What are the common causes of female infertility?

The common conditions causing female infertility are:

• PCOS or polycystic ovarian disease

• Endometriosis

• Fallopian tube damage like tubal block, hydrosalpinx, salpingitis, etc.

• Uterine fibroids, adenomyosis

• Female tuberculosis

• Poor ovarian reserve or low AMH

• Advanced age > 38 years.

When should I consult a doctor?

A woman can consider visiting a doctor if she has not been able to conceive after one year of unprotected intercourse. She can consult early in six months only if:

• Age is more than 35 years.

• The menstrual cycles are irregular.

• Have had an operation for conditions in the ovary.

• Suffering from PCOS or endometriosis.

Should I see a gynaecologist or an infertility specialist?

It is always a good idea to see a specialized doctor with experience in infertility management for consultation.

What should I expect in my first consultation?

A detailed history & examination will be done by the infertility specialist. It is a good idea, to be frank with your doctor and discuss all the issues one is facing. A transvaginal ultrasound will also be done in the same sitting to look at the uterus & ovaries. Also, an initial set of investigations may be advised depending on the history & ultrasound examination.

What are the initial investigations done?

Initially, depending on the history and ultrasound report, the doctor might prescribe investigations like hormone analysis including FSH, LH, AMH, TSH, Prolactin, OGTT. She might look for patency of tubes using a hysterosalpingogram. Also, it is imperative to rule out male causes of infertility by a semen analysis as both male and female factor is seen in 25-30% of infertile couples.

What will be the treatment plan?

The treatment depends on the condition a woman is suffering from.

• PCOS- ovulation induction, weight loss, balanced diet

• Tubal disease- laparoscopy/IVF

• Endometriosis- laparoscopy/IUI/IVF

• Unexplained infertility- IUI/IVF

• Advanced age IUI/IVF

What are the success rates of these treatments?

With increasing advances in reproductive medicine, more and more fertility treatments are available with a high success rate. So, discuss with a fertility expert to choose the treatment that is tailored to suit individual needs.

How do you diagnose male infertility?

• A thorough history and physical examination are the first line in diagnosing male infertility.

• The backbone of investigating the husband is semen analysis. This simple, non-invasive test can give us wealth of information. In simpler layman terms a man must be producing healthy motile sperms in millions of number which are able to fertilize egg. So, if there is any issue with number (COUNT), movement (MOTILITY) or quality (MORPHOLOGY) of sperms, there will be difficulty in penetrating egg (FERTILISATION) resulting in infertility.

Where can you get semen analysis done?

The semen for examination collected by masturbation can be done in any pathological lab. The sample will then be seen under microscope. However, it is a good idea to go for a semen analysis in an IVF lab as their semen will be examined by a trained andrologist or embryologist. So, one will be looking at a more precise report.

Are there any precautions to be taken before semen analysis?

• Before undergoing semen analysis, there should be an interval of 3-7 days of abstinence.

• There should be a gap of only 3-7 days in intercourse as if there are higher gaps, we might find more dead sperms.

• It is a good idea to give your sample inside the lab only as then sperms are not exposed to colder temperatures.

• However, if you will like to go for a home collection, take care that the time from collection of samples to depositing it in the lab is less than 30 minutes

• Do not go for semen analysis if you have recently suffered from illness.

Are there any additional tests recommended?

Depending on the semen analysis report further tests like ultrasound scrotum, hormonal tests like serum FSH, prolactin etc. might be needed. Specialized tests like genetic testing, DNA fragmentation test is needed in few settings.

What are the treatment options?

With advancement in male infertility treatment strategies, more and more patients with male infertility can have their own biological child. The treatment options can start from medical therapy in fore of drugs to IUI or intrauterine insemination to advanced assisted reproductive techniques like ICSI (Intra-cytoplasmic sperm injection), surgical sperm retrieval techniques like PESA/TESA (Percutaneous epididymal sperm aspiration or Testicular sperm aspiration) etc.

Is there any precaution needed in diet or lifestyle to improve sperms?

A good healthy balanced lifestyle and diet are the cornerstone for healthy sperms. It is important avoid smoking and alcohol consumption when you are trying to conceive. Anabolic steroids should be avoided as they are known to cause reduced sperm number.

Diagnostic methods for women

• Ultrasound of the lower abdomen

• Hormones levels

• X-ray of uterus and fallopian tubes – hysteron-salpingography HSG

• Hysteroscopy

• Laparoscopy

• Genetic examination

• Immunological tests

Diagnostic methods for men

• Sperm analysis.

• Sperm cultivation.

• Andrological test.

• Sperm acrosome testing.

• DNA fragmentation of sperm.

• Immunological tests.

• Hormonal tests.

What is ovulation Induction?

Ovulation induction in simpler terms means inducing egg formation in patients in whom eggs are not forming naturally like patients with polycystic ovarian disease (PCOD) or hypogonadotropic hypogonadism. This is different from inducing formation of multiple follicles for IUI or IVF.

Who needs Ovulation induction?

Normally in a woman in each menstrual cycle, ovulation happens in the middle of a cycle. This is the time egg is released in the body and she is most fertile. Different strips or apps designed to help a woman conceive naturally try to predict this time of ovulation and thus the most fertile period. But in patients with Polycystic ovarian disease, eggs are not being released in the mid cycle due to hormonal imbalance. They suffer from anovulation i.e.; eggs not being released; hence are unable to conceive naturally. In another subset of patients called hypogonadotropic hypogonadism, the number of hormones being released from brain is too low, hence no eggs are formed, resulting in difficulty in conception.

