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Hysteroscopy

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hysteroscopyHysteroscopy is visualization of the inside of the uterine cavity (womb) with a thin telescope called as hysteroscope, that is inserted through the vagina, the cervix and into the uterus. A liquid or gas is instilled to expand the uterine cavity for better visibility. The telescope is connected with a camera and light source and the uterine cavity can then be viewed on a video monitor. This is usually done in operating room but can be done as an office procedure . Either general or local anesthesia is used. A hysteroscopy can be done as a diagnostic procedure or additional small instruments can also be inserted through the operative hysteroscope to perform different procedures such a biopsy, treating a fibroid or polyp, septum, adhesions, etc.

Diagnostic hysteroscopy- is an endoscopic visualization of the inside of uterine cavity or womb .it is utilized to diagnose problems of abnormal bleeding like heavy periods ,irregular bleeding and spotting, infertility ,recurrent abortions , secondary amenorrhea(stopping of regular monthly periods),severe dysmenorrhoea , uterine cancers , developmental anomalies of uterus like double uterus ,septate uterus ,adhesions inside uterus due to infections . blind D&C as a diagnostic procedure has no role in modern gynaecological practice with advancements in equipments and technology has made hysteroscopy so simple that it can even be done in a doctors clinic as OPD or day case under local or short general anesthesia when patient can be discharged within few hours and can resume normal routine the very next day.blind D&C has also shown to miss focal lesions like polyps, myomas and even localized cancer of uterus in upto 50% of cases.it has anyway got no role as treatment of these conditions or even heavy bleeding .

Operative hysteroscopy- latest advancements in equipments and technology has allowed us to perform surgical treatment of many benign gynaecological problems hysteroscopically by using very thin operative hysteroscopes Treatment of polyps ,myomas, intrauterine adhesions ,septums, lost IUCD , infertility ,menorrhagia ,DUB are all possible now as day case with the use of bipolar operative hysteroascopy .patient can be easily sent home few hours after hysteroscopic surgery and can resume normal routine the very next day .

It is also possible to follow a “see and treat” management approach where diagnostic and operative hysteroscopy can be done in same sitting .thus it avoids need for giving general anaesthesia twice for diagnostic and operative procedure .

It is ideal for those women who are young (in their 30’s and 40’s)who do not want their uterus removed for bleeding problems and also useful in cases of infertility and recurrent abortions.

In older women it allows us to accurately diagnose and also treat the cause of irregular or heavy periods and other bleeding problems due to local pathology.many a times if only D&C is done ,focal lesions are missed and women end up getting their uteruses removed for trivial problems like polyp or small myoma or even DUB when it can be solved by minimally invasive hysteroscopic surgery.with much less morbidity and faster return to normal life.

When is it useful?
» To find cause of abnormal bleeding like irregular bleeding and heavy periods .some causes like polyps ,fibroids etc can also be treated at the same time.
» To find cause of bleeding after menopause. in this case a biopsy of the lining of uterus may be taken.
» To see whether any problem with in the uterine cavity is the cause for infertility. In this case it may be combined with the laparoscopy
» In case of infertility hysteroscopy is also done to look at the uterine openings of the fallopian tubes and if blocked tubal canulation can be done to open them.
» To find a possible cause of repeated miscarriages like ,septum, adhesions, abnormal shape of uterus etc.
» Locate a misplaced Cu T/ multload.
» Locate and remove small fibroids or polyps
» It may be used to diagnose endometrial /uterine cancer

Laparoscopy

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laparoscopyLaparoscopic surgery is also known by other names like Minimally invasive surgery, Endoscopic surgery, Key hole surgery. It is the latest and best form of treatment available for Gynecological disorders requiring surgery (operation).

How is Laparoscopic surgery carried out ?

A small incision (cut) about 1 cm is made at the lower end of the navel through this a trocar (a sharp instrument) is introduced into the abdomen the carbon dioxide gas is inserted into the abdomen through the trocar (the gas is removed at the end if surgery) following which the laparoscope (Telescope) is inserted this catties with it a fibre optic light source with a powerful xenon light which lights up the area to be operated. The laparoscope is also connected to a camera, and a T V monitor the surgeon then looks at the T V monitor and operates thru, 2 – 3, 1/2 cm size cuts made on the abdomen.

Who should get laparoscopic surgery done ?

Hysterectomy total laparoscopic - Hysterectomy for various disorders of the uterus where the uterus has to be removed.

Myomectomy - For removal of fibroid (non cancerous ball like growth) from the uterus in case where uterus has to be preserved for future child bearing.

Adhesiolysis - Is removal of adhesions. Adhesions are bands of tissue which make organs stick to each other and cause a lot of pain and are responsible for many cases of infertility and chronic pelvic pain these are best removed laparoscopically.

Ovarian Cystectomy - Is removal of cysts from the ovary.

Endometriosis - This is a condition which leads to a lot of menstrual (period) pain dysparenunia (painful intercourse) and infertility. This is the best treated Laparoscopically.

Ectopic pregnancy - Is pregnancy outside the uterus in the tube or ovary is best handled Laparoscopically especially when future child bearing is desired by the patient.

Polycystic Ovarian Drilling - PCOD is soon becoming an epidemic in India and is a major cause of infertility drilling these large ovaries (in selected cases) often restores fertility.

Diagnostic laparoscopy for infertility.

Diagnosticlaparoscopy for Chronic pelvic pain.

Redical hysterectomy - Today even Cancer surgery is best done laparoscopically as in cases of cervical (mouth of uterus) cancers.


