Blissivf Fertility & Andrology Institute

Counselling is an important part of infertility treatment. we have specialists in the field of reproductive medicine who examine patients and advise them on treatment procedures. We thoroughly explain our patients every step involved in the treatment. As fertility treatments are long and can often be frustrating and stressful, our confidential counselling is aimed to help patients overcome the hurdles inherent in the route to successful conception.

Surrogacy refers to a contract in which woman carries a Pregnancy for another couple. “Genetic Couple”, “ Commissioning Couple”, “ Intended Parent”:- The Couple who provide either both sets of gametes or at least one set of gametes. “Surrogate host” or “Host” :The woman Receiving the embryos created from the gametes of the genetic couple. “Gestational surrogacy” or “IVF surrogacy “ or “Full Surrogacy”: It refers to a situation in which the individual provides only for gestation and does not provide her gametes for the child(ren) she gestates. Indications for the treatment by surrogacy: Women without a uterus, but with one or both ovaries functioning, are the most obvious group that may be suitable for the treatment by IVF – Surrogacy. These includes: Women with congenital absence of the uterus or congential uterine abnormalities like T shaped uterus or hypoplastic uterus. Women who have had a hysterectomy for severe hemorrhage or ruptured uterus. Women who suffer repeated miscarriage and for whom the prospect of carrying a baby to term is very remote. Also considered within this group are women who have repeatedly failed to achieve a pregnancy following several IVF treatment cycles, and who appear to be unable to implant normal embryos. Women with untreatable asherman’s syndrome also fall in to this category. Selection of the Surrogate: Gestational carriers may be known to the intended parents or may be anonymous. Known gestational carriers are typically relatives like, sister in laws, cousins,or friends who volunteer to carry the pregnancy. Anonymous gestational carriers are identified through agencies that specialize in ecruiting women to become a gestational carrier. There are no specific data on intrafamilial surrogacy as surrogacy arrangements in general are less common than gamete donation. Treatment of the genetic mother: The genetic mother will be treated with a period of long downregulation with the gonadotropin releasing hormone (GnRH) analog ( Leuprolide or buserelin) for up to 2 weeks after which the serum levels of luteinizing hormone (LH), progesterone and estradiol are measured. After these hormonal tests and baseline ultrasound scanning, the genetic mother is set to undergo ovarian stimulation. Standard controlled ovarian hyperstimulation protocols are used for the genetic parents or egg donors. Recombinant follicle stimulating hormone(FSH) 150 IU or 225 IU daily is given and the patient is followed up after 5 days of stimulation and the stimulation is continued until two leading follicles reach at least 18 mm in mean diameter and serum estradiol levels are commensurate with the number and size of follicles. Human chorionic gonadotropin trigger is given 34 to 36 hrs before the intended time of oocytes recovery. Treatment of the host Mother : The host mother can be prepared to undergo embryo transfer in either a natural cycle or down regulated hormone controlled cycle. ART legislation in india. Surrogate has no legal rights over the child Cost factor is much less. Financial compensation is allowed to the surrogate. No long waiting lists. Birth certificate in the name of the genetic parents. Good results and very efficient IVF treatment.

Medical ultrasound(also known as diagnostic sonography or ultrasonography) is a diagnostic imaging technique based on the application of ultrasound. It is used to see internal body structures such as tendons, muscles, joints, vessels and internal organs. Its aim is often to find a source of a disease or to exclude any pathology. The practice of examining pregnant women using ultrasound is called obstetric ultrasound, and is widely used. Ultrasound is sound waves with frequencies which are higher than those audible to humans. Ultrasonic images also known as sonograms are made by sending pulses of ultrasound into tissue using a probe. The sound echoes off the tissue; with different tissues reflecting varying degrees of sound. These echoes are recorded and displayed as an image to the operator. Many different types of images can be formed using sonographic instruments. The most well-known type is a B-mode image, which displays the acoustic impedance of a two-dimensional cross-section of tissue. Other types of image can display blood flow, motion of tissue over time, the location of blood, the presence of specific molecules, the stiffness of tissue, or the anatomy of a three-dimensional region. Compared to other prominent methods of medical imaging, ultrasound has several advantages. It provides images in real-time, it is portable and can be brought to the bedside, it is substantially lower in cost, and it does not use harmful ionizing radiation. Drawbacks of ultrasonography include various limits on its field of view including patient cooperation and physique, difficulty imaging structures behind bone and air, and its dependence on a skilled operator. Typical sonographic instruments operate in the frequency range of 1 to 18 megahertz, though frequencies up to 50–100 megahertz have been used experimentally in a technique known as biomicroscopy in special regions, such as the anterior chamber of the eye.[3] The choice of frequency is a trade-off between spatial resolution of the image and imaging depth: lower frequencies produce less resolution but image deeper into the body. Higher frequency sound waves have a smaller wavelength and thus are capable of reflecting or scattering from smaller structures. Higher frequency sound waves also have a larger attenuation coefficient and thus are more readily absorbed in tissue, limiting the depth of penetration of the sound wave into the body (for details, see Acoustic attenuation.) Sonography (ultrasonography) is widely used in medicine. It is possible to perform both diagnosis and therapeutic procedures, using ultrasound to guide interventional procedures (for instance biopsies or drainage of fluid collections). Sonographers are medical professionals who perform scans which are then typically interpreted by themselves or the radiologists, physicians who specialize in the application and interpretation of a wide variety of medical imaging modalities, or by cardiologists in the case of cardiac ultrasonography (echocardiography). Sonographers typically use a hand-held probe (called a transducer) that is placed directly on and moved over the patient. Increasingly, clinicians (physicians and other healthcare professionals who provide direct patient care) are using ultrasound in their office and hospital practices. Sonography is effective for imaging soft tissues of the body. Superficial structures such as muscles, tendons, testes, breast, thyroid and parathyroid glands, and the neonatalbrain are imaged at a higher frequency (7–18 MHz), which provides better axial and lateral resolution. Deeper structures such as liver and kidney are imaged at a lower frequency 1–6 MHz with lower axial and lateral resolution but greater penetration.

