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What is infertility?
Infertility is defined as not being able to get pregnant (conceive) after one year of unprotected sex. If a women is older (>35 years) she should seek advice earlier by 6 months.

Is infertility a common problem?
Yes, about 10% of couples in the reproductive age group suffer from this problem.

How does infertility occur
For pregnancy to occur


What causes increased chances of infertility in women?
• Alcohol
• Drugs
• Environmental toxins, including pesticides and lead
• Smoking cigarettes
• Health problems
• Endocrinopathies
• Medicines
• Radiation treatment and chemotherapy for cancer
• Age

How long should women wait before consulting a fertility expert?
Fertility expert should be consulted if pregnancy has not occurred after one year of unprotected sex in women under 35 years and 6 months in women over 35 years. Couples who have known barriers to fertility, such as endometriosis, polycystic ovarian syndrome, male infertility, irregular cycles, blocked tubes should seek expert care for infertility immediately.

Why should you consult an infertility specialist or reproductive endocrinologist rather than a general gynecologist?

Picking a doctor is so very important. It is important to find a doctor who is responsive and well matched to your needs and diagnosis. A reproductive endocrinologist specializes in treating infertility, and is far more likely to have the experience necessary to identify and treat your problem than a general gynecologist who treats only a few infertility cases each year. We find patients wishing that they had not spent all their time and money with their general gynecologist. You may be wasting your time, money and effort with a specialist who cannot get to the root of your problem.

How is infertility treated?
Infertility can be treated with medicine, surgery, intra-uterine insemination, or assisted reproductive technology. Many times these treatments are combined. Doctors recommend specific treatments for infertility based on—
• The factors contributing to the infertility.
• The duration of the infertility.
• The age of the female.

How common is male infertility?
Infertility is a widespread problem. For about two in five infertile couples the problem lies in the male partner

Are there any signs or symptoms of male infertility?

What causes male infertility?
Male infertility can be caused by problems that affect sperm production or the sperm transport process. With the results of medical tests, the doctor may be able to find a cause of the problem. Known causes of male infertility can be:

1. Sperm production problems: The most common cause of male infertility is due to a problem in the sperm production process in the testes. Low numbers of sperm are made and/or the sperm that are made do not work properly. About two thirds of infertile men have sperm production problems. The cause could be many.
• Environmental toxins including exposure to pesticides and lead.
• Genetic factors

2. Blockage of sperm transport: Blockages (often referred to as obstructions) in the tubes leading sperm away from the testes to the penis can cause a complete lack of sperm in the ejaculated semen. This is the second most common cause of male infertility and affects about one in every five infertile men, including men who have had a vasectomy but now wish to have more children. Infection or congenital causes may block the vas

3. Sperm antibodies: In some men, substances in the semen and/or blood called sperm antibodies can develop which can reduce sperm movement and block egg binding (where the sperm attaches to the egg) as is needed for fertilisation. About one in every 16 infertile men has sperm antibodies.

4. Sexual problems: Difficulties with sexual intercourse, such as erection or ejaculation problems, can also stop couples from becoming pregnant. Sexual problems are not a common cause of infertility.

5. Hormonal problems: Sometimes the pituitary gland does not send the right hormonal messages to the testes. This can cause both low testosterone levels and a failure of the testes to produce sperm. Hormonal causes are uncommon, and affect less than one in 100 infertile men

6. In many men with a sperm production problem, the cause cannot be identified.

What are some of the specific treatments for male infertility?

Male infertility may be treated with medical, surgical, or assisted reproductive therapies depending on the underlying cause. Medical and surgical therapies are usually managed by an urologist who specializes in infertility. A reproductive endocrinologist may offer intrauterine inseminations (IUIs) or in vitro fertilization (IVF) to help overcome male factor infertility. If there is mild decrease in sperm count or motility then IUI may be tried where semen is prepared to separate out the best, most motile and normal sperms. These are then introduced in the uterus of the female partner. In cases where there is azoospermia ie no sperms in ejaculate, retrieval of sperms can be done surgically by aspiration or surigical extraction (TESA – Testicular sperm aspiration, TESE – Testicular sperm extraction, testicular biopsy). These sperms are then injected into the recovered oocytes by a technique known as intracytoplasmic sperm injection(ICSI).

What is PESA/TESA?