The Advantages Of Laparoscopic Surgery Over Conventional Surgery

»» For the Patient

Pre operatively only 8 hours of fasting is required by the patient and no enema or bowel preparation except in high risk cases this makes patients very comfortable preoperatively. Patients need to get admitted into the Hospital only on the day of surgery and can be at home one night before so are more comfortable facing the surgery.
» It gives rise to minimal tissue handling and much less tissue trauma to the other adjacent normal organs resulting in very minimal pain after the operation.
» 2-3 very small incisions of 0.5 – 1.0 cm are given on the abdomen resulting in less amount of blood loss, less post operative pain, less chances of wound infection, early healing of wound.
» Blood loss is very less because even the smaller blood vessels are directly visualized on the T V monitor with the magnified view provided by laparoscope.
» As the abdominal incision is very short and the operative work is very specific with minimal blood loss, the chances of post operative infection are very less.
» The hospital stay is usually 1 – 3 days even for the major operations like Hysterectomy while in case of conventional surgery the same procedures will require 5 – 7 or even more days of Hospital stay.
» The recovery time for the patient is very less and they can resume their normal day to day activities in a period of 1 – 2 weeks while in case of conventional surgery the recovery period is quite long and can extend to 6 – 8 weeks or more.
» For infertility patients laparoscopic surgery has come as a boon as with minimal tissue handling, minimal bleeding and much less chances of adhesion formation
» after the operation, the chances of achievement of pregnancy are much greater then that attained by the conventional surgery.

» As far as the total expenditure of the patient is concerned, laparoscopic surgery is more cost effective than the conventional surgery.
» Very small incisions on abdomen are much more cosmetic with very little scarring.

»»  For the Surgeon

» The powerful xenon light source inserted with the laparoscope lights up the area to be operated and helps the surgeon operate better.
» The laparoscope (Telescope) magnifies the area to be operated 5 – 20 times and so very specific area can be seen very clearly (much better then the naked eye can see at open surgery) and the surgeon can operate better.
» Even very small bleeders can be checked at the end of the surgery by the surgeon. As no blood is left behind at the end of the surgery patient feels very little pain and the chances of infection are also minimal.

Where Should One Get The Laparoscopic Surgery Done ?

Before getting the Laparoscopic surgery done, it is always advisable to see that your Gynaecological Laparoscopic Surgeon being a Gynaecologist is well qualified and fully trained in the field of Operative Laparoscopy.

How Can One Get The Laparoscopic Surgery Done ?

If one has been advised an operation for some Gynaecological disorder, it is better to consult a Gynaecological Laparoscopic Surgeon for undergoing Laparoscopic surgery.
An appointment can be taken with the Gynaecological Laparoscopic Surgeon. Before the consultation, it is always advisable to take all the relevant papers, investigation reports along with the Ultrasound / X-Ray report if available, and the previous treatment reports (if any) to show to her, so that your proper treatment can be planned accordingly.
After thorough examination of the patient and carrying out relevant investigations, the operative laparoscopy technique is decided for the patient and it is explained to the patient and her relatives in detail. All the queries regarding the operation are discussed with the patient and a specific date (depending upon various factors like the menstrual cycle status of the patient etc.) is finally set for operative laparoscopy.


Laparoscopy Surgery -
» Minimal discomfort
» Full recovery in 1 week
» Glucose drip for a few hours
» Back home in 1 – 2 days
» Less expensive
» No obvious scar

Open Operation -
» Painful
» Full recovery in 6 weeks
» Glucose drip for 2 – 4 days
» Hospital stay for days
» Expensive
» Big obvious scar

Embryo Adoption

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frozen-embryo-adoptionThis procedure is similar to egg donation. However, instead of borrowing the egg and using the recipients husband's sperm for fertilization, both the egg and the sperms are derived from donors.

Who can opt for embryo donation?
All the patients who are eligible for egg donation can also be eligible for embryo donation. In egg donation, there are the problems of getting patients to donate their eggs. Furthermore it is a relatively costly procedure, as compared to embryo donation. Embryo donation also yields the highest pregnancy rate-as high as 30-40%. Hence if the couple has no objection in using donor sperm, it is a preferred method of choice!

What is the source of Embryo Donation?
In our program there are many young patients who need IVF / ICSI procedure, but who cannot afford it. These patients produce lot of eggs and hence many embryos.

After taking proper informed consent of these patients, some of the extra embryos are used for the recipients. In return, the costs of the drugs of the younger patient are borne by the recipient. This embryo sharing is beneficial for both the patients.

Alternatively, when we perform IVF, young women often produce many eggs, and therefore, many embryos. The best quality embryos are transferred into the womb. The extra embryos can be frozen and stored in liquid nitrogen at (minus)-196 0C. If the patient gets pregnant and do not want more children, they often agree to donate their embryos to other infertile couples, to help them to start a family.

Of course there is voluntary donation by family, friends or altruistic individuals. However this is rare.

What is the pregnancy rate with embryo donation?
The pregnancy rate in our clinic is 30-40% per cycle. The reason for the high pregnancy rate is two fold. Firstly, these are often excellent quality embryos. Also, since we prepare the Endometrium using hormones, the uterine receptivity to these embryos is usually very good.

How is Embryo Donation performed?
This is similar to egg donation. In patients who are menstruating (having their periods) the hormonal control of the cycle is taken over by starting GnRh Analogue Injection such as Suprefact, Lupride or Nasaral spray starting from 21st day of previous cycle. Once the patient gets her period, Estradiol Valerate tablets( Progynova 2 mg) is started from the 2nd day of period. On the 10th day an ultrasound is done to assess the receptivity of the Endometrium by measuring its thickness.

An Endometrial thickness of more than 9mm is good for pregnancy. Once this is achieved, one can wait to obtain good quality embryos, to place back into the womb. It is important to note that with this regime, one can wait for as many as 35 days after starting Progynova, for an embryo transfer. The procedure is non-surgical, and there is no risk involved.

In case of menopausal woman, who have stopped having periods, cyclical hormones are given for 3-6 months till the time the patient starts having her periods. After that the procedure is the same, starting with Progynova tablets from the second day of period. In these women, there is no need to give GnRh analogues such as Suprefact, as the hormonal control has been naturally shut of.

What about confidentiality of the procedure?
In our clinic, embryo donation is totally anonymous, unless it done by a friend or relative of the recipient. There is no contact between the donating couple and the recipients, who never see each other. There are no records maintained about the origin and the ultimate resting place of the embryos.

