Before Treatment Begins, there are a number of things that have to be done before your treatment can begin.

Selection Criteria

Although IVF and other fertility treatments can bring huge benefits to some people, for others they are not appropriate. For these people, allowing treatment to start would only bring false hope and heartache. We would not want anyone to have to go through this.

At Shrishti Fertility Care Center & Women’s Clinic, we will not allow treatment to be started if we do not believe that the chances of success are reasonable. It is for this reason that we have introduced selection criteria:

Screening Tests

Before you commence treatment, some investigations must be performed to ensure that you are both suitable for this type of treatment. If you feel that you have already had any of these investigations please let us know.

AMH: AMH is a hormone measured from a blood test. This blood test needs to have been carried out recently to help us judge what drug regimens will suit you best.

Screening Tests

Before you commence treatment, some investigations must be performed to ensure that you are both suitable for this type of treatment. If you feel that you have already had any of these investigations please let us know.

Prolactin (for the woman): Prolactin is a hormone measured from a blood test.

Rubella (for the woman): A blood sample will be taken to confirm your immunity to rubella (German Measles). It is important to have the result of this test before your treatment starts. If you are shown to be “not immune” you must discuss the need for immunization with your own infertility specialist. Any immunization or repeat immunization must be done before starting the treatment cycle. If you are non-immune and develop Rubella during a pregnancy, this may have serious implications for your baby.

Screening for HIV and Hepatitis B and C: Before treatment can commence, both partners must be screened for previous exposure to Hepatitis B, Hepatitis C and HIV infections. If any of these results are positive, you may require further testing. Based on these results we will be able to advise what treatments we can offer. We can also offer appropriate counselling, and referral to the local infectious diseases service if appropriate.

Chlamydia screening: Chlamydia is a micro-organism which can lead to damage of the fallopian tubes. To see if you carry this organism we test a urine test for the male partner and a vaginal swab for the female partner. It can also be tested by taking a blood test to investigate the presence of antibodies to Chlamydia, which will tell us if you have ever had an infection.

Cervical smear: It is necessary for you to have had a cervical smear within the last three years. If you have not had a recent smear, please visit your GP to arrange this before your treatment starts. If you are not on a normal recall with your smear tests then we need a clear smear test within your recall, e.g. 6 months, 12 months etc. We need to have a copy of your most recent smear test in your notes at the time of your treatment. This might simply be a copy of the letter you receive advising you of the result.

Semen evaluation: Although you may have had a Semen Analysis carried out recently we may still require this to be repeated. If we think you need some form of IVF we will require a sample to be produced on site, which is subjected to a more detailed analysis which allows us to determine which treatment options are available for you. (This may not be necessary for those patients requesting treatment with donor sperm).

Lupus Anticoagulant, Anticardiolipin antibody screening, B2 Glycoprotein antibody screening and TSH: These blood tests may help the clinician assess whether you have an increased risk of a miscarriage or an increased risk of problems during pregnancy. There are many reasons why ladies may miscarry and not all risks can be assessed by a blood test. However, if these blood tests show any abnormalities the clinician can initiate treatment to reduce the risk for you.

Tubal patency test: This investigation can be done in one of two ways;

HyCoSy – an ultrasound investigation of the fallopian tubes. A fluid, which is opaque when viewed by ultrasound, is infused through the tubes. The sonographer will observe the fluid to determine if it spills freely from the end of the tubes and over the ovaries. If the fluid is not seen to pass through the tubes a laparoscopy and dye (see below) will be organized to assess your tubes further.

Laparoscopy and Dye- Performed in theatre under a general anesthetic. An endoscope is passed into the abdominal cavity through the navel. Dye is passed through the cervix into the uterus. The surgeon will then watch the dye pass through the tubes. If the fluid is not seen to pass through the tubes they may be blocked. If any other disease such as endometriosis is found this can be treated at the same time.

