Infertility Treatment FAQs

1. What is infertility?

Infertility is the inability to conceive after 12 months of unprotected intercourse. Often, people plan pregnancy for one or two months and come to reproductive Medicine or gynaecologist thinking they failed to conceive. What exactly happens is if 100 couples try to have a pregnancy in one month, only 15 will conceive. That does not mean the other 85 are infertile. So if somebody feels that they have a Problem or a delay in conception, they should understand that they should try unprotected intercourse for at least 12 months. Then if they fail, they should visit the Doctor.

2. What happens in a regular cycle?

In a regular cycle, ovulation happens between 12 to 18 days. There is a possibility of getting pregnant if the couple have unprotected intercourse during that period. When couples have intercourse, sperms deposited can last there for 48 to 96 hours and sometimes 120 hours. Often, there is a misconception that only pregnancy will happen if couples have intercourse every day. 

The average frequency of a newly married couple will be around four to five times a week. And after three to four years, the average sexual frequency comes down to two or three times a week. As long as a couple is trying to get a pregnancy, a frequency of two or three times a week is adequate for conception.

3. Doctor when should a couple visit a doctor?

If the couple living together failed to conceive after trying unprotected intercourse for 12 months, they should visit a doctor. Many times, there are a lot of misconceptions that only females should see the Doctor and not the male, but the reality is both should visit the Doctor, and the cause of delay can be in the male or the female, sometimes in both. So the couple should see the Doctor for infertility.

4. What exactly happens in the clinic? What does a doctor do when a couple comes to the clinic?

When a couple comes to the clinic, trained personnel will note their age, height, weight, body mass index, and blood pressure. Taking a complete health history will identify any risk factors. Physical examination of the woman includes a pelvic exam to see whether there are any abnormalities in the female reproductive tract. In the man, a general physical examination and a local genital examination is done to assess the male reproductive tract.

5. After my physical examination what investigations will you do and why are you doing those investigations?

After physical examination, the doctor will suggest the following investigations based on individual needs. When a woman comes to the clinic, pelvic ultrasound examination is essential to know if her uterus and ovaries are normal. Transvaginal ultrasound detects any tumors in the uterus or cysts in the ovary more precisely. Knowing ovarian reserves is also important for fertility treatments. Next will be hormone evaluation which may vary from clinic to clinic ranging from standard tests like thyroid and prolactin to ovarian reserves evaluation based on AMH test. Finally, some may need investigations like HSG or laparoscopy to detect abnormalities in the fallopian tube, a passage that connects the ovaries to the uterus.

Further tests will depend on the individual risk factors and the protocols of that clinic. However, along with the investigations of the lady, checking basic health parameters in the man and doing a basic sperm test is essential. A minimum of 2 days of abstinence is required to do Computer-assisted semen analysis, and the gap should not exceed five days. These are the preliminary investigations done for couples facing fertility issues.

6. Ultrasound is done for the women. What information are you gaining by doing this test.?

Infertility is a delay in conceiving. Unless we know the cause of the delay, how can we treat the problem? Investigations like doing an ultrasound, doing hormonal assay, doing a tubal evaluation either by HSG or by Laparoscopy, and then a male semen analysis will identify the causes. Ultrasound gives more details regarding the uterus and ovaries. These are the basic investigations that will help us identify the cause of infertility in 80 percent of the situations.

7. Sometimes people say there is no cause, are there any additional investigations in addition to what you have mentioned?

If a couple married for two years does not find any cause, they call it unexplained infertility. But this unexplained infertility can be of 3 categories. 1) The clinic or doctor did not find the cause. 2) The preliminary investigations did not reveal the cause and may require deeper investigations. 3) Sometimes, all investigations are not done at the same time. In such a situation, something may have changed though we assume it to be normal. In unexplained infertility, the most important aspect is to look deeper and see if we have missed any problems. Most of the time there is a cause for the delay in conception. One must try to find out the cause so that effective treatment happens.

8. When you have identified a problem in women, why are you doing investigations for the man? Or sometimes you have identified the cause in the man.. why can’t you start the treatment without checking the woman?

In infertility, 40% of the couple have two problems. For this reason, we check both at a time. A single female factor can exist in 40% of the people and a single male factor in 20%. When the remaining 40% who come to the reproductive medicine clinic have two or more causes, it is wise to check both. In the short term, it might look unnecessary. The actual reality is that when we diagnose two problems, they feel relieved that the doctor did the right thing. This approach is of paramount importance. 

A lot of clinics in India and globally also miss checking one person. Once they identify one factor, they start treating it. After a few treatment failures, they will investigate again for other factors. In the process, the couple will start losing time and money on unnecessary medications or procedures. That is why we should always know what is the cause of infertility and is that the only cause. Then only give a plan of treatment so that the couple will get good results in the given frame of time. Checking both man and woman will effectively reduce the time to conception.

