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Upkar Nursing Home, College Street

  4.4  (9890 ratings)

Gynaecologist Clinic

30-D, College Street, Opposite Medical College Gate Number 3 Kolkata
1 Doctor · ₹400 · 2 Reviews
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Upkar Nursing Home, College Street   4.4  (9890 ratings) Gynaecologist Clinic 30-D, College Street, Opposite Medical College Gate Number 3 Kolkata
1 Doctor · ₹400 · 2 Reviews
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Dr. Sujoy Gupta lends his expertise in the following areas: Gynaecological Care- Menstrual disorders, PCOS, Fibroid, White discharge, Menopause, Hormone Therapy Infertility- Drug trea......more
Dr. Sujoy Gupta lends his expertise in the following areas: Gynaecological Care- Menstrual disorders, PCOS, Fibroid, White discharge, Menopause, Hormone Therapy Infertility- Drug treatment, Male and Female Infertility, Unexplained Infertility, Endometriosis, PCOS, Fibroid, Low Sperm Count, Ovulation Induction, IUI, IVF Ultrasonography Laparoscopy, Hysteroscopy Sexual Disorders- Male and Female- Low libido, Erectile Dysfunction, Premature Ejaculation, Female Sexual Dysfunction, Painful Intercourse Colposcopy, Cancer Screening, HPV Vaccination Gynaecological operations- Hysterectomy, Cystectomy, Cancer Surgery Pregnancy care- Pre-conceptional Care, Antenatal care, Postpartum Care High Risk Pregnancy- Diabetes, Hypertension, Thalassaemia, Epilepsy, Thyroid Diseases, Babies with abnormalities Delivery Service- Normal Delivery, Caesarean Delivery Miscarriage- Repeated Miscarriage Contraception Services- Family Planning, Abortion Services Abortion Services- Medical, Surgical
More about Upkar Nursing Home, College Street
Upkar Nursing Home, College Street is known for housing experienced Gynaecologists. Dr. Sujoy Dasgupta, a well-reputed Gynaecologist, practices in Kolkata. Visit this medical health centre for Gynaecologists recommended by 90 patients.

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College Street Kolkata, West Bengal - 700073
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Dr. Sujoy Dasgupta

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist
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All About Pregnancy!

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
All About Pregnancy!

Introduction

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

 In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires:

  1. Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes
  2. Transport of these sperms through the sperm conducting ducts from testes to penis
  3. Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina
  4. Transport of these sperms from vagina through cervix to the uterus and the tubes
  5. Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
  6. Pick up of the eggs by the tubes
  7. Approximation of eggs and the sperms to form the embryo
  8. Transport of embryo from the tubes into the uterus
  9. Acceptance of the embryo by the uterus and its growth

What is Infertility?

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.

Thus the common causes may be:

  1. Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
  2. Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examles include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
  3. Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out. 

In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress. 

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

What is insemination?

Insemination literally means putting semen in a particular place. Various forms of insemination exist in fertility treatment. First one is “Intravaginal Insemination (IVI)”, where the raw semen, collected by the husband can be put inside the vagina, taking precautions (to prevent infection) by the husband himself or by the wife. Rarely, it needs medical assistance from a doctor. It’s usually advised to couples having sexual disorders where full penetrative intercourse is not possible (erectile dysfunction of the husband or very painful intercourse experienced by the wife) or where ejaculation cannot happen during intercourse (a very unusual problem). Thus, the success rate of IVI is no better than natural intercourse (success rate 15% per cycle), for those couples who can manage successful intercourse.

“Intrauterine Insemination (IUI)” is the treatment where “prepared” semen is put inside the cavity of the uterus, near the Fallopian tubes. Thus, IUI bypasses some hurdles that can cause problems during natural intercourse. The vagina, cervix and the whole length of the uterus are bypassed, putting the sperms near the eggs. Thus it increases the success rate compared to natural intercourse or IVI.

However, to achieve pregnancy after IUI, the female partner must have open tubes, adequate number of eggs produced by ovaries, eggs must be released by the ovaries and sperms must meet the eggs. And, thus nature plays important role, as in natural intercourse.

Please note, we used the word “prepared” semen. In natural intercourse, as mentioned earlier, the dead sperms and bacteria cannot enter the uterus, because cervix prevents their entry. If they are put artificially by IUI inside the uterus, severe reaction can happen. So, after collection, the husband’s semen is processed in the laboratory to remove all those impurities and to select only the best number of healthy and movable sperms and it definitely increases success rates of IUI

When IUI is generally advised?

As you can understand, to perform IUI, there must be minimum number of sperms in the semen, the tubes must be opened, the ovaries must be releasing eggs. If these are present, IUI is usually advised

  • Less than adequate number of sperm counts, morphology or motility
  • Couples who cannot perform full penetrative intercourse but refuse or unable to conceive by IVI
  • Unexplained infertility- although IVF is better than IUI, but considering the cost, many couples in our country opt for 2-3 cycles of IUI before IVF
  • PCOS and Mild Endometriosis- where natural intercourse or ovulation induction failed
  • Couples in whom only one partner is positive for HIV or Hepatitis B or C- where transmission from one partner to another by unprotected sexual intercourse is not preferable.

What are the tests done before IUI?

The basic infertility evaluation is done before IUI include husband’s semen analysis, assessment of ovarian function (blood tests, ultrasound) and uterus (ultrasound). In some cases, laparoscopy (putting camera to see inside the abdomen by operation) or hysteroscopy (putting camera through vagina inside the uterus, by operation) may be required. Now, if the tubes are blocked, IUI is of no use. So, testing the tubes is advisable before IUI. But some women, who are at low risk of tubal disease (no history of pelvic pain, infection or surgery), one or two cycles of IUI can be done, failing which tubes must be checked by tests like HSG or SSG or in some cases by laparoscopy.

What IUI actually involves?

In the cycle, in which IUI is planned, the woman is asked to take some medicines (or injections) in particular days of the periods as a part of “ovulation induction”. She is then advised to have ultrasound monitoring (TVS- transvaginal sonogram- where ultrasound probe is placed inside the vagina for better accuracy) to see if eggs are growing in response to the medicines or not. If eggs are growing, IUI is planned in a particular time when the egg(s) is more likely to rupture, so that the tie interval between sperm entry and egg release can be kept as minimum as possible.

Is ovulation Induction necessary for IUI?

Frankly speaking, IUI can be done without any medicines (as in case of natural intercourse or IVI), which is called “Natural Cycle IUI”, where only TVS monitoring is done to see how the eggs are growing. This may avoid some side effects of ovulation induction (see below) but is associated with low success rate than IUI done along with ovulation induction.

Is TVS necessary before IUI?

TVS is, undoubtedly, uncomfortable for the woman. But it gives better picture than ultrasound done conventionally. Now, the question is, whether ultrasound monitoring is at all needed or not. TVS directs the doctor how eggs are growing and at what number and size and when they are likely to rupture. Moreover, the rupture can also be confirmed by TVS. Again, the uncommon side effect of ovulation induction can be detected by TVS. That is called OHSS (“Ovarian Hyperstimulation Syndrome”) where excessive eggs can grow inside the ovaries and this can lead to collection of fluid inside abdomen and lungs and can turn very serious. Although very rare, it can be detected by TVS and early actions can be taken to prevent the progress of this condition.

In rare cases, where TVS cannot be done or patient declines, only option is to check urine by LH kit to predict the likely timing of ovulation and at that time IUI is planned. However, it is less accurate than TVS monitoring and is associated with less success.

