Consultant- Gynaecology & Obstetrics
Infertility Specialist & Lapaoscopic Surgeon
DGO, MS, Fellowship in Gynaecological, Lap Surgery (Sydney -Australia)
 
   
 

Laparoscopic Surgery

  Laparoscopic Surgery in Infertility
  Hysteroscopic Surgery
  Infertility
  High Risk Pregnancy
  Hysterectomy
  Myomectomy
  Endometriosis
  Diagnostic Laparoscopy
 

Infertility

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Infertility means not being able to become pregnant after a year of trying. If a woman keeps having miscarriages, it is also called infertility. Lots of couples have infertility problems. About a third of the time, infertility can be traced to the woman . In another third of cases, it is because of the  man . The rest of the time, it is because of both partners or no cause is found.

Drugs or surgery are common treatments. Happily, two-thirds of couples treated for infertility go on to have babies.

 

 

For a woman, infertility (or a state of subfertility) can manifest itself as either:

  • the inability to become pregnant
  • an inability to maintain a pregnancy
  • an inability to carry a pregnancy to a live birth.

When men and women attempt to have a child or to expand their family, the causes and the difficulties encountered can be complex. Many simple, as well as more complex medical interventions can be attempted to help a couple or an individual to reach a state of pregnancy or to be able to maintain a pregnancy which results in a live birth.

 
 

INFERTILITY is defined as an inability to conceive after 1 year of regular, unprotected coitus. MOST cases of infertility can be diagnosed and the vast majority can be treated.

Causes of Infertility:
There are numerous causes for infertility. The commonest ones are listed below.

 
 
  Female - Accounts for 1/3rd of All Fertility Problems


• Endometriosis


This is one of the most common causes of infertility. In this condition, the endometrial tissue (the uterine lining that sheds with each monthly period) grows outside the uterus. The patient usually has painful and heavy menstrual periods and repeated miscarriages.


Promising Solutions:
Laparoscopic surgery to remove abnormal tissue or unblock tubes and assisted reproductive therapy

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• Ovulation Problems

Hormonal imbalances which cause difficulty in release of a mature egg from an ovary. The patient has irregularities in her periods.

Promising Solution:
Ovulation-stimulating drugs , follicle-stimulating hormones and in vitro fertilisation (IVF)

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• Poor Egg Quality

Usually with advancing age, the egg quality declines, eggs become damaged or develop chromosomal anomalies.

Promising Solutions: Egg donation or surrogacy

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• Polycystic Ovarian Syndrome

This is a very common cause of infertility. In this condition the ovaries contain many small cysts which leads to hormonal imbalances. The patient has irregular menstrual periods, excessive hair growth, acne and weight gain.

Promising Solutions: Ovulation-stimulating drugs , follicle-stimulating hormones, and IVF

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• Fallopian Tube Blockages

Damaged fallopian tubes prevent eggs and sperm from coming together. Leading causes include pelvic inflammatory disease and sexually transmitted diseases.

Promising Solutions: Laparoscopic surgery to open tubes. If surgery fails, in vitro fertilisation is an option.

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• Uterine Anomalies

Congenital anomalies like septate or presence of uterine fibroid may alter the shape of the uterus. The patient may have heavy periods and recurrent abortions.

Promising Solutions: Laparoscopic surgery, medications shrink fibroids.

 
 
  Male - Accounts for 1/3rd of All Fertility Problems


• Male tube blockages

Obstructions in the vas deferens or epididymis, varicoceles or sexually transmitted diseases, are associated with inferility.

Promising Solutions: Surgery to repair the blockages.

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• Sperm problems
Low or no sperm counts, poor sperm motility and morphology can all cause infertility.

Promising solutions:
Fertility drugs may boost healthy sperm production. Other options include artificial insemination with donor sperm and injecting sperm directly into the egg.(ICSI)

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Coital problems
Premature or retrograde ejaculation, impotency, lack of sexual drive or other sexual problems may sometimes hamper conception.

Promising solutions:s
Psychosexual counselling may solve a lot of problems. ART is also an option.

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Unexplained Infertility
In this condition no cause for infertility can be found after a full series of evaluations.