9. Doctor you have just done an Ultrasound for me. Why did you do it? And what information did you obtain by doing the Ultrasound?

Ultrasound is a wonderful tool in reproductive medicine and it doesn’t have any harmful effects on women. The first and foremost thing is to understand that it is a safe test that does not carry any risk for your health. It can be done any number of times without harm. The 2nd thing is, Ultrasound is done to what is assess the female reproductive tract. It can be imaged in two dimensions, three dimensions, and four dimensions. What information we get is 1) the size of the Uterus. 2) the thickness of the lining.3) whether there are any abnormalities in the uterus since birth or congenital anomalies of the uterus. The 4th aspect is, are there any tumors growing in the uterus, like fibroid or adenomyosis. 

The fifth is, to see if the bed where the baby grows is normal or abnormal. These are the details about the uterus obtained by ultrasound. Adjacent to the uterus, two ovaries are vital for the female reproductive tract. In the ovaries, we see whether the ovary size is appropriate for your age. The reason why we see the size is, women are born with a fixed number of eggs, and these eggs start growing and developing from the time you have first menses period and when they are getting exhausted at the age of 40 to 50 years, then it is called menopause. Ultrasound helps us to see the size of the ovary, whether it is normal or abnormal. If it is abnormal, what type of abnormality? The other aspect is if the Ovary contains any cyst or tumors. 

A lot of times a woman is diagnosed with polycystic ovary, and then somebody says, PCO or cysts in the ovary. But a lot of times a mistaken diagnosis is made. A polycystic ovary should contain three parameters. One is the women should have irregular cycles, the ovary size should be significantly larger, and third is the number of cysts or follicles should be at least 15 to 20 per each ovary, then only we say it is a polycystic ovary Plus the women should have signs of androgen excess like acne or excessive hair. Just because by ultrasound the ovaries are larger it doesn’t mean polycystic ovary. So we rule out the presence or absence of polycystic ovary, then we rule out whether the woman’s ovaries are appropriate to their age or they are decreased in size. If there is a decrease in size, is an urgency to plan pregnancy early, or if they should not postpone pregnancy. 

The other thing is the presence of a cyst, when it is a functional cyst, it does not harm the reproductive tract and can be left alone. Sometimes the presence of a cyst called endometriosis might need surgery. Sometimes it might need assisted reproduction also known as IVF. 

This is information about the uterus. We also get information about the ovary concerning their function and abnormalities. By using 3D technology at the Krishna IVF clinic I will be able to look at the uterus and the ovary, in 3 dimensions, so I get much better information and in 4 dimensions I get further clarity about the individual pathology. Here I want to add one thing Krishna IVF is working with Samsung for the past 5 years and developed certain technologies using Artificial intelligence. One of the development that has happened at Krishna IVF is the launch of a product in the Samsung Ultrasound as 5D Follicle and on that topic, we had a scientific publication also and Samsung had also got the patent. In the area of Uterus using Artificial intelligence, we also worked with Samsung for a future application called junctional zone which will be coming in 2023 or 2024 machines, where we are trying to assess the lining throughout the cycle and use it as a predictor for treatment success also.

So in short we do an ultrasound to know the health of the uterus and health of the ovary and if its abnormalities picked up in the first visit, within a couple of hours of 1st visit, we have a huge lot of information.

10. What precautions should we take when we are giving a semen analysis sample for testing?

When you are asked to do a semen analysis, the couple should take the following precautions. First and foremost, there should be a gap of 2 days minimum and the gap should not exceed 5 days. The reason for that is if the gap is too low, the volume can come less and the analysis report may be abnormal. If the gap is too long, the volume will come higher and the quality of abnormal sperms might be higher. So while giving a semen sample for analysis, it’s always important that they follow abstinence for two days and that period should not be more than 5 days.

11. Doctor, Are they any conditions when I shouldn’t give semen analysis test and it might be a wrong report?

Should postpone semen analysis if there is a recent episode of high fever or an episode of chemical exposure or an episode of severe health issues or recent radiation exposure. In these situations, it’s ideal to wait for 3 to 6 months before doing a semen analysis. Because in these conditions the report might be abnormal and may not reflect the true value.

12. Doctor, if the reports are abnormal do I have a chance of getting pregnant?

One peculiar thing in semen analysis is, unlike in haemoglobin or WBC count or RBC count, there are no normal values in semen analysis, there are only reference values. That means when a count is out of this range it means probably this couple will take more time to conceive. But it will not tell that the couple will not conceive if the report is abnormal. Because it also depends on women’s fertility. If the woman is highly fertile and the man is sub-fertile, still pregnancy happens. So the abnormal report needs a second validation based on the severity. Sometimes it will need added technology and advanced treatments but no need to worry if a single parameter abnormality is present unless it is a significant type of particular problem and is present in more than one report. 