Laparoscopic surgery involves inserting a telescope through the tummy button (umbilicus) and is used to: Excise Endometriosis – surgery being the Excision of Endometriosis Remove Ovarian Cysts – surgery being Laparoscopic Cyst Removal Divide Adhesions – surgery being Adhesion Removal Remove Fibroids – surgery being either Myomectomy or Hysterectomy Perform Hysterectomies A Laparoscopy involves: General anaesthetic (being put to sleep) A telescope is inserted through the tummy button (umbilicus) A photo is taken of the pelvis Removal of conditions (if necessary ) is carried out via small incisions Laparoscopic surgery takes on average 1 to 2 hours. When you wake after surgery you have a small stitch in any incisions. Most women require two nights in hospital and on your return home you are able to walk, lift, and drive a car within 4-5 days. Normally patients return to work in 7-10 days. Hysteroscopic surgery involves inserting a telescope into the uterus. It enables more precise diagnosis and treatment of women with irregular vaginal bleeding and may be recommended to diagnose and treat the following: Endometrial polyps (over growth of the lining of the uterus) Submucous fibroids (small lumps of muscle) Abnormal endometrial thickening A Hysteroscopy involves a light, general anaesthetic and lasts approximately 20 minutes. You will need someone to drive you to and from Hospital and are generally in Hospital for no more than two hours. Most women take the next day off work and can expect a blood stained discharge for up to one week. The risks related to this surgery are low and complications uncommon.

We Offer Intrauterine Insemination (IUI), in which the processed semen is directly placed into the uterus of a female with the help of a catheter. The process is effective in cases of male factor infertility, unexplained infertility, endometriosis, anovulatory infertility etc. Intrauterine Insemination (IUI,): Uses Risks Success Rate Intrauterine insemination (IUI) is a fertility treatment that involves placing sperm inside a woman’s uterus to facilitate fertilization. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization. IUI provides the sperm an advantage by giving it a head start, but still requires a sperm to reach and fertilize the egg on its own. It is a less invasive and less expensive option compared to in vitro fertilization. When is IUI used? The most common reasons for IUI are a low sperm count or decreased sperm mobility. However, IUI may be selected as a fertility treatment for any of the following conditions as well: Unexplained infertility A hostile cervical condition, including cervical mucus problems Cervical scar tissue from past procedures which may hinder the sperms’ ability to enter the uterus Ejaculation dysfunction IUI is not recommended for the following patients: Women who have severe disease of the fallopian tubes Women with a history of pelvic infections Women with moderate to severe endometriosis How does IUI work? Before intrauterine insemination, ovulation stimulating medications may be used, in which case careful monitoring will be necessary to determine when the eggs are mature. The IUI procedure will then be performed around the time of ovulation, typically about 24-36 hours after the surge in LH hormone that indicates ovulation will occur soon. A semen sample will be washed by the lab to separate the semen from the seminal fluid. A catheter will then be used to insert the sperm directly into the uterus. This process maximizes the number of sperm cells that are placed in the uterus, thus increasing the possibility of conception. The IUI procedure takes only a few minutes and involves minimal discomfort. The next step is to watch for signs and symptoms of pregnancy. What are the risks of IUI? The chances of becoming pregnant with multiples is increased if you take fertility medication when having IUI. There is also a small risk of infection after IUI. How successful is IUI? The success of IUI depends on several factors. If a couple has the IUI procedure performed each month, success rates may reach as high as 20 -30% per cycle depending on variables such as female age, the reason for infertility, and whether fertility drugs were used, among other variables. While IUI is a less invasive and less expensive option, pregnancy rates from IUI are lower than those from IVF. If you think you may be interested in IUI, talk with your doctor to discuss your opinion. JUI with Husband sperm Female factor Anabolic defects of vagina er cervix Hostile cervical mucus Sexual dysfunction Mild to moderate endometriosis Endocrine anomalies Chronic anovulatory menstrual cycle Malefactor Anatomic defect of pens,e.g. hypospasdias Sexual/ejaculatory dysfunction Retrograde ejaculation Semen volume in excess or deficit Immunological factors Male subfertility : e.g. mild oligozoospermia,asthenozoospermia,orteratozoospermia Other factors Idiopathic poor post-coital test (PCT) Combined subfertility factors Unexplained infertility JUI with Husband sperm Male factors Azoospermia Severe oligozoospermia Severe astheno/necrospermia Failure in at least six intrauterine cycles with oligozoospermia Sterility due to disease or vasectomy, orchidectom,chemical or radiation exposure, Sexual / ejaculatory dysfunction, Genetic considerations ( hemophilia, huntington’s chorea) RH-Incompatibility. Semen preparation Prior to IUI, it is necessary to remove seminal plasma to avoid prostaglandins – induced uterine contractions. Insemination with unprocessed semen is also associated with pelvic infection. Removal of the seminal plasma can be achieved by relatively simple procedure. The most frequently used methods involve centrifuging spermatozoa through culture medium or density gradients followed by resuspension in suitable culture media. A systemic review