Hormonal Challenges in Women - Fellowship in Reproductive Medicine
Some girls are over 30 years old now. Or she has periods, irregularity. Then we would suggest at least 6 months. After 6 months of regular pregnancy, they can at least take a specialist opinion to do a certain test to know if there is a problem or not. For many, it will take 1 to 2 years. 80% of them will conceive in the first year. 90% will conceive within 2 years.
We just tell them what are the difficulties of 10%. It is better to approach them once. Ok, so first of all, what are the basic tests for couples? See, when they approach, we take a basic history. Then, what affects a girl's pregnancy? The husband's sperm should come. After the two come together, the sperm should be attached to the uterus. So, our basic test is to check those 4 parameters.
For a girl, just to check, we do a basic scan. In the scan, we can see the uterus and ovaries. So, we at least ensure that there are no cysts in the uterus or ovaries. For men, we do a basic semen testing. We check the sperm count, motility, and structure. We also check the tubes. If the tubes are open or not. Because both the egg and sperm come together in those tubes. And the embryo develops there.
After that, the embryo should be attached to the uterus. So, in ultrasound, we get a picture of the uterus. In scanning, the ovaries will also come to know. We get an idea about the number of the girl's egg. So, after all these tests, if everything is fine, then we just help them in conceiving most naturally possible techniques. Again, we did a 20th scan. May be, we got 90th DNA test. What did you get? 90th DNA test. May be.
I am not writing any doubt about ectopic. But, HSC levels are doubling every 2.5 days. See, mainly if there is an ectopic. Ectopic means, if there is no sac in the uterus, there will definitely be an ectopic doubt. So, beta HCG, serum beta HCG, We got at least 2000 value. But still, if it is not visible in the scanning, Usually, it is an ectopic. 90-99% is an ectopic. If beta HCG is less than that, then we have to monitor. To know whether it is doubling or not.
If it is doubling, we can keep repeating the scan regularly. If it is not doubling, then we need to check for ectopic. So, we scan again. The ectopic is definitely visible in the scanning. If the ectopic is visible, we have two modes of treatment for that. Either we give an injection.
It will be disintegrated. Or we have to remove the tube. If the ectopic is in the tube.
There are many advanced treatments. IVF, ICSI. In such treatments, Pregnancy will definitely happen. If you change it immediately, Success rate will be better. Because, When the age of the girl increases, When you wait like this, The result will decrease. Whichever IVF is successful for you, You have to try up to 2 to 3 IVFs.
If you go early, Success rate is better. Right madam. After the test is done, What are the basic treatments? See, A girl has regular cycles. But still, She is not conceiving. Basic tests are normal.
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We start with IUI. - IUI means Intrauterine Insemination. Because, we don't have tests to check. After the test is done, Will the sperm enter the uterus? Or not? Instead of that, When the husband, we track the ovulation of the girl.
During the ovulation time, If the husband gives us a sample, In the lab, We process it. We separate the active sperm. Through a syringe, We insert it into the uterus. In this, Success rate is 3 times higher. Compared to, Regular intercourse. In most cases, 2 to 3, Maximum 4 cycles, Pregnancy occurs. But, if a girl has irregular cycles, when they approach, For the first time, We correct the cycle. Now, she is getting 1 and a half, 2 months. We give medications.
Regular ovulation, In the middle of the month, 14th or 15th. We correct it first. Then, They can meet naturally. We monitor it. We give dates. Maximum couples, With irregular ovulation, Pregnancy occurs very fast. They do not require, Any high-end treatment. This is something, They have to have the knowledge, To correct it fast, When they get married. In the IUA, How much sperm count, Morphology, Motility should be? Basically, In the IUA, Success rate depends, On the sperm count.
Sperm count should be, at least 10 million. In the sperm, After washing, The movement of the sperm, 5 to 10 million, Minimum count should be there, To get a success rate. Morphologically, Minimum 4 percent, Normal count should be there.