How is this procedure different from adopting a child?
Unlike traditional adoption, the couple undergoes a medical rather than a legal procedure to have a baby. For infertile couples, embryo donation offers a great opportunity to be pregnant, to bond with their child prior to birth, and to give birth. In addition, embryo donation may be much more affordable than traditional adoption in countries such as the US. In India younger couples are given preference for adoption. Couples more than 45 years of age have a very poor chance of adopting a baby. Embryo donation also offers couples privacy and secrecy, so that they do not need to worry about societal acceptance of their adopted child. Also in India, certain groups such as Christians and Muslims cannot adopt. Embryo donation is the only solution to these patients.

Isn't this just similar to surrogacy?
In surrogacy, another woman accepts the embryos of a couple and carries the pregnancy for the benefit of the infertile couple. In contrast in embryo donation, the infertile couple carries the embryos of another couple and ultimately delivers the child that they will parent.

Will the child be normal and what will he look like?
The incidence of abnormal child, miscarriage and other mishaps, is the same as that of natural pregnancy.  The embryos for adoption are normally derived from parents of Indian origin. The children born are generally healthy, with black hair, black eyes, and brown skin-akin to a normal Indian.

Egg Donation

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Egg-donationIn egg donation, eggs are borrowed from a young woman (less than 33 yrs of age) called the donor, with her consent. These eggs are then fertilized with the sperms of the husband of the recipient woman and the resultant embryo (the earliest form of the baby), is inserted into the womb of the recipient. The success rate of this procedure is in the region of 30 to 40%. In fact, many women till the age of 50-55 have become pregnant by this technique. You will be surprised that the oldest woman pregnant by this procedure is 69 year old, residing in Italy. At Babies And Us, the oldest women who has conceived with this technique is 62 years of age. This is probably the oldest woman to have become pregnant, in India.

IVF Odisha is an anonymous egg donation centre that provides personal attention and support to both egg donor and recipient. Check the online information about Egg Donation Clinic, Egg Donation & Egg Donation Centre in India. Please visit www.infertilityindia.com.

Who can qualify for Egg Donation?
A.In this day and age more and more career oriented women are getting married late in life. By the time they start planning to have children, they are nearing the fourth decade of their life (40 years). Fortunately, at this age, many women can conceive naturally. However nearly 10 to 15% women fail to conceive within a year's time. These women who are more than 37-40 years of age then resort to treatment of infertility by their gynecologist. If they still do not become pregnant they take help of newer technologies like IVF - In Vitro Fertilization (test-tube baby) or ICSI - Intra Cytoplasmic Sperm Injection.

egg-donation-3Women after the age of 40 tend to have fewer eggs in their ovaries or the quality of the eggs they produce may be poor. Thus, even new technologies like IVF and ICSI may not ensure a successful pregnancy. Furthermore, after the age of 40 to 42, many women stop producing eggs as they enter the stage of Perimenopause (decreased periods) or menopause (stoppage of periods). Till now, such women could only have a baby through the wonderful route of adoption. However, in the last ten years, a new technique of egg donation has come as a blessing to many such women.

B. In India, preference is given to younger couples to adopt children. Couples over the age of 45 can adopt, but find it difficult to do so, because of Governmental preference for younger parents. Such couples can tremendously benefit by egg donation.

C. Egg donation can also be perfomed on women who have had multiple cycles of test-tube baby (IVF or ICSI) and have still failed to conceive and become pregnant.

D. Besides elderly or menopausal women, egg donation can be done in younger women whose ovaries have prematurely failed or in young women who have undergone radiation or chemotherapy for cancer. Radiation or chemotherapy destroys the eggs and hence these women have a failure of their ovaries.

E. Egg donation is also used in patients who are carrying major chromosomal defects so that they do not pass the genetic defect to their children.

F. Patients suffering from severe Tuberculosis and severe Endometriosis may also produce poor quality eggs and hence can be treated by egg donation.

How are the Donors screened?
Generally, eggs are borrowed from healthy women less than 30-35 years of age and who are not suffering from any illness or genetic disorders. These young women, also called donors, are specially screened for AIDS and Hepatitis. Their family history is taken, to rule out any genetic problems. The donor can be married or unmarried. However, married donors with children would be preferable, primarily because they will have established their ability to bare children.

How is the procedure done?
The Babies And Us staff will coordinate the cycles of the donor and recipient to accomplish a fresh embryo transfer whenever possible. Synchronization of cycles includes using a series of medications to facilitate a hospitable uterine environment for the transfer of embryos. During egg donation, the donor is given injections to produce many eggs. When these eggs are ripe, she is given a short anesthesia and the eggs are removed from inside the vagina without giving a cut on the abdomen. The donor can return home three to four hours' after the procedure. The eggs are then fertilized with the recipient's husband's sperms in the laboratory, either by IVF or ICSI and kept in the incubator for two days.

Incase the recipient's husband's sperm is of poor quality; the eggs can be fertilized by the technique of Intra Cytoplasmic Sperm Injection (ICSI). Two days later, a four-celled embryo is formed. Three days later, a eight-celled embryo is formed or five days later a multi-celled Blastocyst is formed. This embryo (small baby) is then transferred back to the womb either at the four cell, eight cell or the Blastocyst stage.

30 to 40% of such women will become pregnant. Incase they fail to become pregnant they can have a repeat egg donation cycle. Many women undergo two to four cycles and achieve their goal of a child.

Who can be a Donor?
A. As easy as the method may sound, the biggest problem faced by both doctors and patients is the availability and source of egg donors. Ideally, the best donor would be her own sister or near relative from her side (not from husband's blood relative). We have done such cases successfully in Lilavati Hospital. However, in this day and age of small nuclear families many times it is difficult to get such donors.

egg-donation-2Further more, it is very important that if there is a sister donating eggs, there should be a very good mental understanding between the sisters. The donor is not anonymous in this case, and thus many a time there are possibilities of inter-personal conflicts arising when the child becomes older.

We also accept recipients who have identified their own non-anonymous donors.

