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FREQUENTLY ASKED QUESTIONS ABOUT INFERTILITY
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PROGRAMS 1. I've seen ads for a fertility clinic that guarantees success in helping women have babies. Consider me skeptical. Can this or any other clinic really back up such a claim ?

TESTIMONIALS

FAQs 2. My wife and I have been trying to conceive for two years without any luck. I had two sperm counts taken (16 million after three days of abstaining and 28 million after seven days). I
have read that any count under 20 million is "functionally sterile" and the likelihood of conceiving is remote. Is a count under 20 million a great cause for concern? If I abstain from sex for
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longer periods of time (more than seven days) will my count increase ?.
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3. I have no problem with erection, but no semen comes out from either masturbation or even intercourse. A doctor has checked for prostate problems and it is negative. I used to be able
FREE SECOND OPINION to produce semen. I am diabetic ?
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HUMAN SPERM BANKING
4. Until about two months ago my husband was a very heavy drinker. He has had no booze in more than two months. The doctor says my husband's sperm count was that of a 20-year-
LIABRARY old's, but there was little to no motility. Is there something that can be done about the motility? Could the alcohol have any effect on this problem? If so, how long will the effects last, and
OUR GLOBAL PARTNERS what can we do to correct it ?

IVF HUMOR

MALE FACTOR 5. My wife and I have been trying to conceive for six years. I have been told that my body temperature is too high, particularly in my testicles, and this is the cause of my low sperm count.
Is there any solution for us? I once used a device to cool the scrotum area with the slow release of water. Is this effective ?
THE FEMALE FACTOR

HETEROSEXUAL COUPLE

GAY COUPLE 6. My husband was just started on a series of testosterone injections for a low testosterone level (198). His semen analyses were very variable -- 17.1, 5.1, 50.5 and 21.5 million with
good motility and morphology, but with low volume ( 1.5-3mL per specimen). Do you think these injections will help?

7. How long should one wait after a varicocelectomy to see results? I have heard three to nine months. My husband had a varicocelectomy three months ago and the summary says there
has been no significant results. Is this likely to improve with time? Exactly how is the surgery supposed to help, and why might it take a while for results to show ?

8. My husband had a sperm count done and it showed not even one sperm. He then had an LH and an FSH drawn. Both were somewhat elevated. His urologist told him that he shouldn't
bother to do any further testing. Is this true? Or are there any other tests or procedures that can be done to see if he is able to produce sperm ?

9. We have been married for four years, and my husband has a very low sperm count (10,000) with very little motility, dead sperm and deformed ones. The doctor said we should do
intrauterine insemination. Is this painful for the woman? Does it work in a situation like ours? Can we use my husband's sperm ?

10. I am 37 and have no children. I have been diagnosed as having a thin endometrium (3-5mm). Since July 1997 I have had two miscarriages (one blighted ovum and one lost between
8-12 weeks after a heartbeat was detected at eight weeks). I had spotting and bleeding in both cases and D&Cs with both. I am now on a second round of a hormone treatment with
Progynova & Provera after an ultrasound checkup showed a first round produced no visible improvement. This time an estrogen patch will be used & Sildenafil(Penegra) will be advocated
for use vaginally. Are there any additional ways to improve the endometrium thickness -- say, diet, homeopathic remedies, acupuncture, etc.? Can you suggest any other sources of
information on this topic ?

11. Does Viagra have any effect on sperm in a man trying to have a child? Does it affect the sperm count, mobility, etc. ?

12. After years of trying, my husband and I finally had a baby girl through in vitro fertilization. I don't want her to suffer with fertility problems as an adult. Is it possible that infertility is
hereditary ?

13. Does the color of semen give any indication of fertility? Does it make a difference if semen
is clear or white?

14. What is the incidence of infertility worldwide ?

15. My husband and I have an active sex life, we are both healthy, and my periods are regular. However, we have still not conceived?? Please help !

16. Is infertility exclusively a female problem ?

17. How can I determine my "fertile" period ?

18. What are the most common causes of infertility ?

FAQs

19. My gynecologist has done an internal examination and said I am normal. Do I still need to get tests done to determine why I am not conceiving ?

20. What is the general progression of infertility treatment ?

21. Do painful periods cause infertility ?

22. What treatment options do infertile couples have ?

23. My periods come only once every 6 week. Could this be a reason for my infertility ?

24. How successful is infertility treatment ?

25. My husband's blood group is B positive and I am A negative. Could this blood group "incompatibility" be a reason for our infertility ?

26. Are there particular factors influencing the success of a treatment ?

27. After having sex, most of the semen leaks out of my vagina. How can we prevent this ? Should we change our sexual technique ? Could this be a reason for our infertility ?

