Q1. How do I know that I am infertile?
Infertility is not a disease; it is a state of a human body where natural means of conception may not occur due to various reasons. In approximately 30% of infertile couples, the cause is identified only in the female and in 30% the cause is identified only in the male. In 30% of couples, causes can be detected in both partners. In about 10% of cases, the underlying cause is not yet found by the current diagnostic methods.
You can define infertility in 3 short ways.

• Infertility is defined as 12 months of unprotected intercourse without pregnancy
• Primary infertility: Infertility without any previous pregnancy.
• Secondary infertility: When there has been a previous pregnancy.

Q 2. What is the general progression of infertility treatment?
A variety of procedures can be used to diagnose the cause of infertility in a couple; these range from simple blood tests to more complicated analytical methods. In any case, diagnosis is a crucial first step to determine the appropriate therapeutic path that should be followed. In addition to the cause itself, other factors, such as the age of the woman, or problems shared by both partners, might also influence the choice of treatment.

Q 3. What treatment options do infertile couples have?
Several options are offered to couples depending on the type of infertility that has been diagnosed. The vast majority of female patients are successfully treated with the administration of drugs such as Clomiphene Citrate, Bromocriptine or Gonadotrophins. Surgery can also be a means to repair damage to the reproductive organs, such as those caused by endometriosis and infectious diseases. Treatment options for male infertility also include the administration of drugs, surgery and assisted reproductive technologies, such as Intracytoplasmic Sperm Injection (ICSI). Drug therapy and surgery have proved very successful for specific types of male infertility. However, in a great number of cases, the reason why men have fertility problems remains unexplained and the treatment methods applied are empirical. Some patients nevertheless require more complex medical intervention.

Assisted reproductive technologies (ART) refer to several different methods designed to overcome barriers to natural fertilization such as anatomical problems (e.g. blocked fallopian tubes). One of these techniques, in-vitro fertilization (IVF), has now been practiced for more than 15 years. Overall, the estimated number of infertile patients currently treated by ART is around 20%.

Q 4. How successful is infertility treatment?
When talking of success rates for any type of infertility treatment, one should bear in mind that the average chance to conceive for a normally fertile couple having regular unprotected intercourse is around 25% during each menstrual cycle. It is estimated that 10% of normally fertile couples fail to conceive within their first year of attempt and 5% after two years. Comparable to normal fertility rates, effective treatments can be expected to have, on average, up to a 25% success rate per cycle of treatment, and may therefore need to be repeated several times before a pregnancy is achieved.

Simple ovulation induction to compensate for hormonal imbalances has a very high success rate; more than 80% of women suffering from such disorders are likely to conceive after 6 to 12 cycles of treatment with drugs such as Clomiphene Citrate or Gonadotrophins. The pregnancy rates may be increased if this is combined with Intrauterine Insemination (IUI)

Q 5. Are there particular factors influencing the success of a treatment?
In any type of infertility treatment, important factors need to be taken into account when referring to success rates. The age of the woman and the duration of the couple's infertility are likely to influence the success of treatment. In women, fecundity decreases as age increases, particularly after 40 years of age. When the woman is being treated, her chances of conceiving can be lessened if her partner also has infertility problems (e.g. poor quality sperm).

Q 6.   What are my chances of becoming pregnant?
• It depends on your age
• The cause of your infertility
• The number of eggs that you produce following drug induction
• The quality of the semen
• The number of embryos resulting
• The number of embryos transferred

Q 7. Is Intra Uterine Insemination suitable for every infertile couple?
No. In Intra Uterine Insemination (IUI) 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 sub-fertility and male sub-fertility/sperm antibodies). The stimulation is mostly done with Clomiphene citrate or Gonadotrophins.

Nowadays, the indication may be relaxed to include all cases where routine treatments have failed. These patients can be given 3-6 cycles with Gonadotrophin stimulation with Intrauterine Insemination, before they opt for IVF/ICSI.