What, if eggs are not growing in the ovaries?

In some women, particularly those who are overweight, aged or some cases of PCOS, eggs may not respond initially to one medicine. There are various forms of ovulation induction medicines (tablets, injection). If one is not working, your doctor can try increasing the dose of that medicine or add or replace it with other medicines. Please remember, it’s difficult to predict what medicine will be best suited for a particular patient. So, it’s basically a trial and error process.

What is done on the day of IUI?

As timing is important, the couples are requested to stick to the timing, advised by the doctor. The husband will be asked to collect the semen by masturbation, using clean technique (to avoid contamination by germs in the semen container). The semen is then prepared by the embryologist and will be checked to see the final number of sperms and their motility and morphology.

The wife is asked to lie down in the IUI table. After cleaning, a sterile speculum (instruments to separate walls of the vagina to see the cervix) is introduced inside the vagina and then 0.4-0.6 ml of the prepared semen is inserted inside the uterus with the help of a small catheter (fine tube). IUI done, under ultrasound guidance, gives better result than IUI done without it. The patient is asked to lie down few minutes after taking out the catheter and the speculum. The medicines are advised and then they can go home. 

Is IUI painful?

Most women feel little discomfort during IUI but it should not be painful. If there is technical difficulty while putting catheter inside the uterus, your doctor will discuss it with you and in the next cycle, will plan management to solve this issue.

What happens if husband cannot collect semen?

Collection of semen in unfamiliar environment is understandably a matter of discomfort and seems awkward. Proper counseling and maintenance of privacy can help. Stress-free approach is needed. If it fails, do not hesitate to inform your doctor. Some medicines can help. But in those, who are unable to masturbate, there are some instruments, like ejaculator, can help to solve this problem.

What happens if sperm count is low?

IUI can be successful if sperm count is minimum more than 5 million per ml and there is reasonably good morphology and motility. If not, IVF or ICSI would be the better option. But IUI can serve as trial also. That means before putting the semen, the prepared sperms can be examined and it can be predicted what is the success rate of IUI in this particular case and whether IVF or ICSI would be needed. In rare occasions, where sperm count is extremely low but the couple do not wish for IVF or ICSI, pooled semen IUI can help- where the semen is collected in number of occasions and is preserved and the final pool is used for insemination, to give a reasonable success rate.

When donor sperm is used and how?

If a man does not have any sperms or too few sperms to do IUI, IVF or ICSI is not affordable, donor IUI is an alternative. But it is not done without consent from both husband and wife. The donor is not known to the couple or the doctor and no identity of the donor is revealed. No relative or friend can serve as donor. Donor semen is frozen semen, collected 6 months ago and the donor is tested for diseases like STD, HIV, Hepatitis B or C. Usual attempt is taken to chose donor having blood group and skin colour similar to those of the husband. But remember, it’s only given after discussion and written consent by the couple.

Can a couple have intercourse in the cycle where IUI is advised?

Intercourse around IUI increases the number of sperms available at the time of ovulation.

When should one check for pregnancy?

Usually if period does not come within 18 days after IUI, pregnancy test is advised. It can be done at home. If negative, then the cause of not having periods is sorted out.

What is the chance of success after IUI?

In one cycle, chance of success is around 20-25%. Most of the couples conceive after 3rd or 4th cycle of IUI. The chance of pregnancy after 6th cycle is low, so, usually IUI beyond 6 cycles is not advised.

The factors where IUI gives better results include unexplained infertility, sexual dysfunction of any of the partner, PCOS and male subfertility (low sperm count or motility)

What happens if IUI fails?

As said earlier, you should think about further treatment, if 3rd or 4th cycle of IUI fails. There is no use of doing IUI beyond 6 cycles, unless natural intercourse is not possible and the age is favourable. IVF gives better result.

Is there any harmful effect of IUI?

Very few harmful effects have been noted, for examples, hazards of ovulation induction (OHSS< twin pregnancy), pain, infection and discomfort. As mentined, if raw semen is given, unusual allergic reaction can happen.

How IUI is being done in your particular centre by Dr Sujoy Dasgupta?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We try to take nominal charges and help couples to collect medicines (particularly injections) at lower prices than MRPs.

After thorough evaluation of both the partners, we plan for ovulation induction drugs, with consent from them and advise them to come for TVS. After each day TVS, we explain the progress and probable timing of IUI.

On the day of IUI, after requesting the couple to maintain punctuality, we advise the husband to collect semen, in comfortable atmosphere, maintaining the privacy. If there is problem in semen collection, we provide support to him and address his issues in sensitive way.

Our expert trained embryologist then prepares the semen. We always encourage the couples to see the condition of raw and prepared semen under microscope to maintain the transparency.

We advise the woman to fill up the bladder (to take water and not to urinate) to facilitate the passage of IUI catheter. Unlike other places, we perform IUI inside OT to prevent unwanted infection.

Again we maintain our uniqueness in the sense that we perform it under ultrasound guidance. The ultrasound guidance has been scientifically proved to increase the success rate of IUI. Moreover, we show the woman in the ultrasound (real time) how the catheter has been put inside the uterus (to make sure that we are not doing IVI or have placed it in wrong position). This also helps to reduce patient’s anxiety and uncertainty. After that, our nurse takes care of the patient and observes her when she takes rest.

Then we advise the post-IUI medicines and advise them what to expect and when they can go home. Again, this time we try to answer all questions the couples can ask.

 

Conclusion

Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Often we find that patients planning for treatment and in the mean time, they conceive naturally. That means even without treatment, there is some chance of pregnancy. Of course, it’s stressful situation for both the partners. Stress affects conjugal relationships and lead to many couples avoiding conjugal life. Indeed stress can affect the hormone levels in females and affects sexual performances in males. It’s easier for us to advise you to stay stress-free but is difficult to practice. Nevertheless, try relaxation as much as possible. Think that majority of the couples ultimately conceive by some form of treatment. Have faith in yourself and have faith in your doctor.

20 people found this helpful

Fallopian Tube Block In Infertility - What Can You Do?

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
Fallopian Tube Block In Infertility - What Can You Do?

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires:

1.Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes

2.Transport of these sperms through the sperm conducting ducts from testes to penis

3.Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina

4.Transport of these sperms from vagina through cervix to the uterus and the tubes

5.Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries

6.Pick up of the eggs by the tubes

7.Approximation of eggs and the sperms to form the embryo

8.Transport of embryo from the tubes into the uterus

9.Acceptance of the embryo by the uterus and its growth

What is Infertility?

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.

Thus the common causes may be

1.Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.

2.Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examples include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.

3.Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out.

In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress.

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

What is Fallopian Tube(s)?

Fallopian tubes (commonly called “the tubes”) are the structures that are connected to the both sides of the uterus, as mentioned above. Each tube is of 10 cm length. The part attached to the uterus is called the “cornu” and the part remaining free is called the “fimbria”. It’s the fimbria, that is present near the ovary and picks up the ovum and transports it inside the tube. The cornu received the sperms from the uterus and passes it inside. Inside the tube, the sperms and the egg meet to form the embryo, which then travels down the tubes into the uterus and then the pregnancy starts.

What happens if tubes are blocked?

If both the tubes are blocked completely, anywhere along the length (cornu, fimbria or the middle), pregnancy is not possible. This is quite obvious, because either the sperm cannot enter or the egg is not picked up or they cannot meet.