Promising solutions:
Patients are advised timed intercourse and fertility enhancing drugs. Assisted reproductive techniques such as in vitro fertilisation have usual success rates.

 
 
 Combined – Accounts for 1/3rd  of All Fertility Problems
Sometimes a combination of both male and female factors cause infertility.
 
 
 
 

IVF & ICSI:

IVF & ICSI : A Guide to Assisted Reproductive Technologies 

Un-Assisted Reproduction
In order to understand assisted reproduction and how it can help infertile couples, it is important to understand how conception takes place naturally. In order for traditional conception to occur, the man must ejaculate his semen, the fluid containing the sperm, into the woman’s vagina near the time of ovulation, when her ovary releases an egg. Following ovulation, the egg is picked up by one of the fallopian tubes. Since fertilization usually takes place inside the fallopian tube, the man’s sperm must be capable of swimming through the vagina and cervical mucus, up the cervical canal into the uterus, and up into the fallopian tube, where it must attach to and penetrate the egg in order to fertilize it. The fertilized egg continues traveling to the uterus and implants in the uterine lining, where it grows and matures. If all goes well, a child is born approximately nine months later.


In Vitro Fertilization (IVF)
IVF is a method of assisted reproduction in which a man’s sperm and a woman’s eggs are combined outside of the body in a laboratory dish. If fertilization occurs, the resulting embryos are transferred to the woman’s uterus, where one or more may implant in the uterine lining and develop. The basic steps in an IVF treatment cycle are ovarian stimulation, egg retrieval, insemination, fertilization, embryo culture, and embryo transfer.
 


Ovarian Stimulation
Ovulation drugs or “fertility drugs,” are used to stimulate the ovaries to produce multiple eggs rather than the single egg that normally develops each month. Multiple eggs are needed because some eggs will not fertilize or develop normally after egg retrieval. Pregnancy rates are higher when more than one egg is fertilized and transferred to the uterus during an IVF treatment cycle. Timing is crucial in an IVF cycle.

The ovaries are evaluated during treatment with vaginal ultrasound examinations to monitor the development of ovarian follicles When the ovaries are ready, hCG or other medications are given. The hCG replaces the woman’s natural LH surge andhelps the eggs to mature so they may be capable of being fertilized. The eggs are retrieved before ovulation occurs, usually 34 to 36 hours after the hCG injection is given. However, 10% to 20% of cycles are cancelled prior to the hCG injection. IVF cycles may be cancelled for a variety of reasons, usually due to an inadequate number of follicles developing. Occasionally, a cycle may be cancelled to reduce the risk of severe ovarian hyperstimulation syndrome (OHSS).
 


Egg Retrieval

Egg retrieval is usually accomplished by transvaginal ultrasound aspiration, a minor surgical procedure that can be performed in the physician’s office or outpatient center. Some form of anesthesia is generally administered. An ultrasound probe is inserted into the vagina to identify the mature follicles, and a needle is guided through the vagina and into the follicles. The eggs are aspirated (removed) from the follicles through the needle connected to a suction device.


 
Insemination, Fertilization, and Embryo Culture
After the eggs are retrieved, they are examined in the laboratory. The best quality, mature eggs (Figure 4) are placed in IVF culture medium and transferred to an incubator to await fertilization by the sperm. Sperm are separated from the semen in a process known as sperm preparation. Motile sperm are then placed together with the eggs, in a process called insemination, and stored in an incubator. When rates of fertilization are expected to be poor, fertilization may be achieved in the IVF laboratory using specialized micromanipulation techniques. Intracytoplasmic sperm injection (ICSI), which a single sperm is injected directly into the egg in an attempt to achieve fertilization Approximately 40% to 70% of the mature eggs will fertilize after insemination or ICSI. Lower rates may occur if the sperm and/or egg quality are poor. Occasionally, fertilization does not occur at all. Two days after the egg retrieval, the fertilized egg has divided to become a 2-to 4-cell embryo. Embryos may be transferred to the uterus at any time between one to six days after the egg retrieval. If successful development continues in the uterus, the embryo hatches from the surrounding zona pellucida and implants into the lining of the uterus approximately six to 10 days after the egg retrieval.