B. The other and the most acceptable donor would be a voluntary unrelated donor. There are a lot of women who may just out of altruistic (philosophical) reasons donate eggs to women who are suffering from the trauma of infertility. It is important to popularize such egg donation. However, even in an advanced society like Britain's, there is a great dearth of voluntary egg donors, in spite of extensive advertisement in the press.

By voluntary egg donation, we mean donation of the eggs by the donor without expecting any monetary or other reward in return.

C. The third area, which can be a source of donors can be a paid donor. You may be surprised that this is legal in USA and young college girls are paid as much as US$6,000 for donating their eggs. But in a protestant society like Britain's, this form of donation is considered illegal and unethical. Even in the Indian society, where there is no law on egg donation at present, such kind of paid donation may not be socially and culturally acceptable. Clinics in India do not practice paid donation.

Recently the Govt of India has appointed Indian Council of Medical Research to legalize infertility practice in this country including that of egg donation, embryo donation, semen donation & surrogacy. The ICMR has legalised paid egg donation and surrogacy. 

In all the groups of related, voluntary or paid donors, there is a certain degree of risk the donor is exposed to. The donor is given multiple injections to produce eggs, as well as a shot anesthetic. She is also exposed to the risk of surgical egg removal.

D. Hence, there evolved a new concept of shared egg donation which started in Britain but is now popular in the USA and also in India. There are many young women who are infertile due to other reasons and who also need the procedure of IVF or ICSI.

However, they cannot afford to spend money for these procedures. Many of these women produce 8 to 10 eggs during their treatment. These patients are asked to share some of their extra eggs with the recipient. This is done by taking the informed consent of the young woman. In return, a part of the expense of medical treatment of the young woman is borne by the recipient. Thus, both the donor as well as the recipient who need IVF, are benefited, without any extra amount of risk to the donor. The anonymity of both-the donor and the recipient- is maintained so that they don't know each other. With the help of this technique, many young women who cannot afford IVF can mother a child. The same goes for elderly women who can afford IVF and can have a child.


egg-donation-1The process of egg sharing is an excellent example of symbiotic relationship between women, one with a physical need and one with a monetary need, with the ultimate common goal of bearing a child. It is a safe, effective, successful, legal, ethical and socially acceptable method of advanced reproductive technology.


We at the Babies And Us Fertility, IVF & ICSI Centre generally indulge in family related donors or egg sharing.

We hope that more and more voluntary donors will come forth, to help needy infertile patients become pregnant.

What is the age limit of the recipient?
In general, any woman with a medical or genetic indication for using an egg donor can be a recipient, if there are no medical contraindications to pregnancy. Our current age limit is 55 years. The decision to utilize donor eggs is made in association with staff and consultants. If a male factor exists, donor egg with ICSI is also available. Generally a psychiatrist and a physician would assess a recipient. This is done to gauge the mental and physical fitness of the patient. This analysis is very important to withstand the pressures of childbirth.

What is the background of Recipients?
Babies And Us fertility Centre is renowned for its egg donation techniques. Our patients hail from all over the country. They are from different walks of life. Our unit facilities are also utilized by NRI patients (Non Resident Indians) from USA, UK, Africa, Middle East, Sri Lanka & Far East(Singapore). We are also getting some patients from other nationalities who hail from Asian countries..

Surrogacy

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surrogate motherSurrogacy is an arrangement between a woman and a couple or individual to carry and deliver a baby.  Women or couples who choose surrogacy often do so because they are unable to conceive due to a missing or abnormal uterus, have experienced multiple pregnancy losses, or have had multiple in vitro fertilization attempts that have failed. The advantage of gestational surrogacy to the parents is that the embryo is created from the woman’s egg and the man’s sperm, so it is biologically theirs. Surrogacy is a method of assisted reproduction. The word surrogate originates from Latin word surrogatus (substitution) - to act in the place of. The term surrogacy is used when a woman carries a pregnancy and gives birth to a baby for another woman. Surrogacy is gaining popularity as this may be the only method for a couple to have their own child and also because adoption, process may be a long drawn out process.

What are the Types of Surrogacy?

1.  IVF / Gestational surrogacy

2. Traditional / Natural surrogacy


IVF / Gestational surrogacy - This is a more common form of surrogacy. In this procedure, a woman carries a pregnancy created by the egg and sperm of the genetic couple. The egg of the wife is fertilized in vitro by the husband's sperms by IVF/ICSI procedure, and the embryo is transferred into the surrogate's uterus, and the surrogate carries the pregnancy for nine months. The child is not genetically linked to the surrogate.

Traditional / Natural surrogacy - This is where the surrogate is inseminated or IVF/ICSI procedure is performed with sperms from the male partner of an infertile couple. The child that results is genetically related to the surrogate and to the male partner but not to the female partner.

To whom Surrogacy is Advised?

A. IVF Surrogacy

1. Primarily, IVF surrogacy is indicated in women whose ovaries are producing eggs but they do not have a uterus. For e.g., in the following cases:

a) Congenital absence of uterus (Mullerian agenesis)

b) Surgical removal of the uterus (hysterectomy) due to cancer, severe hemorrhage in Caesarian section or a ruptured uterus.

2. A woman whose uterus is malformed (unicornuate uterus, T shaped uterus, bicornuate uterus with rudimentary horn) or damaged uterus (T.B of the endometrium, severe Asherman's Syndrome) or at high risk of rupture, (previous uterine surgeries for rupture uterus or fibroid uterus) and is unable to carry pregnancy to term can also be recommended IVF surrogacy.

3. Women who have repeated miscarriages or have repeated failed IVF cycles may be advised IVF surrogacy in view of unexplained factors which could be responsible for failed implantation and early pregnancy wastage.

4. Women who suffer from medical problems like diabetes, cardio-vascular disorders, or kidney diseases like chronic nephritis, whose long term prospect for health is good but pregnancy would be life threatening.

