Joint Commission International
(JCI) Accredited Hospital

In Vitro Fertilization (IVF)

Overview

The Assisted Reproductive Technology (ART) Program at Apollo Bramwell Hospital (a 200 bed multi-disciplinary private hospital) combines the clinical expertise, focus, and innovation of the world-class care and services of one of the nation’s leading hospital.

The ART clinic is equipped with state-of-the-art equipment and follows General Laboratory practice (GLP) according to international standards with strict quality control procedures in place. We focus on having a fertility program with the highest possible in vitro fertilization success rates.

The program has established collaborations with leading hospital and clinics in Europe and Asia in the fields of IVF. This collaboration enables us to provide superior care and support to our patients and their families.

Click here to download patient application form (70Kb) and please send back to info@apollobramwell.com.

 

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In vitro fertilization and Intrauterine Insemination at ABH

IVF involves stimulating the ovaries to produce multiple follicles and eggs, removing the eggs out of the woman, fertilizing them in the laboratory with her partner's sperm and transferring embryos back to her uterus.

IUI is a technique in which a sperm concentrate, suspended in a nutrient culture media, is inseminated into the uterine cavity bypassing the cervical mucus barrier. IUI should be considered as the first line of treatment in most cases of male sub-fertility as well as for unexplained infertility.

These are the most commonly used Assisted Reproductive Techniques (ART). Babies born by the IVF method are referred to as test-tube babies. In most cases, few embryos are transferred into the uterus so as to have at least one implanted. The IVF clinic at Apollo Bramwell Hospital is equipped with state-of-the-art embryology equipments and run by dedicated scientists, clinicians, nurses and technicians.

Click here to download patient application form (70Kb)
Please send back to info@apollobramwell.com

Who should be treated with in vitro fertilization

IVF can be used as an effective treatment for infertility of all causes except for infertile women who have anatomic problems of the uterus or any other anomalies. It is generally recommended and used for couples who have failed to conceive after at least one year of trying and who also have one or more of the following:

  1. Blocked fallopian tubes or pelvic adhesions with distorted pelvis. Women who underwent tubal ligation and are considering tubal reversal surgery. Similarly men who are considering vasectomy reversal surgery might also consider IVF.
  2. Male factor due to low sperm count or low motility. ICSI is an IVF procedure that can fertilize eggs even with poor sperm quality.
  3. 2-4 cycles of failed ovarian stimulation via intrauterine insemination.
  4. Advanced female age - over about 38 years of age.
  5. Decreased ovarian reserve, which means lower quantity (and sometimes quantity) of eggs. A day 3 FSH and estradiol test, antral follicle counts and AMH hormone levels are usually done as screening tests for egg quantity. Impaired egg quantity and quality is usually treated with IVF.
  6. Severe endometriosis.
  7. Unexplained infertility when intrauterine inseminations have failed. Unexplained infertility means standard fertility tests did not identify the cause of the fertility issue.

Click here to download patient application form (70Kb)
Please send back to info@apollobramwell.com

Infertility

Definition

Infertility is the inability to achieve successful pregnancy after 12 months or more of regular unprotected sexual intercourse. Infertility can be divided into two categories:

  • Primary infertility: Infertility without any previous pregnancy.
  • Secondary infertility: Fertility problems occurring in a couple that has conceived on their own and had a child in the past.

Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women over age 35 years.

Incidence

In healthy couples under age 30 who have sex regularly, the likelihood of getting pregnant ranges 25 - 30% per month. A woman's fertility peaks in her early 20s. After age 35 (and especially 40), the probability that a woman can get pregnant drops considerably.

Causes

A wide range of physical and emotional factors can cause infertility. Infertility may be due to problems in the woman, man, or both.