of sperm preparation techniques concluded that there were insufficient randomized studies to choose the best method. For normal semen samples, it is still under whether there is any advantage in isolating the most motile spermatozoa prior to insemination or whether similar results can be obtained using the whole population of spermatozoa in the sample. Methods of Sperm preparation Sperm preparation technique is a very crucial step in the success of IUI. Several Studies indicate that sperm preparation isolating a high concentration of morphologically normal & motile spermatozoa is necessary for any ART, including IUI. Semen Processing in the laboratory not only separates highly motile functional sperm with normal morphology in high percentage, but also removes seminal plasma that contains prostaglandins & cytokines as well as possible antigenic or infectious matter along with defective & nonovital sperm & debris. Timing of insemination Insemination can be done at various time points around ovulation & can be done once or several times. In the majority of the published studies, the insemination is done 32 to 36 hrs following HCG administration. It is assumed that the timing of insemination relative to ovulation is critical for an optimal success rate so it is rather surprising that few studies were designed to find the optimal time for insemination. Cost effectiveness Local conditions are the most practical source of cost information on IUI & IVF. Studies on the cost effectiveness of infertility treatment mainly involve IVF treatment. Although there are no recent patient based studies, starting treatment with IUI rather than IVF was either cheaper & persistent Infertility. Conclusion In good prognosis couples, the LBR is better without treatment.IUI is widely used with Infertility diagnosis other than bilateral tubal obstruction,severe male infertility & severe ovulation defects. Differences in sperm preparation & IUI methodology do not have profound effects on the success rate. prior to using IVF, IUI with clomiphene ovarian stimulation is relatively cheap & many couples will conceive & not require IVF. There is need for more placebo-controlled trials of CC/IUI, including trials to determine the optimal length of treatment. prevention of premature LH Surges & luteal phase support do not appear major requirements in IUI treatment. IVF is most effective treatment for infertility.

At this moment there are more than a million infertile couples in India trying for a conception. IVF (in vitro fertilization) or ‘test tube baby’ is the magic word for infertile couples desperately desirous of a child. Through this technology which is a boon to mankind, many who had no chance of having their own child, are now proud parents. Though by IVF a couple has up to a 60% chance of success, the success rate may vary from couple to couple and may not be the same for all couples. The different stages of in-vitro fertilization process are as follows : Who Needs IVF Tubal Damage or Block Absent or Low Sperm Count (< 5million /ml) Damaged uterine lining ( Endometrium ) Poor Ovarian (Egg ) capacity Failure of Fertility treatment for more than 3 years. What Happens In An IVF Treatment Cycle Typically an IVF cycle consists of ovarian stimulation, egg collection, fertilization, embryo culture and embryo transfer. Ovarian stimulation consists of daily injection of hormones to the female partner with frequent clinical and ultrasonographic monitoring. This usually continues for 10-15 days. Egg retrieval is performed under anaesthesia through the internal route. There are no incisions or scars. The egg and sperm are either mixed (IVF) (Figure 1) or the sperm is injected into the egg (ICSI – intracytoplasmic sperm injection) (Figure 2). The fertilized egg forms the embryo. The embryo is cultured in the laboratory for 2-3 days (Figure 3). Two-three best embryos are selected and transferred into the womb (uterus) on the second or the third day. The pregnancy test is done 14 days after the day of embryo transfer. What Is The Success Rate of This Process It all sounds so logical and definitive that one would expect success in every case! But unfortunately this is not the reality. One must understand that in the entire process of IVF each step is a hurdle that has to be negotiated successfully. For example, not all women respond to ovarian stimulation, not all eggs are mature, not all eggs fertilize to make good embryos and not all embryos implant. Therefore, there is an attrition or drop out at each stage. It is at the stage of implantation that there is a huge scope for further research. Implantation is the process where the uterus accepts the embryo which then develops to form the baby. Much work has been done on this aspect of IVF and medications such as steroids, aspirin, heparin, sildenafil are being tried to improve implantation rates. The overall success rate of IVF is about 40 % per treatment cycle. In order words 4 out 10 , who otherwise had given up all hopes of parenting a child would conceive after attempting IVF. World over the success rate is highest in younger women where it can reach up to 60% per treatment cycle. In case of failure, IVF may be tried again and the cumulative pregnancy rate over 3 cycles may go as high as 80%. In order to give the optimum benefit to the patient it is essential that the infertile couple is offered the right treatment at the right time. It is also essential that patients understand the entire process of IVF. We are in an era of transparency and constant dialogue with patients. They should be involved in decision making. They must understand the strong points and drawbacks of the entire IVF process. Once there is complete understanding of the process a lot of stress associated with such intensive treatment will automatically be allayed.