5. Woman with Rh incompatibility.

B. Traditional Surrogacy

1. Women who have no functioning ovaries due to premature ovarian failure. Here egg donation also can be an option.

2. A woman who is at a risk of passing a genetic disease to her offspring may also opt for traditional surrogacy.

Is Surrogacy right for you?
For some couples opting for surrogacy is a very straight forward decision, while, for others there are lots of things to be considered and thought about before taking the decision. There are lots of complex issues involved. It is an emotional roller coaster ride for the couple, the families and friends. It is a decision where the 'right' and the 'wrong' are very individual things. An infertility specialist or a counselor can help the couple seeing things in the right perspective. Other options such as, adoption or further infertility treatment can also be considered.

What are the screening criteria for surrogate? How is a surrogate chosen in India?
surrogacy1Medical Tourism's network of hospitals in India, has a very meticulous and stringent criteria for choosing a surrogate. The surrogates are between 21-35 years of age. They are married with previous normal deliveries and healthy babies. Detailed medical history, surgical history, personal history, and family history is looked into. History of blood transfusion and addiction is also taken. It is made sure that the surrogate has an uneventful obstetric history (no repeated miscarriages, no ante-natal, intra-natal and post-natal complications during previous pregnancies). The surrogate and her partner are screened for infectious diseases like sexually transmitted diseases, Hepatitis B, Hepatitis C, HIV, VDRL. Thalassemia screening is also done. Detailed pelvic sonography is done and other tests for uterine receptivity are performed to ensure maximum chances of success. A detailed financial and legal agreement is then drawn up between the surrogate and the commissioning couple.

What does India IVF surrogacy procedure involve?
For IVF surrogacy in India, matching of cycles of the genetic mother and the surrogate is done by adjusting menstruation dates by oral contraceptive pills. When the cycle starts, the surrogate is put onto estrogen tablets to prime the uterus. The protocol used for the genetic mother is day 2 protocol or day 21 protocol, depending on the age of the genetic mother and the other test results. For the day 2 protocol, called the antagon protocol, oral contraceptive pills are given in the previous month. On the 2nd day of the periods, gonadotropin injections are started. USG Monitoring is done daily.

When the size of the follicle reaches 14 mm, the genetic mother is given an antagon injection to prevent the surge of the endogenous hormones. For the day 21 protocol, called the long protocol, GnRH analogues are started on day 21 of the previous cycle. Once the genetic mother gets her periods, gonadotropin injections are started. In both the cases, the patients are monitored daily. When the follicle reaches 18 mm size hCG trigger is given. The surrogate is started onto progesterone tablets on the day of hCG injection that is given to the genetic mother. Oocyte (egg) retrieval is done 36 hours later, which is generally day 12 or 13 of the cycle. On the same day the genetic father gives his semen sample. The eggs of the genetic mother are fertilized with sperms of the genetic father in the laboratory by IVF / ICSI procedure. The resulting embryo is then transferred into the womb of the surrogate under ultrasound guidance. The surrogate is then put on luteal support using progesterone tablets / injections, and pregnancy is confirmed 15 days later.


What is the nine-months journey like, with Indian surrogate?
The surrogate is treated as a high risk pregnancy and is cared for by 2 consultant gynecologists in our hospital. Appointments are scheduled with the consultants every three weeks for the first 6 months, then every 15 days for the next 2 months and then weekly / biweekly in the last month. Blood tests and ultra sound are done as and when required. Routine blood tests like hemoglobin, blood group, VDRL, HBsAG & HIV are done. Special care is given, and tests are done to pick up any obstetric or medical complications like hypertension, diabetes etc., at the earliest. 2 doses of injection Tetanus are given during pregnancy. The baby's growth is monitored stringently. Ultrasound is done at 6 weeks to confirm pregnancy and the viability of the baby, then at 12 weeks to assess growth and certain parameters like nuchal thickness. At 18 -20 weeks, a detailed level III ultrasound is done to detect any abnormalities in the baby. At 16 weeks, after councelling and with the consultation of the genetic parents, amniocentesis is performed, if the genetic mother's age is more than 35 years. At 28 weeks and 34 weeks, color Doppler is performed to assess the growth of the baby and rule out intra uterine growth retardation. Fetal well being tests, like non stress test, are done as per the requirement. Detailed information is given to the surrogates about nutrition and diet during pregnancy. They are regularly provided with supplements from the hospital.

Thus, adequate care and precaution is taken, to ensure that sufficient and optimum nutrition reaches the baby. We have a LDRP (Labor Delivery Recovery Puerperium) room for delivery which is equipped to handle any obstetric emergency. Our NICU setup is also completely equipped to handle any neonatal complications, with a neonatologist who is available round the clock. We keep the couple posted on the progress of the baby and send them ultrasound pictures and blood reports as and when they are done.

What is the success rate of surrogacy in India?
The success rate (carry home baby) of surrogacy is around 45% in case of fresh embyos. In case of frozen embryo's it is about 25%. High success rates and low medical costs are the highlights of surrogate pregnancy in India. No wonder many couples from the US, Australia, the UK, and other European countries seek surrogacy in India.


What are the different ways children born through surrogacy may receive breast milk?
surrogacy fertilityJust because the baby is born through surrogacy, it does not mean he or she cannot receive breast milk and the many health benefits it provides. Breast fed babies have been found to have higher IQs, are better protected from leukemia and are less likely to have problems regarding obesity. Breast milk protects babies from getting diarrhea, ear infections and respiratory disorders such as asthma. Premature babies who receive breast milk are more protected from infections and high blood pressure later in life. Breast milk contains the protein CD14 which works to develop B cells, which are immunity cells that are essential for the production of antibodies in an infant, to build the babies immunity system.