Only then, it can be considered abnormal. For example, if the count is less than 20 million or some other report says less than 15 million. Depending on the WHO classification, we say it is oligospermia. There it does mean the couple will not conceive. It only says that in a given period, like a couple of years, these people might have difficulty. It also depends on how long the couple has been married. If the couple are married for 5 years and they have an abnormal report, this has a lot of importance. When it comes to motility, apart from the count, motility abnormality has more importance than only their count. If the motility is low it shows there is a structural and functional abnormality probably. And when it comes to quality. abnormal shape of sperms is also called teratozoospermia. 

If it is associated with low motility and poor quality, the problem is severe. In other words, the semen analysis report should be looked at in-toto like how much is the volume, how much is the count per ML and how much is the count per ejaculate, then what is the motility. In that motility what is the percentage of active motility and passive motility and how many of them are completely non-motile and how many dead forms are present in the non-motile forms. In the morphology, whether the sperm quality is very poor or only some of them are abnormal. The combination of all these factors is important in a report. Just looking at one factor does not mean anything.

13. Why do we check fallopian tubes in infertility patients? And what are the methods to check fallopian tubes?

In a person who has infertility, the following factors are checked. One is Semen analysis; the ovary function; the uterine function; the hormone function and the tubal function. When we come to the tubal evaluation there are essentially 3 ways of checking the fallopian tube. One is by hysterosalpingography, the 2nd is by Laparoscopy and the third is by Sonosalpingography. These are the 3 methods that are used to check the fallopian tubes. When it comes to hysterosalpingography it is the simplest investigation available to check the fallopian tubes. It is usually done by the radiologist or by the gynecologist and it is done in the following manner as part of the infertility evaluation and it is done in the first 10 days of the menstrual cycle to check the status of both tubes by taking an x-ray after injecting a contrast dye into uterus and tubes. A prophylactic antibiotic is given before the procedure. So that there is no risk for infection. 

The information we obtain with the hysterosalpingography is One-the uterine cavity for any congenital anomalies, Two- the tubal outline, whether both the tubes are normal or one tube is abnormal. The third is the free flow of dye. So Essentially hysterosalpingography checks the uterine cavity and the tubal patency. 

When it comes to the 2nd investigation which I mentioned, that is laparoscopy. This investigation is done under anesthesia. It is done when the period of infertility is longer or when the X-ray of hysterosalpingography is abnormal. Also when there is a previous surgery on the abdomen like a cesarean section or any other surgery. Sometimes when the ultrasound shows abnormality of the uterus or the abnormality is the ovary. In these situations, a laparoscopy investigation is done. What exactly happens in Laparoscopy is- under anesthesia, a video telescope is passed through the umbilicus and then the uterus and tubes are visualized directly. The relation of the fallopian tube to the ovary is checked. Both the ovaries are also analyzed. Then, a blue dye called methylene blue is injected into the uterine cavity. The tubal status is assessed by directly seeing how the dye passes out of both tubes. If everything is normal, it is reported as chromotubation normal. Sometimes, if one of the tubes is abnormal we try to reposition the catheter to recheck it. 

The third method that is used to check the fallopian tubes is sonosalpingography which is of recent origin compared to laparoscopy which is 4 to 5 decades old. It is a similar method to HSG but ultrasound imaging is used instead of an x-ray. In this sonologist or the gynecologist injects a contrast media or a liquid-based media or saline, so sometimes it is also saline sonography in which as the fluid is injected the sonographer looks at the cavity of the uterus in 3D ultrasound and flow of the dye in 3D ultrasound to check the patency of the tube. Compared to laparoscopy, the sensitivity and specificity or the 100% accuracy of sonosalpingography are not as equal. If there is a doubt in this investigation, then we proceed to laparoscopy to check and confirm. Essentially when one is checking the fallopian tubes in an infertile couple there are 3 modalities of investigations 1) HSG, 2)laparoscopy, 3)sonosalpingography. Depending on the necessity and the situation of the patient, a relevant investigation is selected.

14. Doctor you just told me that there is an Ectopic pregnancy. How is it different from normal pregnancy and what is the meaning of an Ectopic pregnancy? Does it mean that I am not going to have a baby in this pregnancy?

Normally, a pregnancy develops in the womb which is also known as the uterus. When the embryo gets implanted, the ovary then starts producing a hormone called HCG which helps the baby grow. Based on the HCG level 14 days of embryo transfer, we check early pregnancy by HCG blood test. When the pregnancy test comes positive, we ask you to come for an ultrasound 2 weeks after the urine pregnancy test. If a pregnancy test is positive and we are unable to locate the pregnancy in the uterus, then we call it pregnancy of an unknown location. 