Female infertility may occur when:

  • A fertilized egg or embryo does not survive once it sticks to the lining of the womb (uterus)
  • The fertilized egg does not attach to the lining of the uterus
  • The eggs cannot move from the ovaries to the womb
  • The ovaries have problems producing eggs

Female infertility may be caused by:

  • Cancer or tumor
  • Clotting disorders
  • Diabetes
  • Growths (such as fibroids or polyps) in the uterus and cervix
  • Birth defects that affect the reproductive tract
  • Excessive exercising
  • Eating disorders or poor nutrition
  • Use of certain medications, including chemotherapy drugs
  • Drinking too much alcohol
  • Obesity
  • Older age
  • Ovarian cysts and polycystic ovary syndrome (PCOS)
  • Pelvic infection or pelvic inflammatory disease (PID)
  • Scarring from sexually transmitted infection or endometriosis
  • Surgery to prevent pregnancy (tubal ligation) or failure of tubal ligation reversal
  • Thyroid disease
  • Autoimmune disease
  • Too little or too much of certain hormones

Male infertility may be due to:

  • A decrease in sperm count
  • Sperm being blocked from being released
  • Sperm that do not work properly

Male infertility can be caused by:

  • Environmental pollutants
  • Being in high heat for prolonged periods
  • Birth defects
  • Heavy use of alcohol, marijuana, or cocaine
  • Too little or too much hormones
  • Impotence
  • Infection
  • Older age
  • Cancer treatments, including chemotherapy and radiation
  • Scarring from sexually transmitted diseases, injury, or surgery
  • Surgery to prevent pregnancy (vasectomy), or failure of vasectomy reversal
  • Retrograde ejaculation
  • Smoking
  • Use of certain drugs, such as cimetidine, spironolactone and nitrofurantoin

Unexplained Causes

No obvious cause detected

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How does IVF improve fertility?

In vitro fertilization has the ability top increase the efficiency of human reproduction – a process which is often not very efficient naturally.

  • Essentially, we are involved in a numbers game that gets worse as the female patient and her partner gets old.
  • With IVF we remove multiple eggs - and after careful culture for 3-5 days of the fertilized eggs, we transfer the most viable embryos back to the uterus.
  • Any remaining viable embryos (if there are any) can be frozen for future use by the couple.

In a way, we are compressing several months of "natural" attempts into one menstrual cycle. By transferring the viable embryo(s) directly to the uterus, fertility is improved for many couples who have sperm defects for the men, or issues on the female side related to egg pickup from the ovary, or tubal transport of the embryo to the uterus. Therefore, with IVF:

  1. We stimulate the body to produce multiple eggs (only one follicle with one egg inside develops in a natural menstrual cycle)
  2. We take the eggs out of the ovaries when they're ready (release and tubal pickup of the egg can be inefficient naturally)
  3. We induce fertilization in the lab (sperm or egg issues can cause fertilization problems in a natural situation)
  4. We culture the embryos for 3-5 days and then pick the best one (or more) for transfer to the woman (selection of the best one(s) increases chances of success)
  5. We transfer the embryo(s) to the best location in the middle of the uterine cavity (tubal transport of the embryo to the uterus is bypassed)

Click here to download patient application form (70Kb)
Please send back to info@apollobramwell.com

Fertility Services for both male and female infertility

  • IntraUterine Insemination - IUI
  • In vitro fertilization with Intracytoplasmic sperm injection - IVF with ICSI
  • Semen analysis
  • Embryo Cryopreservation
  • Sperm Cryopreservation
  • Frozen Embryo Transfer

Intra Uterine Insemination (IUI)

IUI is a technique in which a sperm concentrate, suspended in a nutrient culture media, is inseminated into the uterine cavity bypassing the cervical mucus barrier.IUI should be considered as the first line of treatment in most cases of male sub-fertility as well as for unexplained infertility. The male patient will give his semen sample for analysis. The female patient will be treated with medications to stimulate her ovaries to produce eggs.

IVF with ICSI

In conventional IVF, the eggs collected are mixed with a specific number of processed sperm and incubated for a certain amount of time. After fertilization, they are again incubated in vitro and the resulting embryos transferred into the patient’s uterus 2 to 4 days later. To give the patient optimal chance of conceiving, few embryos will be transferred in one cycle. If necessary, the embryos are frozen and stored for later use. This technique is called cryopreservation and requires the written consent of both partners.