The babies may drink breast milk acquired through a milk bank, breast milk donor may be located or the intended mother may induce lactation before the birth of the baby. Induced lactation has been embraced by the nursing community as a welcome method to enhance the bonding relationship between a new mother and baby born through surrogacy. Prolactin and oxytocin are the two pituitary hormones that cause lactation to occur. They may be stimulated despite the woman's inability to carry a child. Lactation may be induced in a number of ways, and the amount of milk a non lactating woman can produce through inducement varies from woman to woman. The most common way women induce lactation is through manual or mechanical stimulation. With this method lactation is induced by massage, nipple manipulation and sucking either by the baby or breast pump. The second common method used is hormone therapy whereby a woman uses herbal remedies such as Fenugreek or is prescribed medications such as Domperidone and Metoclopromide (Reglan*) to induce and increase her milk supply. Induced lactation milk, skips the colostrum phase. and resembles mature breast milk.

Manual stimulation of lactation usually takes between two and seven weeks and hormone therapy usually takes between one to four months. For this reason intended mothers usually begin during the final trimester of their surrogate mother's pregnancy.

What are the advantages of surrogacy?

a) This may be the only chance for some couples to have a child, which is biologically completely their own (IVF surrogacy) or partly their own (gestational surrogacy)

b) The genetic mother can bond with the baby better than in situations like adoption.
icsiThe most recent microassisted fertilization method is called intracytoplasmic sperm injection (ICSI) and involves the injection of a single sperm into the cytoplasm of the oocytes. ICSI has forever changed the management of male factor infertility. ICSI is now widely available in a large number of assisted conception units internationally and has revolutionized the management of male factor infertility. ICSI is associated with fertilization and pregnancy rates similar to those found following conventional IVF in patients who do not have male factor problems. In ICSI all the steps are similar to the procedure of IVF, except the step of fertilization. Normally in IVF one egg is mixed with 100,000 sperms and one of the sperms fertilizes the egg on its own. In contrast, in ICSI each egg is held and injected with a single live sperm. This micro-fertilization is done with the help of a machine called the Micromanipulator.

IVF Odisha provides comprehensive affordable ICSI treatment and services. ICSI Centre in India, Our clinic deals in Infertility treatment which includes ICSI treatment

Thus the procedure consists of:
1. Controlled Ovarian stimulation with drugs (GnRH Analogues and Gonadotrophins) to produce many eggs.
2. Monitoring of follicles and egg development with the aid of vaginal sonography and serial Estradiol hormone estimation.
3. Administration of hCG injection, (Human Chorionic Gonadotrophins) when the two leading follicles are 18mm in diameter.
4. Oocyte or egg retrieval under short general anesthesia 35 to 37 hours after HCG injection.
5. Identification and isolation of eggs in the laboratory.
6. Sperm collection and processing in the lab. Incase of azoospermia (no sperms in the semen) the sperms are collected directly from the testis with the procedures of PESA/MESA/TESE or TESA.
7. Dissection of the eggs in the laboratory with the help of an enzyme called Hyloronetis. Placement of eggs into small droplets of culture media under oil.
8. Placement of sperms into small droplets of PVP under oil. Immobilization of the sperm with a micro-injection needle (Diameter of 7 microns) and aspiration of the immobile sperm into the needle (tail first).
9. Holding the egg with a holding pipette and injection of the immobilized sperm into the held egg Placement of these eggs into the incubator for 2 to 5 days.
10. Embryo formation 2 to 5 days after fertilization.
11. Embryo transfer of good quality embryos back to the womb, after 2 (four cell embryo), 3 (six-eight cell embryo)or 5(blastocyst stage) days after egg removal.

Indications:
1. Males with severe sperm factors such as low count (less than 5 million), very poor motility or high degree of abnormal sperms.
2. Males with azozoospermia, where there is no sperm present in the semen. The azozoospermia may be of the obstructive type where there is production of sperms in the testis but blockage of the conduction system which brings the sperm out into the semen. Alternately, the azoospermia may be of the non-obstructive type, where there is a failure of the testis to produce sperms. Nowadays, in both these types of azoospermia, sperms can be isolated directly from the testis, using the SPERM

Retrieval Techniques of PESA/TESA/TESE and subsequently, ICSI can be performed on:
1. Males with sperm anti-bodies.
2. Males with ejaculated dysfunction due to spinal chord injury or malfunction such as quadriplegics or paraplegics.
3. Patients with retrograde ejaculation (ejaculation of the sperm into the urinary bladder) who fail to become pregnant with IUI.
4. Patients where fertilization has failed with In Vitro Fertilization.

In our unit we also believe in doing ICSI on patients who have had previous history of tuberculosis or endometriosis as we believe it gives better fertilization rates than standard IVF (this is a personal experience not supported by international literature). Now a days, some units are advocating routine ICSI for all patients, including those with normal sperm counts. We do not believe in such practice as we feel that pregnancy should be achieved with minimum handling of the gametes outside the body. If the sperm count is good enough for fertilization with IVF, we will not do ICSI. However, if a particular patient has a sperm count which is in the grey-zone area, then we may subject half the eggs to IVF and half the eggs to ICSI. Our success rates are in the region of 30 to 40% in both azoospermia and non-azoospermia patients.

Concept:
Similar to IVF, ICSI differs in the fertilization process. Unlike in IVF, where one egg is mixed with 1 lakh sperms, with fertilization taking place on its own, ICSI is a technique where each egg is held and injected with a single live sperm. This micro-fertilization is done with the help of a machine called the Micromanipulator. The procedure (anchor) can be categorised into 11 steps.

Indications for ICSI
ICSI is a technique usually performed in males with:

severely low sperm counts
poor quality of sperms
more… link as an anchor to the retrieval techniques of PESA / MESA etc, lower down in the content paras.

ICSI and IVF Odisha

In ICSI all the steps are similar to the procedure of IVF (procedure of IVF), except in fertilization.