In the post-wash sample, At least 80 to 90 percent, Motility should be there, To get a good success rate. When the sperm count is less, The IUA should not try, For more cycles. If the pregnancy does not occur, After one or two attempts, Then, There are high-end treatments, Like ICSI, IVF, Which will give a, Very good success rate.
Especially, When the sperm count, Is very low. So, For a woman, Who wants to do IUA, What kind of complications, Should not be there? See, IUA is absolutely, A safe treatment. There are no complications, In it. It is one of the, Best treatments, Actually. Just before, If you want to plan, Before IVF, For two to three cycles, It is absolutely safe. But, Do not try for more cycles.
What will happen - Every IUA, there are some patients, for 5 to 6 attempts, they will try for more, For 8 to 10. So, what will happen? For the women, the eggs will decrease, Because of repeated injections, With repeated tablets. So, such treatments, When the success rate, is only 10 to 15 percent, With IUA, you can stop for four cycles.
So, what are the reasons, For IUA to fail? If IUA is not successful, What is the next step? See, In IUA, what we are monitoring, Basically, we are studying the ovulation, We get an idea, When the egg is released, In the scanning. Now, after the egg is released, We do not see, Whether the tube has taken it or not, In the scan. So, You really do not know, Whether the egg has picked up or not, Whether it went inside the tube. And, We are putting sperms, Into the uterus. We are putting it to the uterus. After the sperms, It has to go.
Now, if there is an ovulation on the right side, It has to go to the right side tube, And, It has to mix with the egg. That is called, Fertilisation process. So, For some eggs and sperms, Fertilisation does not happen.
So, that is something, that can fail. Another thing is, After the embryo is developed, The embryo should be healthy. And, the embryo should reach the uterus.
It has to push the tube to the uterus. After it reaches the uterus, The embryo has to go to the uterus. So, whether the egg has picked up or not, whether it has been fertilised or not, Whether the embryo has been developed, whether it has been transported to the uterus, And, So, In these four steps, No clinician, No doctor can assess.
So, It is a matter of error. So, you can just keep checking, three to four times, If it fails repeatedly, Then, Definitely, In these four steps, It will fail at some level. So, For those couples, They have to go forward.
So, Now, We have a doubt, Whether the egg will be collected or not. So, What we do as clinicians, We collect the egg from outside. Now, Whether the fertilisation is happening or not, We are not very sure.
We take the husband's sperm, And, We collect the egg, And, We fertilise it in the lab. Again, The embryo development is not, We cannot see, In the scanning. So, The embryo development is changed in the lab, And, It is cultured for three to five days, Then, The embryo is put back into the uterus. Then, Only the implantation has to happen. So, Definitely, In IVF, No one will get it. In IVF, The success rate is definitely very high.
So, Among the people who get IVF, If only one tube is open, How much success will they get? See, One tube is just, Enough for pregnancy. You need not worry at all. Many people, Due to ectopic, They block the tube, Either because of infection, Or, They remove the tube, Surgically, Because of ectopic.
So, In one tube, Pregnancy may occur, But, The ovary should be released on that side. We monitor that in the scanning. So, If there is a block on the left side, During ovulation on that side, We have to withdraw. So, During right side ovulation time, We change it, And, At least, You can go for IVF, After 3 to 4 attempts.
What is the difference between, IVF, ICSI, and IMSI? What is the success rate?
See, Patients do not have awareness. IVF is a fertilisation procedure. IVF means, In vitro fertilisation. So, We do not collect egg sperm, And, We do not inject it. We just keep it near, In a culture dish, Naturally, Sperm goes inside, Inside the egg.
But There are some criteria for this. Minimum husband's sperm count, should be at least 5 million. But, Now, If the sperm count is very less, And, If the sperm has no motility, Very poor, No motility at all, For such low count, Low motility, We have to go for ICSI.
Anything less than 2 million, For ICSI. ICSI is what? Intracytoplasmic sperm injection. So, Here, In this treatment, We hold the egg, Put the sperm in a needle, And, Directly, We inject the sperm, Inside the egg.