IVF with Intra cystoplamic sperm injection (ICSI): This is an advanced technique which has revolutionized the treatment of male infertility. It has raised the hopes of many couples who previously had little or no chance of having their own children. The eggs are retrieved in the same way as in IVF but one spermatozoon from the semen sample is injected directly into the centre of the egg. This effectively overcomes the final barrier to fertilization, which is the zona pellucida or outer shell of the egg. It is common use and preferred to conventional IVF. This procedure is also used in couples in whom fertilization in previous cycles was not successful.

At our centre ICSI is done with sperms which are obtained from any of the following sources:

  1. Ejaculated sample of semen
  2. Cryopreserved sperm

Embryo Transfer

This procedure is simple, requires no anesthesia and is very similar to intra uterine insemination (IUI). The embryos are placed in the uterus with the help of a cannula (narrow plastic tube) passed through the cervix. Following the transfer, the patient is asked to lie in bed for a little while. During this time the nurse gives written instructions for further medication at home. Medicines are given during the cycle to ensure that the endometrial lining is satisfactory. This improves the chance of implantation of the embryos and thus pregnancy.

Post-embryo transfer instructions:

  • The prescription for that next 14 days should be collected before leaving.

  • Once home, the patient should avoid:
       1. Sexual intercourse for a couple of days
       2. Strenuous exercise
  • The prescribed daily injections/medicines, etc. should not be discontinued without consulting the doctor

In case further assistance is required, the patient is advised to call the IVF Laboratory or the Gynecologist/Embryologist at the hospital.

Cryopreservation of sperm and embryos

Cryopreservation is a technique by which extra viable sperm and embryos are frozen in liquid nitrogen at -196 C. The sperm and embryos preserved by this method are used in case of failure of the present cycle or for a second child. When required, the sperm and embryos will be thawed.

Frozen embryo transfer

The frozen sperm and embryos which were cryopreserved, are thawed and transferred into the uterus.

Pregnancy

A pregnancy test is usually carried out on the fourteenth day post embryo transfer. The patient should come or send a blood sample to the IVF Laboratory for conducting the test on the designated day. The discharge summary should be collected while collecting the report.

If the test is positive, there is a pregnancy:

  • Progesterone therapy may be given for the first 8 weeks of pregnancy. This helps in maintaining the hormones levels.
  • An ultrasound scan is done 3 weeks after pregnancy test to confirm the baby’s development and its heart sound.

As in natural conception a miscarriage may occur and or occasionally the baby may develop in the fallopian tube (ectopic pregnancy).

If the test is negative (i.e conception has not occurred), the patient should consult the doctor about the next cycle or other available options. Patients are advised to keep in touch with the IVF Laboratory throughout their treatment.

Medicines Used

Patients may be prescribed different hormonal medicines in varying doses, depending on individual factors such as age, history of polycystic ovarian disease, obesity and response, as observed by ultrasound scans and blood tests.

GnRH agonists

These hormones suppress the action of natural hormones of the pituitary gland (FSH and controlled by external hormones. This process is known as ”downregulation”. GnRH agonists are administered subcutaneously and are given for 8 to 10 days, after which the dose may be modified and given for another 10 to 14 days. Minor side-effects are temporary and the patient must not discontinue the drugs unless advised by the doctor.

GnRH antagonists

These hormones also suppress the actions of FSH and LH. These are administered from day 6 to 7 of menstrual cycle till we decide to discontinue them.

Gonadotrophins

These hormonal injections are given to stimulate the ovaries to increase the production of eggs. Treatment with these hormones must be carefully monitored to prevent excessive ovarian stimulation and tailor the dosage accordingly. These including hMG, FSH,or r-FSH.

Human Chorionic Gonadotrophin (HCG)

This injection is given to trigger ovulation and to initiate the final stage of maturation of oocytes (eggs) before collection. The timing is very important and the injection should be given 35 to 37 hours, before egg collection. If it is delayed for more than 37 hours, ovulation will occur and the eggs will be released into the abdominal cavity from where they cannot be collected. This usually means that the injection has to be given late at night.

Pure micronized progesterone preparation

This preparation is given as injection or vaginal/rectal suppositories to support the luteal phases.