In that situation, what we do is we also search for the location of the pregnancy other than the uterus, and the common location we see is the fallopian tube and the ovaries, and then if we find a pregnancy in the fallopian tube, we say it is an ectopic pregnancy in the tube. Sometimes, you also find that pregnancy is located on the uterus and in a few instances located at the opening of the womb that is the cervix and sometimes far away. We diagnose ectopic by a combination of HCG levels and ultrasound to confirm the location of the pregnancy. It is not safe for the mother to continue such a pregnancy.

15. Doctor, is Ectopic pregnancy harmful? Can I leave it alone so that it grows?

Any location of pregnancy other than the uterus is dangerous for the woman. We also assess the severity of the problem based on serum HCG levels. Any level more than 5 mIU/ml is considered positive. When the HCG level is 1000 million units per ml but we do not find a pregnancy sac in the scan, there we might ask for a repeat HCG test at the end of 48 hours to 78 hours, wherein we check the doubling of that HCG value. When it is a pregnancy of an unknown location, the doubling may or may not happen. Even if some amount of doubling happens, there we repeat ultrasound. 

If we find a pregnancy sac and the location is outside the uterus then we have three treatment options. One is the surgical option. 2nd is the medical option and in a few selected situations only observation & close monitoring. The observation and close monitoring is done when the HCG levels are relatively low where we serially do a scan and repeat blood test to see that we are not missing out on anything. This is generally done when the HCG levels are less than 500 and the level of doubling is too slow. we monitor you at closer intervals and once the levels fall, you get menstrual bleeding. This opportunity is only for a few because most of the values will be between 1000 to 2000 million units per ml. 

Why I am specifically saying this is, some reports come in litres. Then you should look at whether it is international units per litre or million units per ml. That is where sometimes mistakes happen. If the ultrasound shows a pregnancy measuring up to 3cm in the fallopian tube or it shows foetal heartbeat in the fallopian tube or if there is a mass in the tube with HCG levels above 2000. Some may take above 5000 and in that situation a key whole surgery or otherwise known as laparoscopy is done and then the damaged fallopian tube is removed. In a few instances when it is feasible we try to remove ectopic and repair the tube by a process called salpingostomy which involves just a cut on the tube. 

This is to preserve the tube but it doesn’t mean another ectopic pregnancy will not come in that tube. When the damage is significantly more or in a case of ruptured ectopic, that fallopian tube is removed. This is called salpingectomy. The 3rd option we have is medical management. That means stopping the growth medically. Methotrexate injection is given and then serial monitoring is done till HCG level drops significantly. There are advantages and disadvantages to medical treatment. If we start medical management when HCG is below 2000 to 3000 million units per ml the success rate is close to 95%, the other 5 people might need laparoscopy or surgery. 

If we are taking a value for medical management of around 5000 million units per ml, then the success rate is 66 percent only. 30 percent of the time you will need a laparoscopy at later date. so, you should be in close vicinity under observation. This risk-benefit ratio should be decided by the couple and the doctor in joint consultation. In my personal opinion, the decision should be left to the doctor who is a better judge at that critical point. You will be informed pros and cons.

16. Doctor what are my chances of pregnancy after an ectopic? Any chances of getting an ectopic pregnancy again?

In a woman with a previous ectopic pregnancy, there is always a risk for repeated ectopic pregnancy though the chances vary depending on the age of the woman and the condition of the fallopian tubes. The possibility can be between 5 to 20%. So when you conceive next time with a previous ectopic pregnancy, meet your doctor as early as 35 days to get an ultrasound and HCG blood test. One week later, look for the doubling values and the presence of the pregnancy sac in the uterus. Early medical management or early surgery can be done so that the amount of damage to your health is minimal.

17. What is the chance of getting pregnant after one single ectopic pregnancy?

About 50% to 60% of women conceive spontaneously after one single ectopic pregnancy and the remaining 40 to 50% might need some form of assisted reproduction which is based on the other co-factors that exist and your age by the time you are planning a 2nd pregnancy. One of the fascinating aspects of ectopic pregnancy is the management of ectopic in the present era. 

This is one of the greatest miracles of modern medical science. In the 1950s, if somebody had an ectopic pregnancy, a significant number of women used to die. With the advent of pregnancy card tests between 1970 to 1980. 50% of them were saved by early diagnosis and surgery. When it came to the 1980s with the advent of ultrasound and laparoscopy, a significant amount of deaths are avoided. With the accessibility of trans vaginal ultrasound and serial HCG monitoring now in 2020, very few or hardly any women die. 

Earlier an ectopic pregnancy was considered death for 50% of the women but now it has become a good quality of life following early treatment. That means saving lives in 99 percent of situations. This is a major milestone in the field of reproductive medicine, obstetrics, and gynecology. This century has brought forward to us the advantages of ultrasound, HCG monitoring, and minimally invasive surgery.

