When a pregnancy is not located in the uterus it is called an Extra Uterine Pregnancy (EUP) or ectopic pregnancy. The most common place for an EUP is the fallopian tube but sometimes the ectopic pregnancy is located elsewhere, such as in the cervix, the ovary or in the abdomen. EUP is a rare disease and occurs in 1% of all pregnancies. With IVF treatment the risk can increase. Risk factors for EUP are a history of infection of the tubes (salpingitis), chlamydia infection, Pelvic Inflammatory Disease (PID), former EUP, operation on the tubes or in the lower abdomen, endometrioses and appendicitis. The symptoms of ectopic pregnancy are often similar to those of a normal miscarriage and may include a positive pregnancy test together with or without vaginal bleeding and abdominal pain. Although it is not common, the possibility of EUP has to be considered in patients with the symptoms and one (or more) of the risk factors for EUP. Diagnoses is made by questioning the patient on the risk factors, physical examination, vaginal ultrasound and laboratory findings. Depending on the size and the location of the EUP, different treatments can be given. Mostly the ectopic pregnancy will be removed surgically but occasionally medical treatment or expectant treatment is offered when the pregnancy is very small and thorough control of the patient is possible.

35. I just had a HSG ( X-ray of the uterus and tubes) done, and this shows my tubes are blocked. I've never had symptoms of a pelvic infection, so how could my tubes get blocked ?

Many pelvic infections have no symptoms at all, but can cause damage, sometimes irreversibly, to the tubes.

36. What is timed sexual intercourse?

To increase the chance of getting pregnant spontaneously, timed sexual intercourse is recommended. This means that sexual intercourse, or coitus, has to be taken place around the time of ovulation, which is the most fertile period of a woman. To detect the approximate time of ovulation a temperature curve of several menstrual cycles can be made. The woman takes her body temperature each morning before getting out of bed, starting on the first day of the menstruation until the start of a new period. The body temperature rises around 0.5 degree Celsius after the ovulation. This is mostly about 14 days after the first day of the period and when no pregnancy occurs the temperature drops to normal again; with pregnancy the temperature stays high. One can also use urine or saliva tests to detect the ovulation. The time of ovulation can sometimes vary a few days each month, even in a regular menstrual cycle. Also, if the circumstances are right, sperm can live inside the women for a few days and sperm quality can decrease with high sexual activity. Therefore it is best to have intercourse 3-4 days before the expected ovulation and every other day until 2-3 days after the expected ovulation with no necessity for higher frequency. When tests are used to detect ovulation it is advised to have sexual intercourse on the day of a positive test.

37. My doctor has advised me to take fertility drugs . I don't want to take them because I am scared that if I do , then I'll have a multiple birth.

Fact : Although fertility drugs do increase the chance of having a multiple pregnancy (because they stimulate the ovaries to produce several eggs) the majority of women taking them have singleton births.

38. Egg-donation Women

with no, or not properly working ovaries can, in some cases, get pregnant through egg donation. In this procedure another woman, mostly a relative or good friend, will be the egg donor. This woman will have an IVF stimulation and ovum pick up. After the ovum pick up the collected eggs will be fertilised with sperm of the partner of the recipient woman i.e. donor acceptor. The embryo's are then transferred in uterus of the donor acceptor. If a pregnancy occurs the donor acceptor and her partner will have a child which is only biologically, half their own.

39. My husband's sperm count varies every time we test it ! How do we determine what the "real" sperm count is ?

Even a normal ( fertile ) man's sperm count can vary considerably from week to week. Sperm count and motility can be affected by many factors, including time between ejaculations, illness, and medications. There are other factors which affect the sperm count as well, all of which we do not understand .

40. PCOS Polycystic ovary syndrome or PCOS, is an ovulation disorder which affects 4-6% of all women. Several factors contribute to the disease. At this moment researchers think that the cause of the disease is genetic. The major features of this syndrome are irregular or no menstruation, hirsutism and acne due to high levels of male hormones, obesity (40-50%), high insulin levels with risk for developing diabetes and large polycystic ovaries shown on ultrasound. Women with PCOS usually present at fertility clinics for counseling. To increase fecundity the treatment possibilities are mostly focussed on regulation of the menstrual cycle. For this, several drugs are used (clomiphene citrate, bromocriptine, gonadotrophins) and weight loss is strongly advised. In many cases the cycle will be ovulatory and regulated by these treatments. Furthermore at this moment it is being investigated whether electrocoagulation of the large ovaries can give (long-term) regulation of the cycles.