So, This gives very good success rate. Almost 80 to 90 percent, Fertilises. So, We do not waste the eggs. Now, In IVF, In IVF, Eggs can be wasted. So, In ICSI, We are utilising all the eggs, And, Giving better success rate. Now, What is sperm count, And, Motility is important, Morphology. Now, For many people, Sperm is morphologically abnormal. Sperm has a head, Body, Tail. So, Out of those three structures, If there are any defects, We can magnify them, And, Identify them. That is ICSI, With morphologically selected sperm, That is IMSI. So, We can inject that into that egg. So, When morphology is less, IMSI will give better success rate.
So, Now, Egg and sperm, When we select good quality, And, When we make it, Embryo quality will be good. And, Embryo quality will give you, Whether the success rate will be good or not. So, Our all the goal, Towards, Our centre is only towards, Creating the best possible embryo, And, To put it at the right time.
So, To achieve a good success rate. So, In this, In IVF, In ICSI, With count, With morphology, And, With motility, Is there any relation? Count, Means, Count should be like this, Or, Morphology should be like this, Motility percentage should be like this, Is there any relation? See, Now, In IUI, In IVF, That is very important. But, Now, The technology with ICSI and IMSI, Till now, With the least possible count, Now, Some people do not have sperms.
We are taking from the testers, And doing it. Good success rate. So, That is what we have achieved, With all this technology today.
So, medical condition, BP, sugar, so many associated conditions are also there. So, when we do IVF, we have to consider all this background knowledge, improve that patient's parameters to improve better success rate. So, we are achieving definitely a better of up to 60-70% when we control all these factors. In IVF, the fertilisation is done outside. So, you take good quality eggs. You also take quality sperm.
Why is it not successful? What is the reason? Yeah, so what is the most important in this is the female age. Because we are giving injections in IVF, right? So, it only matures the existing eggs. There, the egg count is not increasing. So, after the maturation, we collect the eggs. Only after that, we get to know the egg quality in the lab. Till now, we do not have any test to know the egg quality before egg collection. That is one important thing. And for some people, the age is more now. There is a thing called pre-IVF medications. For a girl and a boy, which we give to improve the egg and sperm quality. So, we concentrate on that parameter. Now, IVF should not be changed suddenly as an emergency.
If you check that and use the medicines and change the IVF, the result is definitely better. Once you give egg and sperm in the lab, there is nothing you can do about it. So, whatever the best possible is pre-IVF. Within 2 to 3 months, we plan the IVF cycle. Once we get it in the lab, what is in our hands is that we use the best cultured media. The media we have used definitely gives a better success rate.
Technique, who is doing the technique of ICSI? That technique of ICSI is important to get better fertilisation rate. Culturing conditions, how is the quality of the lab now? So, we standardise all those things and try to get the best quality embryos. Day 3 transfer or day 5, we call it blastocyst. There is no difference between the two. Both are giving very good success rate. But, there are certain things, when we do the first IVF, we just go ahead with these things. We just do a simple protocol, simple culture, simple fertilisation and transfer and see. If the IVF fails, then we have a lot of advanced techniques to know. Now, what you are asking, all that we apply in the second IVF. If it fails, what we look at is the pregnancy condition. In the scan, we can only see the endometrium, the thickness of the endometrium, whether the flow is good or not. So, those things we can check.
But, we really do not know whether the endometrium is receptive to the embryo at that time. So, there are certain tests. Now, there is an endometrial receptivity assay, which we do a biopsy and analyse whether there are implantation genes in the embryo or not.
At what time do we transfer the embryo? Because, day 3 transfer is from 6 in the morning to 6 in the evening, day 3. But, for some people, the implantation window will be open only for a few hours for the uterus, for the embryos. At that time, we identify and transfer the personalised embryo. Now, there is something called PRP.’ So, we take the blood of the patient and separate the platelets. Platelets have two advantages. One is that it secretes growth factors, which improves the embryos. The other is that the platelets are adhesive, that is, it acts like a glue. So, the attachment of the embryo to the uterus also improves. So, endometrial PRP and error test actually improves the results in IVF. And, regarding egg and sperm, as I told you, we cannot change that. But we can test the embryo, that is called PGS. Pre-Implantation Genetic Screening.