18. Doctor, when a couple comes to the clinic, why do they check the height and weight of both?

If we check the weight of a woman, say somebody has a weight of 70 kgs and a height of 5′-10″. Another woman who is also 70 kgs but only 5′-2″ in height. There is a significant difference between both of them though the weight is the same. Because of this, the scientific community has defined a word called Body Mass Index. It is a ratio between weight and height which gives a more significant value known as body mass index or BMI. This value tells us about health status and picks up any risk factors such as obesity in the couple.

19. Doctor, what is the normal Body Mass Index?

A normal body mass index is between 18 to 25. Anyone with a body mass index between 25 and 30 is considered overweight but not obese. BMI above 30 is considered obesity.

20. Doctor, Does the weight of man and woman make a difference in fertility aspect?

When a man or woman has a BMI of more than 30, then we say it is obesity. When it is more than 35 we say severe obesity. And when it is more than 40, we say morbid obesity. Obesity is to be considered as one extreme health problem. A lot of people do not think of obesity as a health problem. They think that they are only overweight and it does not have any negative consequences except cosmetic appearance. Obesity in men and women affects fertility. 

For a long period, it was thought that obesity in women will only affect fertility but in the last decade, more and more scientific research has come in and has shown that male obesity is also important. To tell much more, we at Krishna IVF did a research which was published in the Journal of Andrology, where we showed that obese men whose BMI was more than 30 took more time to have a child. Obesity in a man will affect sperm function and sperm quality. The duration of time taken by the couple to get pregnant is longer if a man or a woman is obese. The most important thing here is both the couple should be healthy and within a normal BMI.

21. Doctor, what are the implications of obesity in a lady?

A woman having a BMI of more than 30 will take more months to conceive when compared to a woman having a BMI of 25. That means the probability of having infertility is higher when the BMI is more than 30. The 2nd situation is obese women are more proven to have irregular cycles and they have problems with ovulation. A reduction of obesity to normal means a reduction of BMI from more than 30 to less than 30 will significantly improve the chance of ovulation and they will require less amount of medication and less number of cycles to achieve a pregnancy. 

Another aspect of women with obesity is they are more prone to diabetes which is highly prevalent in India and if their families have diabetes, these women will have a higher risk for diabetes. Either it is pre-existing or more prone for another thing called gestational diabetes which can happen during pregnancy. The 3rd aspect is obese women are frequently associated with thyroid dysfunction. The 4th aspect is there is something called metabolic syndrome. That means obese women have a higher chance of hypertension, a higher chance of cholesterol and triglycerides, and they have a long-term risk of cardiovascular disorders. 

So, in other words, obese women take a longer time to conceive, have more association with diabetes, have more association with thyroid, have more complications during pregnancy, and also very importantly their long-term health is compromised by a situation called metabolic syndrome.

22. Doctor, what happens when an obese woman conceives and has a pregnancy? Does obesity affect the pregnancy outcome?

A woman who is obese, in other words, has a BMI of more than 30 has a higher chance of having a miscarriage, otherwise known as abortion when compared to a woman with a normal BMI. The 2nd thing is they are at a higher risk of diabetes during pregnancy which is also known as gestational diabetes. The 3rd is they are associated with more chances of getting hypertension during pregnancy. The 4th aspect is having a larger baby otherwise known as big-baby or macrosomia which leads to a higher chance of caesarian section and during the postpartum period, they take a longer time for their wound to heal and a longer time to recover. So obesity not only affects fertility but also affects pregnancy.

23. Doctor, what are the infertility problems in obese men?

An obese male who has come to the infertility clinic has a higher chance of having an abnormal semen analysis, be it in terms of count, motility, or quality when compared to men who have a normal BMI. The 2nd aspect is these men who are obese have a higher chance of diabetes and male diabetes also affects sperm quality and sperm function. So a man with obesity should reduce weight before planning pregnancy so that the need for multiple interventions will also reduce. The chances of having repeated cycle failures will be less if their obesity is also given proper attention. There will be a quicker chance of pregnancy with lesser treatment cycles.

24. Doctor, What is the AMH test and why is it done?

Ovary reserves are assessed by a test called Anti Mullerian Hormone. In conventional language or the Doctor’s language, it is also known as AMH Hormone. This is a blood test done to check the ovarian reserves of a woman. AMH is a beautiful hormone that is very accurate and it has no day-to-day variability and it can be done any time of the menstrual cycle. In the earlier days, ovary reserves were checked by some tests on the 2nd day of the menstrual cycle like the FSH hormone, the LH hormone, and the estrogen levels. 

Subsequently, with the advent of the AMH test, the concept of ovarian testing has become simpler and the main reason for it becoming simpler is, it can be done any time of the day and any time of the menstrual cycle. Unlike in FSH hormone where it should be done on the 2nd day of the menstrual cycle, this test can be done at any time. The 2nd aspect is after the first and 2nd generation testing, in the current generation of AMH technology, the test has become very robust and repeatable, qualitatively and quantitatively accuracy is very high. This is also known as positive predictability, sensitivity, and specificity. 