However, if any of the tubes are partially blocked, then the sperms and egg can pass and meet but the embryo cannot come down into the uterus. As a result, the pregnancy continues inside the tube, which is called “Ectopic pregnancy” that is life-threatening for the mother. It’s important to remember that ectopic pregnancy can happen even if both the tubes are open.

What are the reasons for tubal blockage?

Often, the exact cause is not known. Infection is the commonest cause. The infections may be due to sexually transmitted infection (STI), particularly Chlamydia infection or infection from bowel or appendix. Tuberculosis is very common in our country and can affect the tubes, silently, without affecting any other parts (not even the lungs) of the body. Endometriosis is also a common reason for tubal blockage. Any pelvic surgery (surgery in ovaries, tubes, uterus, even appendix) can block the tubes by “adhesion”. This means the tube may be open but attached to the bowel or rotated on itself, so that the tube cannot pick up the eggs from the ovaries. Sometimes fibroid of uterus can compress the tube and cause blockage. Women, with previous history of ectopic pregnancy, are at risk. Uncommonly, some abnormalities, present since birth can block the tubes.

What are the types of tubal blockage?

Tubal block may be one sided or both sided. It may involve only a particular part of a tube or multiple parts of a tube. The site of the block may be the cornu, the fimbria or the middle portion.

Hydrosalpinx, is a thing that you must know. In this condition, the tube is blocked but the mid-portion is dilated and contains some fluid (often infected). This tube is not functional. And the problem is even if there is pregnancy by IVF inside the uterus, this fluid from the tube may trickle down, coming in contact with the embryo and can potentially kill the embryo!

How can I understand that the tubes are blocked?

Unfortunately, very few women have signs or symptoms indicating tubal block. However, if you had previous infections in pelvis, tuberculosis in any part of the body, appendicectomy or other gynaecological surgery, there is chance of tubal block. Patients with fibroid and endometriosis are also at risk of tubal block. If you feel severe pain during periods or during intercourse, there is a chance that the tubes may be blocked.

When the tubes should be tested?

As mentioned earlier, the routine investigation of infertility includes testing for the ‘open-ness’ of the tubes- “Tubal patency tests”. That means if pregnancy does not come within 12 months of regular intercourse, then we usually advise the tests. Sometimes, tests are needed, after 6 months of trying (see above). However, in some women, with low risk of tubal block (no risk factors as mentioned above), it may be appropriate to start treatment and continue it for few cycles and if no response, then tubes should be tested.

How the tubes are tested?

The method of tubal patency test depends on your risk of having blocked tubes and also your wishes, availability of resources, other fertility factors and of course the affordability.

Routine ultrasound (like TVS) cannot detect tubal patency. However, it can detect the hydrosalpinx in most of the cases.

If you do not have any risk factors (like pain during periods, endometriosis, previous infections or surgery), you can choose either HSG or SIS. These are done in out-door basis, without any need of anesthesia.

HSG (Hystero-salingogram) is a method by which, your tubes will be seen under Xray. After visualizing your cervix (mouth of the uterus) by a speculum (instrument inserted in the vagina) a small screw will be inserted inside the cervix and a contrast material (which can be seen by the X ray) will be given through it. If tubes are open, the Xray will show that the contrast material will be going through the tubes into the abdomen.

The advantage of HSG is that, a test showing open tube has good correlation with tubal patency (if HSG shows the tubes are open, it’s likely that tubes are open). It is widely available and also cheaper.

However, the problem is that most of the women feel it painful, although they are given pain-killers for it. In addition, there is small risk of infection, for which antibiotics are prescribed. The contrast material can rarely give rise to allergy in some sensitive women and it may be life-threatening in very rare cases. Another problem is the false positive result. That means if tubes are found to be blocked in HSG, in 50% cases, they will be found to be open subsequently in laparoscopy. This is mainly because of some spasm of the muscles of the tube during the test.

SIS (Saline infusion sonography) or HyCoSy (Hystero-Contrast-Sonography) is the method by which tubal patency is checked by ultrasound (TVS) along with water like material inserted inside the uterus through a small tube. If tubes are open, the passage of water can be seen going into the abdomen through the tubes, in the ultrasound.

The advantage of HyCoSy is that it’s much less painful than HSG, although mild discomfort may be there. Pain-killers and antibiotics are prescribed usually. Additionally, problems inside the uterus can be better visualized, even better than normal TVS. In addition, the false positive result is much lower, only 7%. That means if HyCoSy suggests that the tubes are blocked, in most cases, the tubes will be found to be blocked at laparoscopy.

The problem with HyCoSy is mainly the cost and it’s not available everywhere.

An important merit of doing the tubal test is that, sometimes the water or the contrast material used in these tests can open the “mild” block. That’s why we often find patients who conceive spontaneously with pregnancy inside the uterus, after apparently “blocked” tubes in HSG or HyCoSy.

Now, laparoscopy is reserved for those, who are at high risk of tubal block. This includes women with risk factors (pain, surgery, infection etc) o women having “blocked” tube in HSG or HyCoSy. Clearly, it’s done after hospitalization under general anaesthesia inside the OT. Two or three small opening (key-hole surgery) will be put inside the abdomen and through vagina a coloured material (“dye”) will be given inside the uterus. If the tubes are open, the laparoscopic camera will show that dyes coming out of the tubes inside the abdomen.

The advantage is that it’s a definitive test, can help you to make final decision. It also provides the options of treatment. If there is corneal block in HSG, we can make attempt to open the tubes using laparoscopy (see below). In addition, if there is hydrosalpinx, where the tube serves no function, the tubes can be removed (salpingectomy) or clipped (we put clips to block the tubes) to improve the chance of pregnancy if IVF is the only option left for you. In addition, laparoscopy helps us to see whether there is any other diseases that have been missed by routine tests and that may account for infertility. We can treat the cysts of PCOS (by applying current to destroy some cysts), remove any large cysts, remove any adhesion, treat endometriosis etc.

The disadvantage of laparoscopy is of course, the need of anaesthesia and associated surgical and anaesthetic risks, although in modern era, the serious complications are uncommon.

What are my options if tubes are found to be blocked in HSG?

There are simply two options. It depends on your age, fertility factors and affordability. Number one is directly, you can go for IVF. In that case, you can save time and cost. It may be a preferred option, if you are aged or have some other fertility factors (low sperm count, endometriosis etc). The chance of pregnancy per cycle of IVF is usually 40%.

Another option is that you can confirm the block by other tests, keeping in mind that you may need IVF if the tubes are found blocked ultimately. We usually advise to have laparoscopy. However, some women want to give a trial with HyCoSy, because if HyCoSy shows the tubes are open, then you can avoid laparoscopy and you can try different fertility treatment options.

In laparoscopy, first we see if tubes are open or not. If open, there is no need of further treatment in laparoscopy. However, if tubes are found blocked, especially if the block is in cornu, we can try “hysteroscopic tubal cannulation”, where we put a small catheter through hysteroscope (a telescope, like endoscope, put inside the uterus through vagina so that we can see inside the uterus using a camera) to open the tubes. If tubes can be opened, you have all options for fertility treatment open. However, if we fail to open the tubes, the only option left is IVF. In addition, if there is fimbrial block, it can be released and new opening in the fimbria can be made. The treatment of hydrosalpinx by laparoscopy has already been discussed (see above).

Having said that, there are some group of women, who conceive while waiting for IVF or laparoscopy after a blocked tube found in HSG.

What can I do if tubes are blocked in Hycosy?

In this case also, there is choice between the two- laparoscopy first and IVF directly.

What can I do if laparoscopy suggests tubal block?