Are there any prerequisites for this treatment?

For ovulation induction treatment to work, it is important to ascertain there is no difficulty which can hamper conception naturally. The uterus should be normal, Fallopian tubes patent and no issues with the husband semen analysis.

How is ovulation induction done?

Induction of egg formation in patients with PCO or any other reason for anovulation can be done by multiple drugs. There are oral drugs available like clomiphene citrate, etc. Also, in patients not responsive to oral drugs , injections can be used. These injections can be used alone or in combination with oral drugs.

Who does ovulation induction?

A gynecologist can do ovulation induction cycles. However, if a woman has had previously failed ovulation induction cycles, it is a good idea to meet a fertility expert or an IVF consultant who is specially trained in this field of reproductive endocrinology.

How is the cycle monitored?

The response to drugs is monitored by using transvaginal sonography. This ultrasound is called follicular monitoring or scanning. The benefit of getting treatment done with an IVF specialist like me is that I will myself monitor the patient’s cycle by ultrasound, rather than a sonologist.

Do I need an ultrasound daily?

No, there is no need for daily ultrasound. Ultrasound is usually done on day 2 of periods. Also, on Day 10 of cycle and depending on follicular size on one or more occasions to confirm follicle rupture.

What is the success rate of ovulation induction?

Ovulation induction, as it relies on natural conception, gives a success rate of 15-20%. If done by experienced hands in patients with PCO, almost 85-90% patients conceive by this method, without the need for an IVF cycle. I know my highest success rates in this subgroup of patients and helps them conceive naturally.

What is Intrauterine Insemination (IUI)?

The process of injecting sperms inside a woman’s womb at the time of ovulation is called intrauterine insemination or IUI. This is an outpatient procedure and does not require anesthesia or any special precaution.

Who needs Intrauterine Insemination?

IUI is one of the most common fertility treatments practiced in India. It has been by gynecologists for every indication in the book. But in reality, there are only very few indications in which it is absolutely indicated. These are:

• Male Infertility: An IUI might help a patient if there are mild male issues i.e there are mild issues in the number of sperms or their motility. If there are severe issues in sperm analysis of husband, IUI, as a treatment modality will not be great criteria.

• Unexplained Infertility: If the treating doctor has not been able to pinpoint the reason for sub-fertility and everything is normal- the ultrasound, the husband’s report and have been trying for conception for less than 3 years, intrauterine insemination might be the way forward.

• Vaginismus or irregular intercourse: In today’s busy and stressful world, when both the partners are working, more and more couples are coming up with the problem of difficulty in intercourse or very low frequency of sexual relations. In these patients, intrauterine insemination might give excellent results.

• In patients with a need for donor sperms.

Whom does one consult for IUI?

It is always better to plan the IUI process with one of the best IUI treatment centers with well-educated infertility or IVF specialist. I’m one of the best infertility specialists providing Best IUI treatment in Bangladesh with a high IUI success rate.

What are the steps involved in the treatment of IUI?

In an IUI cycle, usually, the female partner is given drugs to stimulate ovaries. This is done to increase the chances of success with IUI. There will need to see an IVF specialist to monitor the ovaries to see the size of the follicles. When follicles are approximately 18-22 mm, a trigger injection will be given to initiating the process of ovulation. IUI is usually done 38-40 hours post the trigger injection.

Are there any side effects of IUI?

IUI as such is quite a safe procedure done in the ion outpatient department. There are no known severe adverse effects related to the procedure itself.

Do you require bed rest after IUI?

No!!! Not at all. There is no need for bed rest. One can resume work as early as possible, in fact on the same day.

What is the success rate of IUI?

Like in all infertility treatments, the success depends on the female age, history of any previous treatment failure and multiple other factors. In females, less than 35 years of age, who are in good hands, a success rate of 18-20 percent can be expected.

Does one need multiple cycles of IUI?

As IUI has a success rate of approximately 20%, the treating doctor might advise up to 3-4 cycles of IUI.

What is IVF?

IVF or In Vitro Fertilization is a complex of procedures when the eggs of a woman’s and sperms of a man’s are manipulated outside of the female body in a test tube (Test Tube Baby). Following the hormonal stimulation leading towards a higher number of mature eggs these are retrieved straight from ovaries and brought in to a special cultivation solution together with selected sperm. After the fertilization eggs are cultivated in to embryos in special mediums completely naturally without any other intervention. The fertilized egg (embryo) is then inserted in the uterine cavity of the women’s body.

Who needs IVF?

For normal conception to happen a healthy sperm with good motility should pass through cervical mucus, swim through uterus and reach fallopian tube to meet egg around the time of ovulation (when the egg is released in the body). Eggs and sperms meeting in the fallopian tube form an embryo which goes to uterine lining and implants there. It means for normal conception to happen there is a need for healthy motile sperms, open fallopian tubes, good eggs, ovulation happening on its own and good uterine lining. If there is an issue with any of them, then there might need to think about assisted reproduction.

