The most common complication of IVF is twin pregnancies, which occurs in 20% of pregnancies following the transfer of two embryos. Twins are associated with higher maternal and perinatal complications including miscarriage, pregnancy-induced hypertension, ante-partum haemorrhage, gestational diabetes, operative delivery, prematurity and permanent handicap in the newborn. The perinatal mortality rate in IVF twin pregnancies is six times higher than that for singletons and the risk of neurological problems, especially cerebral palsy substantially higher. Rearing of twins is also associated with practical difficulties for parents. Single embryo transfer can minimize twin pregnancies. Single embryo transfer is now being seriously considered as a means of minimizing the risk of multiple pregnancies. However, this needs to be balanced against the risk of jeopardizing the overall live birth rate.
What is Pelvic Inflammatory Disease?
Pelvic inflammatory disease (PID) is a disease of the upper genital tract seen in women between 15 â€“ 45 years of age and involves uterus (womb), fallopian tubes, ovaries and other areas within the pelvis. The infection affects the surface lining in all the above organs leading to damage with short and long term health implications.
The true prevalence of PID is unclear but it is known that nearly 1:50 women will see their GP with some symptoms due to the disease process. The common organisms associated with PID are Chlamydia trachomatis and Neisseria gonorrhoea. The other organisms that cause pelvic infection include Anaerobes, Mycoplasma genitalium, genital Tuberculosis etc.
Screening programes have revealed that asymptomatic Chlamydial infection can be picked up in as many as 6% women seeking contraception advice and up to 5% women undergoing cervical smear test (PAP smear). Overall screening programmes have shown a pick up rate of between 1-17% in asymptomatic women.
What are the causes of PID?
The commonest cause is sexual transmission of infection especially in those that indulge in unprotected intercourse with multiple partners. Other causes include retained tampons, instrumentation of the uterus through various procedures such as termination of pregnancy, tubal patency assessment test with dye, camera procedures for the uterus (hysteroscopy), sepsis or infection post abdominal surgical procedures, appendicitis/ appendicectomy, peritonitis, intrauterine contraceptive device use for long periods of time, etc.
What are the common symptoms of PID?
- Lower abdominal pain which may be continuous through the month in some women
- Offensive and smelly vaginal discharge
- Fever with abdominal pain
How does one diagnose PID?
The doctor will obtain a history and perform a clinical examination during which culture swabs will be taken from cervix (neck of the womb) and vagina to confirm the type of infective organism. This will be followed by blood tests, pelvic ultrasound scan and sometimes laparoscopy (camera procedure through the belly button). Genital Tuberculosis of the uterus can be confirmed following laboratory analysis of the endometrium (biopsy of the lining of the womb). Currently there is no single test that will accurately diagnose the presence of PID.
What is chronic pelvic pain?
Chronic pelvic pain is defined as pain the abdomen / pelvis below the level of the belly button (umbilicus) that has been present for 6 months or more.
It may or may not be associated with menses or periods. It is not a disease but a symptom that can be caused several different conditions.
What are the causes of chronic pelvic pain?
Adenomyosis (Endometriosis in the muscle of the womb)
|Irritable bowel syndrome||Interstitial cystitis (bladder infection)||Adhesions (scarring)|
|Pelvic Infection||Diverticulitis||Pelvic floor pain|
How does one diagnose chronic pelvic pain?
- Detailed history
- Clinical examination
- Blood tests
- Urine test
- Pelvic Ultrasound
- Laparoscopy (key hole camera procedure through the belly button)
- Others: CT scan, MRI scan
How does one manage chronic pelvic pain?
- Pain killer tablets (Paracetamol, Ibuprofen, etc)
- Hormonal manipulation (Endometriosis / fibroids)
- Surgical treatment of endometriosis / fibroids / adhesions or scarring
- Relaxation techniques / hypnosis
- Psychosocial support and counselling (Individual therapy / group therapy / patient support groups)
What is Endometriosis?
The lining of the womb or uterus is called endometrium. Endometriosis is an estrogen hormone-dependent condition that is characterized by the presence of ectopic endometrial tissue in places within the body but outside of the uterus. The disease state and symptoms can be modified by pregnancy, breast feeding and menopause.
The pathogenesis of endometriosis remains an enigma in gynaecology and a topic of heated debate.
There are 2 distinct entities:
- Endometriosis (external – outside of the uterus)
- Adenomyosis (in the muscle of the uterus).