Percutaneous epididymal sperm aspiration (PESA) and testicular sperm aspiration (TESA) are procedures for overcoming extreme male infertility. Men having very low or zero sperm counts, and sperm that are largely dead or completely immotile, can have children by these methods. The sperms are obtained directly from the testis or the tiny ducts leading from the testis (epididymis) before they risk damage from oxidation or are exposed to antisperm antibodies in the epididymis or the vas deferens. For men having azoospermia (complete absence of sperm) caused by the general failure to develop, small fields of sperm production that can often be located using TESA. The sperm collected can be used for intracytoplasmic sperm injection (ICSI).

How is PESA done?

PESA surgery can be peformed under local anaesthesia or a short acting general anaesthetic (depending upon the choice of the patient). The epididymis is aspirated to find motile sperm cells. Sperm removed are either utilized for ICSI or they are frozen for later use. Generally this operation is reserved for instances where obstruction has occurred. The procedure is often combined with testis biopsy for TESA.

How is TESA done?

This procedure can be used for instances where sperm production is a problem (non-obstructive azoospermia) or where there is an obstruction to sperm flow (obstructive azoospermia). Obstructive azoospermia can be due to congenital absence of the vas deferens or after a vasectomy operation.

TESA for non-obstructive azoospermia (low sperm production or maturation arrest) takes around an hour. Here both testicles are usually operated on, and multiple biopsies are taken. It is normally done under general anesthesia. However, very often sperms can be successfully aspirated by fine needle aspiration under local anesthesia or without any cut or stitches.

What should be the timing of PESA/TESA?

MESA and TESE are often performed in advance of the IVF cycle and frozen to reduce stress on the couple since the sperm is “safe in the bank” and can be used at any time. This approach allows each partner to be supportive to the needs of the other at time of their procedure. The chosen sperm retrieval method is timed to coincide with the female egg retrieval and IVF/ICSI cycle. The percutaneous methods are preferably done fresh since sperm quantity and quality may not be sufficient to allow for freezing.

Can my children (born using TESA) inherit my condition?

It is possible that male children of men with severe oligospermia or azoospermia will inherit the same condition. We can test for some abnormalities of the chromosomes that could be passed on to your children. If your azoospermia is due to congenital blockage of the epididymis or absence of the vas deferens, you could have one or more genes associated with cystic fibrosis, a serious lung disease. You and your partner can be tested for some of the more common genes that cause cystic fibrosis and can take advice and counseling about possible genetic causes of male infertility.

Can the sperm retrieved by PESA/TESA be used for IUI?

The minute quantities of sperm obtained at retrieval are not enough to be useful for Intra Uterine Insemination (IUI) or any procedure other than ICSI. PESA and TESE procedures are the most popular because the goal is retrieval of sufficient sperm for freezing and use in future IVF cycles using ICSI.

What is intrauterine insemination (IUI)?

Intrauterine insemination (IUI) is an infertility treatment where prepared sperm are inserted into the woman’s uterus. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.
IUI is often used to treat— Mild male factor infertility, Couples with unexplained infertility.

How do we know if the sperm count is adequate for IUI?

Besides the number of sperm, the percentage with rapid forward-progressive motility and with normal morphology at the time of insemination are important to know. If the functional sperm count (number with normal morphology and rapid forward-progressive motility) exceeds 5 million; chances for pregnancy with well-timed IUI are excellent.

How long do sperm live after timed intercourse or after IUI?

Normal, healthy sperm live approximately 48-72 hours. (Abnormal sperm may have a shorter life, which may vary according to sperm health.) At IVF India we know that washed sperm can survive in the IVF incubator for up to 72 hours. That would be considered the upper practical limit.

What is the life span of an egg?

Eggs are able to be fertilized for about 12-24 hours after ovulation. The older the woman, the shorter this time becomes.

What should my uterine lining be at ovulation and at implantation?
As you approach your LH surge, it should be above 7 mm, ideally between 8 and 12 mm

What should be the blood E2 level during mid cycle ?
It should be 150-200 pg/ml per mature follicle.

What is the relevance of 3-day FSH test.
FSH is more of an indirect measurement of an ovarian reserve. Usually it should be <10. If it is more then it indicates poor ovarian reserve . Better indicator to check for ovarian reserve is Anti mullerian hormone which is preferred and can be done on any day of the cycle

How much do follicles grow each day?
Follicles grow 1 to 2 mm a day while taking ovulatory stimulants.

How many times should I try IUI before moving on to IVF?
Once a patient has had 3-6 IUI cycles , they might consider moving to IVF as the chance of a successful IUI cycle is reduced.

