Dr. Prasenjit Kr. Roy

MBBS, MS (G&O), MRCOGI (London)
Fellowship in Reproductive Endocrinology & Infertility (Tel-Aviv University, Israel)

FREQUENTLY ASKED QUESTION

1) What is Laparoscopy?

Laparoscopy is an operation done to look inside your abdomen with a thin instrument called a laparoscope. Through small holes in your tummy, the doctor looks, examines and operates (if needed) without making large cuts.



2) What are the advantages of a laparoscopic surgery?

In conventional surgery a long incision is made to gain entry into the abdominal cavity and operate. This result in increased post-operative pain, longer stay in hospital, delayed recovery, long and ugly scars, higher chance of wound infection and a higher chance of hernia. The incidence of all these are considerably reduced by a laparoscopic surgery.



3) What is to be expected after a laparoscopy surgery?

There may be some discomfort in the abdomen for a day or two after laparoscopy due to the presence of some carbon dioxide gas. If the surgery is uneventful, feeding can be started on the same day once the patient has recovered completely from the effects of anesthesia. Before you go home you will be given advice about caring for the surgical wounds and when you will need to come back for a follow-up appointment or to have stitches removed. Complete recovery may take longer if any surgery has been carried out. It is important to follow the advice of your surgeon about physical activity, rest and returning to work.



4) What is a hysteroscopy operation?

A hysteroscopy is an operation done to evaluate the inside of the uterine cavity and if necessary operate on the same.



5) How exactly is it done?

A narrow telescope with an illuminated lens at its end is introduced in the uterine cavity through the cervix or neck of the womb. For clear vision, the uterine cavity needs to be distended, which is done with gas or some fluid.



6) When may a hysteroscopy operation be needed?

Hysteroscopy for diagnostic purposes is usually performed to assess the cause of sub fertility or find out the cause of abnormal bleeding. It may also be done to remove polyps, resect septae, release adhesions and retrieve lost IUCDs.



7) When Is A Woman's Most Fertile Time?

• A woman's most fertile time is during ovulation. Ovulation typically occurs within day 11 through day 21 of a woman's cycle.
• Counting from the first day of a woman's last period, day 1 is the first day a woman starts bleeding, and the 11th day is most likely the earliest day a woman will ovulate. The 21st day is most likely the last. A woman's period comes between the 28th and 32nd day of the cycle. This pattern may differ slightly with each woman depending on a variety of factors.



8) Is Infertility A Medical Problem Related To The Woman Only?

• Infertility is a medical condition that is found in both men and women, and men and women are affected almost equally.
• With men, declining sperm counts, testicular abnormalities, and decreased reach of climax are common causes of infertility.Shop Products to Help Increase Sperm Count
• With women, the most common causes are tubal blockage, endometriosis, PCOS, and advanced maternal age which affects egg quality/quantity. Shop Products to Help Female Reproductive Health



9) What is Infertility?

Infertility is a disease of the reproductive system that impairs one of the body's most basic functions: the conception of children. Conception is a complicated process that depends upon many factors: on the production of healthy sperm by the man and healthy eggs by the woman; unblocked fallopian tubes that allow the sperm to reach the egg; the sperm's ability to fertilize the egg when they meet; the ability of the fertilized egg (embryo) to become implanted in the woman's uterus; and sufficient embryo quality.

Finally, for the pregnancy to continue to full term, the embryo must be healthy and the woman's hormonal environment adequate for its development. When just one of these factors is impaired, infertility can result.



10) What Causes Infertility?

No one can be blamed for infertility any more than anyone is to blame for diabetes or leukemia. In rough terms, about one-third of infertility cases can be attributed to male factors, and about one-third to factors that affect women. For the remaining one-third of infertile couples, infertility is caused by a combination of problems in both partners or, in about 20 percent of cases, is unexplained.

The most common male infertility factors include azoospermia (no sperm cells are produced) and oligospermia (few sperm cells are produced). Sometimes, sperm cells are malformed or they die before they can reach the egg. In rare cases, infertility in men is caused by a genetic disease such as cystic fibrosis or a chromosomal abnormality.

The most common female infertility factor is an ovulation disorder. Other causes of female infertility include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a sometimes painful condition causing adhesions and cysts). Congenital anomalies (birth defects) involving the structure of the uterus and uterine fibroids are associated with repeated miscarriages.



11) What Causes Infertility?

No one can be blamed for infertility any more than anyone is to blame for diabetes or leukemia. In rough terms, about one-third of infertility cases can be attributed to male factors, and about one-third to factors that affect women. For the remaining one-third of infertile couples, infertility is caused by a combination of problems in both partners or, in about 20 percent of cases, is unexplained.

The most common male infertility factors include azoospermia (no sperm cells are produced) and oligospermia (few sperm cells are produced). Sometimes, sperm cells are malformed or they die before they can reach the egg. In rare cases, infertility in men is caused by a genetic disease such as cystic fibrosis or a chromosomal abnormality.