28. What about success rates of IVF ?

29. My colleagues at work tell me that if we "work" hard at getting pregnant, and want it enough, we definitely will ! In fact, my mother in law is even suggesting that the fact that I am not
conceiving means that subconsciously I do not wish to have a baby ( because it may interfere with my career) and that this psychological barrier is the reason for our infertility.

30. Are there particular health risks for women undergoing infertility treatment ?

31. My grandmother says that if I just pray and have faith, I will definitely conceive. How far is this true ?

32. OHSS

33. My husband refuses to get his semen tested. He says the fact that it is thick and voluminous means it must be normal !

34. Multiple births

35. My sister conceived only after 6 years of marriage. Does this mean I will also have difficulty conceiving ?

36. Local side effects

37. My doctor just did a physical examination for me, and he feels that the reason for my infertility is that my uterus is tipped backwards, and this prevents the sperm from swimming into
the uterus. He is advising I have surgery to correct this problem. Should I go ahead ?

38. Can ovulation induction increase the risk of ovarian cancer ?

39. My husband says we should be having intercourse every day to achieve pregnancy. Is this true ?

40. What about the health risks for children born following infertility treatment ?

41. My friends say I should have sex exactly on the day I ovulate to get pregnant. How can I do this ?

42. How important is counseling to the patient undergoing infertility treatment ?

43. My sister in law is advising me to keep a pillow under my hips during and after intercourse Will this increase my chances of conceiving ?

44. What is the duration of one IVF or ICSI cycle?

45. My mother feels I am too tense, and that if I just relax, I'll get pregnant.

46. Extra Uterine Pregnancy (EUP)

FAQs

47. 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 ?

48. What is timed sexual intercourse?

49. 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.

50. Egg-donation

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

52. PCOS

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

54. What is embryoreduction?

55. 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.

56. What is cryopreservation?

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

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

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

60. What is TESE or MESA?

61. What are the causes of damaged fallopian tubes?

62. Cystic fibrosis and male infertility

63. What is endometriosis?

64. What does sperm preparation mean?

65. What is reproductive surgery?

66. What does laparoscopy involve?

67. My husband and I have been going through tests for infertility. I am fine, but my husband has no sperm. They did a biopsy and found out that he has maturation arrest. He has the
starting of sperm, but it never matures. I have searched the Internet and cannot find anything on this subject. If he has the start of sperm, can something be done medically to help those
sperm mature? Or do we have to look into IVF or adopting ?

68. Why is Progesterone used for IVF?

69. What is the best route for progesterone administration during an IVF cycle in terms of efficacy and side effect profile?

1. I've seen ads for a fertility clinic that guarantees success in helping women have babies. Consider me skeptical.Can this or any other clinic really back up such a claim ?

It should be the goal of every clinic to succeed in helping every couple that hopes to conceive. In reality, though, this can not be guaranteed. In our practice, we work with couples to
explore the causes of their infertility and to outline all possible treatment options. By empowering couples to explore these options and participate as a partner in the decision-making
process, we believe each and every couple is helped. What these ads refer to is a financial agreement offered by some clinics to couples whose history suggests that they're likely to be
successful in conceiving a child through reproductive technologies. If the couple is accepted into the clinic, they pay in advance for a specified course of treatment. If the couple
successfully conceives and the woman carries the pregnancy beyond the first trimester, the clinic keeps the money. If the couple is not successful, their money is returned. In general,

FAQs

patients pay much more for these "guaranteed" treatments than they would for a single cycle of in vitro fertilization therapy. These programs remind me of the ancient Chinese practice
that required patients to pay their physicians for staying well and not for treating illnesses.

2. My wife and I have been trying to conceive for two years without any luck. I had two sperm counts taken (16 million after three days of abstaining and 28 million after
seven days). I have read that any count under 20 million is "functionally sterile" and the likelihood of conceiving is remote. Is a count under 20 million a great cause for
concern? If I abstain from sex for longer periods of time (more than seven days) will my count increase ?

The issues about sperm count are more complicated than you might realize. To begin with, there are a number of measurements involved in the semen analysis. First, we look at the
concentration -- how many sperm there are per milliliter of semen (the fluid). Next, I need to know how many mL of semen are present. So a count of 40 million sperm per mL with only
1cc of fluid may not be as good as a count with 16 million and 4mL. I like to see more than 20 million sperm per mL and 2-5cc of semen. Another measurement to consider is what
percentage of the sperm are moving forward progressively; 50 percent motility is considered normal. The next factor is sperm morphology -- that is, what percent of sperm look normal.
When you assess the fertilizing potential of a given specimen, you must consider all these factors. Thus, a slight abnormality in sperm count may be compensated for by better motility or
an increase in volume. So you can see this is a bit more complicated than just one number. We find that delaying ejaculation may increase the total concentration of sperm and perhaps
the volume of semen. However, the percentage of normal sperm and the percentage of motile sperm decreases with infrequent ejaculation. Overall, it appears that ejaculation three to
four times per week will ensure the optimum number of "nice-looking" motile sperm. If your sample shows a sufficient number of motile sperm, you may be rewarded by a treatment
protocol that includes ovulation induction and intrauterine insemination.