Unfortunately, in that case, the only option left is IVF. As mentioned before, if hydrosalpinx is found it must be treated before IVF. However, sometimes we find hydrosalpinx in laparoscopy but cannot cut the tube of clip it, simply because you did not give consent to us for doing so. In that case, we can suck out (“aspirate”) the fluid from the hydrosalpinx under ultrasound guidance (no need of further laparoscopy) using the needle.

How tubal block is dealt in your particular centre?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We prefer to have SIS or Hycosy, rather than HSG, to reduce the pain to the women. We discuss all the options if tubes are found blocked.

Conclusion:

Tubal factor can account for 20-25% cases of female infertility. It’s more common in secondary infertility (women who conceived earlier- whatever be the fate of the pregnancy). Tubal test is a part of infertility investigation. The choice between HSG and HyCoCy is open to you. If tubes are found blocked, the options are IVF directly or confirming the block by laparoscopy.​

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Fallopian Tube Block in Infertility- What you can do?

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
Fallopian Tube Block in Infertility- What you can do?

Introduction

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires

1.Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes

2.Transport of these sperms through the sperm conducting ducts from testes to penis

3.Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina

4.Transport of these sperms from vagina through cervix to the uterus and the tubes

5.Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries

6.Pick up of the eggs by the tubes

7.Approximation of eggs and the sperms to form the embryo

8.Transport of embryo from the tubes into the uterus

9.Acceptance of the embryo by the uterus and its growth

What is Infertility?

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.

Thus the common causes may be

1.Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.

2.Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examples include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.

3.Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out.

In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress.

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

What is Fallopian Tube(s)?

Fallopian tubes (commonly called “the tubes”) are the structures that are connected to the both sides of the uterus, as mentioned above. Each tube is of 10 cm length. The part attached to the uterus is called the “cornu” and the part remaining free is called the “fimbria”. It’s the fimbria, that is present near the ovary and picks up the ovum and transports it inside the tube. The cornu received the sperms from the uterus and passes it inside. Inside the tube, the sperms and the egg meet to form the embryo, which then travels down the tubes into the uterus and then the pregnancy starts.

What happens if tubes are blocked?

If both the tubes are blocked completely, anywhere along the length (cornu, fimbria or the middle), pregnancy is not possible. This is quite obvious, because either the sperm cannot enter or the egg is not picked up or they cannot meet.

However, if any of the tubes are partially blocked, then the sperms and egg can pass and meet but the embryo cannot come down into the uterus. As a result, the pregnancy continues inside the tube, which is called “Ectopic pregnancy” that is life-threatening for the mother. It’s important to remember that ectopic pregnancy can happen even if both the tubes are open.

What are the reasons for tubal blockage?

Often, the exact cause is not known. Infection is the commonest cause. The infections may be due to sexually transmitted infection (STI), particularly Chlamydia infection or infection from bowel or appendix. Tuberculosis is very common in our country and can affect the tubes, silently, without affecting any other parts (not even the lungs) of the body. Endometriosis is also a common reason for tubal blockage. Any pelvic surgery (surgery in ovaries, tubes, uterus, even appendix) can block the tubes by “adhesion”. This means the tube may be open but attached to the bowel or rotated on itself, so that the tube cannot pick up the eggs from the ovaries. Sometimes fibroid of uterus can compress the tube and cause blockage. Women, with previous history of ectopic pregnancy, are at risk. Uncommonly, some abnormalities, present since birth can block the tubes.

What are the types of tubal blockage?

Tubal block may be one sided or both sided. It may involve only a particular part of a tube or multiple parts of a tube. The site of the block may be the cornu, the fimbria or the middle portion.

Hydrosalpinx, is a thing that you must know. In this condition, the tube is blocked but the mid-portion is dilated and contains some fluid (often infected). This tube is not functional. And the problem is even if there is pregnancy by IVF inside the uterus, this fluid from the tube may trickle down, coming in contact with the embryo and can potentially kill the embryo!

How can I understand that the tubes are blocked?

Unfortunately, very few women have signs or symptoms indicating tubal block. However, if you had previous infections in pelvis, tuberculosis in any part of the body, appendicectomy or other gynaecological surgery, there is chance of tubal block. Patients with fibroid and endometriosis are also at risk of tubal block. If you feel severe pain during periods or during intercourse, there is a chance that the tubes may be blocked.

When the tubes should be tested?

As mentioned earlier, the routine investigation of infertility includes testing for the ‘open-ness’ of the tubes- “Tubal patency tests”. That means if pregnancy does not come within 12 months of regular intercourse, then we usually advise the tests. Sometimes, tests are needed, after 6 months of trying (see above). However, in some women, with low risk of tubal block (no risk factors as mentioned above), it may be appropriate to start treatment and continue it for few cycles and if no response, then tubes should be tested.

How the tubes are tested?

The method of tubal patency test depends on your risk of having blocked tubes and also your wishes, availability of resources, other fertility factors and of course the affordability.

Routine ultrasound (like TVS) cannot detect tubal patency. However, it can detect the hydrosalpinx in most of the cases.

If you do not have any risk factors (like pain during periods, endometriosis, previous infections or surgery), you can choose either HSG or SIS. These are done in out-door basis, without any need of anesthesia.

HSG (Hystero-salingogram) is a method by which, your tubes will be seen under Xray. After visualizing your cervix (mouth of the uterus) by a speculum (instrument inserted in the vagina) a small screw will be inserted inside the cervix and a contrast material (which can be seen by the X ray) will be given through it. If tubes are open, the Xray will show that the contrast material will be going through the tubes into the abdomen.

The advantage of HSG is that, a test showing open tube has good correlation with tubal patency (if HSG shows the tubes are open, it’s likely that tubes are open). It is widely available and also cheaper.

However, the problem is that most of the women feel it painful, although they are given pain-killers for it. In addition, there is small risk of infection, for which antibiotics are prescribed. The contrast material can rarely give rise to allergy in some sensitive women and it may be life-threatening in very rare cases. Another problem is the false positive result. That means if tubes are found to be blocked in HSG, in 50% cases, they will be found to be open subsequently in laparoscopy. This is mainly because of some spasm of the muscles of the tube during the test.

SIS (Saline infusion sonography) or HyCoSy (Hystero-Contrast-Sonography) is the method by which tubal patency is checked by ultrasound (TVS) along with water like material inserted inside the uterus through a small tube. If tubes are open, the passage of water can be seen going into the abdomen through the tubes, in the ultrasound.

The advantage of HyCoSy is that it’s much less painful than HSG, although mild discomfort may be there. Pain-killers and antibiotics are prescribed usually. Additionally, problems inside the uterus can be better visualized, even better than normal TVS. In addition, the false positive result is much lower, only 7%. That means if HyCoSy suggests that the tubes are blocked, in most cases, the tubes will be found to be blocked at laparoscopy.

The problem with HyCoSy is mainly the cost and it’s not available everywhere.

An important merit of doing the tubal test is that, sometimes the water or the contrast material used in these tests can open the “mild” block. That’s why we often find patients who conceive spontaneously with pregnancy inside the uterus, after apparently “blocked” tubes in HSG or HyCoSy.

Now, laparoscopy is reserved for those, who are at high risk of tubal block. This includes women with risk factors (pain, surgery, infection etc) o women having “blocked” tube in HSG or HyCoSy. Clearly, it’s done after hospitalization under general anaesthesia inside the OT. Two or three small opening (key-hole surgery) will be put inside the abdomen and through vagina a coloured material (“dye”) will be given inside the uterus. If the tubes are open, the laparoscopic camera will show that dyes coming out of the tubes inside the abdomen.