Micronized estrogen preparations

These are available as oral tablets or dermal patches to prepare the endometrium in unstimulated cycles before embryo transfer (frozen/donor).

Click here to download patient application form (70Kb)
Please send back to info@apollobramwell.com

Complications of IVF

Apart from the mental strain faced by the couple undergoing IVF there are a few physical risk also.

  • Ovarian hyper stimulation syndrome (OHSS)
    The medicines taken to stimulate the ovaries may lead to production of an excessive number of follicles, 3 to 5 days after the injection of hCG. OHSS is characterized by enlarged ovaries causing discomfort, weight gain, abdominal and pleural effusion and may require intensive care & management.
  • Multiple pregnancy
    The chance of multiple pregnancy is there because few embryos are transferred into the uterus. Twins are the easier to manage but triplets and higher order pregnancies may have complications, including abortion and pre-term deliveries.
  • Drug allergy
    The patient may be allergic to any of the medicines used during the entire procedure.
  • Anesthesia
    Complications related to the administration of anesthesia may occur.
  • Bleeding and infection
    These are likely during the process of egg collection but are extremely rare.

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Failure of IVF

Failure of IVF could be due to

  • Failure to retrieve eggs
  • Failure of sperms to fertilize the eggs
  • Poor quality of embryos
  • Failure of the proper development of embryos
  • Failure of the embryo to implant

Click here to download patient application form (70Kb)
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Initial Consultation

A detailed medical and surgical (past and present) history of the couple is taken. This is followed by medical examination and fertility evaluation. The outcome of the examination decides the best course of action and nature of the procedure to be undertaken.

All previous investigations and infertility treatments are also discussed. Personalized counseling is provided to every couple by the consultant before accepting them into the IVF program.

Click here to download patient application form (70Kb)
Please send back to info@apollobramwell.com

Entering the ART Program

After a couple is accepted into the ART Program, the following steps are taken:

  1. Registration
  2. Signing of consent forms
  3. Medication to stimulate the  ovaries to form multiple follicles which contain eggs in the treatment cycle
  4. Tracking the development of follicles with ultrasound and blood tests
  5. Collecting the eggs from the ovary by an oocyte retrieval procedure
  6. Collecting a semen sample
  7. Fertilization
  8. Embryo transfer
  9. Pregnancy testing

Registration

The couple is expected to report to the IVF laboratory with all previous investigation reports and prescriptions. The wife should come after fasting for four hours so that if required, a blood test can be conducted on arrival. International patients will be registered and will be given a temporary registration number when requesting the service. Upon arrival to the hospital they will be issued a permanent registration number (UHID)

Consent form

After meeting with the gynecologist, embryologist and psychologist, both partners are asked to sign a consent form for the administration of medicines and IVF procedures. It ensures legal and procedural formalities, which are taken care of with prior consent of the couple.

Drug administration

Treatment may start on the day of registration or day 2 of the treatment cycle. This shall be decided by the consultant in charge of the case (GnRH agonist or antagonist). The staff nurse will demonstrate the method of injection so that the patient can take them at home. The injections should be stored in the fridge, not freezer, and taken daily at the same time to obtain best results. Under no circumstances must the patient discontinue the drugs on her own.

Ultrasound Scan

An ultrasound scan is a painless procedure that helps to track the development of the follicles in a woman’s ovaries. An ultrasound scan of the ovaries is needed at the beginning of menstruation on day 2 or 3 to rule out the presence of cysts and also assess the inner lining of the uterus, that is, the endometrium.

Once treatment for ovarian stimulation by gonadotrophins has started, a repeat scan is performed nearly a week later and further scans are done on alternate days till the follicles reach the right size and the lining of the uterus is of appropriate thickness. The time taken for the follicles to mature differs according to the size of the follicles.

If the response to the drugs is poor, that particular treatment cycle may be cancelled. In such cases, other treatment modalities and options are discussed with the couple.

Blood test for hormonal levels

Before starting on gonadotrophins in the IVF cycle, basal hormone levels, e.g serum FSH, LH, E2 and progesterone, are estimated on the day 2 of menstruation. The level of E2 is estimated periodically coupled with ultrasound scan to monitor the ovarian response and thus tailor the dosage of gonadotrophins.

