An Ultrasound scan can give basic diagnostic information of the female anatomical problems and with a transvaginal scan we can know whether apart from anatomical remarkability there is ovulation,size of ovulation and also the time of ovulation. A color Doppler scan can give much more detailed and indepth information than the regular USS. The resolution and quality of a doppler scan machine can prove crucial in follicular studies and the treatment schedule for an Assisted Reproduction program.

Endometrial biopsy is to done to see whether the woman has a healthy endometrium, favourable for a pregnancy. Implantation of the embryo depends on the quality and thickness of the endometrial lining. Conditions like Luteal Phase Defect (LPD), which is due to progesterone deficiency, can lead to early miscarriage.
The Post Coital Test (PCT) is used to determine whether you are producing good quality mucus at the time of ovulation and whether your husband's sperm can live normally in this mucus. In cases such as the wife having anti-sperm antibodies (ASA), a PCT will be negative. Which means healthy and actively motile sperms will not be found in sufficient numbers in the cervical mucus sample.

A hormone study of the patient is crucial to diagnose the cause as well as to the treatment of infertility. Cases such as polycystic ovarian disease (PCOD),prolactinomas and other diseases due to hormonal imbalance can be detected easily. During an IVF or ICSI program, regular hormonal assays are done to see the body's response and to decide on further treatment. Hormones routinely evaluated include Estradiol, Progesterone, LH, FSH, Thyroid hormones ( T3, T4, TSH) and Prolactin.
Blood tests will include routine hematological examination as well as tests to rule out diseases such as HIV, Hepatitis B and C, VDRL, immunological disease screening tests and other tests.

A Hysterosalpingogram (HSG) can give information about the tubal patency and is a very important diagnostic tool. It is a procedure that can detect abnormalities such as scar tissue, polyps and fibroids in the uterine cavity and congenital defects of the uterus. The HSG is performed right after menstruation stops but before ovulation. A small catheter is placed in the cervix and a dye visible to X-ray is injected into the uterus. As the dye fills the uterus, fallopian tubes and pelvic cavity, X-rays are taken, allowing us to see the shape of these organs. If the tubes are damaged or closed, the dye will not travel into them or spill out through the fimbrial end. If an HSG indicates an abnormality, a laparoscopy with a chromotubation may be necessary to confirm it. If the tubes do not fill, a proximal tubal cannulation may be attempted.

The male factor can be easily detected by a series of Semen Analyses. The semen is evaluated mainly for volume, pH, number of sperm, motility and shape. However, a normal looking sperm sample does not necessarily rule out other abnormalities. Together with a Fructose test, cases of obstructive and non-obstructive male factors can be diagnosed. While obstructive factors can be corrected by surgical procedures, other severe factors may require direct aspiration of sperm from the testes,epidydimis, vas or sperm retrieval from a testicular biopsy together with an ICSI program. Worst cases may require Donor programmes.

Hysteroscopy provides a very definitive diagnosis of intra uterine anomalies. This involves using the hysteroscope, a long narrow lighted television camera, to view the inside of the uterine cavity and cervical canal. Any fibroid, septae or band may be diagnosed and attempted to be corrected immediately.

In most cases of infertility, a diagnostic laparoscopy is required to rule out anatomical problems, endometriosis and other subtle causes; and also to make a definitive statement of the female factor. Laparoscopy is a common surgical procedure that allows us to directly view the uterus, tubes and ovaries. It is a relatively minor operation, usually performed under general anesthesia in a day surgery unit. A small incision is made below the navel and a laparoscope, a long narrow lighted television camera, is inserted into the abdominal cavity. The doctor can then see if any significant adhesions, scar tissue, endometriosis or fibroids affecting fertility exists. However, laparoscopy may miss microscopic tubal damage. Chromotubation is also be done along with a diagnostic laparoscopy routinely. Other problems including poly cystic ovaries and other ovarian cysts may be required to be corrected via the laparoscope before attempting an IVF program.

In this fairly simple procedure, sperm is placed within the uterus around the time of ovulation. With the aid of an ultra sound scan the exact size, time and state of the ovarian follicles can be known. The semen is washed in a special media and then processed so that the most active and healthy sperms are available, leaving the dead sperm and other debris. This processed sample is placed into the uterus of the woman. And when the woman’s egg travels down her tubes on their own at the time of ovulation, these sperm fertilise it, as would happen naturally.. Ovulation induction combined with IUI is often the first course of treatments. IUI alone offers a good conception rate per cycle while combining ovulation induction with IUI may boost this rate. Gonadotropins combined with IUI offers a 25-30% per cycle conception rate. (Rates worked considering minimal to mild tubal damage, normal to mild sperm abnormalities and women less than 40 years old.)