What is the advantage of giving oral medication like clomiphene along with injectables?
Mixing injectables and Clomiphene will help to overcome adverse effects of clomiphene on lining and cervical mucus and give better stimulation. It also brings the cost down in comparison to using only injectables.

What is assisted reproductive technology (ART)?
Assisted reproductive technology (ART) includes all fertility treatments in which both eggs and sperm are handled outside of the body. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and depositing them in the woman’s or surrogates uterus.

Common methods of ART include—
• In vitro fertilization (IVF), meaning fertilization outside of the body. IVF is the most effective and the most common form of ART.




What would I have to undergo in an IVF cycle?

IVF is a complex process consisting of several steps. First, fertility drugs are given to stimulate the ripening of several eggs. Blood test and ultrasound examination allow for precise monitoring of egg development. At the appropriate time, the eggs are retrieved under anesthesia. The sperm is then added to the eggs in the laboratory where the fertilized eggs develop for 2-3 days. In case of micromanipulation for male infertility a single sperm is injected into egg ICSI (Intra cytoplasmic sperm injection). Finally, the embryos (fertilized dividing egg) are placed in the womb by a simple non-surgical procedure similar to a pelvic examination. A mock embryo transfer is done during the IVF process prior to starting the cycle to ensure that we do not encounter any unexpected problem on the day of the actual embryo transfer. Two weeks after embryo transfer, a pregnancy test is done. At IVF India all this is done on an outpatient basis.

How will I come to know how many eggs am I going to produce when stimulated or what is my ovarian reserve ?
Ovarian reserve can be checked through blood test for FSH and LH hormones on Day 2 / Day 3 of cycle . If FSH is more then 10 , it indicates poor ov. Reserve . The better indicator is AMH. IF AMH is < 1ng/ml, indicates poor ovarian function. The no. of eggs a lady is going to produce can be known on ultrasound on day 2 for antral follicle count. These are the number of small follicles one can count in the ovaries at the beginning of the cycle. 10 – 12 is a good number. Anything less than 4 indicates a poor ovarian reserve.

What are the side effects of the medications I will be taking for IVF?

What constitutes day one of my cycle?
Day one of your cycle is considered your first day of full flow menstrual bleeding, not spotting. If this occurs after 2 p.m., the next day is considered day one.

How many monitoring visits will I have while I am in treatment?
This will depend on your individual response to the medications. During an IVF cycle at our clinic, you will have between four to six appointments, including one for the egg retrieval. We do not encourage unnecessary travel to the clinic. However, this varies from patient to patient and also with the stage of treatment. During these visits egg and endometrial development are checked. Some blood tests may be advised to assess egg maturity and decide on the drug dosage.

The first visit is on day 2/3 of the cycle. At this visit an ultrasound is done to rule out any residual ovarian cysts and to check for endometrial thickness. Drug administration is withheld in case these parameters are not within the required limits.
Egg recovery is generally carried out under anesthesia unless you opt to have it under sedation and requires you to be in hospital for half a day. For embryo transfer you are required to come in with a full bladder and you will be asked to rest for couple of hours after the transfer.

Can I exercise while going through treatment?
Some exercise is acceptable during in-vitro fertilization treatment, but as the IVF treatment cycle progresses, only low impact exercise (such as walking) is recommended. The ovaries may become enlarged from the fertility medications, and high impact exercise may put you at risk for ovarian torsion, a condition in which the ovary can twist on itself. This is a very rare but serious side effect.

Should I avoid air travel or ground travel after my transfer?
We don’t prohibit travel but just advise not to overdo it. Air travel is fine as long as the pressure is maintained, which it generally is in commercial aircraft. We do not recommend any rough road rides.

Is the egg retrieval process painful?
No, not generally. It lasts approximately 15 to 20 minutes, and general anaesthesia is given. Some patients have mild cramping after the procedure and are discharged with a prescription for pain medication.

Is there a higher risk of birth defects with a child born from IVF?
No. Children born from IVF are no more inclined to any particular birth defect than those conceived naturally.

Are there limitations on the number of IVF tries per couple?

How long a wait is recommended between a failed IVF cycle and trying again?

How soon after IVF can a pregnancy test be performed?
Since hCG is used to finalize egg maturation, a pregnancy test (which is a measurement of hCG hormone in the urine or blood) will be positive for a number of days following egg retrieval. Some women will metabolize the hormone quickly and it will be out of the blood stream in about a week, while others may take up to 9 or 10 days to do so. We therefore recommend that a pregnancy test not be performed until 14 days after the egg retrieval

Is assisted hatching performed on all embryos?
In some cases only e.g. women over 38 years of age, previous failed IVF cycles, unusually thick zona pellucida assisted hatching will increase the implantation and pregnancy rates. Since performing assisted hatching on every single embryo of all couples did not increase the expected pregnancy rates it is not recommended in all.