Procedure:
Controlled Ovarian stimulation with drugs (GnRH Analogues and Gonadotrophins) to produce many eggs.
Monitoring of follicles and egg development with the aid of vaginal sonography and serial estradiol hormone estimation.
Administration of hCG injection, (Human Chorionic Gonadotrophins) when the two leading follicles are 18mm. in diameter.
Oocyte or egg retrieval under short general anaesthesia, 35 to 37 hours after HCG injection.
Identification and isolation of eggs in the laboratory.
Sperm collection and processing in the lab. Incase of azoospermia (no sperms in the semen) the sperms are collected directly from the testis with the procedures of PESA/MESA/FTNB/TESE or TESA.
Dissection of the eggs in the laboratory with the help of an enzyme called Hyloronetis Placement of eggs into small droplets of culture media under oil.
Placement of sperms into small droplets of PVP under oil. Immobilisation of the sperm with a micro-injection needle (Diameter of 7 microns) and aspiration of the immobile sperm into the needle (tail first).
Holding the egg with a holding pipette and injection of the immobilized sperm into the held egg Placement of these eggs into the incubator for 2 to 5 days.
Embryo formation 2 to 5 days after fertilization.
Embryo transfer of good quality embryos back to the womb, after 2(four cell embryo), 3 (six-eight cell embryo)or 5(blastocyst stage) days after egg removal.

Indications:
1. Males with severe sperm factors such as:
low count (less than 5 million)
very poor motility
high degree of abnormal sperms.

Although ISCI is carried out among patients even with normal sperm counts, IVF Odisha believes that pregnancy should be achieved with a minimum handling of the gametes outside the body. If a particular patient has a sperm count that is in the grey-zone area, then we may subject half the eggs to IVF and half the eggs to ICSI.

Males with azoospermia have no sperm present in the semen. The azoospermia may be of the obstructive type where there is production of sperms in the testis but a blockage in the conduction system disallows sperms to enter the semen. Alternately, the azoospermia may be of the non-obstructive type, where there is a failure of the testis to produce sperms. Fortunately, today, sperms can be isolated directly from the testis, using the Sperm Retrieval Techniques of PESA/TESA/TESE and subsequently, ICSI can be performed. IVF Odisha maintains a competent success rate of 30-40% in males with azoospermia.

2. Males with sperm anti-bodies.

3. Males with ejaculated dysfunction due to an injury to the spinal chord or in quadriplegics or paraplegics.

4. Patients with retrograde ejaculation (ejaculation of the sperm into the urinary bladder) who fail to allow pregnancy under.

5. Patients where In Vitro Fertilisation has proved to be unsuccessful.

6.  At IVF Odisha, ICSI is performed for on patients with a history of tuberculosis or endometriosis as we believe ICSI shows higher fertilization rates than standard IVF.
iuiIntrauterine insemination ( IUI) or artificial insemination with husband's sperm (AIH) is a procedure where the doctor is giving nature a helping hand by increasing the chances of the egg and sperm meeting. Sometimes nature needs help to start a pregnancy - and the doctor can do this by giving the sperm a piggy back ride through a fine tube into the body and effectively, the doctor is giving nature a helping hand by increasing the chances of the egg and sperm meeting. In this method, the sperms are removed from the seminal fluid by processing the semen in the laboratory and they are then injected directly into the uterine cavity. IUI is useful when the woman has a cervical mucus problem.
ivfIn vitro fertilization (IVF) is one of the most successful techniques available for improving your chances for a pregnancy. This reproductive journey is exhaustive and needs your involvement, but when you are guided properly, it will ease as many of the complexities that may occur along the way. In this technique, since fertilization occurs in the laboratory rather than in the woman’s body, this procedure is called “in vitro”. The eggs and sperm are maintained in a special culture medium within a controlled environment. After fertilization is complete, if the fertilized egg is developing well, it will consist of 6-8 cells on Day 3 after egg retrieval. If an embryo is progressing appropriately, it will form a blastocyst by Day 5-6. Among the best embryos, one or more are selected for transfer into your uterus and the rest may be frozen to be transferred at a future time, if unfortunately the first attempt fails.

The Journey of IVF

Though the steps of each individual cycle vary, most of the assisted reproductive technologies have similar steps.

» Evaluation and preparation phase

» Ovulation induction/ Stimulation phase

» Egg/Oocyte retrieval

» In-Vitro Fertilization of retrieved eggs

» Embryo transfer

» Luteal support phase

»» Evaluation and Preparation

A detailed schedule of the protocol will be handed over to you for your reference. In many cases, oral contraceptive pills (OCPs) will be prescribed to regulate you for the procedure. The reason for prescribing the OCP is to lessen the chances of you developing an ovarian cyst during the treatment and to have flexibility in the timing of the cycle.

Uterine Assessment: If your uterus was not assessed within the last year, your fertility expert may suggest a screening test as a hysteroscopy or a diagnostic laparoscopy before the IVF cycle. A complete assessment and rectification of any complications will be done, if present during the procedure.

»» Ovulation Induction

Any assisted reproductive technology (ART) procedure has better success and improved results if multiple mature oocytes are available for retrieval. To achieve good number of matured eggs, systematic stimulation of the ovaries is performed by the fertility expert by administering hormone injection on a daily basis. The medications are in a class called gonadotropins. Some of the most common and most preferred gonadotropins are Follistim, Gonal-F, Menopur and Repronex. Before starting the stimulation protocol, your consultant will start with the baseline ultrasound. If the ultrasound is normal, you will begin gonadrotropin injections. This medication will support a group of several follicles to develop together. Most of them ideally develop about 10-12 follicles, but the response is quite variable and there are ample chances that you may develop only 2-3 follicles, or as many as 20-30. The dosage of medication you will receive is based on a calculation of how your ovaries will respond based on your age, your baseline FSH and estradiol (E2) levels, and any previous ovulation induction output.

When you begin the gonadotropin medication, it is important to avoid intense physical exercises because such activity could be of hindrance to the follicles development. The majority of women taking hormone injections for IVF will experience a sense of fullness in their ovaries. Risks include Ovarian Hyperstimulation Syndrome (OHSS) and multiple births.

hCG Timing: During the follicular monitoring, your consultant will closely monitor the follicle development and when the lead follicle reaches to a size of about 18mm in diameter, you will be administered with Human Chorionic Gonadotropin (hCG) injection. The timing at which the hCG is given is critical, so you need to take it precisely at the given time. The Egg/Oocyte retrieval will follow after 35 hours.