Ultrasound scan: All patients having IVF will have an ultrasound scan carried out to exclude cysts in the ovaries, fluid within in the fallopian tubes (hydrosalpinges), fibroids in the wall of the uterus, or polyps within the cavity of the uterus.

The management of these, if necessary, will be discussed with you before treatment commences.

We may also perform a scan early in your cycle to determine the number of follicles beginning to grow. This is referred to as an antral follicle count, and may help us determine the correct dose of stimulation drugs for you.

Hysteroscopy for Fertility and Reproductive problems

Hysteroscopy is the inspection of the uterine cavity that allows for the diagnosis and treatment of various uterine conditions. Some of which, could lead to fertility problems.

A hysteroscope is a fiber optic telescope. Some hysteroscopes are “rigid” and straight. Others hysteroscopes are semi-flexible. The hysteroscope contains several channels all with a specific purpose. In addition to the “optic” channel that allows the doctor to see inside the uterus, one channel carries a fiber optic light in order to see inside the ordinarily dark uterus. One channel allows the introduction of fluid or gas to hold open the uterine walls and another channel is to allow the fluid back out again. Some hysteroscopes have an additional “operative” channel that allows the doctor to introduce instruments to do various tasks inside the uterus.

Hysteroscopy Procedure

 

Hysteroscopy may be performed in a doctor’s office, surgicenter or hospital. The more complicated cases are typically done in a surgicenter or hospital. During the procedure, the patient can be fully awake, under light anesthesia or completely asleep under general anesthesia. Again, the choice of anesthesia depends on the complexity and length of the surgery being performed.
The patient will lie on an operative table. Her legs will be elevated in “stirrups”. A speculum is placed into the vagina to allow the doctor to see the cervix which is the natural opening to the uterus.
The cervix is gradually stretched open or “dilated” in order to allow the doctor to slide the hysteroscope into the uterus. “Dilators” are metal rods of increasing diameter. The surgeon first chooses a rod with a small diameter that will fit into the cervical canal. Then a slightly larger dilator is passed. This is repeated until the cervix has been stretched open enough to allow the hysteroscope to be inserted.
Cervical dilation can be uncomfortable and is one of the reasons why anesthesia is sometimes used for hysteroscopy. Operative hysteroscopes are larger in diameter than hysteroscopes that are for diagnostic use only and thus require dilation of the cervix to a larger diameter.
Normally, the inside of the uterus has no open space. The inside walls of the uterus are pressed against each other in the same was that the tongue presses against the roof of the mouth when it is closed. The walls of the uterus can be held open by introducing fluid or gas through the hysteroscope under pressure. In a doctor’s office, where diagnostic hysteroscopy is performed, carbon dioxide gas is usually used to open the walls of the uterus. In the surgical center or hospital, fluid is usually the distending medium of choice. One of the safest fluids to use for hysteroscopy is simply saline (salt water). This is the same type of saline that is contained in intravenous (IV) fluids that patients receive in the hospital and so is very safe compared to other types of synthetic fluids.
At this point, with the hysteroscope inside the uterus, the uterine walls held apart and the hysteroscope light on, the doctor can begin viewing the inside of the uterine cavity. The cervical canal leading to the uterine cavity is like a long tunnel. The uterine cavity is like a large cave at the end of the tunnel. The “cave” has a “floor” (which is the back side of the uterine cavity), a “ceiling” (the front side of the uterine cavity), a back wall (the top of the uterine cavity), and left and right side walls. On the left and right sides near the top of the uterine cavity, there are two small opening which are the openings to the fallopian tubes. The uterine cavity shape is roughly triangular.
Hysteroscopy is usually an outpatient or same day procedure – meaning that patients do not typically need to be admitted overnight to a hospital. Once the procedure is completed, the patient is taken to the recovery area. After the patient is fully awake, vital signs are normal and stable and the patient can go to the bathroom and having something to eat or drink, she can be released to go home. There are many types of problems that can be diagnosed and fixed through the use of hysteroscopy.