The most common female infertility factor is an ovulation disorder. Other causes of female infertility include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a sometimes painful condition causing adhesions and cysts). Congenital anomalies (birth defects) involving the structure of the uterus and uterine fibroids are associated with repeated miscarriages.



12) How is Infertility Diagnosed?

Couples are generally advised to seek medical help if they are unable to achieve pregnancy after a year of unprotected intercourse. The doctor will conduct a physical examination of both partners to determine their general state of health and to evaluate physical disorders that may be causing infertility. Usually both partners are interviewed about their sexual habits in order to determine whether intercourse is taking place properly for conception.

If no cause can be determined at this point, more specific tests may be recommended. For women, these include an analysis of body temperature and ovulation, x-ray of the fallopian tubes and uterus, and laparoscopy. For men, initial tests focus on semen analysis.



13) How is Infertility Treated?

Most infertility cases -- 85 to 90 percent -- are treated with conventional therapies, such as drug treatment or surgical repair of reproductive organs.



14) What impact does infertility have on psychological well-being?

Infertility often creates one of the most distressing life crises a couple has faced. The long-term inability to conceive a child can evoke significant feelings of loss. Coping with the multitude of medical decisions and the uncertainties that infertility brings can create great emotional upheaval for most couples. Many couples experience anxiety, depression, and feelings of being out of control or isolated. For more information, view the FAQs About the Psychological Component of Infertility.



15) Is infertility just a woman's problem?

No, infertility is not always a woman's problem. In about one-third of cases, infertility is due to the woman (female factors). In another third of cases, infertility is due to the man (male factors). The remaining cases are caused by a mixture of male and female factors or by unknown factors.



16) What causes infertility in men?

Infertility in men is most often caused by:
• Problems making sperm -- producing too few sperm or none at all
• Problems with the sperm's ability to reach the egg and fertilize it -- abnormal sperm shape or structure prevent it from moving correctly

Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury. For example,cystic fibrosis often causes infertility in men.



17) What increases a man's risk of infertility?

The number and quality of a man's sperm can be affected by his overall health and lifestyle. Some things that may reduce sperm number and/or quality include:

• Alcohol
• Drugs
• Environmental toxins, including pesticides and lead
• Smoking cigarettes
• Health problems
• Medicines
• Radiation treatment and chemotherapy for cancer
• Age



18) What causes infertility in women?

Problems with ovulation account for most cases of infertility in women. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods.

Less common causes of fertility problems in women include:
• Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy
• Physical problems with the uterus
• Uterine fibroids



19) What things increase a woman's risk of infertility?

Many things can affect a woman's ability to have a baby. These include:
• Age
• Stress
• Poor diet
• Athletic training
• Being overweight or underweight
• Tobacco smoking
• Alcohol
• Sexually transmitted diseases (STDs)
• Health problems that cause hormonal changes



20) How Is Female Infertility Treated?

Female infertility can be treated in several ways, including:

• Laparoscopy - Women who have been diagnosed with tubal or pelvic disease can either undergo surgery to reconstruct the reproductive organs or try to conceive through in vitro fertilization (IVF). Using a laparoscope inserted through a cut near the belly button, scar tissue can be removed, endometriosis treated, ovarian cysts removed, and blocked tubes opened.

• Hysteroscopy - A hysteroscope placed into the uterus through the cervix can be used to remove polyps and fibroid tumors, divide scar tissue, and open blocked tubes.

• Medical Therapy - Women suffering from ovulation problems may be prescribed drugs such as clompiphene citrate (Clomid, Serophene), letrozole, or gonadotropins (such as Gonal F, Follistim, Humegon and Pregnyl), which can lead to ovulation. Gonadotropins can induce ovulation when Clomid or Serophene do not work. These drugs also can enhance fertility by causing multiple eggs to ovulate during the cycle (normally, only one egg is released each month). Gonadotropin therapy may be offered for unexplained infertility or when other factors have been corrected without resulting in pregnancy.Metformin (glucophage) is another type of medication that may restore or normalize ovulation in women who have insulin resistance and/or PCOS (polycystic ovarian syndrome).

• Intrauterine Insemination - Intrauterine insemination refers to an office procedure in which semen is collected, rinsed with a special solution, and then placed into the uterus at the time of ovulation. The sperm are deposited into the uterus through a slender plastic catheter that is inserted through the cervix. This procedure can be done in combination with the previously listed medications that stimulate ovulation.

• In Vitro Fertilization- IVF refers to a procedure in which eggs are fertilized in a culture dish and placed into the uterus. The woman takes gonadotropins to stimulate multiple egg development. When monitoring indicates that the eggs are mature, they are collected using a vaginal ultrasound probe with a needle guide. The sperm are collected, washed, and added to the eggs in a culture dish. Several days later, embryos -- or fertilized eggs -- are returned to the uterus using an intrauterine insemination catheter. Any extra embryos can be frozen for later use, upon the consent of the couple.

• ICSI - Intracytoplasmic sperm injection is used when there is sperm-related infertility. The sperm are injected directly into the egg in a culture dish and then placed into the woman's uterus.