Is bed rest recommended after the embryo transfer?
It is really not clear that prolonged rest after transfer is helpful. In nature, the embryo floats freely in the endometrial cavity for a number of days before implantation and it will do the same in an IVF cycle. We do recommend that you take it easy following transfer for the rest of the day, but routine work activities can be resumed the next day. If there is an increased risk of Ovarian Hyperstimulation, we will recommend prophylactic bed rest.

Is the embryo transfer painful?
The embryo transfer does not require any anesthesia. It is performed using a speculum that allows the doctor to see the cervix, (like a Pap smear) and is very similar in technique to an intrauterine insemination (IUI). Usually the woman feels only the speculum and nothing else.

Is it normal to retrieve an egg from every follicle?
Not necessarily. Although we will usually get an egg from most mature sized follicles, most women will have a mixed group of follicles after ovulation induction. Some of those follicles will have immature eggs or post mature eggs, which may not be identifiable so they will seem to have been “empty” follicles.

Is bleeding expected after the egg retrieval?
Vaginal bleeding is not uncommon after an egg retrieval. Usually this bleeding is from the needle puncture sites in the vaginal wall. It is usually minor and similar to a period or less. The bleeding experienced is analogous to the bleeding that will take place from an IV or from the arm after blood has been drawn. Unfortunately there is no way to put Band-Aids on the vaginal puncture sites!

Will the egg retrieval damage my ovaries?
It does not. There have been many women who have undergone multiple egg retrievals. The fact that they have responded to stimulation on subsequent occasions and gotten eggs and pregnancies on these occasions implies that the ovaries are not damaged after egg retrieval. There have been some studies looking at the appearance of the ovaries in women who have had egg retrievals and subsequent laparoscopic surgery. In those patients, the findings were normal

How long does it take to get started with IVF?

We break down the IVF treatment into phases:



Phase Four is egg retrieval and embryo transfer. There are three to five days between the time when eggs are retrieved and embryos are put back into the uterus.

Phase Five is a pregnancy test and beyond.

What are the risks of ART?

The spontaneous abortion rate is slightly higher than in the general population. This is not related to the procedure, it is due to inherent problems with the patient that led to infertility in the first place . There is an increased chance of multiple births, which can be limited by the number of embryos transferred. There is no difference in the delivery –vaginal /caesarian section, if all routine parameters are normal. During stimulations ovaries may go into excessive stimulation a condition known as ovarian hyperstimulation syndrome. This would require specialized care

Is there an increased risk of malignancy of ovary?
Current knowledge does not show any definite increase in malignancy.

I am afraid that I might have ovarian hyperstimulation. What can you tell me about this?

First, if you are concerned about the possibility of OHSS you should call your clinic as soon as reasonably possible. OHSS (Ovarian Hyperstimulation Syndrome) is when you have an unusually large number of immature and mature follicles. When these follicles release, there is a very high concentration of estrogen-rich fluid in the peritoneal cavity, and the ovaries are generally enlarged far beyond their usual size. In milder cases, women experience bloating and some pain from the oversized ovaries. The treatment then is just a matter of rest and staying well hydrated. In more severe cases, the fluid leaks out of the circulatory system into the peritoneal cavity. This can cause marked discomfort and bloating, and can cause difficulty breathing due to pressure on the diaphragm. The leaking of the fluid may lead to hypovolemic shock and organ damage because of a lack of perfusion. Although there are exceptions, generally you do not see severe OHSS until the Estradiol gets into the 5000+ range. Mild hyperstimulation can occur at lower levels. As long as your doc keeps a close eye on your dosage and development, the chances of anything other than mild discomfort (especially on a non-IVF cycle) are minimal. The best pre-ovulation predictor of hyperstimulation is the E2 level, but it is not a perfect predictor. If you experience symptoms of OHSS, you should always play it safe and check with your doctor

Why choose the Donor Egg IVF program at The Fertility Clinic?

You can also begin treatment within the time frame you prefer. Furthermore, you can depend on personalized, compassionate care and attention from your physician and donor egg coordinator. Every egg donor is screened in-house. Our counselors will review the patient’s family history, the biological father’s family history, the egg donor’s history, and answer any questions the patient may have about heredity. There is no sharing of donors between two patients. One donor is assigned to one couple and all the eggs she produces are for the couple.