3. I have no problem with erection, but no semen comes out from either masturbation or even intercourse. A doctor has checked for prostate problems and it is negative. I
used to be able to produce semen. I am diabetic ?

You probably have a common condition called retrograde ejaculation, which is frequently seen in people with diabetes. The semen enters the penis via the ejaculatory ducts, which pass
through the prostate. At the time of ejaculation, a muscle at the opening to the bladder squeezes shut. With each muscle contraction, the semen is propelled down the urethra and out the
opening of the penis. However, if there is nerve damage due to diabetes, the muscle at the opening to the bladder will not close off properly, and the semen enters the bladder instead of
shooting out the end of the penis. Your urologist can diagnose this condition easily by checking your urine for semen after ejaculation. If this is the problem, you may try medication to
strengthen the function of the muscle that closes the bladder. Or you may have sperm collected from the bladder to use for insemination or for in vitro fertilization.

4. Until about two months ago my husband was a very heavy drinker. He has had no booze in more than two months. The doctor says my husband's sperm count was that of
a 20-year-old's, but there was little to no motility. Is there something that can be done about the motility? Could the alcohol have any effect on this problem? If so, how long
will the effects last, and what can we do to correct it ?

Alcohol may result in abnormal liver function and a rise in estrogen levels, which may interfere with sperm development and hormone levels. Alcohol is also a toxin that can kill off the
sperm-generating cells in the testicle. As sperm take at least three months to develop, I would check his semen again after a three- to four-month period of abstinence. In some
situations, sperm motility may be improved with alternative medicines called Addyzoa and Rejuspermin. If no motile sperm are seen, a testicular biopsy may be necessary. If this reveals
any live sperm, you may consider in vitro fertilization with sperm injection (ICSI) to introduce the sperm into the egg.

5. My wife and I have been trying to conceive for six years. I have been told that my body temperature is too high, particularly in my testicles, and this is the cause of my low
sperm count. Is there any solution for us? I once used a device to cool the scrotum area with the slow release of water. Is this effective ?

While body temperature -- about 98.6 degrees F. -- may be detrimental to sperm, the scrotum is designed to keep the testicles from overheating. In fact, the supportive muscles of the
testicle are temperature sensitive. In a cold environment, the testicles pull closer to the body. When the body temperature rises, the muscle relaxes, allowing the scrotum to descend and
keep the testicles at a more favorable temperature. A few years ago a device called the testicular hypothermia device (THD) was available. Essentially it was a water-cooled jockstrap;
evaporating water kept the jockstrap a bit cooler than the surrounding environs. This was believed to benefit men with varicoceles (dilated testicular veins). Unfortunately, the role of high
temperature regulation as a means to restore fertility for men with varicocele has never been convincingly proven. In fact, more recent studies suggest that varicocele surgery may be of
limited value for all but large varicoceles. Rarely are any therapeutic efforts aimed at improving sperm count or function effective. After six years of infertility, I would suggest that if other
fertility factors have reliably been ruled out by a trained fertility physician, you may wish to consider either ovulation induction and intrauterine insemination or in vitro fertilization for male
factor infertility.

6. My husband was just started on a series of testosterone injections for a low testosterone level (198). His semen analyses were very variable -- 17.1, 5.1, 50.5 and 21.5
million with good motility and morphology, but with low volume ( 1.5-3mL per specimen). Do you think these injections will help?

Low testosterone may result from two different types of abnormality. The first, a failing testicle, is identified by the blood FSH level (too high a level means the testicle is failing) or small,
very firm testicles, which may indicate previous infection or damage. The second condition occurs when the testicle is not receiving appropriate hormonal stimulation from the pituitary
gland, which releases the hormones LH and FSH. LH stimulates the testicle to produce testosterone, while FSH stimulates sperm production. In this case, examination of the testicle may
demonstrate normal to small testicular size with a softer-than-normal consistency. Testosterone supplementation would not usually be the first treatment considered for infertility
associated with low testosterone. In my experience, the use of testosterone injections may actually depress sperm production further. After a thorough medical history and examination
and a blood test to confirm normal liver function, I would consider the use of clomiphene, 1/2 tablet every other day. After three months a beneficial effect may be seen on semen analysis.
In your husband's case, it would appear that all but one of the specimens for semen analysis ( 5.1 million sperm/mL) were normal. I would suggest consideration of clomiphene therapy
followed by a repeat semen analysis after three months. If infertility persists, ovulation induction combined with intrauterine insemination would be the treatment of choice.