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Egg Collection

Another consent form has to be signed before the eggs are collected, granting permission for anesthesia or sedation for oocyte (egg) retrieval. On the day of egg retrieval the patient should have been fasting from midnight.

Egg collection is carried out as a day-care procedure under general anesthesia by a transvaginal ultrasound-guided needle aspiration technique. As the patient may feel drowsy for some time after the procedure, she is kept under observation for a few hours.

After recovering from anesthesia the patient is given a drink and asked to pass urine. If there are no unusual signs or symptoms, she is allowed to go home. If abnormal symptoms arise, the patient may be asked to stay overnight.

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Instructions before egg collection

  • The patient should be fasting from midnight
  • She should not wear any jewellery
  • Nail polish must be removed

Ensure that there is someone to take the patient home

The husband must be present until it is certain that an adequate semen sample has been collected & assessed.

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Instructions after egg collection

  • The patient can have a light lunch 4 hours after recovering from anesthesia have worn off.
  • She must have adequate oral fluids
  • Normal activity is permissible when the after-effects of anesthesia have worn off
  • Paracetamol can be taken to relieve the mild-to moderate pain in the lower abdomen.

For any other problems, the patient can talk to her consultant or the staff in the IVF Laboratory

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Semen Collection

It is imperative that semen collection correlates with the retrieval of eggs. Semen is collected by masturbation.

Precautions from intercourse a minimum of 3 or 4 days prior to semen collection

  • Abstinence from intercourse minimum 3 to 4 days prior to semen collection
  • The husband has to come to ABH IVF Department for semen collection
  • Pass urine before collecting semen
  • Wash hands and genitals properly before masturbating to collect semen
  • The hands and genital organs must be washed thoroughly after masturbation and dried using a tissue paper
  • The inside of the container or the LID should not be spilled and the total amount of semen should be collected
  • The lid should not be held by the rim and screwed tight immediately

A faulty technique of semen collection may result in contamination with bacteria and other organism which are harmful for fertilization.

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When to see a fertility specialist?

In general, it is recommended to see a doctor for medical assistance after 12 months of trying to get pregnant on your own. Many couples will start the infertility workup process with their gynecologist, while others prefer to go straight to a fertility specialist. Either option is appropriate. It is also advised to see a specialist sooner if the female partner is over 35 years old. It is prudent to seek medical help for fertility issues without waiting for a year of trying on your own if you have a condition that is a known risk factor for fertility problems, as mentioned above.

The appropriate amount of time to try on your own can be longer, or shorter than one year. For example, if you are only 25 years old and feel that you want to give it more time to occur naturally - you might try on your own for another 6 months before seeing a doctor for help. For couples with a female partner age 40 or older, it is appropriate to see a fertility specialist if not pregnant by 3-4 months of trying to conceive. A high percentage of women over 40 will have age-related issues (egg quality) and will need medical help to get pregnant. If the female partner is 42 or older, it is recommended to see a specialist right away if she wants to have a baby.

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Fertility advice

You do not need to have intercourse all the time in order to get pregnant. If you like it that way, then no problem - it doesn't reduce a couple's fertility potential either. The best fertility advice in terms of frequency of intercourse is at least every 3 days before and during around ovulation.

  • Ovulation is usually on day 14 - if the menstrual cycle length (from day 1 to day 1) is 28 days, or on day 16 if periods are 30 days apart. In other words, ovulation usually occurs 14 days before the next period comes. The egg only lives about 12-24 hours, while the sperm (if normal) will live in the female's reproductive tract for up to 2-5 days - while maintaining the ability to fertilize an egg.
  • Ovulation occurs about 2 weeks before the next menstrual cycle (period) starts. If a woman gets her period every 28 days, the couple should have sex at least every 3 days between the 10th and 18th day after the period starts. Having intercourse more than about 24 hours after ovulation should be fun and all that, but it isn't likely to increase the planetary population.

Click here to download patient application form (70Kb)
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