The normal Anti-Mullerian hormone levels are between 1.5 ng/mL to 5.0 ng/mL. if a person has less than 1.5 ng/mL, then they are considered on the lower side of the anti-Mullerian hormone, and in that situation, they should do not delay the pregnancy. If their Anti-Mullerian hormone is less than one, then they should not postpone their pregnancy more than six months to a year, because it will make a huge difference. When the levels are less than are <0.6 ng/ml then it’s a real crisis. 

In such a situation, the number of eggs we get during the IVF treatment becomes very low and the treatment gets compromised. So Anti-Mullerian hormone helps us to understand what is the current status of the woman’s hormone reserves, how much time is there, and whether early decisions for reproduction should be taken. Sometimes, the anti-Mullerian hormone is also used to diagnose a polycystic ovary. This is not universally accepted, but if the anti-Mullerian hormone is more than 5.0 ng/mL in that situation, there is a high possibility of polycystic ovary. 

The reliability and repeatability of these tests have few exceptions. If it is done immediately after delivery, the levels will be low and it should not be taken. If it is done after an ovarian surgery like endometriosis again the level has reliability issues. The 3rd is after you give Gonadotropins and if you measure AMH during that time, then you might get a false result. 

The 4th and the most important is, if the woman is using an oral contraceptive pill at least wait for two or three months before you do an AMH test otherwise, it gives a false value the other parameter which can help to validate AMH result is antral follicle count in the ultrasound. so in the current era, the golden standard of measuring ovarian reserves is the anti-Mullerian hormones, and sometimes a combination of antral follicle count and AMH gives a very accurate status of where things stand so whenever you have an AMH test, it is telling you where things stand in terms of ovarian reserves and this will help you to speed up your decision in certain situations.

25. Doctor, is there a possibility of having an abortion after IVF treatment? You are selecting the SPERMS and the EGGS, why should an abortion happen?

In a natural pregnancy, if 100 couples conceive 15 to 20 of them lose the pregnancy. Abortion happens for various reasons. The most common cause for abortion in a woman who conceives normally is an abnormal genetic material also known as aneuploidy. It is nature’s quality control to prevent an abnormal pregnancy or abnormal baby from coming into this world. The negative consequences of it when nature does its quality control job we are unhappy but if it fails to do quality control and have an abnormal pregnancy or an abnormal child again we are unhappy. 

The reality is, nature plays a role in IVF also similarly. An embryo in an IVF lab can look normal but it has to implant and further progress for 14 more days for a positive pregnancy test. It should further progress for two weeks before we see in ultrasound and then progress for 8-10 weeks more to make out abnormalities. To a large extent, a pregnancy loss happens with a blood test positive but the scan does not show anything. It can be called a biochemical pregnancy loss. When the ultrasound shows a pregnancy that is inappropriate to the duration and with no formation of fetus we say a blighted ovum. 

The other category is the formation of the heartbeat which subsequently stops which is called a fetal demise. A pregnancy loss can be due to various reasons. In an IVF pregnancy earlier people used to think it reduces the abortion rate, but the answer is whatever happens in a natural pregnancy all rules apply to an IVF pregnancy, be it abortions, be it abnormalities, be it hypertension in the mother or, pregnancy-induced diabetes in the mother or bigger babies or smaller babies whatever applies to a normal pregnancy will happen in IVF pregnancy also. 

It is on the higher side because here you are treating a failure of nature to produce a natural pregnancy. In a normal pregnancy, nature is playing its role of quality control but here you are trying to disturb a situation where nature does not want the pregnancy to happen. When we are trying to correct it and still nature protects it what are the current ways of avoiding that situation. 

One is pre-pregnancy evaluation. It is important to have optimal health before planning a pregnancy. the second is the precautions for the male in terms of health weight diabetes smoking alcohol. In the woman similarly smoking alcohol control of weight and healthy pre-pregnancy nutrition will minimize some problems to a certain extent and during the transfer of the embryo, certain embryo selection methods possibly reduce but do not eliminate abortions. 

The current technologies in those areas are time-lapse embryo monitoring and pre-implantation genetic diagnosis or embryo biopsy to rule out any chromosome abnormality and then transfer those embryos selectively. Even this reduces the chance of miscarriage but does not eliminate a pregnancy loss. Any couple who are planning an IVF should also anticipate the possibility of a miscarriage so IVF is not an assurance that you will hundred percent have a baby. 