7. How long should one wait after a varicocelectomy to see results? I have heard three to nine months. My husband had a varicocelectomy three months ago and the
summary says there has been no significant results. Is this likely to improve with time? Exactly how is the surgery supposed to help, and why might it take a while for results
to show ?

A varicocele is a dilation (enlargement) of the veins of the scrotum. This pooling of blood in the testicle causes an increase in temperature, which may interfere with the testicle's
production of sperm. Up to 60 percent of men with varicocele will note an improvement in their sperm production after surgical repair. Repair consists of tying or clipping the veins. This is
performed through a small incision in the groin. Improvement can be seen in as little as three months, and further improvement may be seen for up to two years. If you see no
improvement at all by six months, you should consider alternative therapies .

8. My husband had a sperm count done and it showed not even one sperm. He then had an LH and an FSH drawn. Both were somewhat elevated. His urologist told him that
he shouldn't bother to do any further testing. Is this true? Or are there any other tests or procedures that can be done to see if he is able to produce sperm ?

What you were told is NOT true. There are many conditions that might result in an absence of sperm in the ejaculate. We divide these conditions into three main classifications. The first
possibility is failure to stimulate sperm production by the testicles. Sperm production depends on appropriate release of the hormones FSH and LH from the pituitary gland -- no LH/FSH,
no sperm production. In your husband's case, the FSH and LH are slightly elevated, so let's cross this problem off our list. The next possible culprit is "outflow obstruction." The sperm are
produced in the testicles and mature in a nearby structure called the epididymis. Then the sperm pass through the vas deferens and ejaculatory ducts, through the prostate and penis and
out of the body. If any of these passages are absent or blocked, sperm cannot reach the ejaculate. Clues can be obtained by noting the volume of ejaculate. If ejaculate volume and
hormone levels are all normal, the problem might be a blockage close to the testicle, which might be caused by infection. If volume is low, there may be a neurological abnormality that

FAQs

allows the sperm to be diverted into the bladder, rather than taking the correct path down the urethra to escape the male genital tract. Or there may be a blockage in the prostate gland
that can keep the sperm volume low. If this is suspected, the urologist will check the bladder for sperm after ejaculation or perform a prostate ultrasound. While obstruction may be
repaired with microsurgery, the most cost-effective option is to surgically retrieve and cryopreserve (freeze) sperm for later use in IVF and ICSI, procedures in which eggs are retrieved
and a single sperm is injected into each egg. The final possible culprit is the testicle. Is it doing its job? The physical exam may provide clues. Is one of the testicles small & firm? Is there
a dilation of veins (varicocele) surrounding the testicle? These findings may suggest testicular failure. Other tests may indicate that the testicle does a great job when it comes to making
the male hormone testosterone, but fails to make sperm. The elevated FSH is a clue to this condition. This diagnosis is made by taking a small biopsy from the testicle, a simple outpatient
procedure. If no sperm-producing cells are seen, a condition called Sertoli-cell-only syndrome is diagnosed. But the results can be misleading. It is best to do this in a fertility laboratory,
because often live sperm cells can be missed after processing. If an embryologist is present at the time of biopsy, any live sperm can be cryopreserved for later use in an IVF cycle. If the
initial specimen is inadequate, additional biopsies or a biopsy from the other side may provide adequate sperm for cryopreservation.

9. We have been married for four years, and my husband has a very low sperm count (10,000) with very little motility, dead sperm and deformed ones. The doctor said we
should do intrauterine insemination. Is this painful for the woman? Does it work in a situation like ours? Can we use my husband's sperm ?

Intrauterine insemination (IUI) should not be painful. If the semen specimen is properly prepared before insemination and the procedure is performed by a skilled physician, your
discomfort should be limited to mild cramping. In your case, IUI will work only if you choose to use donor sperm. Pregnancy is unlikely using your husband's sperm for insemination. With
sperm counts that low, the only successful approach is to perform in vitro fertilization with intracytoplasmic sperm injection (ICSI). With that procedure, results depend in large part on your
age and not his sperm count, as long as a few hundred motile sperm are available. If his urologist has ruled out obstruction as the cause of the abnormal semen analysis, you may wish to
consider genetic testing. In about 10 percent of cases, a genetic abnormality or an abnormality in a small section of his DNA (called a microdeletion) may be responsible for the problem. If
this is the case, you will need to be aware that the particular defect could be inherited by a male offspring, who may subsequently have fertility problems.

