Infertility is a condition where the couple is unable to conceive after 12 months of regular sexual relationship without birth control.

There are two kinds of infertility - primary and secondary:

• Primary infertility means that the couple has never conceived.
• Secondary infertility means that the couple has experienced a pregnancy before and failed to conceive later.

A number of people face these problems but are embarrassed or hesitant to seek help.

To understand infertility, we need to understand the process of fertilization.

Recognizing infertility

If you've had more than a year of regular sexual relationship without birth control and you haven't achieved pregnancy, it's best to seek help. If a year hasn't passed yet, a good strategy is to plan to have sexual relationship during the days the womanis ovulating. If a woman has regular menstrual cycles, sexual relationship between the 8th & the 20th day will help.

Facts about infertility

It's a myth that infertility is always a "woman's problem". Half of all cases of infertility result from problems with the man's reproductive system. Of couples that seek medical treatment for infertility, 20% conceive before the treatment actually begins. One reason may be that anxiety about infertility may have contributed to the fertility problem, so contacting a doctor and counseling helps. 50% conceive within two years from starting treatment. Most infertility results from physical problems in a man or woman's reproductive system.

How is infertility investigated?

Apollo Hospitals, India offers several specialized investigative procedures for infertility for men and women. Both the partners are expected to come for the first visit wherein a detailed history and previous reports are reviewed.

Investigations for the male

Apart from necessary basic blood and urine examination, semen analysis will be done.

Investigations for the female

Routine investigations such as CBC, FBS, urine routine, TSH,/ FSH / LH / Prolactin (Day 2 of the cycle), VDRL, Hepatitis B, HIV and Blood grouping and Rubella IgG levels will be done.

The following tests could be done as per the doctor's requisition:

• Serum FSH
• Serum LH
• Serum PRL
• Serum TSH

The above tests are to be done on day 2 or 3 of the menstrual cycle. (First day of the period is counted as Day 1.). Other procedures that may be done include:

HSG (Hysterosalpingogram)

This is a procedure where X-ray pictures of the uterus (Hystero) and fallopian tubes (Salpingo) are taken. A dye is injected into the uterus and pictures are taken to identify abnormalities in the uterine cavity and the tubes. An alternative method is Sonohystero Salpingogram where ultrasound is used instead of X-ray.

Trans-vaginal Ultra Sonogram

This is done to check for abnormalities in the uterus, tubes and ovaries. This is best done around the 13th day of the cycle. Follicular tracking and monitoring of follicle development in patients who are undergoing treatment with ovulation induction drugs is also done through a trans-vaginal scan.

Laproscopic Hysteroscopy

This is visualization of the interior aspects of the uterus with an endoscope. This helps in:

• Identification of pathology in the uterine cavity
• Release of adhesions inside the uterus
• Resection of fibroid/ polyp which protrudes into the uterine cavity
• Cannulation of uterine end of tube if blocked
• Resection of uterine septum

Laparoscopy

This is direct visualization of the peritoneal cavity with an endoscope. This is useful for:

• Visualization of the uterus, tubes, ovaries and structures adjacent to it
• Performing the dye test to check tubal patency
• Operative interventions if necessary

All these investigations will be individualized as per the doctor's decision.

The doctor would review the results of the investigations and depending upon the cause of infertility, treatment will be initiated.

Assisted Reproductive Technology (ART) is the term used for infertility treatments. These treatments are designed to increase the number of eggs or sperm, and to bring them together, thus improving the likelihood of pregnancy.

Infertility treatment can range from practical lifestyle changes to extended medical procedures - depending on the nature of the problem. As a first step, it may just be a few simple measures, like awareness of fertile period and psycho social interventions (Quit Smoking / Alcohol, Relaxation Therapy).

The types of treatment are:

Ovulation induction

This is offered when the female has irregular ovulation. Medication is provided to regularize the ovulation cycle and also to enhance the quality of the egg. Drugs commonly used are Clomiphene Citrate, HMG, purified and recombinant FSH. Usually HMG, FSH are used for recruiting more follicles - which is necessary in IVF/ ICSI procedures.

Clomiphene Citrate is used from day 3 to day 7 of the cycle with alternate day relationship from day 8 to day 20. Progesterone supplementation is provided from day 15. Follicular tracking can be started from day 10/11. If IUI (Intra Uterine Insemination) is planned, from day 3 to day 7 Clomiphene Citrate will be prescribed (plus HMG if needed).From Day 10, follicular study will start. When the dominant follicular size is 18 to 20 mm, an injection is given to release the egg which is evident in the scan. IUI is done 40 hours after the injection.

Procedures

• IUI (Intra Uterine Insemination): This is the method by which processed semen is placed directly in the uterus with the help of a catheter. On an average, 50-60 IUI are done every month.
• IVF (Invitro Fertilization): IVF means fertilization of an ovum outside the body and consequently, the transfer of the fertilized ovum (embryo) into the uterus of the woman. Apollo Hospitals conducts approximately 20-25 IVF per month.
• ICSI (Intra Cytoplasmic Sperm Injection): ICSI is the technological breakthrough in the field of IVF which is used to overcome the inability of sperm to fertilize an egg (which may be either due to sub-optimal sperm parameters, oocyte defects or other reasons). In this technique, a single sperm is directly injected into the cytoplasm of an egg in order to achieve fertilization.
• TESA (Testicular Sperm Aspiration): Apollo Hospitals carries out on an average 8-10 TESA every month.
• Embryo Freezing Excess (Surplus): Embryos can be Cryo-preserved at ultra low temperatures for many years. These frozen embryos can be used subsequently, without the need for ovarian stimulation and egg retrieval.
• Assisted Hatching: The procedure is based on the fact that an alteration in zona pellucida (outer covering of egg) either by drilling a hole through it or by thinning it, will promote hatching or implantation of embryos that are otherwise unable to escape intact from the zona pellucida.
• Semen/Sperm freezing: Semen/Sperm can be stored frozen at ultra low temperatures for long duration which could be helpful in a variety of circumstances - semen freezing prior to chemotherapy, inability of the male partner to be present or to deliver the semen on the day of procedure, testicular biopsy/sperm freezing to avoid repeated biopsies, donor semen, etc.