So, what we do here, Previously, IVF failed. They are saying that it is of good quality in the previous cycle. So, then what we do, Now, to see the embryo, how we grade it in the lab, we tell grade 1 embryo, grade 2, grade 3, on the development panel.
Now, if we see a baby, it looks good from head to toe. It looks normal. But, only after talking to a patient, you will know whether it is mentally retarded or IQ. So, that is what we do in the lab. In the lab, you just see the growth development. Today, there are 4 cells and 8 cells. So, we will only come to know that the embryo is alive. But, it is of good quality when we do the genetic study. So, what we do then is, through embryo biopsy, we take some cells of the embryo, especially on day 5, after doing the biopsy of the blastocyst, we send it to a genetic lab. Till then, we keep the embryo in freezing. From the genetic lab, within 15 to 20 days, they will give a report. Whether the embryo is genetically normal, healthy or unhealthy.
So, this is called functional testing of the embryo. So, if it is unhealthy, it should be thrown away. There is no use in transferring the embryo. And, it will give an indication as to why the previous IVF failed. It is probably because of genetic problems. So, if it is healthy, our IVF success rate improves to 70-80%. If I normal embryo to a good uterus, our IVF success rate is almost very high. So, these are the techniques today to improve our IVF success rate. So, they should not go for it in the first IVF.
Because, in almost 10, in 6, in simple IVF, a positive comes. But, the remaining 4 to 5 people who failed the first IVF, they can do the evaluation and if they need the techniques, they can change it. So, to get an IVF MC, how much should a woman's age be? And, if a woman's age is low, the eggs will also become hard, right? What should be the treatment for such people? See, one important thing about age.
They will not understand this. Age is basically what I am telling now. For a girl, she may tell she is 25 years. She may tell she is 30 years. She may be 35 years. But, we are IVF specialists. What we are worried about is the over age. So, there are tests to know your over the age. For a 25 year old girl, now we are getting, when we do IVF, the eggs look like a 35 year old.
Why does it happen? Because, certain women are ageing fast. So, their eggs decrease very fast. So, because of quantity decline, the quality also decreases. So, for us, as IVF clinicians, we want to know, how is the egg quality over the age? With respect to that, our IVF success rate is best for women before 35 years. The moment 35 years pass, the egg quality, what do you mean by quality? There will be genes in the egg. Basically, women are giving 50% of their genes to the baby.
There will be changes, genetic mutations. That is why, the risk of abortion increases after 35 years. So, whatever you plan, you have to plan before 35 years.
That is the critical period. If there is an advance, there are a lot of techniques today. Whatever I told, ICSI is a very good, giving good fertilisation rate in women with advanced age.
Another is laser assisted hatching. So, when the embryo, shell is very hard, when the thickness is more, we will do a laser thinning. By thinning the zone, the implantation potential will improve. So, these are done additionally for aged women. Okay. So, when the tubes are blocked, will you go directly to IVF or is there anything to clear the blocks? See, now we have a HSG test. That is basically a simple X-ray. That is a screening test. We give it to everyone. In that, for those who have a block, 90% of them can open it. There is a procedure called FTC by laparoscopy. Where we do fallopian tube catheterisation. You can open it with a laparoscopy. But the remaining 10% of the block could be a permanent block. That is because of infections.
So, for those who have a permanent block, IVF will give a good success rate. So, how much success rate is there for this infertility problem in Head Day Fertility Centre? See, we are giving a very good success rate because we have a very big team. Actually, we are almost 7 clinicians, 3 embryologists.
So, 10 brains are working for a single patient's success rate. So, I think the big team definitely gives a very good, high success rate. So, that is what I believe in. And one of the most important thing is today we get by patients only. Our success rate is mainly because of our patients referring. So, one of the good technologically advanced team, I would tell.
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