10. I am 37 and have no children. I have been diagnosed as having a thin endometrium (3-5mm). Since July 1997 I have had two miscarriages (one blighted ovum and one
lost between 8-12 weeks after a heartbeat was detected at eight weeks). I had spotting and bleeding in both cases and D&Cs with both. I am now on a second round of a
hormone treatment with Progynova & Provera after an ultrasound checkup showed a first round produced no visible improvement. This time an estrogen patch will be used &
Sildenafil(Penegra) will be advocated for use vaginally. Are there any additional ways to improve the endometrium thickness -- say, diet, homeopathic remedies, acupuncture,
etc.? Can you suggest any other sources of information on this topic?

Thin endometrium at the time of ovulation can be a concern and may be a factor in poor placental development and miscarriage. Normally, in response to estrogen, the uterine lining or
endometrium grows about 1-2mm every other day. By the time of ovulation, I like to see the endometrium at least 8mm thick. The endometrium also has a very specific ultrasound
appearance marked by three bright lines. This is often called a grade-C or triple layer pattern, and it is a good sign. Failure to develop a normal uterine lining may reflect any of several
factors such as infection, scarring from D&Cs, low estrogen levels, poor uterine blood supply or maybe endometrial antibodies. Clomiphene (Siphene, Ovofar) is an antiestrogen and as
such can block the stimulatory effect that estrogen has on the endometrium and cause thin endometrium. If clomiphene is the problem, other ovulation induction medications may be
chosen. Uterine leiomyomas or a condition called adenomyosis may also predispose to thin endometrium. While adenomysosis may be successfully addressed with a GnRH-agonist such
as Lupride or Zoladex, success has been limited. The use of antibiotics or antioxidants such as vitamin C has been proposed, but these too are rarely successful and little supportive data
exist. "Thin endometrium" is a finding -- not a condition or disease or syndrome. As such there are few, if any, research papers addressing this problem specifically. I suggest that your
physician try to determine the cause in your case; then you can seek information about that particular condition. Unfortunately, for most women with this finding, no discernible cause is
identified and treatment is rarely successful.

11. Does Viagra have any effect on sperm in a man trying to have a child? Does it affect the sperm count, mobility, etc.?

Viagra has no known effects on sperm production, morphology (shape), motility (movement) or count. If a man has organic impotence -- meaning the problem is due to a medical rather
than psychological condition -- then Viagra may improve the chances for achieving conception simply by restoring potency. Remember, though, that while Viagra can improve rigidity, it
does not necessarily bring about ejaculation. Many men with impotence may have diabetes or other conditions that affect the penis. In this situation, the muscular sphincter that constricts
to help ejaculate the sperm may not close properly. In such a case, retrograde ejaculation occurs: The sperm are shot into the bladder rather than out through the penis to begin their
journey to find an egg. If your partner is concerned about his fertility, I would suggest that he consider a semen analysis, regardless of whether Viagra helps his performance. If he has
psychological impotence, counseling may be very helpful to ensure that pregnancy is advisable.

12. After years of trying, my husband and I finally had a baby girl through in vitro fertilization. I don't want her to suffer with fertility problems as an adult. Is it possible that
infertility is hereditary ?

Genetics sometimes plays a role in both female and male infertility. If you suffer from endometriosis, your daughter is at increased risk for the same condition. Endometriosis, which
affects about 10 percent of all women, can cause tubal infertility. Another condition that could be hereditary is polycystic ovarian syndrome - a source of ovulation problems. There also
seems to be a genetic component to certain aspects of male factor infertility. A small percentage of men have microscopic abnormalities in the DNA of the Y chromosome that leads to
their infertility problems. With the advent of in vitro fertilization and ICSI (taking a single sperm and injecting it into the egg) many of these men pass this genetic defect to their offspring.
But DNA isn't necessarily destiny. And even if your daughter does suffer from infertility, it's unlikely that her struggle will be comparable to yours. When we compare our present
understanding of infertility and its treatment with that of 20 years ago, we realize that we have made remarkable progress. Our ability to identify the cause of infertility and develop cost-
effective treatments continues to improve. I suspect that when your daughter comes of age, the diagnostic and treatment options that will be available to her will certainly be different and
will likely make the process of infertility treatment much less of an ordeal.

13. Does the color of semen give any indication of fertility? Does it make a difference if semen is clear or white?

The color of sperm is usually a whitish yellow and semitranslucent. The color does not seem to play a role in fertility

14. What is the incidence of infertility worldwide ?

The World Health Organization (WHO) estimates that approximately 8-10% of couples experience some form of infertility problem. On a worldwide scale, this means that 50-80 million
people suffer from infertility. However, the incidence of infertility may vary from region to region. In France, 18% of couples of childbearing age said that they had difficulties in conceiving.

15. My husband and I have an active sex life, we are both healthy, and my periods are regular. However, we have still not conceived?? Please help !