One might need IVF if one is suffering from:

• Male Infertility: Sperms less in number (oligospermia), sperms not motile (asthenospermia), sperms abnormal in shape (teratospermia), or all three issues (Oligoasthenoteratospermia or OATS). It might also be possible there are no sperms seen in the routine analysis (Azoospermia)

• Female Infertility: A female might be sub-fertile due to number of reasons like issues with blocked fallopian tubes, fluid in tubes (hydrosalpinx), adhesions, issues with eggs Polycystic ovarian syndrome (PCOS) - no egg releasing or anovulation; low number of eggs – advanced age, low AMH; endometriosis-cyst in ovary, ssues with uterus – fibroid, adenomyosis, poor endometrial lining or thin ET (endometrial thickness), adhesions in uterus (Ashermann syndrome).

Who does IVF?

IVF is done by only trained IVF treatment specialists, who have worked in the field of Reproductive Endocrinology. It is very important to choose the right doctor with impeccable qualifications.

Are there any investigations required before IVF?

Besides routine investigations and viral serology, the treating IVF doctor needs to do a transvaginal ultrasound to look at the uterus and ovaries. The doctor will have a look at an endometrial thickness (ET) as well as the number of eggs in Ovary (Antral follicle count or AFC) Also, hormonal investigations including AMH (Anti Mullerian Hormone) will be done Hysteroscopy might be required prior to IVF if there are issues with the uterine lining.

How much time does the process of IVF take?

If the process is started from Day 2 of the cycle, the whole treatment till embryo transfer is completed in a duration of 15-20 days.

What are the steps involved in the process of IVF treatment?

• Initial Consult: In the first consult, a detailed history, examination & have a thorough look at the patient’s old records and investigations are needed. Also, a Transvaginal examination will be undertaken. It is always a good idea to bring all the old records including any Hystero-salpingogram (HSG) X-ray if any. A follow-up detailed plan will be accordingly made on the patient’s first visit.

• Ovarian Stimulation: For an IVF cycle to succeed, there is a need to get more eggs, to have more good quality embryos and to increase the chances of success. This is done by taking hormonal injections. These are pen-style injections and can be self- administered by the patient.

• Hormonal stimulation: Multiple growth of follicles increases the chances for achieving a bigger amount of quality eggs and consequently more embryos suitable for transfer. This is achieved by hormonal stimulation under constant doctor’s control.

• Ultrasound Monitoring: To see the response of hormonal injections, transvaginal ultrasound (TVS), is done at an interval of 2-4 days.

• Egg retrieval: After the follicles are ready, the egg retrieval is performed under short general anesthesia guided by trans-vaginal ultrasound and it takes about 5-10 minutes. The procedure is done with a special thin needle, which goes via vaginal whole straight to an ovary. From there are the eggs suctioned. The patient is discharged about 2 hours post procedure. So, there is no incision, no mark. This surgery is quite safe.

• The sperm collection and preparation: A sperm sample is collected from a partner on the day of egg retrieval in special room. Sexual abstinence is recommended 2-5 days prior the collection in aim to get the best possible quality sample. Following its laboratory preparation eggs are fertilized by partner’s sperm in a special solution. Fertilization happens spontaneously, the sperm moves towards the egg and penetrates its shell. The common cultivation of eggs and sperm lasts 16-20 hours. After this time the embryologist finds out about the success of fertilization which is proved by the presence of two pronucleus. If the man is in any doubt about the ability to give a sample in the day of egg retrieval, he can use the option of cryopreservation in advance. For men who have no sperm in the ejaculate is MESA/TESE one of the options to get the sperm in IVF cycle.

• Embryo cultivation: The day the patient’s eggs are taken; the same day the patient’s husband’s sperm sample is taken. Eggs are then fertilized by sperms using conventional IVF or advanced techniques like ICSI (Intracytoplasmic Sperm Injections), IMSI, PICSI, etc. The next day the number of eggs fertilized is seen under a microscope or embryo scope. Embryos are then developed to day 2, day 3 or day 5 (Blastocyst) stage. The lab keeps the patient updated about the progress and accordingly plans for embryo transfer.

Cultivation to the state of blastocyst/ Blastocyst Culture

Blastocysts are embryos which have grown till day 5 or 6 after fertilization. By using the special solutions, it is possible to extend the time of cultivation of embryos for up to 5 or 6 days (state of a blastocyst). The benefit of this procedure is the option to choose the best quality embryos for transfer and increase the chances for pregnancy. Use of the long cultivation is suitable especially when the number of mature eggs is sufficient (6 and more). Determination of an optimum date for ET is very individual and can be different in repeated cycles. Normally in an IVF cycle on the day of egg pick up, sperms are injected into eggs through the process of ICSI. Next day fertilization check is done and embryos are cultured in the incubator. Blastocyst or extended culture as we say it is taking the embryos till day 5 of culture to select the best embryo available for freezing or transfer.

Are Day 3 embryos better or day 5?

As we do extended culture of embryos, only those embryos which have the potential to implant inside uterus will go on to form blastocysts. Hence a natural selection helps us in selecting the best embryos to transfer. As there are embryonic activation blastocysts can result in better pregnancy rates. So, it does improve pregnancy rates.

When should you go for blastocysts in IVF?

