COUPLE FRIENDY APPROACH ON ONE - DAY PROTOCOL

ONE DAY PROTOCOL:(Followed in our centre)

The couple on registration will undergo all the simple tests, such as detailed history, clinical examination, semen analysis and ultrasound study. These tests could be completed over a period of 30 to 60 minutes. On completion of these basic tests the infertility specialist will get a clear picture as to the cause of infertility in majority of occasions. A decision is made on the treatment strategy, and the chances of pregnancy could also be speculated. On the same day the optimal treatment is administered, be it surgery or medical. Frequent follow-up visits are not needed. Such of those to conceive do so even without any frequent clinic visits, ultrasound studies and checkups. Moreover, the feeling that the needful has been done, and chances of pregnancy is high and that the strain of frequent travel could be avoided are the important factors which console the couple and pave the way for high conception chances.

By and large, if the male is proved normal, the female partner will have to be studied in detail with other advanced procedures such as laparoscopy. Those normal appearing females with regular menstrual cycles are usually ovulating normally, and hence will seldom need investigations such as hormone studies to prove ovulation. Hence they will not need any treatment with ovulation inducing drugs.

On the contrary these subjects with regular menstrual cycles are at high risk for factors such as endometriosis, tubal or ovarian adhesions, uterine or ovarian conditions that could be responsible for infertility. On ultrasound examination conditions such as ovarian cysts, uterine conditions are identified clearly and these subjects are best treated at laparoscopic surgery. The surgery could be undertaken the same day, and a pregnancy rate ranging from 40 to 80 % could be ensured.

Laparoscopy (Keyhole Surgery)

Laparoscopy is a surgical procedure, (keyhole surgery), and performed under general anesthesia. The patient does not experience any discomfort or pain, and can have regular food 5 hrs after operation, and get discharged after 12 hrs, and perform her routine the very next day. By this procedure, the internal organs such as uterus, ovaries, tube, appendix, gall bladder, liver and intestines could be clearly visualized. Otherwise this is a method of direct visualization and inspection of the abdominal organs without opening the abdomen. Once the organs are clearly visualized it is evident that any disease affecting the organ could be delineated, and simultaneously corrected at the same sitting. Thus diagnosis of the cause of infertility and treatment for the condition are undertaken side by side.

The laparoscopy operation is completely video recorded and could be shown to the couple, who can better understand the exact cause of infertility and will remain informed as the chances for conception. This counseling helps the couple feel happy, and understand their situation better.

Moreover, since no further follow-up visits or other forms of treatment are not usually needed, they are relieved from the strain of repeated clinic visits, travel, loss of working days and monetary constraints. Routine semen injection and other assisted procedures are also not recommended, and we observe that pregnancy chances are better under the natural course, than by other measures.

These make the couple satisfied, happy and relieved of many hurdles, and this psychological factor is an added factor in increased pregnancy rate.

Usually the couple will be expected to stay together and have regular coitus from the 3rd or 4th day of the pro. Coitus should be daily or on alternate days. Since the entire treatment has been completed on the "one day protocol" no further medicines or follow-up will be need except is a few special circumstances. With in 6 months to 1 year pregnancy occur to a tune of 40 - 80 %, depending on the condition that is treated. In those women where laparoscopy shows all organs normal, still there is a chance for conception, which is due to treatment effect of the surgery.

OVULATION:

Women who are not having regular periods (2 to 3 months' cycles) are usually infertile because of failure to ovulate. These subjects are benefited by ultrasound study, hormone study and newer medicines used for induction of ovulation. However, women with polycystic ovary syndrome (one form of ovulatory failure with mild excess of male hormone) remain benefited by laparoscopy ovarian surgery combined with newer drugs. Many of these subjects have a familial tendency for diabetes and many antidiabetic drugs combined with laparoscopic surgery achieve a pregnancy rate to the tune of 60 %. These patients also do not require frequent clinic visit, frequent scanning and check-up. After the treatment has been decided the couples are expected to try pregnancy, and over a period of 3 to 6 months (at the most 1 yr) conception occurs.

IUI: Intrauterine insemination:

IUI: Intrauterine insemination: Semen is collected and prepared under sterile conditions, wherein good quality Actively motile sperms alone are separated and introduced into the uterine cavity with the help of a cannula. This is an outdoor procedure, performed in and around the time of ovulation. To improve ovulation, the female partner will be administered ovulation inducing drugs and try to get even more than one follicle to mature, so that the chances of conception could be improved. Similarly the male partner, also may get some treatment to improve his seminal quality.

The couple benefited by this procedure are those with reduced sperm count, those in whom no other cause for infertility could be detected at detailed evaluation, and those who have failed to achieve pregnancy inspite of optimal treatment for 6 months.

The procedure could be attempted for 3 to a maximum of 6 cycles, within which such of those to conceive will do so. If not the next option be to accept IVF or ICSI

Invitro Fertilization and Embryo Transfer:

IVF and ET: Invitro fertilization and embryo transfer. In this procedure the female partner made to develop multiple follicles in her ovary with the help of ovulation inducing hormone injections. These follicles are aspirated and mature oocytes (eggs) are collected in the ART lab. The eggs are inseminated with the husband's sperms. After ensuring the eggs have been fertilized and entered the embryo phase, few of the healthy embryos are placed into the uterine cavity of the female. Then one watches for the growth of the embryo inside the uterus:

The women who have damaged fallopian tubes are ideal candidates for this procedure. Also those who have failed to achieved pregnancy after laparoscopic correction of tubal or ovarian cause of infertility. After laparoscopy the couple should wait for 6 months to one year to opt for IVF. Such of those who fail to ovulate inspite of optimal treatment with ovulation inducing drugs are another category to be benefited by IVF. Male partner with reduced sperm count also is another indication, however, they are better served by the following (ICSI) procedure.

Intra Cytoplasmic Sperm Injection:

ICSI: Intracytoplasmic sperm injection. This procedure is still more advanced and is the latest technology in ART (ASSISTED REPRODUCTIVE TECHNOLOGY). Just as for IVF the eggs are collected in the laboratory. The good quality sperms are prepared. Under the microscope of the micromanipulator one sperm is pippetted in, and is injected directly into the egg (into the cytoplasm of the egg). This allows the sperm pronucleus to fuse with the female pronucleus that is present in the egg. This facilitates formation of the embryo more efficiently that the IVF procedure, and hence pregnancy changes are invariably better that IVF. The embryo is transformed into the uterine cavity and watched for further growth.

All patients suited for IVF are suited for ICSI, and specially it has benefits in partners with male factor, such as reduced sperms count. Even in men with no sperms in the semen, if they have sperms in the testicle and are not ejaculated in the semen, the sperm could be collected directly from the testes and used for ICSI procedure.