When the Semen Analysis shows very poor results such techniques are required to retrieve sperm for the IVF or ICSI program. Various techniques such as Vasectomy Reversal, Microscopic Vasovasostomy, Microscopic Epididymovasostomy, Microscopic Vasal Sperm Aspiration, Microscopic Epididymal Sperm Aspiration (MESA), Testicular Sperm Retrieval from Biopsy(TESA), Transurethral Resection of Ejaculatory Ducts, Sperm Retrieval by Fine Needle Aspiration (PESA) are attempted now. Sperm retrieval from Testicular Biopsy (TESA) is the most commonly practised procedure. Multiple biopsies have succesfully retrieved mature sperm from over 60% of male patients diagnosed as Sertoli cell only syndrome (SCOS) cases. These techniques combined with an ICSI cycle offer hope even to azoospermics and have allowed such couples to have a baby of their own.

In Vitro Fertilisation (IVF) involves removing eggs from a woman, fertilizing them with sperm in the laboratory (in a culture dish, actually, not a test tube) and then transferring the fertilized eggs, or embryos, into the uterus a few days later. More specifically, after super ovulation with hormones to produce multiple eggs, the IVF team retrieves the eggs under ultrasound guidance. The semen is processed meanwhile in special media to obtain the most active and healthy sperm excluding all the dead sperm and other debris cells found in the semen. This processed semen and the retrieved eggs are placed in sterile culture media and kept at normal body temperature inside an incubator, where fertilization and early cell division take place. The team returns the embryos into the uterus at an apprpriate stage of the embryo development. From that point, if the embryos implant successfully, the pregnancy continues as it would naturally.

IVF is a particularly good alternative for a woman who produces mature eggs but can't conceive naturally because of blocked, damaged or absent fallopian tubes and patients with luteinized unruptured follicle syndrome,who develop but doesn't release mature eggs from her follicles. In Vitro Fertilization (IVF) offers a much higher chance of success per cycle for tubal damage than can surgery. Tubal scar tissue is often inside the fallopian tube and surgery can only repair the outside of the tube.

Once the egg is fertilised, it takes around 48 hours for the embryos to develop into a four celled stage. Usually embryo transfer into the uterus is done any time after the four celled stage is attained. Depending on the time of transfer, the embryos may be anywhere between the four celled, six celled or eight celled stage.

When the Embryo is cultured upto the fifth day, it develops into a Blastocyst. The chances of a blastocyst implanting and continuing as a healthy pregnancy is more than that of an embryo at an earlier stage. But it should be noted that the success rates have not increased with Blastocyst transfer. It allows avoiding multiple pregnancy as the number of embryos required to be transferred is lesser in the blastocyst stage.

Intra Cytoplasmic Sperm Injection or ICSI has brought a revolution in Assisted Reproduction, offering lot of hope for infertile couples and a much higher success rate for the ART programs. Intra Cytoplasmic Sperm Injection is a micromanipulation technique developed to help achieve fertilization for couples with severe male factor infertility or couples who have had failure to fertilize in a previous.
In Vitro Fertilization attempt. The procedure overcomes many of the barriers to fertilization and allows couples with little hope of achieving successful pregnancy to obtain fertilized embryos. Sperm being injected into an Egg.
The ICSI procedure like an IVF program requires that the woman partner undergo ovarian stimulation with fertility medications so that several mature eggs develop. These eggs are then aspirated through the vagina, under ultrasound guidance, and incubated under precise conditions in the embryology laboratory. The semen sample is prepared by centrifuging (spinning the sperm cells in a special medium). This process separates live sperm from debris and the dead sperm. The micromanipulation specialist picks up a single live sperm in a special needle and injects it directly into the egg. Fertilisation is almost assured with an ICSI program. Through the ICSI procedure, many couples with difficult male factor infertility problems such as oligospermics and azoospermics have achieved pregnancy. The success rates of ICSI programs are higher than a regular IVF program.

Pre Implantation Genetic Diagnosis offers the latest technology for diagnosis of Genetic disorders before implantation of the Embryo in the uterus. This is an alternative to Pre-natal genetic diagnostics which can only detect disorders once the embryo has implanted and grown into a foetus. PGD offers the hope of a healthy baby in couples with genetic disorders. The embryos cells are taken before implantation or transfer into the uterus and examined for genetic disorders. Taking a cell or two at this stage does not hamper the normal growth and health of the foetus as all cells at this stage are totipotent (capable of growing into a full foetus by itself). PGD is done by techniques such as Fluorescent in-situ hybridisation(FISH) and karyotyping.

Cryopreservation or freezing allows preservation of sperms in future spontaneous ovulation cycles and embryos in future frozen cycles of IVF. This is an advantage if many eggs are retrieved and fertilized.