It is always a better idea to go for blastocysts than day 3 embryos. However, in patients at higher age or in patients with repeated IVF failures, it is always a good idea to opt for blastocyst culture. Also, in patients trying to avoid multiple pregnancy in IVF blastocyst culture is a good idea.

Are there any drawbacks of blastocyst culture?

For extended culture it is imperative that embryology lab conditions are strictly maintained. Also, there is 1-2 percent risk of no blast forming in a cycle which should be taken into account.

Our Clients can now take advantage of a safer system of embryo cultivation. This revolutionary new technology enables our embryologists to monitor and evaluate embryos during their development without disturbing their natural environment in the incubator. This brings many advantages. Within the incubator embryos have a natural environment similar to the one within a mother’s body. This non-invasive method brings the option of monitoring embryos without the need for taking them out of the incubator. Less manipulation of the embryos means the lower the risk of damage. A camera is placed inside the incubator and it records the embryos every 30 minutes. The embryologist receives constant information on the status of all embryos and above all the embryologist receives precise documentation on the embryos condition and their development can be checked as well. The camera is less harmful for embryos as it uses a different wavelength from light. Within the embryoscope CO2 is regulated precisely and the temperature is controlled. The oxygen atmosphere is also reduced.

The Embryoscope enables the dynamics of the development to be monitored continuously and then the selection of the most genetically suitable embryos. In addition to the increased success rate, this method also brings the advantage that the doctor can transfer a lower number of embryos to the womb.

Our Clinic is one of the few centers which offers the unique Embryoscope system.

What is ICSI?

ICSI or Intra-cytoplasmic sperm injection is a procedure done during the process of IVF (In Vitro Fertilization). In this process sperms are injected directly in the eggs to ensure fertilization. The method of intra-cytoplasmic injection of sperm (ICSI) is an elaborate micromanipulation technique when the sperm is aspirated in to a thin sharp glass capillary and inserted in to an egg through its shell.

Indication for ICSI is the inability of the sperm to fertilize the egg spontaneously (low count, low motility), immunological causes of infertility, failing of classical IVF cycles, later age, low number of matured eggs, when cryo-preserved sperm is used or when the sperm is collected by MESA/TESE method, when donor’s eggs are used etc. This method has a very high success rate of fertilization. The patient has to indeed undergo the normal procedure of super-ovulation and egg retrieval and the partner has to provide the sperm. In the view of collected data we can say that by fertilization of the egg using this method is not increased risk of a child with congenital developmental defect when compared to spontaneous conception.

Who should consider ICSI?

ICSI as a treatment method was first carried out in the year 1991 and since then has revolutionized IVF treatment and its success rates. The indications for ICSI include:

• Male factor infertility – In patients having any issues with number of sperms (oligospermia), motility of sperms (asthenospermia) or quality of sperms (teratatospermia), fertilization by using ICSI is indicated.

• Also, in patients with azoospermia in whom sperms are retrieved using surgical sperm retrieval techniques like PESA, TGSA, TESE, Micro-TESE will need ICSI.

• In patients with high sperm DNA fragmentation.

• In patients with unexplained infertility.

• In advanced age group patients.

• In patients whom in previous cycle, fertilization rate of eggs was low.

• Frozen eggs are being used for fertilization.

How successful is ICSI?

With ICSI, fertilization rates of mature eggs are in the range of 70-80%. However, ICSI as such does not increase success rate in an IVF cycle if done in an unindicated case. Its only when ICSI is used in the indications stated above that a better fertilization rate and better pregnancy rate is seen.

Will all of our eggs be injected?

All mature eggs or M 2 eggs will be injected in ICSI process to ensure fertilization. Immature eggs cannot be used for ICSI.

What are the risks associated with ICSI?

An ICSI cycle does not increase the risk of major birth defects as compared to naturally born babies. Babies born through the ICSI or Intracytoplasmic sperm injection are healthy. Problems that cause infertility may be genetic in a few cases. As an example, male children conceived with the use of ICSI may have the same infertility issues as their fathers.

There are certain techniques which if used correctly might increase IVF success rates. One of them is assisted hatching. In This process the outer hard layer of embryo called zona pellucida is partially opened by laser or acid to help improve IVF pregnancy and implantation rates.

Why is assisted hatching done?

For an embryo to implant it should break free of its protective layer or zona and then implant in the uterus. In a certain subset of patients with hard outer layer embryo is not able to break free and hence results in failure of implantation or IVF failure.

Is assisted hatching needed in all patients?

No, it is beneficial for only a subset of patients like patients more than 38 years of age, previous IVF failures to name a few.

Can assisted hatching damage my embryos?

For any process involving manipulation of embryos, skill of embryologist is foremost. If done properly with skillful hands, risk of damage is minimal. There is a small risk of identical twins with assisted hatching.

Do I need assisted hatching to improve my pregnancy rates?

Needed for a particular treatment depends on a lot of factors. So, IVF specialist will take the decision.

Preimplantation genetic testing of aneuploidies (PGT-A) makes it possible to detect, in particular, acquired or inherited variations in the number or structure of the chromosomes. These abnormalities are often associated with miscarriages.

Preimplantation genetic testing for monogenic diseases (PGT-M) can detect changes (mutations) in individual genes associated with a specific inherited disease that has already occurred in the family.