Intracytoplasmic Sperm Injection (ICSI) technique is used in situations where there is poor sperm quality. In these situations, Intracytoplasmic Sperm Injection ICSI finds use in directly retrieving of the sperms from testis/epididymis which is then followed by injection of a single sperm into center of egg for achieving fertilization. ICSI is an assisted reproductive procedure used as part of a wider in vitro fertilisation (IVF) program. This fertility treatment is used in cases of male infertility, either if the quality of the sperm is causing infertility, or in cases of erection problems. ICSI involves selecting a single sperm which is injected into an egg. The eggs can be sources either from a donated egg (frozen or fresh), or eggs harvested from the ovaries of the partner. Features: The process assist in the treatment of sperm related infertility issues It helps in enhancing fertilization phase of in-Vitro Fertilization Centre (IVF) through injection of single sperm into mature egg which is then placed in a woman’s uterus/fallopian tube Treating issues related to severe male infertility where little/no sperm is ejaculated in semen Patients also choose this technique after repeat in-vitro fertilization is unsuccessful It is also used by couples planning for genetic testing of embryo for checking certain genetic disorders. ICSI Procedure Prior to ICSI treatment, screening tests are made of both the man and woman. In rare cases, the male may have zero sperm count, so the chances of extracting suitable sperm from the semen could be very low. Alternative options of sperm donation may be explored if this is the case. The donor sperm is checked for genetic abnormalities before insemination. The female recipient of the fertilised egg is given fertility drugs prior to embryo transfer at the fertility clinic. The general health of the woman is also screened via a medical examination. Success Rates of ICSI Sperm injection ICSI fertility treatments have relatively good success rates. The chances of becoming pregnant from ICSI depends partly on the quality of the egg, but also depends on the quality of the sperm, and the age of the women – the younger the woman is, the greater the chance of success. Generally if a woman is young the chance of getting pregnant via IVF is a little over 30-40% per cycle. After the age of 35, the chance of pregnancy decreases dramatically. After the age of 40 there is only about 10% chance for couples or have a baby.

Percutaneous Epididymal Sperm Aspiration (PESA) Testicular Sperm Aspiration (TESA) Bliss IVF & Test tube baby center also offers the PESA and TESA services in which sperms from men with obstructive azoospermia can be removed from the epididymis or the testis and used to fertilize eggs by the ICSI method. Surgical sperm retrieval and its use in infertility treatment For most of human history, fertilisation of a single egg produced by the female partner involved a swimming race between millions of sperm. The single winning sperm was the one that entered the egg first. The modern infertility treatments intracytoplasmic sperm injection (ICSI) and in vitro fertilisation (IVF) now make it possible to extract a single sperm and use it to directly fertilise an egg. The latest surgical sperm retrieval techniques combined with ICSI and IVF also mean that infertility can be overcome even in men who produce hardly any sperm. A low sperm count is a common cause of male infertility but if a man produces even the tiniest number of sperm in his semen, these can be collected fairly easily. Men who ejaculate no sperm, because of blocked tubes in their testes, or because of a genetic condition that prevents their sperm being released, require some form of surgical sperm retrieval to enable intracytoplasmic sperm injection to take place. Methods of surgical sperm retrieval The main methods of surgical sperm retrieval available include: PESA: percutaneous epididymal sperm aspiration. MESA: microsurgical epididymal sperm aspiration. TESA: testicular sperm aspiration. This includes testicular fine needle aspiration (TFNA). Blastocyst Culture and Transfer Blastocyst culture and transfer is a technique developed for in vitro fertilization (IVF). This procedure intends to maximize pregnancy rates while minimizing the risk of multiple pregnancies. Embryos are typically cultured for 3 days (cleavage stage with 4-10 cells) before being transferred into the uterus. By extending the culture to 5 or 6 days (blastocyst culture), some embryos will develop to the blastocyst stage (up to hundreds of cells). This allows the embryologist to select more advanced embryos with better potential for implantation at the time of the transfer. A significant benefit of blastocyst culture and transfer is the reduction of multiple births that can result from IVF, since there are fewer embryos (1 or 2) to be transferred. Blastocyst transfer may be appropriate for those patients who have: a better chance of having blastocyst development (this will be determined by age and infertility conditions) previous failed attempts at achieving a pregnancy strong concerns about delivering high-order multiple pregnancies