Saving eggs for future use by fertilizing them with sperm and then freezing them as pre-embryos can be helpful. Frozen pre-embryos can be transferred during subsequent spontaneous (natural) ovulation cycles without subjecting the woman to any additional medications and another egg retrieval. At the right time during succeeding treatment cycles, the frozen pre embryos are thawed & transferred into the uterus.
The ability to preserve pre-embryos for future use lowers the total cost of repeated IVF treatments since the most costly first few stages (ovulation induction, egg retrieval, fertilization) don't have to be repeated. Another advantage is that one or more pre-embryos can be transferred during a natural ovulation cycle when the woman's uterus is naturally ready for implantation.

Cryopreservation of sperms also are particularly useful when the husband is not living with the wife. This allows the wife to go ahead with the IVF program while the husband is away. In the state of Kerala, in India this facility is valuable for many couples whose husbands are in the Gulf states, so that the wives can continue treatment in their absence. Sperm freezing is also relevant for patients undergoing surgery or radiation or chemotherapy that can affect their fertility. Sperm can be frozen before the therapy and maybe later used for an IVF or ICSI program if desired.

Freezing eggs and then using it succesfully for a live pregnancy is still at research level. Though eggs can be frozen the quality of the eggs are affected. Research is on to find a suitable cryo preservant for eggs which can preserve the quality as well. But excised ovarian tissue has been frozen and then later transplanted back to the patient to obtain mature eggs from the woman. This technology is relevant for patients undergoing surgery or radiation or chemotherapy that can affect their fertility. Such women can have their ovarian tissue frozen for later use before the procedure.

For the worst hit patients we provide Donor programs. Patients who have no chance of obtaining their own sperm or egg, can opt for donor programs and thereby the couple can have a natural pregnancy, though the genetic material of the off-spring is different. After completing all medico-legal formalities and signing appropriate informed consent forms patients can chose to join such a program.

Before you decide to undergo treatment at any center, you should understand what your problem is and the entire IVF process, step-by-step, why a particular program or medicine or test is chosen for you, what each test is for, how each program is conducted, how and when drug therapy begins, how often the woman needs blood tests and ultrasound monitoring, when egg retrieval will likely take place.
The Assisted Reproduction Technology (ART) programs are long drawn and exhaustive, both mentally and physically. Investigative procedures can seem never ending. These include blood tests for both partners to rule out immunological problems or diseases and to confirm that the woman is ovulating; a complete physical exam for the woman, including a measurement of her uterine cavity; and a semen analysis, sperm antibody assay, and semen cultures for the man. You should be aware of each step and know what each drug is for. You should also receive instructions on how to administer the fertility drugs yourself if needed. Patients should also be aware of possible complications they could face such as an Ovarian Hyper stimulation syndrome (OHSS), pelvic pain, drug reactions and other side effects. ART centers usually provide information material and some centers provide specialist counselors for the patient support.

Feel free to talk and discuss with your Doctor anything that you dont understand or cannot follow. The couples develop a bond with the doctor. Trust and confidence is a major part of a succesful ART program. You can discuss with your Doctor all your psychological, emotional and physical problems.

Assisted Reproduction is a relatively new and fast developing technology. Like all developing sciences lot of ethical and legal issues are involved with ART too. Though the beauty and wonder of ART cannot be denied, such issues have to be addressed. Hence you may require to sign lengthy informed consent forms and contracts before undergoing treatment. Whether man should interfere in reproduction, which is considered a natural process is core to the issue. Other issues include whether manipulation of embryos and gametes can be justified, whether it is right for man to over ride the natural selection process and choose the sperm for ICSI, the issue of cryo-preservation of embryos, disposing extra embryos, donor program justification, surrogacy etc.

Before deciding on an ART program, the couple should understand their financial commitments fully. The equipments, drugs, culture media, sterile disposables used in Assisted Reproduction are very expensive, thereby running up the cost of the program. In India, the costs can vary anywhere between Rs.75,000 to Rs.1,50,000 per cycle of an ART program of IVF or ICSI, depending on the amount and quality of the drugs, media and equipments. Though using cheaper drugs is a way of reducing the cost, individual response to various drugs may vary thereby neccessitating use of more expensive drugs. Quality of embryos obtained is also seen to vary with the quality of drugs and media used.

Finally the most important thing patients should understand is that the ART programs are not always successful. Success rate depends on a number factors and it is difficult to arrive upon a standard rate. Success rates for an IVF program world over may vary between 25-40%, while an ICSI cycle gives a slightly higher rate. Though this rate is comparable to a natural reproduction rate, the emotions involved with an ART cycle is tremendous. The emotions can range from the expectation of a beautiful healthy to the devastation of a failed cycle. Hence good counseling and patient education is central to the program

The latest in drug delivery system is the injection pen, which allows the patient to do away with daily cumbersome visits to the doctor for drugs. The Pen not only offers a more convenient method of self-injection for patients, it is also designed to administer different drug dosages. It can be administered at home, or in clinics by a nurse or doctor.