The advantage is that it’s a definitive test, can help you to make final decision. It also provides the options of treatment. If there is corneal block in HSG, we can make attempt to open the tubes using laparoscopy (see below). In addition, if there is hydrosalpinx, where the tube serves no function, the tubes can be removed (salpingectomy) or clipped (we put clips to block the tubes) to improve the chance of pregnancy if IVF is the only option left for you. In addition, laparoscopy helps us to see whether there is any other diseases that have been missed by routine tests and that may account for infertility. We can treat the cysts of PCOS (by applying current to destroy some cysts), remove any large cysts, remove any adhesion, treat endometriosis etc.

The disadvantage of laparoscopy is of course, the need of anaesthesia and associated surgical and anaesthetic risks, although in modern era, the serious complications are uncommon.

What are my options if tubes are found to be blocked in HSG?

There are simply two options. It depends on your age, fertility factors and affordability. Number one is directly, you can go for IVF. In that case, you can save time and cost. It may be a preferred option, if you are aged or have some other fertility factors (low sperm count, endometriosis etc). The chance of pregnancy per cycle of IVF is usually 40%.

Another option is that you can confirm the block by other tests, keeping in mind that you may need IVF if the tubes are found blocked ultimately. We usually advise to have laparoscopy. However, some women want to give a trial with HyCoSy, because if HyCoSy shows the tubes are open, then you can avoid laparoscopy and you can try different fertility treatment options.

In laparoscopy, first we see if tubes are open or not. If open, there is no need of further treatment in laparoscopy. However, if tubes are found blocked, especially if the block is in cornu, we can try “hysteroscopic tubal cannulation”, where we put a small catheter through hysteroscope (a telescope, like endoscope, put inside the uterus through vagina so that we can see inside the uterus using a camera) to open the tubes. If tubes can be opened, you have all options for fertility treatment open. However, if we fail to open the tubes, the only option left is IVF. In addition, if there is fimbrial block, it can be released and new opening in the fimbria can be made. The treatment of hydrosalpinx by laparoscopy has already been discussed (see above).

Having said that, there are some group of women, who conceive while waiting for IVF or laparoscopy after a blocked tube found in HSG.

What can I do if tubes are blocked in HyCoSy?

In this case also, there is choice between the two- laparoscopy first and IVF directly.

What can I do if laparoscopy suggests tubal block?

Unfortunately, in that case, the only option left is IVF. As mentioned before, if hydrosalpinx is found it must be treated before IVF. However, sometimes we find hydrosalpinx in laparoscopy but cannot cut the tube of clip it, simply because you did not give consent to us for doing so. In that case, we can suck out (“aspirate”) the fluid from the hydrosalpinx under ultrasound guidance (no need of further laparoscopy) using the needle.

How tubal block is dealt in your particular centre by Dr Sujoy Dasgupta?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We prefer to have SIS or HyCoSy, rather than HSG, to reduce the pain to the women. We discuss all the options if tubes are found blocked.

Conclusion

Tubal factor can account for 20-25% cases of female infertility. It’s more common in secondary infertility (women who conceived earlier- whatever be the fate of the pregnancy). Tubal test is a part of infertility investigation. The choice between HSG and HyCoCy is open to you. If tubes are found blocked, the options are IVF directly or confirming the block by laparoscopy.

Fallopian Tube Block in Infertility- What you can do?

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata

Introduction

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

 In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires

  1. Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes
  2. Transport of these sperms through the sperm conducting ducts from testes to penis
  3. Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina
  4. Transport of these sperms from vagina through cervix to the uterus and the tubes
  5. Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
  6. Pick up of the eggs by the tubes
  7. Approximation of eggs and the sperms to form the embryo
  8. Transport of embryo from the tubes into the uterus
  9. Acceptance of the embryo by the uterus and its growth

What is Infertility?

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.

Thus the common causes may be

  1. Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
  2. Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examples include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
  3. Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out. 

In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress.

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

What is Fallopian Tube(s)?

Fallopian tubes (commonly called “the tubes”) are the structures that are connected to the both sides of the uterus, as mentioned above. Each tube is of 10 cm length. The part attached to the uterus is called the “cornu” and the part remaining free is called the “fimbria”. It’s the fimbria, that is present near the ovary and picks up the ovum and transports it inside the tube. The cornu received the sperms from the uterus and passes it inside. Inside the tube, the sperms and the egg meet to form the embryo, which then travels down the tubes into the uterus and then the pregnancy starts.

What happens if tubes are blocked?

If both the tubes are blocked completely, anywhere along the length (cornu, fimbria or the middle), pregnancy is not possible. This is quite obvious, because either the sperm cannot enter or the egg is not picked up or they cannot meet.

However, if any of the tubes are partially blocked, then the sperms and egg can pass and meet but the embryo cannot come down into the uterus. As a result, the pregnancy continues inside the tube, which is called “Ectopic pregnancy” that is life-threatening for the mother. It’s important to remember that ectopic pregnancy can happen even if both the tubes are open.

What are the reasons for tubal blockage?

Often, the exact cause is not known. Infection is the commonest cause. The infections may be due to sexually transmitted infection (STI), particularly Chlamydia infection or infection from bowel or appendix. Tuberculosis is very common in our country and can affect the tubes, silently, without affecting any other parts (not even the lungs) of the body. Endometriosis is also a common reason for tubal blockage. Any pelvic surgery (surgery in ovaries, tubes, uterus, even appendix) can block the tubes by “adhesion”. This means the tube may be open but attached to the bowel or rotated on itself, so that the tube cannot pick up the eggs from the ovaries. Sometimes fibroid of uterus can compress the tube and cause blockage. Women, with previous history of ectopic pregnancy, are at risk. Uncommonly, some abnormalities, present since birth can block the tubes.

What are the types of tubal blockage?

Tubal block may be one sided or both sided. It may involve only a particular part of a tube or multiple parts of a tube. The site of the block may be the cornu, the fimbria or the middle portion.

Hydrosalpinx, is a thing that you must know. In this condition, the tube is blocked but the mid-portion is dilated and contains some fluid (often infected). This tube is not functional. And the problem is even if there is pregnancy by IVF inside the uterus, this fluid from the tube may trickle down, coming in contact with the embryo and can potentially kill the embryo!

How can I understand that the tubes are blocked?

Unfortunately, very few women have signs or symptoms indicating tubal block. However, if you had previous infections in pelvis, tuberculosis in any part of the body, appendicectomy or other gynaecological surgery, there is chance of tubal block. Patients with fibroid and endometriosis are also at risk of tubal block. If you feel severe pain during periods or during intercourse, there is a chance that the tubes may be blocked.

When the tubes should be tested?

As mentioned earlier, the routine investigation of infertility includes testing for the ‘open-ness’ of the tubes- “Tubal patency tests”. That means if pregnancy does not come within 12 months of regular intercourse, then we usually advise the tests. Sometimes, tests are needed, after 6 months of trying (see above). However, in some women, with low risk of tubal block (no risk factors as mentioned above), it may be appropriate to start treatment and continue it for few cycles and if no response, then tubes should be tested.

How the tubes are tested?

The method of tubal patency test depends on your risk of having blocked tubes and also your wishes, availability of resources, other fertility factors and of course the affordability.

Routine ultrasound (like TVS) cannot detect tubal patency. However, it can detect the hydrosalpinx in most of the cases.