How does Endometriosis grow or develop?
Endometriosis may develop in some women that are genetically prone to develop or grow the endometrial cells in ectopic sites outside of the uterus (runs in the families e.g., mother, sisters). In others it may develop due to retrograde flow of menstrual blood through the fallopian tubes or due to an altered immune environment in the pelvis.
What are the common sites affected by endometriosis?
Endometriosis predominantly affects the ovaries by forming cysts and the back of the uterus. It may also be found in the space between the womb and bowel and very occasionally in areas as remote as bladder, in caesarean section scars, lungs etc.
How does endometriosis present or manifest?
A woman may be completely asymptomatic and the condition may be diagnosed as an incidental finding during either sterilization surgery or during infertility assessment. Some women may suffer from painful periods and others may suffer from pain at the time of intercourse. Others may also experience painful opening of bowels around the time of the periods. It has been seen that occasionally women may have a cyclical bleeding (during menses) from the back passage (along with stools) or from the bladder (while passing urine). Women with endometriosis in the operation scar sites may find that the scar develops painful nodules that grow during periods.
It has been shown that less than 10% of women would be accurately diagnosed with the disease when they first present to the doctor with symptoms.
Does Endometriosis cause infertility?
Endometriosis can cause anatomical distortion of the pelvic organs due to scarring e.g chocolate cysts in the ovaries, adhesions etc. Distortion in the pelvis can impair the fertilization process. In addition it can affect the egg release process. Endometriosis is known to alter the immune environment within the body which in turn affects the fertilization process.
How does one diagnose Endometriosis?
A good clinical history and a thorough clinical examination help point in the direction of the correct diagnosis. To confirm the diagnosis, a woman will be advised to undergo a pelvic ultrasound assessment and laparoscopy (keyhole camera procedure) which is considered the “gold standard” tool. Other sophisticated tests such as MRI, intravenous urography (IVU), barium enema (X-ray procedure) may be required in some women with severe disease.
How does one treat Endometriosis?
Endometriosis can be managed either with the help of drugs or with surgery. The drugs used for the management are geared towards reducing the impact of the oestrogen hormone.
What are the drugs used for the management of endometriosis?
- Combined oral contraceptive pill (COCP)
- Progesterone only pill
- Gonadotropin releasing hormone agonist (GnRHa e.g. Zoladex, Prostap, Luprolide acetate etc)
- Mirena IUS (Progesterone loaded IUCD)
Initial management of pain symptoms is generally with painkillers or analgesics. If a woman is not desirous of fertility and pain is her main symptom, the use of the combined oral contraceptive pill continuously for 3 – 6 months followed by short breaks of 7 days could help relieve the symptoms.
In women that are overweight or obese, those that have a family history of blood clots, or those that smoke and those with an altered liver function, the use of oestrogen containing pills is contraindicated. In such cases, one may use the progesterone only pill continuously for 3 – 6 months
GnRH analogues are injections that will be given to cases with moderate to severe endometriosis. These injections are given either or a monthly or 3 monthly basis. The GnRH analogues temporarily switch off the ovaries thereby reducing the impact of oestrogen on the endometriotic deposits and causing a regression in their size and improvement in the pain symptoms. Women may need to use a small dose of hormone replacement therapy (HRT) during the GnRH analogue treatment to combat symptoms of low oestrogen such as hot flushes, night sweats, mood swings and irritability.
The Mirena IUS is a progesterone (levo-norgestrel) loaded intra-uterine device that has been found to have a beneficial impact on symptoms of pain.
Unfortunately, none of the above will allow a woman to conceive or fall pregnant during treatment.
What is the role of surgery in the management of endometriosis?
Surgery is indicated for the initial diagnosis and staging of the disease (laparoscopy). Subsequently, surgery is useful in correcting the anatomical distortion caused by the disease process in the pelvis, ovaries and other organs. This procedure generally helps relieve symptoms of pain and may help restore fertility potential. It may also be necessary to perform surgery prior to starting fertility treatment.
Surgery may be accomplished through minimal access or keyhole surgery (laparoscopy) or via the open abdominal cut (laparotomy) technique. The open techniques is generally used when the anatomical distortion and scarring from the disease process is extensive. It may also be necessary for those that have had multiple previous surgeries.