At Bliss IVF & Test tube baby center we have a comprehensive facility for ovum and embryo donation for patients who cannot produce eggs or sperms required to conceive. In some cases the ovaries fail to produce eggs and the only option to conceiving is using eggs donated by another woman. Using donated ovum also eliminates chances of genetic diseases that pass on from mother to child. Similarly, if it becomes impossible to collect sperm even from testes in an azoospermic male, donated sperms have to be made use of. In certain cases both the sperms and ova from a third person are required for pregnancy. In this case, embryos donated by other couples are transferred into the uterus of the female patient. Egg donation is the process by which a woman donates eggs for purposes of assisted reproduction or bio-medical research. For assisted reproduction purposes, egg donation typically involves in vitro fertilization technology, with the eggs being fertilized in the laboratory; more rarely, unfertilized eggs may be frozen and stored for later use. Egg donation is a third party reproduction as part of assisted reproductive technology (ART). In the United States, the American Society for Reproductive Medicine (ASRM) has issued guidelines for these procedures, and the FDA has a number of guidelines as well. There are boards in countries outside of the US who have the same regulations. However, egg donation agencies in the U.S. can legally choose whether to abide by ASRM regulations or not. INDICATION: Congenital absence of eggs Turner syndrome Gonadal dysgenesis Acquired reduced egg quantity / quality Oophorectomy Premature menopause Chemotherapy Radiation therapy Autoimmunity Advanced maternal age Compromised ovarian reserve Other Diseases of X-Sex linkage Repetitive fertilization or pregnancy failure Ovaries inaccessible for egg retrieval Types of donors Donors includes the following types: Donors unrelated to the recipients who do it for altruistic and/or monetary reasons. In the US they are anonymous donors or semi-anonymous donors recruited by egg donor agencies or IVF clinics. Such donors may also be non-anonymous donors, i.e., they may exchange identifying and contact information with the recipients. In most countries other than the US and UK, the law requires such donors to remain anonymous. Designated donors, e.g. a friend or relative brought by the patients to serve as a donor specifically to help them. In Sweden and France, couples who can bring such a donor still get another person as a donor, but instead get advanced on the waiting list for the procedure, and that donor rather becomes a “cross donor”. In other words, the couple brings a designated donor, she donates anonymously to another couple, and the couple that brought her receives eggs from another anonymous donor much more quickly than they would have if they had not been able to provide a designated donor. Patients taking part in shared oocyte programmes. Women who go through in vitro fertilization may be willing to donate unused eggs to such a program, where the egg recipients together help paying the cost of the In Vitro Fertilisation (IVF) procedure. It is very cost-effective compared to other alternatives. The pregnancy rate with use of shared oocytes is similar to that with altruistic donors. Procedure Egg donors are first recruited, screened, and give consent prior to participation in the IVF process. Once the egg donor is recruited, she undergoes IVF stimulation therapy, followed by the egg retrieval procedure. After retrieval, the ova are fertilized by the sperm of the male partner (or sperm donor) in the laboratory, and, after several days, the best resulting embryo(s) is/are placed in the uterus of the recipient, whose uterine lining has been appropriately prepared for embryo transfer beforehand. The recipient is usually, but not always, the person who requested the service and then will carry and deliver the pregnancy and keep the baby. Being an egg donor leads to a very exciting and rewarding journey provide an opportunity to help infertile couples make dream come true of having own child. Many couples out there find it difficult to conceive by their own and need donated eggs to get pregnant. Egg donation is a wonderful program whereby an infertile woman uses occytes (eggs) from a donor to fulfill her desire of becoming a mother. Becoming an egg donor is a serious commitment and results are gratifying. The generosity and compassion is appreciated for the infertile couples. However in order to become a fertility egg donor, there are certain criteria you need to fulfill to establish your suitability. As all women are not eligible for donating her eggs, some criteria are fairly standard including donor age limits which should be less than 35 years, screening tests and consent (a legal document for the use of donated eggs in treatment). Prior to egg donation process, you will be required to undergo certain screwing tests such as blood tests, ultrasounds, pelvic exam and psychological screening etc. The egg donation process involves (In Vitro Fertilization) the retrieval of occytes from the donor and will be combined with the sperm from the recipient couple or donor and kept for 3-5 days in laboratory to produce embryos. Once healthy embryos are produced, one or two are transferred to the recipient in order to achieve the pregnancy. The program recommended to: Women with ovarian failure Women unable to get pregnant with their own eggs or repeated IVF failure Women who have had repeated miscarriages Have chromosomal abnormalities Age more than 35 years or older women We have proven fertile donor who are well educated and willing to help infertile couples for financial/emotional reasons. BLISS – IVF we have complete and standard arrangements for egg donor/rent womb and already successfully treated.