Q 8. 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 (Nidacon Puresperm or Spermgrad) and using those that succeed for IUI / IVF.

Q 9.  We have been told that my husband has poor sperm quality, we were not told the reason for this. I find this strange as we have a daughter. How do you investigate the reason for this problem?
The low sperm count even 5 million / ml is enough to get pregnancy in the first year of marriage. But after that get pregnancy with low count is difficult. You may be having a daughter, but after that the count may have been low or even may have gone down. Also the motility may not be good. This may be due to various reasons like-tobacco, alcohol, certain drugs, stress, lifestyle changes, hormonal alterations.

Q 10.  My husband had a vasectomy many years ago, how successful is reversal of sterilisation?
The chance of success i.e. sperm to appear in the ejaculate is about 50%. The alternative to reversal of vasectomy would be to retrieve sperm from the testicles and the tube transporting the sperm from the testicle to the outside, using a technique pioneered by Professor Craft and his team called PESA/TESA (Percutanous Epididymal Sperm Aspiration/Testicular Sperm Aspiration). The retrieved sperm can then be used to fertilise your eggs. However you will have to go through an ICSI treatment (Intracytoplasmic sperm injection) cycle.

Q 11. What about success rates of IVF?
Overall, success rates for IVF have steadily improved over the last ten years. Birth rates for IVF vary according to the expertise of the centers practicing this technique. Based on results, after three to four cycles of IVF, a woman under 40 whose partner does not have any fertility problems could reasonably expect to give birth. Again, in general, success rates may vary from one center to another, since they are influenced not only by the level of expertise of the medical team but also by the characteristics of the patients treated. A clinic treating a large number of women over 40 is likely to report lower success rates than a clinic having a majority of patients under 35. This is because the success rates are better in women who are less than 35 years of age.

Q 12. What is the duration of one IVF or ICSI cycle?
One complete IVF or ICSI cycle takes approximately six to eight weeks. First, the normal menstruation cycle of the woman is down regulated by injection of specific hormones each day. This part of the cycle can vary from a few days to few weeks. When the ovaries have become inactive, shown on ultrasound control and laboratory findings, the stimulation of the ovaries start by muscular or subcutaneous injections of hormones. The mean stimulation period is 12 days, depending on the responseof the ovaries. The ovum pick up takes place within two days after stopping the stimulation. Now the real IVF or ICSI follows in the laboratory. When fertilization occurs, embryos are transferred into the uterus after two to four days and drugs supporting the uterus are given. After approximately 15 days a pregnancy test will show whether the IVF treatment has been successful or not.

Q 13. What is 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 fertilized with sperm of the partner of the recipient woman i.e. donor acceptor. The embryos 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.

In recent times, another concept called egg sharing , has also become very popular.

Q 14. Why do not all embryos implant in the human?
After IVF, as after spontaneous conception embryos are susceptible to chromosome abnormalities. The egg or the sperm may have born the anomaly to start with, but at each cleavage division, mistakes may happen that lead to abnormal daughter cells in the embryo. These abnormal cells may fragment and get lost to the embryo. In case the embryo loses too much cells, its abilities to progress until the blastocyst stage and to implant may seriously be hampered and no pregnancy will follow. Actually the relatively low implantation potential of human embryos is an example of natural selection, which is very efficient in eliminating abnormal concept uses.

Q 15. How can we improve the implantation rates of human embryos in human IVF?
We cannot. All we can do is try to select the better ones so that the transfer will lead to a higher pregnancy rate. Some centers are experimenting with embryo biopsy and Aneuploidy screening to select the genetically sound embryos. Other centers ( ours included ) choose to culture the embryos to a later stage (the blastocyst stage) to select the best ones. Indeed both strategies seem to lead to higher implantation rates. These strategies, however, work only if a sufficient number of embryos are available. The major problem is, in couples in whom only a low number of embryos can be obtained, since no selection can be performed there and the pregnancy rates will remain low.

Q 16. How much do the different treatments cost?
Click on Financial issues and you will find information covering all the treatment modalities.