Even if you’re pregnant it does not mean all IVF pregnancies will end up in a live birth so there is a new definition that is coming in where a clinic should say what is a live birth rate and it is a better indicator of quality control of that clinic and what is the miscarriage rate, preterm delivery rate, and the other complications. A lot of clinics can say I have a 70% pregnancy rate but that can mean only HCG value. One should always ask what do they mean by pregnancy rate and another term is an ongoing pregnancy rate but finally, the most important is the live birth rate per started cycle which is the ultimate thing that defines the quality of the clinic.

26. Doctor, If a semen analysis report shows teratozoospermia, what does it mean?

In a semen analysis report, sometimes you find a word called teratozoospermia. What we essentially look at, is the volume, the count, the motility, and the quality of the sperm which is also known as morphology. When the morphology of the sperm is abnormal, then we say teratozoospermia. 

The sperm has 3 components, the head, the neck, and a tail. It is one of the smallest cells in the body which is exposed to different pH’s and external environments as it travels from the male body into the female body to meet the egg. So, it needs a robust quality to reach that point and fertilize the egg. In the sperm head abnormalities, we have the tip abnormality called abnormal acrosome which can be smaller or absent. we can have the whole head abnormality which is an elongated shape called pyriform or an irregular shape called amorphous form. 

The second part of the sperm is the neck which contains the energy packet that is the mitochondria that drive the sperm movement and it is called the energy pack. Neck abnormalities are short neck, bent neck, or an irregular neck which can also affect the pregnancy chances. The third part is tail abnormalities like the absence of a tail, a short tail, a coiled tail also known as head in coils. Quality assessment of the sperm is known as morphological assessment of the sperm which includes counting the head, the neck, the tail abnormalities of the total number of sperm that are present. 

The WHO cutoff level is one should have at least four percent normal forms to get a reasonable chance of pregnancy. 4% is the lowest level and if somebody has levels less than that, they need further evaluation in terms of health evaluation, male infection screening. The DNA fragmentation test and other sperm function tests are needed to understand why there is teratozoospermia. 

It is often an undiagnosed or misdiagnosed or incompletely diagnosed problem and most of the couples are labeled as unexplained infertility. If more attention is given to sperm morphology, the instance of unexplained infertility might significantly decrease. This teratozoospermia can give pregnancies but may not be within the given frame of time. The treatment modalities will depend on the severity of the problem and the co-existing health conditions. In conclusion, teratozoospermia or teratospermia is a quality issue of the sperm which requires proper interpretation.

27. Doctor, Does thyroid hormone affect fertility and pregnancy?

Thyroid hormone disturbance is very common in women than in men. And it constitutes between 3 to 10 percent out of every 100 women. In the area of reproductive medicine, the common hormones we check are the thyroid hormone, the prolactin hormone and in the ovarian reserves, we check the AMH levels. Here I’ll be talking about the role of the thyroid hormone. When excessive, it is called hyperthyroidism and if it is deficient, it is called hypothyroidism. If a woman has hypothyroidism, it affects the menstrual cycle and also affects ovulation which in turn affects fertility. 

That means a woman who has a deficiency of thyroid hormone, will have ovulation problems which can delay conception. The other impacts of this thyroid hormone are if we don’t diagnose a thyroid problem, it can also affect the neurological development of the baby. so in the last decade, there has been a lot of importance in testing TSH or thyroid-stimulating hormone.TSH increases in hypothyroidism and the accuracy of these tests will depend on the type of diagnostic techniques used. Essentially there are three generations of technology. 

The third generation which has an accuracy of 0.1 million units per liter is done at Krishna IVF using the VIDAS technology. Once you have a diagnosis of thyroid dysfunction then either your reproductive medicine person or your gynecologist or your physician or endocrinologist will ask you to take a tablet called thyroxine and the dose is determined by your weight and the amount of thyroid deficiency that is there. The most important thing when you’re taking a thyroid tablet is you should take it in the morning and avoid taking thyroid tablets along with iron tablets or calcium tablets as it affects the absorption. 

Once you start taking thyroid tablets, at the end of six to eight weeks you should check whether the amount of drug that is given to replace your hormones is adequate by checking the TSH hormone which is also known as a thyroid-stimulating hormone. Free t4 levels are also checked to accurately adjust the dosage. When levels are normal, a lot of people mistake that they can stop the thyroid tablet but the answer is no. 

They have been corrected adequately and they should continuously use it and see the physician once in six months for evaluation. In pregnant women, if they are already having a thyroid disturbance, a dose adjustment is needed every three months throughout the pregnancy since the development of the baby might be affected. 

So even though the thyroid looks very common, it is a very sensitive hormone, a very important hormone, and one should use it regularly and have it monitored regularly so that you get the full benefit of the treatment. Unlike deficiency of the hormone, the thyroid hormone excess generally does not affect infertility but affects the pregnancy. So, the management of excess thyroid hormone is also important during pregnancy. It can be diagnosed easily by the TSH estimation, and it can be corrected easily tablets.