The term ‘blastocyst’ refers to the human embryo 5 – 6 days after fertilisation. It is the stage of development that the embryo must reach before it can implant in the uterus. The structure of the blastocyst is more complex than earlier embryo stages because as well as increasing in cell number, the cells have become organised into 2 types, the trophectoderm, whose main role is in the implantation into the uterine lining and the inner cell mass which will give rise to the foetus itself. The egg is fertilised following ovulation from the ovary and the embryo goes on to divide (cleave) as it travels along the fallopian tube. Blastocyst formation occurs as the embryo reaches the Why does it make sense to choose the best blastocysts? Only about three out of an average of 12 oocytes produced within one year by a woman having a regular menstrual cycle (an ovulation each month = 12 ovulationsper year) are capable of developing into a child after fertilization. Additionally, one or two more oocytes may lead to pregnancy, however, eventually end in miscarriage. In theory, almost all 12 oocytes could develop up to day 3 (including those not leading to pregnancy), even though they have never met a sperm. This is referred to as parthenogenesis (may also be triggered by an electric pulse or some other stimulus, e.g. “pricking” with a pipette). It is only then that the egg cells “realize” the absence of the sperm. Such oocytes often present a chromosomal abnormality (aneuploidy). These chromosomal disorders may be identified by aid of the pre-implantation genetic diagnosis(examination of the egg’s polar body). Unfortunately, there is a negative correlation between increasing age and the frequency of chromosomal abnormalities, since the oocytes are aging. Suboptimal incubation conditions or less than optimum fertilization techniques might be the reason why fertilized eggs and the resulting embryos may stop developing on days 2-3. It is only by choosing the best blastocysts that one can make a statement as to whether 2-3 day embryos really have the potential for further development. Choosing the best blastocysts implies that the poorly developing blastocysts have to be identified and discarded! Using this technique in the IVF treatment of a young woman (25-30 years of age), pregnancy rates of up to 80% may be achieved. The risk of miscarriage is about 5-10%, which corresponds to a baby-take-home rate of 70-75%. Culture of embryos up to the blastocyst stage Owing to new insights into embryonic physiology, advanced culture media have been developed permitting in vitro incubation up to the blastocyst stage. Incubator and culture – dishes for embryos These innovative media minimize the detrimental effects on the viability of the embryos, which used to occur previously in prolonged culture. The following new media are used for in vitro culture: Sequential media These media apply the principle „back to nature“: Medium I is used for incubation until day 3 (= 8-cell-stage). Each blastomere is like a unicellular organism. Medium II is used for embryo culture after compaction (morula-stage) and embryonic gene activation (paternal effect). Neighboring cells start forming cell clusters and communication between blastocyst cells is established. The enormous differences in embryonic metabolism before and after compaction are taken into account by these new media. KSOM Media This is an optimized medium, which is referred to as “Let the Embryo Choose “- medium, or “KCl-enriched simplex optimization medium” (KSOM). After having intensively investigated the requirements of oocytes and embryos throughout their first days in culture, a simple optimized medium („one-step“-protocol) has been designed. International clinical studies confirmed clearly, that this medium supports effectively the development of human embryos up to blastocyst stage. In a comprehensive prospective study the best results were achieved when using both media for culture (sequential media + KSOM). It seems that each individual embryo has its own “preferences”, which we cannot predict yet. Using this technique, we try to benefit from the advantages of both media in order to improve pregnancy rates! It is desirable to keep the embryos in culture up to day 5 (blastocyst – stage), because of the advantages outlined below: Enhanced synchronization between uterus (womb) and early embryonic development. Compared to the in vivo situation an embryo transfer performed on day 2 or day 3 after follicle puncture is at least two days too early. Culture of the most viable embryos: Applying this technique, embryos showing high developmental potential can be identified and used for transfer. Patients exhibiting certain chromosomal disorders might benefit from blastocyst culture, too, since specific chromosomal disorders often result in a halt of early embryonic development during a prolonged embryo culture. Blastocyst culture provides us with the opportunity to choose a viable embryo and thus improving the chances of giving birth to a healthy child. In that context blastocyst culture is advisable for women beyond 38 years of age. The risk for aneuploidy (abnormal number of chromosomes) increases in correlation with female age. Embryos with aneuploidy tend to stop development after day 3. Higher implantation rates may be achieved by transferring one to two embryos at the blastocyst stage. Another important advantage consists in the reduced uterine contractility from the 5th day onwards. Performing embryo transfer beyond that day may prevent the failure of the embryo to implant into the uterine wall. This was clearly confirmed by a scientific study based on measuring uterine contractions. What’s so special about blastocyst culture in an IVF setting? Standard practice in IVF involves the replacement of embryos into the uterus after 3 days when the embryos are at the cleavage stage of development. Blastocyst transfer however involves extending the period that the embryos are cultured in the laboratory to 5 or 6 days. Why extend the time that the embryos are cultured in the laboratory? It is known that a lot of embryos are destined to arrest at early stages so extended culture allows the embryologist to identify which (if any) of a group of embryos have the best potential for implantation by identifying those which form a normal blastocyst in culture. Transferring embryos at the blastocyst stage also provides a better co-ordination between the embryo and the uterus by putting the embryo back in the right place (the uterus) at the right time (blastocyst stage). What are the benefits of blastocyst culture? Overall, if you have a normal blastocyst for transfer on day 5, the chances of pregnancy are higher (in our hands) than if you have embryos transferred on day 3. HOWEVER the chances of having NO embryos for transfer at all are also higher.