Who is a Donor Egg IVF candidate?
Any woman with a medical or genetic indication for using an egg donor can be a recipient, if there are no medical contraindications to pregnancy. The decision to use donor eggs is made in association with the patient and their reproductive endocrinologist (infertility specialist) after looking at the woman’s ovarian reserve. If ovarian reserve is poor or she is in premature ovarian failure then she would require a donor.

What are my chances of getting pregnant using donor eggs?
Donor Egg IVF opens up a world of possibilities for women who have struggled to conceive. It allows many women who could not become pregnant with their own eggs to become pregnant very easily. Our success rates are among the best in the country and our vast experience assures outstanding rates of success for donor egg cycles.

Who are the egg donors?
We are committed to providing a large, diverse selection of fully-screened donor. Information available on our egg donors includes physical characteristics (height, weight, hair color and type, body build, and blood type), ethnic background, educational record, occupation. The choice of egg donor is always made by the patient.

Will I have to wait on a waiting list to start Donor Egg IVF treatment?
Unlike many infertility clinics, we do not require that donor egg recipients join a waiting list. Donor Egg IVF cycles can match one donor to one recipient (sole match). We do not share donors. She can begin treatment immediately and will not be required to wait for a donor. It is our goal to provide our patients with as many options as possible so they will not have to wait unnecessarily to begin treatment.

What does the Donor Egg IVF procedure involve?
Donor egg recipients are asked to select one or more egg donors whom they find suitable. One of the selected egg donors will be offered to a recipient couple upon availability of the egg donor and the completion of all screening. The donor and recipient cycles are synchronized. Synchronization of cycles includes using a series of medications to facilitate a hospitable uterine environment for transfer of embryos. Viable eggs produced in a single donor cycle are inseminated, and all embryos created belong to the recipient couple. If there are embryos in excess of the number for safe transfer, cryopreservation of additional embryos is available and is strongly recommended. Cryopreserved embryos can be used for subsequent attempts at pregnancy whether or not the fresh transfer is successful, and still produce high rates of success.

What is Cryopreservation?


What is the advantage of storing these embryos?
There are many advantages of Cryopreservation in IVF(In vitro fertilisation):

1. Patients who did not achieve successful pregnancies in that particular cycle in IVF(In vitro fertilisation) may use these stored cryopreserved embryos in the next cycle. Such a cycle is called “frozen embryo transfer” cycle. Here, one or more of the embryos are thawed and transferred to the lady’s uterus in a much less complicated cycle. Patients choosing this option can minimize their time, expense and the need for repeat egg retrievals.

2. Patients having successful pregnancies from their “fresh” IVF (In vitro fertilisation) can use their frozen embryos for a second child after a few years.

3. Embryo cryopreservation in IVF(In vitro fertilisation) also allows patients and physicians the possible option of reducing multiple births by controlling the number of embryos transferred and, at the same time, maximizes the efficiency of the fresh cycle they have already gone through.

4. In patients with a risk of severe ovarian hyperstimulation (a rare but serious complication of IVF(invitro fertilisation) when a transfer of “fresh” embryos in that cycle would put the patient at high risk, all of the embryos are frozen and later warmed and transferred to the patient at a later time.

What is Vitrification in IVF(In vitro fertilisation)?
Vitrification is a newer technique to freeze embryos. Here, the embryo formed in the IVF cycle is coated with a cryoprotectant and rapidly dipped in liquid nitrogen in a much shorter procedure. With the older slow-freeze technique, water, normally found in and between embryo cells, is frozen into ice crystals. As these embryos are thawed for transfer, the crystals can cause damage, which may lead to cell death. With vitrification, water is sealed out and embryos are “warmed,” potentially resulting in less damage and hopefully higher pregnancy rates.

What are my choices if my tubes are blocked?
Basically there are two choices, surgery to try and repair the tubes or IVF. There are pros and cons to each choice and often the best choice depends on your individual cycles situation. Surgery offers the option of attempting pregnancy naturally indefinitely without repeated treatments, but carries the rare risks of surgery and in some cases is not successful depending on the type of tubal ligation or tubal damage done initially. IVF offers the chance for pregnancy without having to undergo an operation.

What surgeries can be performed at your centre?
The complete range of reproductive surgeries can be performed including laparoscopy, hysteroscopy, myomectomies, tubal reconstruction or reanastomosis, polypectomies, and uterine reconstruction for congenital anomalies and lysis of intrauterine adhesions.