28. Doctor, what are the causes for small ovaries and does it affect fertility?

Following your visit to a gynecologist or an infertility specialist sometimes, they say your ovaries are smaller. Every woman is born with a fixed number of eggs and they start declining as they reach menopause. At the time of their first menstrual cycle, there are close to 400 000 eggs and by the time they reach menopause, there are hardly any or less than a thousand eggs. Two ovaries are present on either side of the uterus. After menarche, every month one egg is selected and that gets ovulated around the 12th to 14th day of the menstrual cycle. If it is fertilized, then it gives a pregnancy but if it is not fertilized, then a menstrual cycle follows. 

In this selection process, hundreds are selected but if there is a disturbance in the selection method the eggs get over early in that situation we might get smaller ovaries. This problem can be genetic, can be a childhood nutrition problem or sometimes it can be an interplay of growth hormones during the period between 8 to 10 years. so a variety of causes can produce small ovaries but when these small ovaries are diagnosed it tells us the results are lower and this can be confirmed by another test called anti-mullerian hormone.

When the ovary volume is lower you can also have a low anti-mullerian hormone and if you are in the age group of 25 to 30 and you have lower ovarian volume and a lower anti-mullerian hormone or AMH it is very important for you not to postpone your pregnancy because your results or your eggs might get exhausted in the next few years. 

There is another situation where you find small ovaries as the woman reaches 37 years and as they come closer to 40 years the volume of the ovaries becomes smaller because the number of eggs in the ovary gets diminished from 400 000 at the time of your first menstrual period to less than a thousand at the time of menopause so essentially smaller ovaries can be classified into two groups. smaller ovaries where the chances of pregnancy are reasonably satisfactory, there should not be any delay and then you have the second group closer to 40 years who are at the end of their reproductive life. Here, the chances of pregnancy with smaller ovaries are significantly low. In other words, what I wanted to convey in this is, assessing ovarian reserves is an important component of reproduction, and if they are compromised then career women should not postpone their pregnancy but seek medical help to get an early pregnancy. 

One thing that has not been beaten by technology is age and smaller Ovaries. As of today, we do not have solutions. So it is prudent and wise on the part of the career woman to prioritize if the doctor says your ovarian volumes are low or your ovarian reserves are low or your AMH values are low. In that situation, they have to prioritize their life goals between career and motherhood. It all depends on their individualization but this is a word of caution about the importance of that information because seldom do we realize that technology has limitations and some of the areas of limitations in reproduction are age, small ovaries, or low AMH where there are very few options available.

29. Couples should visit infertility clinics after twelve months of cohabitation. What are the exceptions to these rules?

A couple should visit an infertility clinic only if they fail to get pregnant after trying for 12 months. There are some exceptions when a couple needs to visit before 12 months. The first one is irregular cycles, which means that the periods are longer than 45 days to 3 months. The second one is when they have sexual dysfunction, they should see the doctor earlier than 12 months. The third situation is when one of the partners or both have a lot of pain during intercourse. The fourth is if the male report has come abnormal and shows the absence of sperms. The fifth exception is when the uterine organs are found abnormal during any previous surgery. 

In such exceptions, they should see the doctor early. In other words, the couple should see a Doctor at the end of 12 months, if everything is normal and in the above conditions, they should see the Doctor earlier than 12 months, so that they don’t lose time. The most important exception to this rule is if a woman is married at 37 years or older they should not wait for 12 months. At the end of six months of trial, they should see a doctor so that they can find out if there are any other problems or if they can wait for 6 more months. So the most important factor is the lady’s age. These are the reasons to visit a Doctor earlier than 12 months.

30. Now you have completed investigations and you have written the protocol saying this is the treatment how do I know where I stand?

After completion of the investigations, clinicians write out the list of problems the couple has. If it is one factor or two factors or multiple factors. The second thing is we should tell them what is the appropriate treatment and we should also tell them is that the only treatment or a second option is there. Thirdly, we should also tell them what is the difference between the first option and the second option of the treatment and are there any limitations of that in terms of success rate, in terms of cost, in terms of time. 

This is the most important aspect the couple should know when they are visiting the Doctor for a review consultation wherein treatment is discussed and the couple can freely ask questions like- Is this the only treatment or do I have alternative treatments? 

what is the amount of time I need to spend? 

Can I go for the second option and if it fails, then go to the first option later? 

what is the chance of me conceiving in the first option and second option? 

One most important thing the couple should understand is none of the treatments is 100 percent successful. There are only relative outcomes in a given time. Sometimes the doctor might give only one treatment option. Nothing wrong with taking a second opinion or asking whether alternative treatments are possible. The most important thing is the second opinion should be in a documented form because if somebody says orally that this treatment can also be done and if they’re not willing to put that on paper, then you should think twice before going to such a place for treatment if there is ambiguity.

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