At Bliss IVF & Test tube baby center we have a comprehensive facility for ovum and embryo donation for patients who cannot produce eggs or sperms required to conceive. In some cases, before implantation, the embryo has to hatch out of its protective shell – zonapellucida. Otherwise the embryo will fail to implant itself in the uterus of the mother and pregnancy would fail. A covering layer, or ‘shell’ surrounds embryos or blastocysts called the ZonaPellucida (ZP). The zona has an important role in fertilization as it allows only one sperm to penetrate the zona and enter the egg to achieve fertilization. It also acts to prevent premature implantation in the Fallopian tube and may help prevent the early embryo from being attacked by cells of the immune system. The embryos have to “hatch” or break out of the zona in order to embed into the endometrium lining the uterine cavity. This occurs about four to five days after embryo transfer when the embryo is at the blastocysts stage. Naturally this takes place by expanding/contracting of the zona until it distorts, allowing the blastocysts to “hatch”. If the zona is not functional, this hatching may not occur. It has been reported that up to 75% of normal embryos never hatch through the protective layering of the zona. Laboratory techniques involved in IVF may result in hardening of the zona. In natural fertilization there are enzymes present within the fluid in the Fallopian tube, which may “soften” the zona. This does not happen in IVF as the tube is bypassed. The zona may also be thicker following IVF, especially in older ladies. Frozen embryos may also have a hardened zona. Methods of Assisted Hatching Chemical This involves chemicals (acid tyrodes) used to produce a weakened area of the zona. The chemical is applied through a microtool, manipulated by an embryologist. It is not entirely accurate, as when working with such small amounts of chemicals, it is hard to quantify the dose with pinpoint accuracy. The acid then has to be washed off in order to prevent further damage to the embryo. Laser Thezona is drilled by the microlaser system called Fertilase. It creates a clean-cut precise incision in the zona. This is more accurate for several reasons: The process is fast compared to the chemical method, thus the embryo does not have to be held still by a suction pipette. As well as this factor, we use a vibration free table to avoid any accidental movement of the embryo. The accuracy of the laser is predetermined by its programming, and is therefore not dependent on the skill of the operator. There is a high degree of reproducible accuracy. Who is suitable for Laser Assisted Hatching? At the IVF Centre patients who will be considered for laser assisted hatching are: • Those patients who have IVF or ICSI who are over 37 years Patients having Frozen Embryo transfer. Patients who have had a previous failed IVF or ICSI treatment cycle Patients undergoing IVF/ICSI for the first time, who are considered poor responders because they have required a high dose of gonadotrophins for poor ovarian response Patients who in an earlier IVF cycle have had a low fertilisation rate, for example, less than one third of the embryos achieving fertilsation

In addition to freezing sperm for men as part of their fertility treatment or before receiving chemotherapy or radiotherapy, MFS is able to freeze sperm for men for a variety of other elective reasons. Who may benefit from sperm freezing? men who work in high risk occupations, for example: men in the military have frozen sperm and completed posthumous use consent forms before deployment in case of their serious injury, or even death when on active service where there is a family history of premature andropause, especially in the man’s father, uncles or paternal grandfather men who are away from home for extended periods of time and whose wives or partners may require fertility treatment during their absence any man whose sperm counts are declining and there is concern that he could become a zoospermic For whom is sperm freezing not suitable? MFS is unable to register patients under the age of 18 years any man who is known to be azoospermic any man who has screened positive for a sexually transmitted disease What does sperm freezing involve? During a single consultation appointment: a blood sample will be taken for routine infection screening information will be given about the procedure and counselling will be offered consent to freeze sperm and the issue of posthumous use will be explained and if the patient wants to go ahead with the procedure, he will give consent in writing by completing standard HFEA forms the man will be invited to provide a sperm sample, and one of the scientific team will check the: count (the number of sperm) motility (movement) morphology (shape) PH volume if any viable sperm are evident, the sample will be loaded into labelled ‘straws’ and stored in liquid nitrogen at ?196°C, for possible future use. (The sperm count and quality do not have to meet the criteria required for sperm donation.) the cost of sperm freezing includes the fee for the first year’s storage a SSR may be recommended if there are no sperm in the ejaculate and if surgery will allow a sample of testicular tissue to be extracted in the future, the stored sperm samples may be used with IUI, IVF or ICSI: if he and his partner have been unable to conceive naturally by his partner, in the event of his death and if the appropriate posthumous use consent forms