You need to remember that it's not possible to determine the reason for your infertility until you undergo tests to find out if your husband's sperm count is normal; if your fallopian tubes
and uterus are normal; and if you are producing eggs. Only after undergoing these tests will your doctor be able to tell you why you are not conceiving. While testing does cause
considerable anxiety, it's far better to intelligently identify the problem so that we can look for the best solution.

16. Is infertility exclusively a female problem ?

No. The incidence of infertility in men and women is almost identical. Infertility is exclusively a female problem in 30-40% of the cases and exclusively a male problem in 10-30% of the

FAQs

cases. Problems common to both partners are diagnosed in 15-30% of infertile couples. After thorough medical investigations, the causes of the fertility problem remain unexplained in
only a minority of infertile couples (5-10%).

17. How can I determine my "fertile" period ?

Your fertile period is the time during which having sex could lead to a pregnancy. This is the 4-6 days prior to ovulation ( release of a mature egg from the ovary). Women normally ovulate
14 days prior to the date of the next menstrual period. If you are mathematically challenged, you can use this online ovulation calendar .

18. What are the most common causes of infertility ?

The most common causes of female infertility are ovulatory disorders and anatomical abnormalities such as damaged fallopian tubes. Less frequent causes include, for example,
endometriosis and hyperprolactinemia. Causes of male infertility can be divided into three main categories: Sperm production disorders affecting the quality and/or the quantity of sperm;
anatomical obstructions; Other factors such immunological disorders. Approximately a third of all cases of male infertility can be attributed to immune or endocrine problems, as well as to
a failure of the testes to respond to the hormonal stimulation triggering sperm production. However, in a great number of cases of male infertility due to inadequate spermatogenesis
(sperm production) or sperm defects, the origin of the problem still remains unexplained.

19. My gynecologist has done an internal examination and said I am normal. Do I still need to get tests done to determine why I am not conceiving ?

A routine gynecological examination does not provide information about possible problems which can cause infertility, such as blocked fallopian tubes or ovulatory disorders. You need a
systematic infertility workup.

20. 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.

21. Do painful periods cause infertility ?

Painful periods do not affect fertility. In fact, for most patients, regular painful periods usually signal ovulatory cycles. However, progressively worsening pain during periods (especially
when this is accompanied by pain during sex) may mean you have endometriosis.

22. 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%.

23. My periods come only once every 6 week. Could this be a reason for my infertility ?

As long as the periods are regular, this means ovulation is occurring. Some normal women have menstrual cycle lengths of as long as 40 days. Of course, since they have fewer cycles
every year, the number of times they are "fertile" in a year is decreased. Also, they need to monitor their fertile period more closely, since this is delayed (as compared to women with a 30
day cycle).

24. 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 several cycles of treatment with drugs such as clomiphene citrate or gonadotrophins.

25. My husband's blood group is B positive and I am A negative. Could this blood group "incompatibility" be a reason for our infertility ?

There is no relation between blood groups and fertility.

26. 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).

27 . After having sex, most of the semen leaks out of my vagina. How can we prevent this ? Should we change our sexual technique ? Could this be a reason for our infertility
?

Loss of seminal fluid after intercourse is perfectly normal, and most women notice some discharge immediately after sex. Many infertile couples imagine that this is the cause of their
problem. If your husband ejaculates inside you, then you can be sure that no matter how much semen leaks out afterwards, enough sperm will reach the cervical mucus. This leakage of
semen ( which is called effluvium seminis) is not a cause of infertility. In fact, this leakage is a good sign - it means your husband is depositing his semen normally in your vagina ! Of
course, you cannot see what goes in - you can only see what leaks out - but the fact that some is leaking out means enough is going in !

FAQs

28. 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. However, centers
in Europe have reported pregnancy rates after one cycle of IVF equal or superior to 25%. In 1993, the French IVF registry (FIVNAT) reported a pregnancy rate of 25.4% per embryo
transfer on a total of 23,025 oocytes retrieved. Based on such 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.

29. My colleagues at work tell me that if we "work" hard at getting pregnant, and want it enough, we definitely will ! In fact, my mother in law is even suggesting that the fact
that I am not conceiving means that subconsciously I do not wish to have a baby ( because it may interfere with my career) and that this psychological barrier is the reason
for our infertility.

Unlike many other parts of your lives, infertility may be beyond your control. Don't blame yourself if you are not getting pregnant - it's a medical problem which often needs appropriate
medical treatment. The attitudes you are encountering are often born out of ignorance - and are a kind of "victim-blaming" - ignore them !

30. Are there particular health risks for women undergoing infertility treatment ?

Along with their intended benefits, drugs used to treat infertility may on occasion cause side effects. In ovulation induction, close monitoring of follicular growth is crucial to ensuring
successful treatment. Monitoring techniques (such as ultrasound scan and blood tests) and adequate use of treatment protocols help the physician to avoid ovarian hyperstimulation
syndrome (OHSS) and minimize the risk of multiple pregnancy. Current treatment protocols have been designed to reduce the risk of multiple births and OHSS.