In those with extensive disease, it may be necessary to use GnRH analogue injections pre and post surgery to achieve a greater degree of relief in symptoms.
In women that have severe disease and have completed child bearing, it may be necessary to perform definitive surgery in the form of hysterectomy. The ovaries may be left behind if the woman is less than 45 years of age. This helps in reducing the risk of osteoporosis (thinning of the bones) and cardiac problems. The downside however is that the endometriosis process may recur as the ovaries will continue to supply the oestrogen hormone until the natural age of menopause.
Can endometriosis be completely cured with surgery or medications?
Unfortunately, one cannot completely cure endometriosis or eradicate the disease by surgery or medications.
Following surgery for mild, moderate or severe disease, the chances of recurrence may be as high as 50% in 2 – 3 years. Also, symptoms of pain may recur once the medications are stopped.
Can women conceive with a despite endometriosis?
In those with minimal to mild disease, conception can occur spontaneously. Failure to conceive following 6 – 12 months of trying may necessitate help in the form of assisted conception treatment e.g., Intra-uterine insemination of semen (IUI) or In-vitro fertilization (IVF). The IUI treatment may result in 10 – 15% chance of pregnancy and IVF results in 25 – 30% chance of success provided the reserve of eggs in a woman’s ovaries is good and the woman is less than 37 years of age.
What is PCOS?
Polycystic ovary syndrome (PCOS) is a common condition affecting 6-7% of women in the reproductive age group. This syndrome is often diagnosed if any two of the following three symptoms or signs are present: absence of periods or irregular periods associated infrequent or no release of eggs every cycle or every month (anovulation or oligo-ovulation), a raised level of male hormone (testosterone) with presence or absence of associated symptoms such as acne, oily or greasy skin, excess hair growth and presence of polycystic ovaries (ovaries with many small cysts of 2-9 mm in size) on ultrasound scan. Although polycystic ovaries are seen in 20 – 33% of women, majority of them are healthy, ovulating normally and not having PCOS.
What causes PCOS?
Weight gain or obThe exact cause of PCOS is not yet clear. Whilst PCOS may run in families and several genetic factors have been implicated with its development, not all women with a genetic trait will develop the condition. However, one of the main underlying problems appears to be ‘insulin resistance’. This means that cells in the body such as muscles are resistant to the effect of a normal level of the insulin hormone secreted by the pancreas. Insulin is a hormone that is responsible for control of the blood sugar in your body. The resistance to the insulin effect in these individuals is compensated by an increased production of insulin to keep the level of sugar in the blood normal. The resultant increase in insulin levels in the blood act on the ovaries as well leading to increased production of the male hormone testosterone. A high level of testosterone slows the normal development of follicles or eggs in the ovaries resulting in an abnormally large number of small follicles, which remain immature and subsequent ovulation (release of egg) is hampered.
Short term and long term problems associated with PCOS:
Weight gain or obesity is not a consequence of PCOS however obesity or excess weight gain tends to worsen the manifestation of this syndrome. Excess body fat can also make insulin resistance worse, leading to further elevations in blood insulin concentrations with a progressive burn out of the gland producing the hormone.
Women with PCOS may develop symptoms in their late teens or 20s. Symptoms can vary from mild to severe and may change over the years. Apart from period related problems, which affect 7 in 10 women affected with PCOS, unwanted hair growth may occur over face, lower abdomen or chest depending on the degree of the rise in testosterone levels. Acne and thinning of scalp hair may also occur. 40% of women are obese and this may be secondary to increased insulin levels. Because of the disturbance in ovulation associated with PCOS, most women experience subfertility although majority of them conceive following treatment of stimulation of the ovaries using fertility drugs.
Nearly 10-20% of women with PCOS develop diabetes at some point in their life. The risk is increased if women are obese (body mass index more than 30), have a strong family history of type 2 diabetes or are above 40 years of age. Women who have been diagnosed as having PCOS are more likely to develop diabetes during pregnancy. A sleeping problem called sleep apnoea, a condition associated with snoring, is also more common than average in women with PCOS. They are also at increased risk of having a stroke and heart disease in later life because of the problems described above in addition to other associated conditions such as obesity, raised blood pressure and increased cholesterol levels. If women suffer from infrequent periods particularly with intervals between menstrual cycles of more than three months, the risk of pre-cancerous changes and subsequent cancer of the lining of the womb is higher than women having regular menstrual cycles. Because of these associated risks women having PCOS should have regular checks for blood sugar, cholesterol levels and blood pressure to detect any abnormality as early as possible. They should also be advised to have at least four menstrual cycles, which could be induced by taking either the ordinary contraceptive pills or progesterone tablets as prescribed by a doctor to prevent any changes within the lining of the womb.