41. I have no problems having sex. Since I am virile, my sperm count must be normal.

There is no correlation between male fertility and virility. Men with totally normal sexdrives may have no sperms at all.

42. What is embryoreduction?

Assisted Reproductive Therapy (ART) has caused an increase in multiple pregnancies. Especially in ovulation induction and Intra Uterine Insemination this situation is encountered. In order to prevent the risk of severe premature birth and handicaps as well as risks for the mother, embryoreduction is sometimes performed: The amount of embryo's in the uterus are reduced and the remaining pregnancy has more chance of normal development and delivery. Of course this is not an easy decision for both patient and doctor. With careful guidance of the patient during treatment and good counseling when the patient is at risk for a large multiple pregnancy many triplets or higher pregnancies are already avoided.

43. I don't think infertility treatment should not be offered in India, because there are too many babies in this country already. Why should we exacerbate the population problem by producing more? In any case, IVF treatment is too expensive for India to be able to afford.

The right to have children is a fundamental right of every human being and a very basic biological urge. Just because a neighbour has too many children should not deprive the infertile couple of their right to have their own. IVF and related technologies are undoubtedly expensive, but, then, so is heart surgery. Yet, no one objects when over Rs 1 lakh are spent to try to salvage the heart of a 70 year old man (whose life expectancy in any case is only about 5 years and is not extended by the surgery). Why then should medical technology not be used to help couples in their thirties (with their whole lives ahead of them) have their own baby? In fact, IVF is a much more cost-effective use of medical resources than a number of other accepted surgical procedures (such as joint replacement surgery or kidney transplants).

44. What is cryopreservation?

Cryopreservation means preserving in a frozen condition. The best known cryopreservation is of semen. This is mostly done in case of cancer of the testicles before treatment of the cancer. Furthermore cryopreserved semen is used in donor insemination. It is also possible to freeze fertilised eggs after IVF or ICSI. If more embryo's are left after an IVF or ICSI procedure they can be frozen and transferred another time. In this way there is more chance on a pregnancy while only one IVF or ICSI cycle is performed. For human oocytes cryopreservation is much more difficult. Only in very few experiments this is done successfully. The attention of researchers now is on developing a way to freeze ovarian tissue and after thawing, to obtain the oocytes in it. This procedure is not yet fully refined but when it is it can offer great opportunities in the future.

45. My semen analysis report shows I have no sperm in the semen ( azoospermia ). Is this because I used to masturbate excessively as a boy ?

Masturbation is a normal activity which most boys and men indulge in. It does not affect the sperm count. You cannot "run" out of sperms, because these are constantly being produced in the testes.

46. Is Intra Uterine Insemination suitable for every infertile couple?

No. In Intra Uterine Insemination (IUI) processed semen is directly put into the uterus. It is a technique used for couples with fertility problems based on specific causes. These causes are:
Cervical hostility: This means that the cervix is not permeable for semen shown after the Post Coital Test.
Idiopathic subfertility: No cause has been found for the inability to conceive Male subfertility The sperm quality is decreased. Clinics use different ranges for sperm count in which they perform IUI.
Sperm Antibodies: Inability for vaginal ejaculation with decreased sperm quality For example in men with retrograde ejaculation or spinal cord injury. IUI can be performed either in a spontaneous ovulatory cycle (cervical hostility) or in a cycle with ovarian stimulating hormones (idiopathic subfertility and male subfertility/sperm antibodies). The stimulation is mostly done with clomiphene citrate or gonadotrophins.

47. My wife is frigid and does not enjoy having sex. Could this be the reason for her infertility ?

There is no connection between sexual pleasure and fertility. Don't forget that even a woman who gets raped can get pregnant ! And don't forget that the commonest reason women do not enjoy sex is because their husbands are unskilled lovers ! Maybe you should improve your sexual technique, and spend more time in foreplay and in pleasuring your wife !