The PGT method is especially recommended for couples where:

• The female partner's age is older than 35 years, which increases the probability of giving birth to a child with an abnormal number of chromosomes (eg Down's syndrome).

• A miscarriage or birth of a fetus with a chromosomal disorder has already occurred.

• There are repeated failures in IVF treatment or repeated miscarriages in early pregnancy.

• Chromosome rearrangement was detected cytogenetically in one of the partners. Although the individual itself is not clearly affected, this rearrangement may result in the formation of germ cells (eggs or sperm) with abnormal genetic makeup and the transmission of the defect to offspring.

• There is a so-called gender-related disease in the family (the disease only affects male individuals, but is genetically transmitted by women - such as hemophilia).

• One of the partners has undergone or is undergoing some type of chemotherapy or radiotherapy.

Preimplantation genetic testing cannot fully guarantee the selection of an embryo that has no defect. This is due to the principle of the method, where it is possible to examine only a certain spectrum of abnormalities by which the embryos of a given pair are most endangered. Nor can it guarantee the success of an IVF program, ie the implantation of an embryo after transfer to the uterus and the onset of pregnancy. It cannot guarantee the birth of a healthy child. All this is influenced by a large number of other factors.

The success rate of the transfer of frozen embryos-defrosted embryos (cryo-embryo transfer) is lower than with fresh embryos. For the lady this is more convenient as she does not need to repeated hormonal therapy and egg retrieval. Based on current knowledge there is not known increased risk of abnormalities or congenital developmental defects caused by this method.

Who needs freezing?

Depending on your fertility needs, you might need egg, sperms or embryo freezing. Embryo freezing is the one most commonly done procedure in In Vitro Fertilization or IVF.

By this procedure any extra embryos left after transfer or in freeze all cycles embryos are cryopreserved for later use. Egg freezing is recommended in patients who are going to receive chemotherapy for cancer as it might affect their future fertility. Also, in patients who want to stop their biological clock, egg freezing does give them good chances of conception a d motherhood at later ages.

Sperm Freezing as a procedure is recommended for cancer patients undergoing chemo or radiotherapy which might affect their future fertility, in patients with varying sperm counts, in patients planned for IVF cycle if there is a concern that, there might be difficulty in sperm collection on the day of egg retrieval.

Where is freezing or cryopreservation done?

Freezing can only be done in embryology labs of an IVF center. It is essential to use quality labs for this procedure as it directly impacts the conditions in which your gametes are preserved.

Whom should we consult for the procedure?

If you are planning to preserve your fertility through cryopreservation at the IVF center, meet an IVF specialist our IVF doctor at the earliest. They can answer all your queries and provide you with the chances of success with these procedures.

What is Third Party Reproduction?

Third party reproduction in layman’s terms means taking the help of a third person by a couple for the process of IVF. The most common ways it can be done is by using donor eggs, donor sperms, donor embryos or by surrogacy.

Who needs Third Party Reproduction?

As more and more couples are delaying marriage and childbirth, there is an increasing trend toward third party reproduction being seen in recent years.

• Donor eggs: One of the most common reason for the need of donor egg is advanced age. As the couples waste their precious reproductive years moving from doctor to doctor trying to conceive naturally, by the time they are seen by a reproductive specialist, they already have low ovarian reserve or poor AMH results. Also, there might be poor number of eggs due to previous ovarian surgery for endometriosis, cystectomy or even drilling. In certain patients there might be need for donor eggs due to poor egg quality in previous IVF cycles.

• Donor sperms: There is a considerable increase in the number of cases of male infertility. The need for donor sperms is there only when in an azoospermia (no sperms) male, the doctor has not been able to retrieve any sperms by the process of Testicular sperm extraction or TESE.

• Donor embryos: It is like adoption and may only be indicated when there are both male and female factors or due to financial constraints.

• Surrogacy: In simple terms means renting a womb or taking the help of another woman’s womb to carry one’s child. It might be needed in patients with uterine abnormalities like fibroid, adenomyosis, unicorn ate uterus etc.; in patients with recurrent IVF failures or if a pregnancy is dangerous for maternal health.

Laparoscopy:

With laparoscopy, we can see the uterus as well as tubes in ovaries from outside by using a very minimal incision in the abdomen. The outcome is as good as an open surgery without requiring a long hospital stay and the cost is also reduced. Also, there is no need for a big incision and as we are using higher magnification we can see better tissues so it definitely improves the outcome of the surgery as well. The most common indications for laparoscopy in patients with infertility are:

• Evaluation of tubal patency: It can be done when we are suspecting tubal blocks like in an HSG showing bilateral tubal blocks. In patients with unexplained infertility - In patients with history of endometriosis in whom we are suspecting adhesions.

• Secondly, we can do laparoscopy in patients with endometriosis to do cystectomy and blade ablate the ovarian endometriomas. We can also do adhesiolysis to improve the ovarian tubal relationship and chances of conceiving

• Thirdly in patients with PCOS we can do laparoscopy to do ovarian drilling and chances of ovulation in patients who are not responding to drugs alone.

• Fibroids - In patients with fibroids a myomectomy can be done through laparoscopy route and that can also increase the results of your fertility treatment procedures.