 

Uterine Septum (Septate uterus)

This is the most common uterine malformation and a common cause of miscarriage. It is unclear whether a uterine septum increase the chances for infertility or not. A wedge of tissue is present inside the uterine cavity, which divides it into two halves (also called uterine horns).
When seen through a hysteroscope, the uterine horns are seen as two dark openings separated by a wedge of tissue. By introducing an electrode through the hysteroscope, the septum can be shaved or vaporized all the way to the top of the cavity. The finished product is a uterine cavity that is unified into one large space instead of divided in two.

Polyps

These are uterine growths a few millimeters to centimeters in size. Polyps arise from the uterine lining (endometrium). A polyp may be attached to the uterine wall directly or by a thin “stalk”. Patients often have no symptoms from polyps but will occasionally notice irregular vaginal bleeding. This bleeding may occur in between periods or cause the period to be longer in duration or heavier than normal.
Polyps are also associated with an increased risk for miscarriage. Large polyps, which occupy the majority of the uterine cavity, are also probably responsible for infertility. Small polyps can be most easily vaporized in place. Polyps which are attached by a stalk can sometimes be removed by cutting through the stalk and removing the entire polyp through the cervix. Larger polyps may have to be removed by shaving small strips one at a time until the polyp is completely gone.

Fibroids

These benign tumors arise from the muscle layers of the uterus. Often they will stay in the muscle layer but on occasion, fibroids can grow into the uterine cavity. Like polyps, fibroids can cause bleeding, infertility, and as well as miscarriage.
Removal of fibroids from the uterine cavity is performed using the same methods as for polyps.

Scar tissue

Scar tissue inside the uterine cavity, also called adhesions, can arise from infection or trauma to the uterine lining. Although rare, the most common cause for uterine adhesions to form is from a previous D&C procedure. Scar tissue inside the uterus can be small and isolated to a certain spot. This type of adhesion looks like a band running from one wall of the uterus to another. Sometimes adhesions take the form of two walls that are stuck together causing the cavity at that spot to be completely obliterated. In rare instances, the entire cavity can be obliterated. Uterine adhesions can cause infertility or miscarriage. If the uterine cavity is partially or completely obliterated, a woman may notice that her period are lighter or even stop altogether. Band adhesions can be easily cut restoring the normal anatomy of the uterine cavity. When the walls are stuck together, the surgeon must carefully dissect between them in order to separate the walls. This can be a very difficult process if there is little normal uterine cavity that remains to serve as a guide.

Laparoscopy for infertility

Laparoscopy is a surgical procedure that allows a fertility doctor to see inside of the abdomen. In a female, the uterus, fallopian tubes and ovaries are located in the pelvis which is at the very bottom of the abdomen. Laparoscopy allows the fertility doctor to see abnormalities that might interfere with a woman’s ability to conceive a pregnancy. The most common problems are endometriosis, pelvic adhesions, ovarian cysts and uterine fibroids.

What is a laparoscope?

A laparoscope is a thin fiber optic telescope that is inserted into the abdomen usually through the belly button. The fiber optics allow a light to see inside the abdomen. Carbon dioxide (CO2) gas is placed into the abdomen prior to inserting the laparoscope. This lifts the abdominal wall and allows for some separation of the organs inside the abdomen making it easier for the fertility doctor to see the reproductive organs during the surgery. If abnormalities are found during the laparoscopy, additional instruments can be placed into the abdomen through tiny incisions. The incisions are usually made at the pubic hair line on the left and/or right side. Together with the laparoscope in the belly button, this forms a triangle that allows the fertility doctor to perform virtually any surgical procedure that can be performed by using a more traditional “open” surgery where a large incision is made. Laparoscopy is performed using general anesthesia. This means that the patient is completely asleep during the entire procedure.

What are the advantages of laparoscopy for infertility?