were signed What is included in the sperm freezing treatment cost? routine infection screening the laboratory analysis of the sperm sample(s) storage of the sperm sample for the first year What is not included in the sperm freezing treatment cost? SSR procedure any other investigations or treatments storage of the sperm sample after the first year How long does sperm freezing treatment take? From consultation to sperm freeze, about two to three weeks. Surgical Sperm Retrieval ICSI Embryo Freezing: In a typical IVF or ICSI treatment cycle, the woman’s ovaries are stimulated to produce many eggs. Following fertilisation and embryo culture, the best embryos are selected for embryo transfer. For about 50% of couples, there will also be good embryos which are surplus to those required for embryo transfer. These embryos can be frozen at this point for future use. Embryo freezing (cryopreservation) is a method of preserving the viability of embryos be carefully cooling them to very low temperatures (-196&degC). This is carried out in the laboratory using specialised freezing equipment and the embryos can then be safely stored in liquid nitrogen for extended periods. Why do we freeze embryos? Embryo freezing gives you more opportunities for a pregnancy for each hormone stimulation cycle and egg collection. During a fresh IVF cycle, we’ll sometimes be able to create more than one embryo, however there are serious risks associated with multiple pregnancies, so generally we won’t transfer more than one embryo at a time. We’ll usually recommend transferring one, and freezing the others. If you do not become pregnant in that first cycle, we can transfer another embryo during a frozen embryo transfer cycle. Where are the frozen embryos stored? When you go through an IVF treatment cycle any excess embryos will be stored at an Bliss IVF facility, where they will be kept frozen in cryostorage until you decide to either use, donate or discard them. How does embryo freezing work? Embryos can be frozen from Day 2 (four cell stage) to Day 5 (Blastocyst). They are placed in thin plastic straws, sealed at both ends, and labelled with your name and identification number. They then go into a freezing machine, where the temperature rapidly drops to -150° Celsius. The straws are then placed in goblets, and put into tanks filled with liquid nitrogen, which keeps the temperature at -196° Celsius. Success rates with frozen embryos At Bliss IVF, many of our births, over many years, have come from the transfer of frozen and thawed embryos. On average the success rate is about 30%, but this mainly depends on the age of the woman’s eggs when the embryos are frozen. So, if you were to freeze your embryos in your first IVF cycle at the age of 38, and then use them when you’re 42, your fertility chance will be relative to that of a 38-year-old woman rather than a 42-year-old. What to do with any remaining embryos? Once you feel that your family is complete, and you have no further personal use for your frozen embryos, you may decide to donate them to another couple who are unable to conceive with their own embryos. Your specialist can discuss all your options with you. What are the benefits of embryo freezing? The main benefit of embryo freezing is the option to have frozen embryos thawed and transferred to the woman’s uterus in the future without having to undergo stimulation of the ovaries or egg retrieval. It is also possible that there may be enough frozen embryos for more than one subsequent cycle. What does a frozen embryo transfer cycle actually involve? Frozen embryo transfer cycles are relatively simple. In some cases, the woman’s natural cycle will be monitored by ultrasound to assess the development of the lining of the uterus and to determine the timing of ovulation and hence embryo transfer. In other cases, depending on the woman’s history a more hormonally controlled cycle may be warranted. The decision regarding the most appropriate treatment will be made in consultation with the clinician. Are there any disadvantages to embryo freezing? Approximately 70% of the embryos that are frozen will survive the thawing process. This does however vary between patients and it is possible that none of a couple’s embryos will survive the freezing and thawing process. How successful are cycles involving the transfer of frozen / thawed embryos? Overall, frozen embryos have a slightly lower chance of implanting than fresh embryos. This is mainly because in general the best embryos in a group will already have been transferred on the fresh embryo transfer.

This process cools the sperm and embryos very slowly to sub zero temperatures. Cyropreservation is used to store semen and embryos for an indefinite period. It is typically effective if men face a possibility of sterilization due to vasectomy, prostate or testicular surgery, radiation or chemotherapy etc. At times semen is also frozen prior to IVF as back up, incase of difficulty in semen collection on the day of oocyte retrieval. Vitrification is one of the latest advancements in fertility treatment. The process refers to the freezing of eggs (also embryos) to store them for an indefinite period. Unlike sperms, unfertilized ova cannot be stored using the slow freezing technique. Rather, vitrification works by using higher concentrations of cryoprotectants that ensure much faster cooling rates, and without the formation of ice crystals. It is useful for women who face the possibility of sterilization in future.