If you do not have any risk factors (like pain during periods, endometriosis, previous infections or surgery), you can choose either HSG or SIS. These are done in out-door basis, without any need of anesthesia.

HSG (Hystero-salingogram) is a method by which, your tubes will be seen under Xray. After visualizing your cervix (mouth of the uterus) by a speculum (instrument inserted in the vagina) a small screw will be inserted inside the cervix and a contrast material (which can be seen by the X ray) will be given through it. If tubes are open, the Xray will show that the contrast material will be going through the tubes into the abdomen.

The advantage of HSG is that, a test showing open tube has good correlation with tubal patency (if HSG shows the tubes are open, it’s likely that tubes are open). It is widely available and also cheaper.

However, the problem is that most of the women feel it painful, although they are given pain-killers for it. In addition, there is small risk of infection, for which antibiotics are prescribed. The contrast material can rarely give rise to allergy in some sensitive women and it may be life-threatening in very rare cases. Another problem is the false positive result. That means if tubes are found to be blocked in HSG, in 50% cases, they will be found to be open subsequently in laparoscopy. This is mainly because of some spasm of the muscles of the tube during the test.

SIS (Saline infusion sonography) or HyCoSy (Hystero-Contrast-Sonography) is the method by which tubal patency is checked by ultrasound (TVS) along with water like material inserted inside the uterus through a small tube. If tubes are open, the passage of water can be seen going into the abdomen through the tubes, in the ultrasound.

The advantage of HyCoSy is that it’s much less painful than HSG, although mild discomfort may be there. Pain-killers and antibiotics are prescribed usually. Additionally, problems inside the uterus can be better visualized, even better than normal TVS. In addition, the false positive result is much lower, only 7%. That means if HyCoSy suggests that the tubes are blocked, in most cases, the tubes will be found to be blocked at laparoscopy.

The problem with HyCoSy is mainly the cost and it’s not available everywhere.

An important merit of doing the tubal test is that, sometimes the water or the contrast material used in these tests can open the “mild” block. That’s why we often find patients who conceive spontaneously with pregnancy inside the uterus, after apparently “blocked” tubes in HSG or HyCoSy.

Now, laparoscopy is reserved for those, who are at high risk of tubal block. This includes women with risk factors (pain, surgery, infection etc) o women having “blocked” tube in HSG or HyCoSy. Clearly, it’s done after hospitalization under general anaesthesia inside the OT. Two or three small opening (key-hole surgery) will be put inside the abdomen and through vagina a coloured material (“dye”) will be given inside the uterus. If the tubes are open, the laparoscopic camera will show that dyes coming out of the tubes inside the abdomen.

The advantage is that it’s a definitive test, can help you to make final decision. It also provides the options of treatment. If there is corneal block in HSG, we can make attempt to open the tubes using laparoscopy (see below). In addition, if there is hydrosalpinx, where the tube serves no function, the tubes can be removed (salpingectomy) or clipped (we put clips to block the tubes) to improve the chance of pregnancy if IVF is the only option left for you. In addition, laparoscopy helps us to see whether there is any other diseases that have been missed by routine tests and that may account for infertility. We can treat the cysts of PCOS (by applying current to destroy some cysts), remove any large cysts, remove any adhesion, treat endometriosis etc.

The disadvantage of laparoscopy is of course, the need of anaesthesia and associated surgical and anaesthetic risks, although in modern era, the serious complications are uncommon.

What are my options if tubes are found to be blocked in HSG?

There are simply two options. It depends on your age, fertility factors and affordability. Number one is directly, you can go for IVF. In that case, you can save time and cost. It may be a preferred option, if you are aged or have some other fertility factors (low sperm count, endometriosis etc). The chance of pregnancy per cycle of IVF is usually 40%.

Another option is that you can confirm the block by other tests, keeping in mind that you may need IVF if the tubes are found blocked ultimately. We usually advise to have laparoscopy. However, some women want to give a trial with HyCoSy, because if HyCoSy shows the tubes are open, then you can avoid laparoscopy and you can try different fertility treatment options.

In laparoscopy, first we see if tubes are open or not. If open, there is no need of further treatment in laparoscopy. However, if tubes are found blocked, especially if the block is in cornu, we can try “hysteroscopic tubal cannulation”, where we put a small catheter through hysteroscope (a telescope, like endoscope, put inside the uterus through vagina so that we can see inside the uterus using a camera) to open the tubes. If tubes can be opened, you have all options for fertility treatment open.  However, if we fail to open the tubes, the only option left is IVF. In addition, if there is fimbrial block, it can be released and new opening in the fimbria can be made. The treatment of hydrosalpinx by laparoscopy has already been discussed (see above).

Having said that, there are some group of women, who conceive while waiting for IVF or laparoscopy after a blocked tube found in HSG.

What can I do if tubes are blocked in HyCoSy?

In this case also, there is choice between the two- laparoscopy first and IVF directly.

What can I do if laparoscopy suggests tubal block?

Unfortunately, in that case, the only option left is IVF. As mentioned before, if hydrosalpinx is found it must be treated before IVF. However, sometimes we find hydrosalpinx in laparoscopy but cannot cut the tube of clip it, simply because you did not give consent to us for doing so. In that case, we can suck out (“aspirate”) the fluid from the hydrosalpinx under ultrasound guidance (no need of further laparoscopy) using the needle.

How tubal block is dealt in your particular centre by Dr Sujoy Dasgupta?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We prefer to have SIS or HyCoSy, rather than HSG, to reduce the pain to the women. We discuss all the options if tubes are found blocked.

Conclusion

Tubal factor can account for 20-25% cases of female infertility. It’s more common in secondary infertility (women who conceived earlier- whatever be the fate of the pregnancy). Tubal test is a part of infertility investigation. The choice between HSG and HyCoCy is open to you. If tubes are found blocked, the options are IVF directly or confirming the block by laparoscopy.

IUI (Intrauterine Insemination)- Treatment Option for Infertile Couples

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
IUI (Intrauterine Insemination)- Treatment Option for Infertile Couples

Introduction

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina. 

 In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm. 

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires

  1. Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes
  2. Transport of these sperms through the sperm conducting ducts from testes to penis
  3. Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina
  4. Transport of these sperms from vagina through cervix to the uterus and the tubes
  5. Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
  6. Pick up of the eggs by the tubes 
  7. Approximation of eggs and the sperms to form the embryo
  8. Transport of embryo from the tubes into the uterus
  9. Acceptance of the embryo by the uterus and its growth

What is Infertility?

 

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor. 

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%. 

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage. 

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned. 

Thus the common causes may be

  1. Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
  2. Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examles include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
  3. Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out.  

In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress. 

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

What is insemination?

Insemination literally means putting semen in a particular place. Various forms of insemination exist in fertility treatment. First one is “Intravaginal Insemination (IVI)”, where the raw semen, collected by the husband can be put inside the vagina, taking precautions (to prevent infection) by the husband himself or by the wife. Rarely, it needs medical assistance from a doctor. It’s usually advised to couples having sexual disorders where full penetrative intercourse is not possible (erectile dysfunction of the husband or very painful intercourse experienced by the wife) or where ejaculation cannot happen during intercourse (a very unusual problem). Thus, the success rate of IVI is no better than natural intercourse (success rate 15% per cycle), for those couples who can manage successful intercourse. 

“Intrauterine Insemination (IUI)” is the treatment where “prepared” semen is put inside the cavity of the uterus, near the Fallopian tubes. Thus, IUI bypasses some hurdles that can cause problems during natural intercourse. The vagina, cervix and the whole length of the uterus are bypassed, putting the sperms near the eggs. Thus it increases the success rate compared to natural intercourse or IVI.