• In patients undergoing IVF - In patients undergoing IVF if we are suspecting hydrosalpinx, we can do a salpingectomy before IVF to improve the success of in vitro fertilization, so a laparoscopy can improve your chances of conceiving by evaluating your tubes, by increasing your tubo ovarian relationship in helping the evolution to occur and in improving your uterine lining if there is a fibroid present there.

• Also, we can do a laparoscopy to do Adhesiolysis.

Hysteroscopy:

Hysteroscopy can be done inpatient with infertility if there is a history of failed IVF if they are suspecting thin endometrium due to ashermann syndrome, if there is a polyp inside the cavity which needs to be removed if there is a history of multiple implantation failures or recurrent pregnancy losses and we are suspecting septate arcuate or bicornuate uterus.

So, a laparoscopy and hysteroscopy can definitely improve your chances of conceiving naturally also and also in patients who are undergoing a pre-IVF laparoscopy and hysteroscopy, when done in properly selected patients can definitely improve your success rates.

What next?

Don’t give up. It is not the end of the world. Even a failed IVF cycle can tell me what went wrong and how can I improve our chances next time, what do we do which is different from previous cycle? Hence it is imperative to keep all our records of IVF- what drugs were used for stimulation, were there any problems encountered in follicular growth? Do keep the embryology records like number of eggs retrieved, the grade or the quality of embryos transferred. Was it a day 3 or a day 5 (blastocyst) transfer? It is imperative that after a failure you meet your IVF consultant to discuss regarding the reasons for failure and any further steps needed to improve your chances of success.

Why did my IVF cycle fail?

There can be multiple reasons for failure of an IVF cycle. It can be an issue with -

• Eggs: if the number of eggs retrieved are low less than 5, or the quality of eggs is poorer there is abnormal morphology of eggs, it might result in failure of an IVF cycle.

• Sperms: If there is issue with morphology of sperms or there is an infection in semen, we might see poor fertilization rates (a smaller number of eggs and sperms join to form embryos).

• Poor quality of embryos.

• Uterine issues like thin endometrium, uterine adhesions or polyps, adenomyotic uterus

• Unexplained if everything was fine great embryos, great endometrium but still pregnancy doesn’t happen So in nutshell if there is an issue with the seed (embryo) or the soil, there might be failure of an IVF cycle.

How do we plan our treatment further?

IVF is a man-made science which can never guarantee 100% success. Even in the best prognosis patients we do see failures. It is essential to reflect and try to understand what went wrong. However, as it is not an exact science don’t lose hope and stop trying because IVF as a treatment has the highest success rate and has the best potential to give you your child. But if you lose hope and don’t try, you might lose your precious reproductive years.

What does PCOS mean?

PCOS or Polycystic Ovarian Syndrome is a complex disease manifesting as an irregular cycle or excessive hair growth or infertility. It is one of the most common diseases in women in today’s age. It is a metabolic disorder with varied manifestations.

How PCOS diagnosed?

PCOS is diagnosed using Rotterdam criteria, which are-

• Irregular cycles

• The excessive hair growth or hair fall (excessive male hormone)

• Ultrasound showing polycystic ovaries

Does PCOS cause infertility?

Yes, PCOS is an important cause of infertility in India. As in patients with polycystic ovaries. Eggs are not released in a body on time every month, Pregnancy does not occur. So, PCOS patients suffer from an anovulation or oligo ovulation.

How is PCOS treated?

There is no cure for PCOS. By using PCOS treatments we can relieve symptoms like no egg formation or irregular cycles, but the disease remains.

How can I get pregnant with PCOS?

As in PCOS, eggs are not forming; a treatment called ovulation induction in which drugs are given to form eggs can be used to help you get pregnant. Also, a variety of lifestyle modifications increases your chances of getting pregnant faster. These include:

• Regular Exercise

• Healthy diet

• Weight reduction

• Avoid smoking/alcohol

• Low carbohydrate inhale

• Increase green leafy vegetable/fruit in the diet

Do I need to get Surgery done for PCOS?

There is no need for laparoscopy or any surgery to diagnose PCOS. In case you are not responding to drugs for egg formation, your doctor might prescribe laparoscopic ovarian drilling. However, I, with the judicious use of oral drugs & injections to form eggs has never felt the need for surgery in PCOS patients.

What are the drugs used in PCOS?

Depending on your individual case, variety of ovulation-inducing drugs like clomiphene, Tamoxifen, letrozole, etc. Can be used also if you are not responding to oral drugs injection like Recombinant, FSH or HMG (human menopausal gonadotropin). Adjuvant drugs like metformin or myoinositol are also used in the case to case basis.

Do all PCOS patients require IVF or in vitro fertilization?

No, not at all, As in PCOS patients’ eggs are not Forming Simple drugs which form eggs can alleviate infertility. Eighty percent (80%) patients conceive by oral drugs only. IVF is only needed if there are associated tubal disease, male partner problem or failure of multiple cycles of ovulation induction, there might be a need for IVF treatment.

What is endometriosis?

Endometriosis is a condition in which cells like of inner lining of the uterus can be seen outside it. It can affect ovaries, fallopian tubes, and even bowel or bladder. When an endometrial gland (uterine lining) grows inside the muscle of the uterus, it is called adenomyosis.

What symptoms do you have with endometriosis?

Endometriosis can present with a variety of symptoms.

• Pain: You might have dysmenorrheal or pain during periods.