48. What is TESE or MESA?

TESE (Testicular Sperm Extraction): Sperm collected out of the testicles after operation.
MESA (Microsurgical Epididymal Sperm Aspiration): Sperm collected out of the epididymis after operation.
TESE or MESA is a technique developed for patients with no sperm cells in their sperm due to an undeveloped or obstructed spermatic cord. The cause of obstruction can be a former sterilisation or an infection of the epididymis. When the testicles make no sperm cells at all, of course TESE or MESA is not possible. If sperm cells are obtained, an ICSI procedure (Intra Cytoplasmic Sperm Injection) will follow. ICSI is like IVF; only now one sperm cell is injected into an egg to fertilise it and make an embryo.

49. What are the causes of damaged fallopian tubes?

In the beginning In Vitro Fertilisation (IVF) was developed for patients facing infertility due to damaged fallopian tubes. Later on the indications to perform IVF was broadened, for example unexplained infertility and male infertility. Nowadays tubal damage still accounts for a large number of all IVF treatments. The main cause is abdominal infection. For the tubes this is mostly due to sexually transmitted diseases (for example chlamydia or gonorrhea) but complicated appendicitis or Pelvic Inflammatory Disease (PID) can also cause damaged tubes. Other causes are abdominal operations (gynecological operations, cesarean section, sterilisation or other) and internal diseases like Crohn's disease. Affected patients can have fertility problems and are at risk for having a pregnancy located in the tubes (ectopic or tubal pregnancy).

50. Cystic fibrosis and male infertility Men who have cystic fibrosis often have a congenital anomaly in the male genital tract. The vas deferens, the tube connecting the testicle and epididymis to the ejaculatory duct is congenitally absent. This makes it impossible for the sperm to pass through the penis. Using testicular sperm aspiration, the urologist can obtain sufficient sperm to allow excellent success with IVF and ICSI (intracytoplasmic sperm injection). Insufficient numbers of sperm are obtained to make intrauterine insemination an effective option. As cystic fibrosis is a recessive genetic disorder, abnormal gene contributions from both parents are necessary for this disorder to be present. Both copies of the gene are abnormal in men with CF. While persons carrying a single copy of an abnormal gene do not have this condition, when paired with a partner with CF, they have a 50% chance of CF in their offspring. This makes testing the female partner advisable. If the woman tests normal, the children will be carriers for an abnormal gene and although they will not likely have CF, it is advised that their spouses be checked for CF gene abnormalities.

51. What is endometriosis?

Tissue hitologically identical to endometrium (the inner lining of the uterine wall) outside the uterine cavity. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported to be in other areas, as well. Endometriosis is one of the most common problems that gynaecologists currently face. It is one of the most complex and least understood diseases in our field and, despite many theories, we still do not have a clear understanding of the cause or of its relationship to infertility. Since this disorder is primarily a human disease and rare in other animal species, accumulation of the facts has been slow. Although endometriosis has been considered a pathological or separate disease entity, it may not be a disease at all. It may actually be the clinical manifestation of a more basic underlying disorder, such as a basic chemical or physiological abnormality that affects the tubal motility or immune system which could be responsible for the initiation or progression of endometriosis in patients with retrograde menstrual flow. By the same token, endometriosis may not be the cause of infertility, but the result of it. Further technological developments may be necessary in order for us to fully understand this problem.

 

52. What does sperm preparation mean?

Spermatozoa are ejaculated in the seminal fluid during intercourse or masturbation. During assisted reproduction the spermatozoa are extracted from the semen by a series of processes - centrifugation and washing, layering (to select the active sperm and leave the immotile or dead sperm behind) or selecting the best sperm by making them swim through a denser medium and using those that succeed.

53. What is reproductive surgery?

Reproductive surgery is a subspecialty that treats anatomical abnormalities interfering with normal reproductive function. Advanced reproductive surgery requires meticulous surgical technique for optimal results, including rapid patient recovery and avoiding the need for routine hospitalisation. Reproductive surgeons treat tubal obstruction, endometriosis, uterine fibroids, scarring of the ovaries or other pelvic structures resulting from pelvic inflammatory disease (PID) in the female, and varicocele and vas obstruction in the male as well as other abnormalities.

54. What does laparoscopy involve?

The laparoscope allows visual inspection of the pelvic organs through a very tiny incision. Abnormalities that lead to infertility can be treated surgically through additional small incisions to remove scar tissue, laser, coagulate, or excise endometriosis, and repair tubes blocked at the fimbrial end. Many types of female reproductive surgery can be performed laparoscopically in the outpatient setting.