Laparoscopy will allow the diagnosis of infertility problems that would otherwise be missed. For example, a woman who has severe endometriosis can be identified by using ultrasound. A woman with mild endometriosis can only be identified using surgery such as laparoscopy. Another problem that can only be identified through surgery are pelvic adhesions. Also known as scar tissue, adhesions cannot be seen with ultrasound, x-rays or CT scans. Adhesions can interfere with the ability to conceive if they make it more difficult for the egg to get into the fallopian tube at the time of ovulation. Many people view laparoscopy as a less invasive surgery that traditional surgery. Traditional surgery requires making an incision in the abdomen which is several centimeters long. This in turn means that the patient has to spend two to three nights in the hospital. Laparoscopy utilizes one to three smaller incisions. Each incision may be one half a centimeter to a full centimeter in length. Most often, patients who have had a laparoscopy will be able to go home the same day as the surgery. In other words, a hospital stay is not usually required.

Which infertile patients should have laparoscopy?

Generally, laparoscopy should be reserved for couples who have already completed a more basic infertility evaluation including assessing for ovulation, ovarian reserve, ultrasound and hysterosalpingogram for the female and semen analysis for the male. Some couples may elect to skip laparoscopy in favor of proceeding to other fertility treatments such as superovulation with fertility medications combined with intrauterine insemination or in vitro fertilization. There may be instances in which the fertility doctor may have a high suspicion for finding problems with laparoscopy. for instance, if a woman had a history of a severe pelvic infection or a ruptured appendix, this would increase the likelihood that she may have pelvic adhesions and therefore more likely to benefit from laparoscopy. There may be instances in which the fertility doctor may have a high suspicion for finding problems with laparoscopy. for instance, if a woman had a history of a severe pelvic infection or a ruptured appendix, this would increase the likelihood that she may have pelvic adhesions and therefore more likely to benefit from laparoscopy.

What to expect after laparoscopy?

The incisions will be covered with bandages that can be removed after twenty four hours. The fertility doctor will give prescriptions for postoperative pain and for nausea. The pain medicine will almost always be needed, the nausea medicine may or may not be needed. The length of time needed for recovery will depend on the type of procedure that was done, the length of time the surgery took, the number of incisions that were made, whether the patient has had surgery previously, the state of health the patient was in before the surgery, whether any complications occurred and what the tolerance of the patient is naturally.
The patient can eat or drink whatever she feels up to having after an uncomplicated laparoscopy for infertility problems. Due to the anesthesia, she should rest for twenty four hours. Generally thereafter, she may resume normal activities as soon as she feels well enough.
Depending on the type of procedure, some women may be able to return to work in a few days. Other women may require a few weeks.
In india, Tuberculosis is a very common disease; unline pulmonary tuberculosis (Tuberculosis of lungs. Pelvic tuberculosis has no prominent symptom and is a silent killer. Pelvic tuberculosis can be diagnosed & confirmed only by hysterolaparoscopy. Tuberculosis adversely affects fallopian tubes & implantation of embryo leading to decreased success rates with any form of infertility treatment.
All investigations must be up to date before commencing a treatment cycle and the office staff will liaise with you regarding any investigations that are outstanding. If you have any queries regarding this please do not hesitate to contact us.

Keeping yourself healthy

Keeping yourself healthy will maximize your chance of the treatment being successful. Before treatment starts, both partners should:

  • Stop smoking, including substitutes such as vaping.
  • Reduce alcohol intake to within Government advised limits.
  • Eat a healthy, balanced diet.
  • Stop Caffeine.
 

We also strongly recommend that the female partner takes a daily folic acid supplement. The dose of the supplement should be 400mcg (unless you are taking anti-epileptic drugs, in which case the dose of folic acid is 5 mg. Secondly, we will give you a form to take to your GP. If appropriate, your GP will sign this letter to confirm that he/she knows of no reason why you should not be treated. Please do not hesitate to contact us if you have any questions relating to the Welfare of the Child Assessment.

 
 
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