31 . My grandmother says that if I just pray and have faith, I will definitely conceive. How far is this true ?

Believing in god can help you to maintain a positive outlook - but sheer will and blind faith won't overcome a physical problem like blocked tubes or absent sperms.

32. OHSS Ovarian Hyperstimulation Syndrome (OHSS) is a side-effect that can occur during infertility treatment with ovulation inducing drugs. Symptoms of this syndrome
may include ovarian enlargement, accumulation of fluid in the abdomen and gastrointestinal disorders (nausea, vomiting, diarrhea). Severe cases of OHSS are however very
rare (1-2% of cases).

33. My husband refuses to get his semen tested. He says the fact that it is thick and voluminous means it must be normal !

Semen consists mainly of seminal fluid, secreted by the seminal vesicles and the prostate. The volume and consistency of the semen is not related to its fertility potential, which depends
upon the sperm count. This can only be assessed by microscopic examination.

34. Multiple births

Multiple births occur more frequently after infertility treatment than in the normal population. About 80% of pregnancies achieved following simple ovulation induction with gonadotrophins
result in single births, the remaining 20% being multiple pregnancies, mostly twin pregnancies. New treatment regimens carefully adapted to the patient's response help to decrease the
risk of a multiple pregnancy. After IVF, one pregnancy out of four is multiple (20% twin pregnancies and 3-4% triplets. In IVF centers, physicians now frequently choose to replace a
maximum of three embryos after fertilization, to further reduce the chance of multiple births.

35. My sister conceived only after 6 years of marriage. Does this mean I will also have difficulty conceiving ?

If your mother, grandmother or sister has had difficulty becoming pregnant, this does not necessarily mean you will have the same problem! Most infertility problems are not hereditary,
and you need a complete evaluation.

36 . Local side effects

Common local side effects experienced by patients who receive gonadotrophins by intramuscular injection include skin redness, swelling and bruising. Pain and discomfort sometimes
reported after intramuscular injections are now likely to be lessened with the availability of gonadotrophins produced by recombinant DNA - or genetic engineering - techniques which are
administered by subcutaneous injection

37.My doctor just did a physical examination for me, and he feels that the reason for my infertility is that my uterus is tipped backwards, and this prevents the sperm from
swimming into the uterus. He is advising I have surgery to correct this problem. Should I go ahead ?

About one in five women will have a retroverted uterus. If the uterus is freely mobile, this is normal, and is not a cause of infertility. This is not an indication for surgery!

38. Can ovulation induction increase the risk of ovarian cancer ?

Ovarian cancer is a rare disease; the chance of a young woman developing an ovarian malignancy during her lifetime is lower than 1.5%. A number of factors have been found to
increase the risk of ovarian cancer, including genetic predisposition and dietary habits. Scientific studies carried out in the last few decades have demonstrated that infertility itself is a risk
factor for ovarian cancer. There is evidence that each pregnancy reduces the risk of a woman contracting ovarian cancer (this risk could be reduced by more than 25% by a first
pregnancy). No epidemiological study has ever established a causal link between ovulation promoting drugs and ovarian cancer. An extensive study on this issue, reporting on more than
2,600 women treated between 1964 and 1974 and followed for an average of twelve years, found no association between ovulation inducing drugs and ovarian cancer.

39. My husband says we should be having intercourse every day to achieve pregnancy. Is this true ?

Sperm remain alive and active in woman's cervical mucus for 48-72 hours following sexual intercourse; therefore, it isn't necessary to plan your lovemaking on a rigid schedule.

FAQs

40. What about the health risks for children born following infertility treatment ?

Regarding children born following treatment with ovulation promoting drugs, the incidence of birth defects has never been found to be higher than that in the normal population.

41. My friends say I should have sex exactly on the day I ovulate to get pregnant. How can I do this ?

Although having sexual intercourse near the time of ovulation is important, no single day is critical. So, don't be concerned if intercourse is not possible or practical on the day of ovulation.

42. How important is counseling to the patient undergoing infertility treatment ?

The physician helps the infertile couple find the most appropriate therapeutic path to overcome barriers to conception, but, before a treatment is started, patients need to be aware of all its
aspects, including its constraints. Beyond the medical expertise, infertile couples are also looking for counseling and support. From a psychological point of view, infertility is often a hard
condition to cope with. During treatment and before a pregnancy is achieved, feelings of frustration or loss of control usually experienced by the infertile couple are likely to be
exacerbated. Management of infertility includes both the physical and emotional care of the couple. Therefore, support from physicians, nurses and all people involved in treating the
infertile couple is essential to help them cope with the various aspects of their condition. Offering counseling and contact with other infertile couples and patient associations can provide
help outside the medical environment.