»» Egg - Oocyte Retrival

The egg retrieval will be scheduled approximately 35 hours after the hCG injection. The retrieval will be performed in our IVF theatre under sedation. You will be given prior instructions for preparing yourselves for the retrieval. Usually you will be asked not to have anything to eat or drink before the egg retrieval. The procedure is done by inserting a needle through your vagina and into the ovary, under ultrasound guidance. Since you are under sedation, mostly you will not feel this procedure at all. The follicles which contain the eggs are precisely ruptured and the fluid is collected in test tubes and quickly passed to the embryologists in the IVF laboratory. The egg retrieval takes approximately 30-40 minutes.

After the procedure is completed, you will be allowed to rest under supervision and then transferred to the room after an hour. The chances of risks or serious problems are extremely small as the whole procedure is done under the guidance of highly effective ultrasound machines. You should avoid any work on the day your egg retrieval is scheduled. Many of them do return to work the next day, while others also rest the day following the retrieval. You may feel some pelvic heaviness or soreness and cramping. Often there is a small amount of spotting. Your bleeding should be less than a normal period. Avoid vaginal intercourse from the day of the retrieval for several days to allow the vagina to heal.

Semen Sample: Your partner will be asked to give his semen sample on the day of the egg retrieval. It is recommended that he abstain from ejaculation for 2 to 5 days before the scheduled day of retrieval.

»» Fertilization of Retrival Eggs

Once the eggs are retrieved, they are safely placed in special culture medium and put inside the incubators for few hours. By then the given semen sample is prepared for fertilization. The highly efficient sperms are then inseminated to allow them to fertilize the eggs in the petridish. Fertilization can also be accomplished by directly injecting the sperm into the oocyte by performing ICSI (Intra-Cytoplasmatic Sperm Injection). ICSI is highly recommended if the fertility expert suspects that there will be a considerable chance of no fertilization or a low rate of fertilization with usual insemination of the oocytes in the laboratory.

It is essential to understand that all the embryos may not continue to grow. Normally an embryo begins to cleave, first into two cells, then into four after 36-48 hours. After 3 days, an healthy embryo which is growing properly will have 6-8 cells. An embryo should reach a blastocyst stage at 5-6 days after retrieval. The best embryos are transferred either on third day or fifth day according to the fertility expert’s suggestion.

»» Embryo Transfer

Three to five days after the oocyte retrieval you will be scheduled for your embryo transfer. Your consultant will recommend which day is most appropriate for you. In general, blastocyst transfer is recommended when there are a large number of embryos of good quality. Your consultant will recommend the number of embryos to be transferred based on your age, your previous IVF history if you have had performed in the past, and the quality of the available embryos.

Your fertility expert will perform the transfer under the guidance of a highly efficient ultrasound. The embryologist will load the embryos into a small catheter and your physician will ease the tip of the catheter through the cervix into the uterus and the embryos are transferred. If there are any good quality embryos that are in excess, they are can be frozen for future use, if unfortunately the current cycle fails or if you want to have another baby in future. To know more about freezing your embryos.

On the day of your transfer wear comfortable clothing and socks to keep your feet warm. Your bladder should feel full, but not very uncomfortable. A partially full bladder often will allow the transfer to be completed more easily and will allow a better picture on the abdominal ultrasound. We suggest that you rest the day after the transfer, to allow yourself time to relax as much as possible. However, it is important to know that nothing you will do, such as walking or going to the bathroom will cause the embryos to dislodge from the uterine wall. The main factors that determine whether an embryo will implant are the viability of the embryo and the quality of the uterine lining. Healthy embryos will be much more likely to implant and develop than embryos which are not viable.

»» Luteal Support Phase

You will be asked to take progesterone as it increases your chances for a successful IVF. Progesterone is the natural hormone that your body produces to support the uterine lining and maintain an early pregnancy. It is common to have a sensation of heaviness or cramping in your pelvis 5-8 days after egg retrieval. Your ovaries frequently enlarge at this time. Light bleeding sometimes occurs in the weeks following egg retrieval, even if there is a normally developing pregnancy.

A pregnancy test will be performed approximately two weeks after your egg retrieval. Waiting for your pregnancy test is not an easy task. It is usual to have symptoms of pregnancy that frequent due to the hormonal changes. Spotting or bleeding may occur even if a pregnancy is developing normally. Please do not discontinue your progesterone intake that is prescribed until your pregnancy test, even if you think you may not be pregnant. Avoid guessing or doing home pregnancy tests before the scheduled blood test. They may not be accurate.

On the day of your pregnancy test, if the test is positive, you will be asked to return for a follow-up test 2-3 days later to check if your Beta hCG level is increasing appropriately. Hopefully we will have good news to know that pregnancy test is positive and have follow-up as recommended by your physician. If unfortunately you are not pregnant, you will be instructed to stop the progesterone and expect to see your period within 2-5 days. If the cycle was unsuccessful, you may find it supportive to schedule a follow-up visit with the physician, so we can counsel you concerning your next steps. Another cycle of treatment can begin as soon as one month after a failed cycle.

Do’s and Don'ts after completing the IVF cycle:

» Avoid heavy lifting or vigorous exertion such as running or aerobics.

» It is okay to take stairs slowly, and walk short distances, less than a mile.

» Avoid any vaginal creams, lubricants, or spermicides other than the progesterone that is prescribed.

» Avoid hot tubs and Jacuzzis.

» Avoid intercourse until advised by your physician.

» If you travel, give yourself twice as much time as usual and minimize stress.

Team IVF Odisha

drpltripathy
Dr. P. L. Tripathy
Obstetrician & Infertility Specialist
  • Dr. Neeraj Pahlajani
    Obstetrician & Infertility Specialist

    dr sameerpahlajaniDr. Sameer PahlajaniInfertility Consultant & Sonography ExpertDr Dibyajit_MohantyDr. Dibyajit MohantyMD, Obs. & GynecDr Sasmita_DasDr. Sasmita DasMD, Obs. & Gynec