 
Embryo Transfer
The next step in the IVF process is the embryo transfer. No anesthesia is necessary, although some women may wish to have a mild sedative. The physician identifies the cervix using a vaginal speculum. One or more embryos suspended in a drop of culture medium are drawn into a transfer catheter, a long, thin sterile tube with a syringe on one end. The physician gently guides the tip of the transfer catheter through the cervix and places the fluid containing the embryos into the uterine cavity. The procedure is usually painless, although some women experience mild cramping.


 
Cryopreservation
Extra embryos remaining after the embryo transfer may be cryopreserved (frozen) for future transfer. Cryopreservation makes future ART cycles simpler, less expensive, and less invasive than the initial IVF cycle, since the woman does not require ovarian stimulation or egg retrieval. Once frozen, embryos may be stored for several years. However, not all embryos survive the freezing and thawing process, and the live birth rate is lower with cryopreserved embryo transfer. Couples should decide if they are going to cryopreserve extra embryos before undergoing IVF.


 
Success rates
It is important to understand the definitions of pregnancy rates and live birth rates. For example, a pregnancy rate of 40% does not mean that 40% of women took babies home. Pregnancy does not always result in live birth, and even the word “pregnancy” has more than one meaning. A biochemical pregnancy is common after IVF. This is a pregnancy confirmed by blood or urine tests but not by ultrasound, because the pregnancy miscarries before it is far enough along to show up on ultrasound. A clinical pregnancy is one in which the pregnancy is seen with ultrasound, but miscarriage may still occur. Therefore, when comparing the “pregnancy” rates of different clinics, it is important to know which type of pregnancy is being compared. Most couples are more concerned with a clinic’s live birth rate, which is the probability of delivering a live baby per IVF cycle started. Pregnancy rates, and more importantly live birth rates, are influenced by a number of factors, especially the woman’s age. In general, the live birth rate for each IVF cycle started is approximately 30% to 35% for women under age 35; 25% for women ages 35 to 37; 15% to 20% for women ages 38 to 40; and 6% to 10% for women over 40.


 
Donor sperm, eggs, and embryos
IVF may be done with a couple’s own eggs and sperm or with donor eggs, sperm, or embryos. A couple may choose to use a donor if there is a problem with their own sperm or eggs, or if they have a genetic disease that could be passed on to a child. Donors may be known or anonymous. In most cases, donor sperm is obtained from a sperm bank, and sperm donors undergo extensive medical screening. Donor eggs are an option for women with a uterus who are unlikely or unable to conceive with their own eggs. Egg donation is more complex that sperm donation and is done as part of an IVF procedure. The egg donor must undergo ovarian stimulation and egg retrieval. During this time, the recipient (the woman who will receive the eggs after they are fertilized) receives hormone medications to prepare her uterus for pregnancy. After the retrieval, the donor’s eggs are fertilized by sperm from the recipient’s partner and transferred to the recipient’s uterus.


The recipient will not be genetically related to the child, but she will carry the pregnancy and give birth. In some cases, when both the man and woman are infertile, both donor sperm and eggs have been used. Donor embryos may also be used in these cases

 
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Laparoscopic and Hysteroscopic Evaluation of Infertility:


• Hysteroscopy:

Office hysteroscopy is a procedure which involves the fertility specialist directly looking at the inside of the uterus (uterine cavity) using a special instrument called a hysteroscope. The hysteroscope has a small telescopic lens which is placed through the cervix into the uterus. Saline is injected into the uterus to distend the uterine wall and allow visualization of the uterine cavity. The hysteroscope is attached to a camera and can be viewed on a video monitor.

The test is performed between cycle days 6-10, with Cycle Day 1 being the first day of the period. If full flow of menses does not occur, a blood pregnancy test will be obtained prior to the procedure. Patients undergoing this procedure will be encouraged to take 800 milligrams of ibuprofen or another over-the-counter pain medicine one hour before the procedure as cramping may be experienced when the hysteroscopy is performed. An antibiotic, doxycycline (100 mg), may also be prescribed to prevent a uterine infection. Doxycycline will be taken twice daily, starting the day before the HSG, and continue for a total of three days—the day before, the day of, and the day after the hysteroscopy. 