43. My sister in law is advising me to keep a pillow under my hips during and after intercourse . Will this increase my chances of conceiving ?

Sperm are already swimming in cervical mucus as sexual intercourse is completed and will continue to travel up the cervix to the fallopian tube for the next 48 to 72 hours. The position of
the hips really doesn't matter.

44. 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 or nasal application of specific
hormones each day. This part of the cycle can vary from a few days to several 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 reaction of 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 fertilisation occurs, embryo's 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.

45. My mother feels I am too tense, and that if I just relax, I'll get pregnant.

If pregnancy has not occurred after a year, chances are there is a medical condition causing infertility. There is no evidence that stress causes infertility. Remember, all infertile patients
are under stress - it's not the stress which causes infertiliity, it's the infertility which causes the stress!

46. Extra Uterine Pregnancy (EUP)

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.

47. 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.

48. 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.

49. 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.

50. Egg-donation Women

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

FAQs

own.

51. 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 .

52. 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.

53. 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.

54. 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.

55. 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).

56. 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.

57. 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.

58. 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.

59. 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 !

60. 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.

61. What are the causes of damaged fallopian tubes?

FAQs

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).

62. 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.

63. 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.

64. 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.

65. 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.

66. 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.

67. My husband and I have been going through tests for infertility. I am fine, but my husband has no sperm. They did a biopsy and found out that he has maturation arrest. He
has the starting of sperm, but it never matures. I have searched the Internet and cannot find anything on this subject. If he has the start of sperm, can something be done
medically to help those sperm mature? Or do we have to look into IVF or adopting?

Depending on the stage of sperm maturation arrest, it may be possible to harvest round cells (immature spermatocytes) and inject them into the eggs to attempt fertilization, as part of an
IVF procedure. This approach, called ROSNI, is experimental and not performed by most IVF centers at present. Success rates after this procedure are quite low. An evaluation as to why
your husband has this problem is in order. If no obvious cause is determined, then chromosomal testing and DNA testing for microdeletions are necessary to make sure the condition will
not be passed on to his male offspring.

68. Why is Progesterone used for IVF?

Progesterone is required for the success of early pregnancy. In a natural cycle progesterone is made by the corpus luteum (CL). If the CL is removed during the first 5 weeks after
conception, the pregnancy will miscarry. By about 9 weeks' gestation, the luteal-placental shift takes place: the trophoblast itself makes sufficient progesterone, and the pregnancy is no
longer dependent on the CL. There are 2 reasons for giving extra progesterone after an IVF.

The first is that the CLs in IVF were all disturbed by the IVF needle during egg pick-up. The CLs start as follicles containing eggs. At the retrieval, the needle is placed inside the follicle,
the egg is removed; and other cells may also be removed. The follicle is mostly fluid, but it also contains tons of cells that make up the follicle and surround the egg. These are called the
granulosa cells; and these are the cells that convert to CL cells after ovulation. So if the needle removes some of these cells, as is usually the case, the CL would not work as well, and
less progesterone is produced.

The second is to do with IVF medication. In a natural cycle, the hormone LH is secreted by the pituitary in small doses after ovulation, as this LH helps the CL to produce progesterone.
However, during an IVF cycle, most women are given Lupride, Gonapeptyl or Ovurelix to suppress a premature LH surge at ovulation. In a natural cycle or IUI, surges are fine, they cause
ovulation. In IVF, we need to time the retrieval to the hour, so that a surge at the wrong time ruins everything. So we give medicines to stop LH; but this means LH is no longer available to
help the CL with progesterone production as well.

69. What is the best route for progesterone administration during an IVF cycle in terms of efficacy and side effect profile?

The best route of administration has not been clearly established. There are pros and cons associated with each route.

Oral preparations - Oral supplementation is not recommended because although some studies have not found a difference in efficacy between oral and other routes of administration, a

FAQs

few studies did report lower implantation rates, lower pregnancy rates, and /or higher miscarriage rates in women receiving oral compared with IM or vaginal progesterone.

Intramuscular progesterone - The main downside of IM progesterone is local skin inflammation at the site of injection. At times, this reaction can be quite painful and can lead to induration
that may persist for weeks after the injections are complete.

Vaginal preparations - Because the progesterone is first absorbed locally, intrauterine concentrations are high despite serum levels that are lower than with IM progesterone. Vaginal
progesterone may be administered using compounded suppositories, tablets or 8% gel. The main side effects with vaginal preparations are vaginal irritation, discharge and dyspareunia.
The principal advantage of the vaginal preparations is that they are less painful than IM injections. IM injections may be difficult for a patient to administer herself, whereas vaginal
preparations can be self-administered. However, vaginal preparations must be used 2-3 times per day, whereas IM progesterone is administered once daily.

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