However, to achieve pregnancy after IUI, the female partner must have open tubes, adequate number of eggs produced by ovaries, eggs must be released by the ovaries and sperms must meet the eggs. And, thus nature plays important role, as in natural intercourse.

Please note, we used the word “prepared” semen. In natural intercourse, as mentioned earlier, the dead sperms and bacteria cannot enter the uterus, because cervix prevents their entry. If they are put artificially by IUI inside the uterus, severe reaction can happen. So, after collection, the husband’s semen is processed in the laboratory to remove all those impurities and to select only the best number of healthy and movable sperms and it definitely increases success rates of IUI

When IUI is generally advised?

As you can understand, to perform IUI, there must be minimum number of sperms in the semen, the tubes must be opened, the ovaries must be releasing eggs. If these are present, IUI is usually advised 

  • Less than adequate number of sperm counts, morphology or motility
  • Couples who cannot perform full penetrative intercourse but refuse or unable to conceive by IVI
  • Unexplained infertility- although IVF is better than IUI, but considering the cost, many couples in our country opt for 2-3 cycles of IUI before IVF
  • PCOS and Mild Endometriosis- where natural intercourse or ovulation induction failed
  • Couples in whom only one partner is positive for HIV or Hepatitis B or C- where transmission from one partner to another by unprotected sexual intercourse is not preferable.

What are the tests done before IUI?

The basic infertility evaluation is done before IUI include husband’s semen analysis, assessment of ovarian function (blood tests, ultrasound) and uterus (ultrasound). In some cases, laparoscopy (putting camera to see inside the abdomen by operation) or hysteroscopy (putting camera through vagina inside the uterus, by operation) may be required. Now, if the tubes are blocked, IUI is of no use. So, testing the tubes is advisable before IUI. But some women, who are at low risk of tubal disease (no history of pelvic pain, infection or surgery), one or two cycles of IUI can be done, failing which tubes must be checked by tests like HSG or SSG or in some cases by laparoscopy. 

What IUI actually involves?

In the cycle, in which IUI is planned, the woman is asked to take some medicines (or injections) in particular days of the periods as a part of “ovulation induction”. She is then advised to have ultrasound monitoring (TVS- transvaginal sonogram- where ultrasound probe is placed inside the vagina for better accuracy) to see if eggs are growing in response to the medicines or not. If eggs are growing, IUI is planned in a particular time when the egg(s) is more likely to rupture, so that the tie interval between sperm entry and egg release can be kept as minimum as possible. 

Is ovulation Induction necessary for IUI?

Frankly speaking, IUI can be done without any medicines (as in case of natural intercourse or IVI), which is called “Natural Cycle IUI”, where only TVS monitoring is done to see how the eggs are growing. This may avoid some side effects of ovulation induction (see below) but is associated with low success rate than IUI done along with ovulation induction.

Is TVS necessary before IUI?

TVS is, undoubtedly, uncomfortable for the woman. But it gives better picture than ultrasound done conventionally. Now, the question is, whether ultrasound monitoring is at all needed or not. TVS directs the doctor how eggs are growing and at what number and size and when they are likely to rupture. Moreover, the rupture can also be confirmed by TVS. Again, the uncommon side effect of ovulation induction can be detected by TVS. That is called OHSS (“Ovarian Hyperstimulation Syndrome”) where excessive eggs can grow inside the ovaries and this can lead to collection of fluid inside abdomen and lungs and can turn very serious. Although very rare, it can be detected by TVS and early actions can be taken to prevent the progress of this condition. 

In rare cases, where TVS cannot be done or patient declines, only option is to check urine by LH kit to predict the likely timing of ovulation and at that time IUI is planned. However, it is less accurate than TVS monitoring and is associated with less success.

What, if eggs are not growing in the ovaries?

In some women, particularly those who are overweight, aged or some cases of PCOS, eggs may not respond initially to one medicine. There are various forms of ovulation induction medicines (tablets, injection). If one is not working, your doctor can try increasing the dose of that medicine or add or replace it with other medicines. Please remember, it’s difficult to predict what medicine will be best suited for a particular patient. So, it’s basically a trial and error process.

What is done on the day of IUI?

As timing is important, the couples are requested to stick to the timing, advised by the doctor. The husband will be asked to collect the semen by masturbation, using clean technique (to avoid contamination by germs in the semen container). The semen is then prepared by the embryologist and will be checked to see the final number of sperms and their motility and morphology.

The wife is asked to lie down in the IUI table. After cleaning, a sterile speculum (instruments to separate walls of the vagina to see the cervix) is introduced inside the vagina and then 0.4-0.6 ml of the prepared semen is inserted inside the uterus with the help of a small catheter (fine tube). IUI done, under ultrasound guidance, gives better result than IUI done without it. The patient is asked to lie down few minutes after taking out the catheter and the speculum. The medicines are advised and then they can go home.  

Is IUI painful?

Most women feel little discomfort during IUI but it should not be painful. If there is technical difficulty while putting catheter inside the uterus, your doctor will discuss it with you and in the next cycle, will plan management to solve this issue.

What happens if husband cannot collect semen?

Collection of semen in unfamiliar environment is understandably a matter of discomfort and seems awkward. Proper counseling and maintenance of privacy can help. Stress-free approach is needed. If it fails, do not hesitate to inform your doctor. Some medicines can help. But in those, who are unable to masturbate, there are some instruments, like ejaculator, can help to solve this problem.

What happens if sperm count is low?

IUI can be successful if sperm count is minimum more than 5 million per ml and there is reasonably good morphology and motility. If not, IVF or ICSI would be the better option. But IUI can serve as trial also. That means before putting the semen, the prepared sperms can be examined and it can be predicted what is the success rate of IUI in this particular case and whether IVF or ICSI would be needed. In rare occasions, where sperm count is extremely low but the couple do not wish for IVF or ICSI, pooled semen IUI can help- where the semen is collected in number of occasions and is preserved and the final pool is used for insemination, to give a reasonable success rate.

When donor sperm is used and how?

If a man does not have any sperms or too few sperms to do IUI, IVF or ICSI is not affordable, donor IUI is an alternative. But it is not done without consent from both husband and wife. The donor is not known to the couple or the doctor and no identity of the donor is revealed. No relative or friend can serve as donor. Donor semen is frozen semen, collected 6 months ago and the donor is tested for diseases like STD, HIV, Hepatitis B or C. Usual attempt is taken to chose donor having blood group and skin colour similar to those of the husband. But remember, it’s only given after discussion and written consent by the couple. 

Can a couple have intercourse in the cycle where IUI is advised?

Intercourse around IUI increases the number of sperms available at the time of ovulation.

When should one check for pregnancy?

Usually if period does not come within 18 days after IUI, pregnancy test is advised. It can be done at home. If negative, then the cause of not having periods is sorted out.

What is the chance of success after IUI?

In one cycle, chance of success is around 20-25%. Most of the couples conceive after 3rd or 4th cycle of IUI. The chance of pregnancy after 6th cycle is low, so, usually IUI beyond 6 cycles is not advised.

The factors where IUI gives better results include unexplained infertility, sexual dysfunction of any of the partner, PCOS and male subfertility (low sperm count or motility)

What happens if IUI fails?

As said earlier, you should think about further treatment, if 3rd or 4th cycle of IUI fails. There is no use of doing IUI beyond 6 cycles, unless natural intercourse is not possible and the age is favourable. IVF gives better result. 