• Laparoscopy:

Laparoscopy is a common diagnostic and surgical procedure for infertility and other conditions. Laparoscopy for infertility usually involves making two small incisions, one at the pubic hairline, and the other at the navel. The laparoscope, which is a small telescope-like device, is inserted in one opening and surgical tools are inserted in the other.

The laparoscope allows the fertility specialist to visualize the internal organs, including the ovaries, uterus, tubes, and other structures. Many complex surgeries that once required opening the abdomen (laparotomy) are now performed using the laparoscope, which is an outpatient procedure. There is little pain associated with a laparoscope and the recovery time is very short. It also costs less compared with other procedures.

A reproductive endocrinologist/fertility specialist should perform the diagnostic laparoscopy.  Fertility specialists have years of advanced training performing delicate microsurgical procedures. One major reason for choosing a specialist is that many conditions, such as endometriosis, can be treated during the diagnostic laparoscopy, thus eliminating the need for a repeat procedure.

Scar tissue can form following any surgery, and is especially problematic if the scar tissue forms on reproductive organs such as the fallopian tubes. This is another reason why a fertility specialist should perform the laparoscopy, as they are experienced in avoiding this complication.

Our Dallas Fertility Center has board certified infertility specialists with extensive experience performing laparoscopic procedures for a vast array of gynecologic conditions.

 
 
 

Surgical Treatment of Infertility:

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A woman’s pelvic anatomy can be disrupted by various conditions that can interfere with her chances of achieving a successful pregnancy, and in many situations, the condition causing infertility is treatable with surgical options. These women may be labeled with unexplained infertility, when, in fact, surgical treatment could help.

“There are several situations where infertile patients might be better served by more diligent evaluation and treatment of underlying disease,” says Ron Feinberg, M.D., a reproductive endocrinologist with Reproductive Associates of Delaware. “Patients with active endometriosis, polyps, fibroids or even subtle tubal abnormalities may stand a very good chance of conceiving without necessarily needing IVF.”

Diseases Affecting Pregnancy Success:
There are several diseases can block embryo implantation and hurt pregnancy chances, including endometriosis, uterine polyps and fibroids, and diseased fallopian tubes. Pelvic adhesions can also restrict blood flow to the ovaries and interfere with normal egg development.

These diseases may also affect a woman’s risk of miscarriage if she does become pregnant. For example, a recent British study found that removing fibroids that distort the shape of a woman’s uterus significantly improved outcomes, with a live birth rate increasing from 23.3 percent to 52 percent.

“Uterine anatomical defects such as fibroids are one of the treatable causes of recurrent miscarriage,” says Laurence Jacobs, M.D., a fertility doctor with Fertility Centers of Illinois in Chicago. “I do hysteroscopic myomectomies for this reason and have much success with them.”

In addition, there are situations in which surgical treatment of endometriosis, polyps and fibroids may increase the chances of success with in vitro fertilization. “Others have published that IVF success can be improved with careful surgical intervention,” Dr. Feinberg explains. “So that has always been our strategy with our patients.”

Surgical Options:
Treating conditions that contribute to infertility is often done with minimally invasive laparascopy and hysteroscopy performed in an outpatient setting. However, some surgeries may be performed in a hospital operating room.

Laparoscopy is an outpatient surgical procedure in which your fertility doctor will use a narrow fiber optic telescope inserted through an incision near your navel. Laparoscopic procedures include:

  • Tuboplasty — repair of the fallopian tubes
  • Ovarian cystectomy — removal of cysts from the ovary
  • Treatment of endometriosis
  • Myomectomy — removal of fibroids
  • Lysis — removal of adhesions


Hysteroscopy is an outpatient procedure in which the fertility doctor will use a narrow fiber optic telescope inserted into your uterus through your cervix to look for and sometimes remove adhesions inside your uterus. Hysteroscopic procedures include:

  • Lysis — removal of intrauterine adhesions
  • Myomectomy — removal of fibroids
  • Correction of congenital abnormalities of the uterus, such as uterine septum


Microsurgery optons include:

  • Microsurgical tubal reanastomosis — performed to reconnect the two ends of the fallopian tubes to reverse a tubal ligation
  • Myomectomy — removal of fibroids
  • Ovarian cystectomy — removal of cysts from the ovary
  • Salpingectomy — removal of part of a fallopian tube when a tube has developed a buildup of fluid
  • Salpingostomy to create a new opening in the part of the tube closest to the ovary when the end of the fallopian tube is blocked by a buildup of fluid.
  • Fimbrioplasty to rebuild the fringed ends of the fallopian tube when part of the tube closest to the ovary is partially blocked or has scar tissue
 
 
 
F.A.Q:
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Q) Is infertility treatment affordable for people from middle class backgrounds?

Yes, of course! At URVARAA IVF, infertility treatment is very much affordable . Here we are treating patients from all sections of the society as our pricing is very competitive. We do not prescribe any unnecessary tests and keep the treatment protocol as simple and patient friendly as possible.



Q) How does conception occur naturally?

In each menstrual cycle a single egg is released from the woman’s ovary. For conception to take place the man’s sperm has to meet the woman's egg. This usually takes place in one of the woman’s fallopian tubes and the fertilized egg then travels to the uterus and is implanted there. For pregnancy to take place, fertilization of the egg must be followed by a successful implantation.




Q) Does age affect a woman's fertility?

As a woman ages, hormonal changes in her body can cause difficulties in ovulation. The quality and quantity of her eggs decline. The ability of an egg to become fertilized may also decrease with time, lowering the chances of conception. Miscarriage rates also increase with age.


Q) Can an impotent man have children?

Sterility and virility are entirely different conditions. An impotent man may have a good sperm count and he can impregnate his wife by artificial methods.
Likewise, a virile man who has regular sexual activity may not have any sperm in his semen at all. He may need ART with donor semen to solve his problem.


Q) Is it abnormal for semen to flow out of the vagina after a sexual act?

Semen overflowing from the vagina is not an unnatural phenomenon. If there is excessive semen some of it may overflow, which results in wetting of bedclothes. This happens to a lot of women and has never been a cause for infertility. It is advisable to keep a pillow beneath the buttocks during intercourse to prevent the overflow.


Q) When is the best time to have intercourse in a menstrual cycle for enhancement of fertility?

The timing of intercourse should of course be targeted at the time of ovulation which is the most fertile period of a woman, but the couple should try at other times as well.

A recommended time is usually on alternate days from Day9 to Day 19 of a regular cycle.

 

Q) What is the cause of frigidity? Is lack of sexual desire associated with infertility?

There is no connection between sexual pleasure and fertility. A normal sexual drive in a male or female depends primarily on the hormones, general health and social conditioning of a person. The kind of physical and emotional bond that has evolved between a couple, including matters related to sexual arousal, timing of ejaculation, orgasm is of great importance. In essence, any kind of breakdown in communication in a long term sexual relationship can often be the cause for such a loss in sexual desire. At URVARAA IVF we have trained and compassionate counsellors to help couples deal with these problems.


Q) When is IVF (In-Vitro Fertilization) indicated?

The common indications are:
• Severe Tubal blockage
• Severe male factor infertility such as low sperm count / low motility
• Moderate to severe endometriosis
• Unexplained infertility

Our doctors review the patient’s history and then guide them to the most appropriate treatment and diagnostic procedures.


Q) What is the success rate with each IVF cycle?

The possibilities of success with IVF vary from patient to patient. The doctor can best predict the outcome only after a complete evaluation, which includes reviewing the history and any prior response to fertility medications. In India success rates have drastically improved for couples taking treatment under ART.



Q) Is the egg retrieval process painful?

No, not usually. It lasts approximately 20 to 30 minutes and patients are usually sedated during this time.



Q) Is there a higher risk of birth defects with a child born from IVF?

Not at all. The risks are the same as for children conceived naturally

 
 
 
 
 
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