The common diagnoses for you would then be:
Tubal factor – blocked fallopian tubes. Here, it very important
that any hydrosalpinx (water filled in the tube) should be removed before proceeding
with IVF. If not possible, the part where the tube joins the uterus should be clipped.
If this is not done, the water from the tubes will flush out the embryos which are
transferred at IVF and cause repeated failures.
Endometriosis – The first treatment option is a good laparoscopic
surgery with enucleation and removal of chocolate cysts and pelvic adhesions. Thereafter,
the couple may try naturally or optimize their chances with Intrauterine insemination.
If this fails, early resort to IVF is often the best way out. One needs to be careful
in patients with moderate or severe endometriosis as aggressive surgery might cause
a depletion of the egg reserve. In such cases we prefer to do the IVF first (to
freeze the embryos) and then proceed with surgery. It is always best to estimate
the serum AMH level for existing egg reserve before proceeding with surgery
Polycystic Ovaries – Treatment begins with ovulation induction
2-3 months followed by IUI for 2-3 months. If all this fails, IVF is extremely successful
for this group of patients. Modern protocols using FSH injections with an antagonist
(cetrorelix) followed by IVF and freezing of all embryos are very successful for
these patients. With IVF and transfer of only frozen embryos, they can expect a
60% chance of pregnancy in two cycles. Also, we make sure that there is no Ovarian
Hyperstimulation in these patients (with the judicious use of hormone injections
and some modern protocols)
Male factor - Patients with low sperm counts or poor sperm motility
would need an andrological evaluation and some tests such as serum FSH, Prolactin,
Testosterone, scrotal color Doppler and others. Thereafter, medicines are prescribed
for 3-6 months. Please remember that the efficacy of medicines would only be known
after 3 months so it is futile to repeat the semen analysis before that. Sometimes,
the doctor might recommend a simple surgery such as varicocelectomy. After 6 months,
if the problem is not too severe, IUI for 3 cycles could be tried. However, the
best and most successful treatment for most cases of sperm problems is ICSI wherein
a single sperm is required to produce the embryo.
Unexplained Infertility - If all the above investigations show
normal results you would be categorized as unexplained infertility. These patients
are often told that all is normal and it is just a matter of time before they achieve
pregnancy. This may be true for some of them but for the majority it implies that
there are other factors such as subtle egg and sperm defects or even FAILURE of
the sperms to fertilize the eggs which are at play. Unfortunately, there are no
tests to prove these events. You would be recommended two to three cycles of IUI
followed by ICSI.
Repeated IVF failures / Recurrent implantation failures / Recurrent miscarriages
/ Impaired endometrial receptivity : The best options are hysteroscopy
with endometrial scratching, use of frozen embryo transfer with high dose estrogen,
vaginal sildenafil, aspirin, Heparin injections, and intrauterine instillation of
Granulocyte Colony stimulating factor. If all these fail, we recommend intrauterine
instillation of platelet rich plasma (PRP). Finally, there is gestational surrogacy
for these patients.
Poor ovarian reserve:This is usually diagnosed if the serum AMH level is low or there are very antral follicles seen on ultrasound. It indicates a low number of eggs and can be seen in all age groups although more common after age of 34. The best treatment option is one month of pre-treatment with an androgenisation protocol (combination of testosterone, coenzyme Q, resveratrol) followed by IVF. The IVF would entail embryo accumulation over 2-3 ovarian stimulation cycles. We would perform one conventional long agonist protocol and one antagonist cycle. It is ideal to have a minimum of three top quality embryos in the freezer before planning an embryo transfer in patients with a poor egg reserve. If all these measures fail, then egg donation is the final option for these patients. Dual stimulation (two stimulations in one menstrual cycle) was popular a few years ago. However, studies have shown that it’s utility is limited to patients with cancer going in for chemotherapy where time is of essence. It is no longer recommended for patients with a poor ovarian reserve.