• GIFT (Gamete iIntrafallopian Tube Transfer) & ZIFT (Zygote Intrafallopian Transfer)- Like IVF, these procedures involve retrieving an egg from the woman, combining with sperm in a lab then transferring back to her body. In ZIFT, the fertilized eggs -- at this stage called zygotes -- are placed in the fallopian tubes within 24 hours. In GIFT, the sperm and eggs are mixed together before being inserted.

• Egg Donation - Egg donation helps women who do not have normally functioning ovaries (but who have a normal uterus) to achieve pregnancy. Egg donation involves the removal of eggs -also called oocytes -from the ovary of a donor who has undergone ovarian stimulation with the use of fertility drugs. The donor's eggs are then placed together with the sperm from the recipient's partner for in vitro fertilization. The resulting fertilized eggs are transferred to the recipient's uterus.

Medical therapy and in vitro fertilization can increase the chance of pregnancy in women diagnosed with unexplained infertility.




21) How long does an egg retrieval take?

Egg retrieval is a fairly rapid procedure. The length of the procedure depends on how many follicles are present. Also the accessibility of the ovaries will determine how long the procedure will take. Accessibility means how easy is it to reach the ovaries with the ultrasound probe, whether they have a tendency to move away from the probe and so on. The typical egg retrieval will take from 20-30 minutes.



22) Is the egg retrieval painful?

We do our egg retrievals under anesthesia; our patients are asleep. Our anesthesia specialists use medications which heavily sedate you. You will be "asleep" however; you will not require a breathing tube. The beauty of this approach is that you will feel absolutely nothing, remember absolutely nothing, and will have few of or none of the typical side effects of anesthesia such as nausea and vomiting.



23) Will the egg retrieval damage my ovaries?

The data we have available tells us that it does not. There have been many women who have undergone multiple egg retrievals. The fact that they have responded to stimulation on subsequent occasions and produced eggs and pregnancies on these occasions implies that the ovaries are OK after egg retrieval. There have been some limited studies looking at the appearance of the ovaries in women who have had egg retrievals and subsequent laparoscopic surgery. In those patients, the findings were normal.



24) Is bleeding expected after the egg retrieval?

Vaginal bleeding is not uncommon after an egg retrieval. Usually this bleeding is from the needle puncture sites in the vaginal wall. It is usually minor and similar to a period or less. The bleeding experienced is analogous to the bleeding that will take place from an IV or from the arm after blood has been drawn.



25) Is it normal to retrieve an egg from every follicle?

Not necessarily. Although we will usually get an egg from most mature sized follicles, most women will have a mixed group of follicles after ovulation induction. Some of those follicles will have immature eggs or post mature eggs, which may not be identifiable so they will seem to have been "empty" follicles.



26) Is the embryo transfer painful?

The embryo transfer does not require any anesthesia. It is performed using a speculum that allows the doctor to see the cervix, (like a Pap smear) and is very similar in technique to an intrauterine insemination (IUI). Usually the woman feels only the speculum and nothing else.



27) Is bed rest recommended after the embryo transfer?

It is really not clear that prolonged rest after transfer is helpful. In nature, the embryo floats freely in the endometrial cavity for a number of days before implantation and it will do the same in an IVF cycle. We do recommend that you take it easy following transfer for the rest of the day, but routine work activities can be resumed the next day. If there is an increased risk of Ovarian Hyperstimulation, we will recommend prophylactic bed rest.



28) Can anything be done to improve embryo quality?

Ultimately the answer is no. If an embryo is of poor quality because it is genetically abnormal, there is nothing that can be done to salvage it. However, there are procedures that we do that can improve the chances of a borderline embryo. These include use of assisted hatching. It has been shown that procedures such as these can increase implantation rates in couples with a poor prognosis.



29) Is assisted hatching performed on all embryos?

In some cases yes. We have good data showing that in some groups (e.g. women over 38 years of age, previous failed IVF cycles, unusually thick zonae pellucida) assisted hatching will increase the implantation and pregnancy rates.



30) What is done with any "leftover" embryos?

Embryos which are not transferred in the retrieval cycle are maintained in culture to determine if they develop to the blastocyst stage. If they do, they will be cryopreserved, if that is your wish.



31) How soon after IVF can a pregnancy test be performed?

Since HCG is used to finalize egg maturation, a pregnancy test (which is a measurement of hCG hormone in the urine or blood) will be positive for a number of days following egg retrieval. Some women will metabolize the hormone quickly and it will be out of the blood stream in about a week, while others may take up to 9 or 10 days to do so. We therefore recommend that a pregnancy test not be performed until 12-14 days after the egg retrieval.



32) How long of a wait is recommended between a failed IVF cycle and trying again?

We would recommend at least one full menstrual cycle of waiting before undergoing IVF a second time. We know that it can take up to 6 weeks for inflammation to resolve; therefore, it is reasonable to wait a similar amount of time before restarting the process.



33) Are there limitations on the number of IVF tries per couple?

We find that most couples will get pregnant within 3 tries. Occasionally, there may be a reason to do a 4th attempt but that is not common. More than this would really require extenuating circumstances such as a miscarriage due to a non-recurring reason.

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