• Infertility: Also, endometriosis is an important reason for infertility or difficulty in conceiving.

• Ovarian cyst: With endometriosis. ovaries are might develop blood-filled cyst called endometriomas

Is there a test to diagnose endometriosis?

No blood test can definitely diagnose this condition. It is only through clinical findings & by laparoscopy; a definitive diagnosis can be made.

Why does endometriosis occur?

The cause or the reason endometriosis happens is not clear. The common understanding that is used to explain endometriosis is that menstrual blood goes backward through fallopian tubes into the abdomen & around the ovarian to cause this condition.

Why does endometriosis cause infertility?

Endometriosis causes scarring of pelvic tissues. This damages the tube-ovarian relationship and causes difficulty in conceiving.

How do you treat infertility associated with endometriosis?

The treatment depends on a number of factors. It depends on the age of patients, presence of endometriosis on ultrasound, previous history of surgery and duration of infertility, to name a few. It is always better to consult a fertility specialist to decide the course of treatment.

Do all endometriosis require surgery?

No, not at all. There is no indication for repeated surgeries in case of infertility as it might further decrease the number of eggs in the ovary.

Can IVF be done with endometrioma?

Yes, IVF can be done even with endometriomas present in ovaries. They do not impact the number of eggs retrieved and do not impair your success rates.

Do all women with endometriosis require IVF?

The treatment of choice depends on the stage of endometriosis & age of patients. In women who are younger than 35 years of age and have mild endometriosis can be offered a trial of nutrition induction & IUI (intrauterine insemination) but in order women (> 35 years) and with severe endometriosis. It is a good idea to directly resort to IUF.

So, to summarize endometriosis is an important cause of infertility. It is always better to consult a fertility specialist or IVF doctor sooner rather than later if suffering from this condition. I am a best IVF doctor for endometriosis with advanced training and experience.

What are the common types of ovarian cysts?

• Follicular cyst or functional cyst: These cysts are simple fluid filed and occur due to unruptured follicles or inadequate progesterone release. They are benign and go away on their own.

• Ovarian dermoid: These cysts contain different types of structures like skin, hair, fat inside them. These cysts are slow-growing and usually require surgery.

• Endometriosis or chocolate cysts: Endometriosis or chocolate cysts are seen in patients suffering from endometriosis.

• Hemorrhagic Cysts: These are benign cysts and usually go away on their own and do not require surgery.

How are these Cysts diagnosed?

These Cysts can be an incidental finding during an examination by your gynecologist. Ovarian Cysts are confirmed by an ultrasound which can be done transvaginally or per abdomen. Further tests like MRI might be needed if required by your gynecologist. Also, certain blood tests like CA-125, LDH, B- HCG, etc. Might be done to differentiate different types of ovarian cysts.

Do Ovarian cysts affect fertility?

Yes, certain ovarian cysts like endometriosis do impair your chances of conceiving naturally. However, there is no indication to remove endometriosis if you are planning for IVF as it does not impair your success rate.

How are ovarian cysts operated?

With the advent of laparoscopy, almost all ovarian cysts are operated upon laparoscopically. This reduces pain and decreases recovery time. If you are suffering from ovarian cyst and infertility do consult with me for the best IVF treatment in Bangladesh.

What do you mean by Recurrent Pregnancy Loss?

Recurrent Pregnancy Loss is defined as three consecutive pregnancy losses. Even biochemical pregnancies or pregnancies with the only beta – HCG positive blood tests but no pregnancy seen on ultrasound are also considered in the definition of recurrent pregnancy loss. It is also categorized into primary or secondary depending on whether a normal pregnancy has happened previously or not. If it is secondary, the prognosis is better.

How common is recurrent pregnancy loss or miscarriage?

While miscarriage is quite common and affects approximately 15% pregnancies, recurrent pregnancy loss or consecutive miscarriages are seen only in approximately 1-2% couples, so this condition affects approximately 1 in 100 couples.

Why recurrent pregnancy loss does occur?

There can be many reasons or factors causing recurrent pregnancy loss. However, it is important to understand that in almost half of patients, no discernible cause can be found.

What are the risks of subsequent miscarriages?

As the number of miscarriages increase, the chances of further miscarriage also increase. After 3 miscarriages, the risk of subsequent miscarriage is approximately 30% so there are almost 70% chances of carrying a normal pregnancy, even after 3 miscarriages. But this is not a blanket statement as with advancing age of mother, the risk of subsequent miscarriage is higher. This may due to poor egg quality in women with advanced age. So, in a woman who is approximately 40, her risk of miscarriage is as high as 40% and a woman of 45 years, has an 80% risk of miscarrying.

How can I prevent miscarriage or pregnancy loss?

If you are suffering from pregnancy loss, it is a good idea to see a gynecologist evaluate for the causes of pregnancy loss. The common reasons are high blood sugar, elevated thyroid levels, and abnormalities in the structure of uterus to name a few. To detect these disorders your doctor may advise blood tests as well as a specialized investigation like hysteroscopy. Also, an immunological blood test might be done to look for specific causes.

Is IVF the treatment for recurrent miscarriages?

IVF as such does not prevent recurrent pregnancy loss. But in IVF we can do preimplantation genetic testing to look for chromosomal abnormalities in the embryo, hence transfer only embryos which are normal. When PGT-A is done in IVF. It does reduce your risk of miscarriage. Also inpatient with genetic issues, IVF donor eggs or sperms can be used to reduce miscarriage risk.

