 days to increase egg production.
"The purpose of giving this injection is to make all the follicles grow simultaneously because from the 11th day to 12th day, there is egg retrieval," Dr Chaudhary said.
Normally, out of 10 follicles, a woman will release one egg during her natural cycle.
"But in IVF injection, we try to grow all those 10 follicles so we get more eggs. So this egg development may take about eight to 10 days, or maybe 11 days," he said.
In between the 10 days of egg development, the patient is called in two to three times for doctors to monitor the follicle development.
Dr Chaudhary said the monitoring is done through blood tests and scans.
When the follicles are ready, the patient is called in for egg retrieval, which is done under anaesthesia.
"On the same day, the husband needs to come or we must have their frozen sperm prior because we need to fertilise the egg," he said.
Let it be known that there is no surgery involved for the IVF treatment at any point.
The doctor harvests one's eggs using a catheter, which is inserted into the vagina while viewing what is happening through a microscope.
EMBRYO AND EMBRYOLOGIST
Once the egg retrieval is done after the 10th day, the egg is handed to the embryologist, who will prepare both the egg and the semen for fertilisation.
"The success of IVF largely depends on the embryologist's work, which is delicate, and the maintenance of the embryology lab," Dr Chaudhary said.
Embryologist Dr Manju Chaudhary said it is possible for her to do her work perfectly but implantation fails to take place.
Once Dr Manju receives the fluids containing the eggs and sperms, she first screens them to collect the eggs and sperms.
"The eggs are kept in an incubator for 2 hours as I screen the sperms in search of the best ones," Dr Manju said.
With the eggs and best sperm at hand, Dr Manju then proceeds to introduce them to each other for fertilisation.
For IVF, the sperm is allowed to get to the egg on its own in a culture dish, while for ICSI, it is injected directly into the egg.
Dr Manju conducts fertilisation checks in the incubator to see whether the eggs got fertilised or not. Fertilisation continues between day three to day five.
"When it gets to the third or fifth day after fertilisation, the embryo is ready for transfer," the embryologist said.
Dr Manju said the most difficult part of her work is handling a woman who is almost past fertility age, telling her that her one last egg did not get fertilised.
At times, some men come with poor quality sperm, and she struggles to get even a single sperm from their fluid.
"Generally, out of 10 eggs, eight would get fertilised on the first day. At the end of the process, I would have at least two or three good embryos in hand," she said.
Once the embryo is ready, the doctors now plan for embryo transfer, and at this point, Dr Manju's work is done.
"For us, we have adopted the principle of frozen embryo transfer. This is where we freeze the embryo, and the next cycle after the egg retrieval, we call the couple," Dr Chaudhary said.
When the woman reports to the hospital during their subsequent cycle, she is given some oral medicine, which will prepare her womb lining to get ready for implantation by 10 to 15 days.
Once the womb lining is ready, doctors now prepare for the embryo transfer process.
At this point, the frozen embryo is first thawed then loaded in a fine catheter, then transferred into the womb lining.
The number of embryos transferred depends on a number of factors, such as the age of the woman. The older the patient, the more embryos will be transferred into her womb.
"Quality of the embryo transferred is also considered, the number of times one has tried the procedure before unsuccessfully and how many kids they want," he said.
However, Dr Chaudhary warned against asking for twins as it is a very complicated pregnancy.
"A woman's womb is meant for a single pregnancy. We are not pigs or rabbits. Though multiple pregnancies have happened, they are not common," Chaudhary said.
The stage of the embryo is also considered. If it is a three-day embryo, more are transferred as it has lesser chances of implanting, unlike a five-day embryo, which has higher chances.
"If it is a day-five embryo, then we don't put more than two in the womb," he said.
For day-three embryos, three are transferred into the womb to increase chances of implantation.
"The implantation potential of one embryo is about 30 to 40 per cent. So not all embryos have the potential to get implanted. To increase the chances of a successful implantation, we transfer three embryos," he said.
Two weeks after the embryo transfer is done, a blood test for pregnancy is done.
It is possible to get twins through IVF treatment because when three embryos are transferred into the womb, two or three might attach and one might get even triplets.
Though a woman of any age can use IVF to get babies, Chaudhary said it is good to use one's eggs before the age of 35.
He said after 40, there is a low chance of having a healthy baby. Chaudhary advised that one over the age of 40 uses a donor egg for such a treatment to get healthy babies.
"Uteruses don't age. They can hold babies up to the age of 55, but eggs reduce in quality," he said.
Let it be known that IVF is not necessarily done because the woman has infertility issues.
Imagine what a woman goes through. There is a blood test, a series of ultrasounds and a series of other tests. Yet a husband just has to come and give semen. That is all, but they are still reluctant
Dr Chaudhary said most times, women go to the clinic on their own and do the fertility tests only to find that they are clinically okay.
He said most husbands are reluctant to visit the fertility clinic.
"Imagine what a woman goes through. There is a blood test, a series of ultrasounds and a series of other tests. Yet a husband just has to come and give semen. That is all, but they are still reluctant," he said.
Dr Chaudhary said when a couple is struggling to conceive, 30 to 40 per cent of the time, it is the man's fault.
He said a man may have had children before but struggle to impregnate a woman again.
This is because the testis, like a woman's reproductive organ, can deteriorate over time, making the man infertile.
"This is most common these decades because of the improper lifestyles people are leading and the environmental factors that can make someone infertile even if he was fertile five or 10 years back," Dr Chaudhary said.
Additionally, a man might have a condition where there is no sperm in the semen. In other words, he may be azoospermic.
The doctor urged men to go for fertility tests as they might also have infertility issues.
Fertility Point customer experience head Yunis Dakane said the treatment is very costly and requires one to have a lot of emotional support throughout.
Dakane said a lot of counselling, both financial and emotional, is done before the couple undergoes the treatment.
He said there are times the procedure might fail in that the embryos never attached to the womb or the woman miscarried.
"If the procedure failed, we try to do a follow-up to understand what caused the failure," he said.
Dakane said there are pregnancies that are not complicated and the patient is handed to her gynaecologist after the first trimester.
"For a complicated pregnancy, we still hand you over to your gynaecologist, but we follow up from afar to ensure a live baby came through," he said.
All in all, the fertility specialists said there is hope for every couple out there to sire children.