Whilst there is no cure for PCOS, life style and dietary modification may alleviate some of the symptoms and long term consequences. Weight loss and regular exercise in obese women have been shown to improve fertility and lowering of androgen levels and associated symptoms of hair growth and acne. It also reduces the long term risk of diabetes, heart disease and even cancer of the lining of the womb. Even a small reduction in weight of about 2-5% has been shown to improve the ovulation and resumption of menses. Dietary modification such as low calorie diet, avoiding sugary drinks and also snacks between meals are useful to complement the efforts to reduce weight. Small frequent low calorie diet may be an alternative to avoid persistent increase in insulin levels, which is the key mechanism for the development of most symptoms of PCOS (make your portions small). Daily moderate sweat inducing exercise lasting for at least 30 minutes is one of the most important lifestyle measures to reduce the risks of both the short term and long term consequence of PCOS.
Azoospermia meaning absence of Sperm in the semen. This can commonly Obstructive Azoospermia because of block in the epididymis or in the vas either because of injury, infection or surgery. Azoospermia could also be caused by failure of production of sperm called Non obstructive azospermia. In these case Sperms can be retrieved by surgical techniques.
Microsurgical Epididymis Sperm Aspiration (MESA): By this technique epididymis is opened by fine dissection and sperms are aspirated by a fine needle from the epididymis. It is a day care procedure, done in the operation theater with facility of sperm freezing.
Testicular Sperm aspiration (TESA): This is similar to the other technique but the testes is aspirated from the testes. Finding good number of sperm in testes is not as good as in epididymis.
Sperm extracted in these methods are frozen and later used for Intra Cytoplasmic Sperm injection ICSI.
What is a human Embryo?
The Human Embryo – Human embryogenesis is the process of cell division and cellular differentiation of the human embryo that occurs during early stages of development. From a biological standpoint, human development is a continuum, starting with the germ cells (ovum and spermatozoon), through fertilization, prenatal development, and growth to adulthood. The germinal stage, refers to ovum (egg) prior to fertilization, through the development of the early embryo, up until the time of implantation.
What are the expenses in freezing the embryo?
The expenses are around 10,000 to 20,000 per year depending on centers.
What are the ways in freezing the embryo?
There are 2 ways in freezing the embryo:
- Slow Freezing
What is vitrification?
Vitrification in the context of freezing embryos is the process whereby the solution containing the embryos is cooled so quickly that the structure of the water molecules doesn’t have time to form ice crystals and instantaneously solidifies into a glass-like structure.Unlike previous slow freeze methods, which took up to two hours to lower the embryo to the correct temperature, vitrification takes just a few minutes. The embryo is suspended in a very small volume of fluid on the end of a small flat specialisedvitrification device. The device with the embryo is lowered onto a metal block that has been cooled by liquid nitrogen where the fluid containing the embryo hardens into a small “glassy” bead.
Freezing or Vitrification of Eggs or Embryos
Freezing embryos & eggs
An IVF cycle will hopefully produce a number of viable embryos. Those that aren’t immediately transferred back to the patient are placed in cryostorage by lowering their temperature to that of liquid nitrogen (-196Â°C). At this temperature, embryos can be stored until they are needed for later transfer. This process is also used at Genea on unfertilised eggs.
The problem with freezing any cell in the body is that the fluid inside the cells can form ice crystals that expand and damage the cell membranes. Enormous care must be taken to avoid this. In the past this has meant that eggs and embryos were frozen using a slow programmed decrease of temperature using expensive machinery.
What does this mean to me?
Rigorous studies at Genea have shown that a greater percentage of the embryo’s cells survive thawing following vitrification than after slow freezing. Live birth rates for 2006 following the transfer of vitrified embryos increased by 50% over those where slow frozen embryos were transferred.
What is the span in which the embryo or eggs can be frozen?
According to HECA guidelines the eggs can be frozen up to 10years
Once the embryo is formed it has to be frozen with in a span of 5 days (Day 1 to Day 5) Embryo can be collected through IVF or ICSI procedures.