So, to summarize don’t lose heart, help is just a click away. Book your appointment with me as an Infertility & IVF specialist for detailed consultation.

Why does tubal blockage happen?

There can be multiple reasons for tubal block. The most common reasons for fallopian tubes blockage are:

• Pelvic Inflammatory disease: Any past infection of the upper genital tract or previous silent Chlamydia infections might result in damage to fallopian tubes

• Tuberculosis: T.B. is one of the most common reason for tubal infertility in Indian population.

• Adhesions due to surgery: Previous surgeries might result in adhesion formation in pelvic area resulting in distortion of tubo-ovarian anatomy.

Are there any symptoms of tubal block?

Usually there are no symptoms due to blocked fallopian tube and it is only during investigations for infertility that blocked fallopian tubes are diagnosed. However, in certain patients, there might be fluid in fallopian tubes causing hydro-salpinx. In these patients there might be symptoms of persistent pain in lower abdomen or continuous discharge per vaginum.

How are blocked fallopian tubes diagnosed?

To diagnose fallopian tubes blockage Hysterosalpingography or HSG is the most common imaging technique used. Other techniques which can be used are sonosalpingography or SSG or HyCoSy technique.The Gold standard to diagnose and treat fallopian tubes is through diagnostic laparoscopy.

When do you need IVF with blocked tubes?

If by laparoscopy it is seen that there is extensive damage to fallopian tubes, it is advised to proceed with assisted reproductive treatments or IVF. In patients with fallopian tubal block, usually high success rate in IVF treatment is achieved.

For further enquiries contact me as an Infertility & IVF Specialist.

Why does fertility decline as age advances?

There is a decline in fertility with advancing age because of many factors. A woman is born with a fixed number of oocytes which decline with each menstrual cycle. So as the age advances, there is a decline in the number of eggs which are present. Also, there is a decline in the quality of the eggs which we have. As the women cross 35, more and more abnormal oocytes are formed. Thirdly, there is a factor of smoking, environmental toxins and any previous ovarian surgery which can hasten the process of advanced age. So, with increased age, we will see a decline in both the quality as well as the number of eggs.

What is fecundity?

Fecundity is your chance of conceiving in one menstrual cycle. There is a steep decline in fecundity as the women cross more than 37 years of age. So, the chances of conceiving spontaneously after 37yeras of age decrease with each menstrual cycle, so she might require more time to get pregnant compared to women who are 22 or 23 years of age.

What should you do if you are more than 35years of age and trying to conceive?

It is a good idea to see a doctor after trying to conceive for more than six months. Don’t delay your treatment because your time window to try naturally is low here. It is always better to see a fertility specialist rather than a gynecologist. An IVF specialist knows in detail both the quality as well as the quantity of the eggs and will give you the correct opinion.

What are my treatment options?

The treatment options will depend upon the duration of infertility as well as your age. As the duration of infertility increases and the age advances, the chances of getting more aggressive like IVF, ICSI or even donor eggs might be required; but to prevent these conditions, it is always better to see a doctor sooner because if you are approximately 35 years to 37 years of age ovarian stimulation with intrauterine simulation can also give you good pregnancy rates.

Whom should you consult?

It’s always better to see a fertility specialist and IVF specialist have an in-depth discussion about your fertility treatment. I am known to advanced age infertile patients for their high pregnancy rates.

How do you measure ovarian reserve?

The two gold standard tests to diagnose ovarian reserve are Antral Follicle count (AFC) and Anti-Mullerian hormone (AMH) tests. The other tests like FSH, estradiol levels, inhibin etc are not that definitive in diagnosing poor ovarian reserve.

What is AMH or Anti-Mullerian hormone?

AMH is the hormone which is produced by small follicles in ovary. Its value tells us about the quantity of eggs in ovary. Its level is tested by a blood test. The good part about AMH is that there is no variation with menstrual cycle and can be done at any time in the cycle. Value of AMH less than 1.5 ng/ml is considered as low normal and values below 1 ng/ml are considered as low.

What is Antral Follicle Count?

Antral Follicles are small follicles in the ovary seen through a trans-vaginal ultrasound. An antral follicle count is done between day 2-5 of cycles, when ovaries are dormant. An antral follicle count (AFC) gives us a good idea of the number of eggs available each cycle for stimulation. An antral follicle count of more than 10 , counting eggs in both ovaries, is a good AFC.

Why is ovarian reserve important?

Ovarian reserve tells us about the number of eggs, hence might indirectly tell us about fertility span. It does not predict pregnancy, but with poor or low ovarian reserve, the time we have available to plan pregnancy does decline. Also, in patients undergoing IVF, the number of eggs is an important determinant of IVF success. In patients with long standing infertility, low AMH values might be an indication for IVF or assisted reproduction directly.

Can you increase your AMH?

AMH values are an indication of ovarian ageing. As ageing is an irreversible process, there is little which can be done to increase your AMH values. Certain supplements might be beneficial in improving oocyte quality.

With low AMH do we need IVF?

There are multiple indications for IVF and poor ovarian reserve and Low AMH is one of them. DO you need IVF is more individual question and it is better to consult with me to get a clear picture.