Is there any harmful effect of IUI?

Very few harmful effects have been noted, for examples, hazards of ovulation induction (OHSS< twin pregnancy), pain, infection and discomfort. As mentined, if raw semen is given, unusual allergic reaction can happen.

How IUI is being done in your particular centre by Dr Sujoy Dasgupta?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We try to take nominal charges and help couples to collect medicines (particularly injections) at lower prices than MRPs.

After thorough evaluation of both the partners, we plan for ovulation induction drugs, with consent from them and advise them to come for TVS. After each day TVS, we explain the progress and probable timing of IUI.

On the day of IUI, after requesting the couple to maintain punctuality, we advise the husband to collect semen, in comfortable atmosphere, maintaining the privacy. If there is problem in semen collection, we provide support to him and address his issues in sensitive way.

Our expert trained embryologist then prepares the semen. We always encourage the couples to see the condition of raw and prepared semen under microscope to maintain the transparency. 

We advise the woman to fill up the bladder (to take water and not to urinate) to facilitate the passage of IUI catheter. Unlike other places, we perform IUI inside OT to prevent unwanted infection. 

Again we maintain our uniqueness in the sense that we perform it under ultrasound guidance. The ultrasound guidance has been scientifically proved to increase the success rate of IUI. Moreover, we show the woman in the ultrasound (real time) how the catheter has been put inside the uterus (to make sure that we are not doing IVI or have placed it in wrong position). This also helps to reduce patient’s anxiety and uncertainty. After that, our nurse takes care of the patient and observes her when she takes rest. 

Then we advise the post-IUI medicines and advise them what to expect and when they can go home. Again, this time we try to answer all questions the couples can ask.

 

Conclusion

Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Often we find that patients planning for treatment and in the mean time, they conceive naturally. That means even without treatment, there is some chance of pregnancy. Of course, it’s stressful situation for both the partners. Stress affects conjugal relationships and lead to many couples avoiding conjugal life. Indeed stress can affect the hormone levels in females and affects sexual performances in males. It’s easier for us to advise you to stay stress-free but is difficult to practice. Nevertheless, try relaxation as much as possible. Think that majority of the couples ultimately conceive by some form of treatment. Have faith in yourself and have faith in your doctor.

1 person found this helpful

IUI (Intrauterine Insemination)- Treatment Option for Infertile Couples

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
IUI (Intrauterine Insemination)- Treatment Option for Infertile Couples

Introduction
When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be mom and dad, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a full life.

What is needed for pregnancy?
In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires


    Production of healthy (normal morphology) and movable (normal motility) sperms in adequate number (normal count) in the testes
    Transport of these sperms through the sperm conducting ducts from testes to penis
    Successful erection and ejaculation during intercourse to deposit adequate number of these sperms in the vagina
    Transport of these sperms from vagina through cervix to the uterus and the tubes
    Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
    Pick up of the eggs by the tubes
    Approximation of eggs and the sperms to form the embryo
    Transport of embryo from the tubes into the uterus
    Acceptance of the embryo by the uterus and its growth


What is infertility?
Literally, the word infertility means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called absolutely infertile. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word regular and frequent are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, subfertility seems better and more scientific than infertility, to describe the couples who have reduced chance of conception, due to any cause. However, the word infertility, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like pcos or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes infertility?
Please look at the point thus, to summarise, pregnancy requires where 9 points have been mentioned.

Thus the common causes may be


    Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- erectile dysfunction or less commonly, ejaculatory dysfunction). Examples include hormonal problems (testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
    Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examples include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (pcos), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (pid), tuberculosis (tb), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
    Unknown causes- despite thorough investigations, 25-30% causes of infertility remain unknown. This is called  unexplained infertility. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (iui, ivf or icsi), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out. 


In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it's very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It's quite natural that you might be in stress.

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which iui and finally ivf is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, ivf would be the first line of treatment.

What is insemination?
Insemination literally means putting semen in a particular place. Various forms of insemination exist in fertility treatment. First one is intravaginal insemination (ivi), where the raw semen, collected by the husband can be put inside the vagina, taking precautions (to prevent infection) by the husband himself or by the wife. Rarely, it needs medical assistance from a doctor. It's usually advised to couples having sexual disorders where full penetrative intercourse is not possible (erectile dysfunction of the husband or very painful intercourse experienced by the wife) or where ejaculation cannot happen during intercourse (a very unusual problem). Thus, the success rate of ivi is no better than natural intercourse (success rate 15% per cycle), for those couples who can manage successful intercourse.

intrauterine insemination (iui) is the treatment where prepared semen is put inside the cavity of the uterus, near the fallopian tubes. Thus, iui bypasses some hurdles that can cause problems during natural intercourse. The vagina, cervix and the whole length of the uterus are bypassed, putting the sperms near the eggs. Thus it increases the success rate compared to natural intercourse or ivi.

However, to achieve pregnancy after iui, the female partner must have open tubes, adequate number of eggs produced by ovaries, eggs must be released by the ovaries and sperms must meet the eggs. And, thus nature plays important role, as in natural intercourse.

Please note, we used the word &#x201c;prepared&#x201d; semen. In natural intercourse, as mentioned earlier, the dead sperms and bacteria cannot enter the uterus, because cervix prevents their entry. If they are put artificially by iui inside the uterus, severe reaction can happen. So, after collection, the husband's semen is processed in the laboratory to remove all those impurities and to select only the best number of healthy and movable sperms and it definitely increases success rates of iui

When iui is generally advised?

As you can understand, to perform iui, there must be minimum number of sperms in the semen, the tubes must be opened, the ovaries must be releasing eggs. If these are present, iui is usually advised


    Less than adequate number of sperm counts, morphology or motility
    Couples who cannot perform full penetrative intercourse but refuse or unable to conceive by ivi
    Unexplained infertility- although ivf is better than iui, but considering the cost, many couples in our country opt for 2-3 cycles of iui before ivf
    Pcos and mild endometriosis- where natural intercourse or ovulation induction failed
    Couples in whom only one partner is positive for hiv or hepatitis b or c- where transmission from one partner to another by unprotected sexual intercourse is not preferable.


What are the tests done before iui?

The basic infertility evaluation is done before iui include husband's semen analysis, assessment of ovarian function (blood tests, ultrasound) and uterus (ultrasound). In some cases, laparoscopy (putting camera to see inside the abdomen by operation) or hysteroscopy (putting camera through vagina inside the uterus, by operation) may be required. Now, if the tubes are blocked, iui is of no use. So, testing the tubes is advisable before iui. But some women, who are at low risk of tubal disease (no history of pelvic pain, infection or surgery), one or two cycles of iui can be done, failing which tubes must be checked by tests like hsg or ssg or in some cases by laparoscopy.

What iui actually involves?

In the cycle, in which iui is planned, the woman is asked to take some medicines (or injections) in particular days of the periods as a part of ovulation induction. She is then advised to have ultrasound monitoring (tvs- trans vaginal sonogram- where ultrasound probe is placed inside the vagina for better accuracy) to see if eggs are growing in response to the medicines or not. If eggs are growing, iui is planned in a particular time when the egg (s) is more likely to rupture, so that the tie interval between sperm entry and egg release can be kept as minimum as possible.

Is ovulation induction necessary for iui?

Frankly speaking, iui can be done without any medicines (as in case of natural intercourse or ivi), which is called  natural cycle iui, where only tvs monitoring is done to see how the eggs are growing. This may avoid some side effects of ovulation induction (see below) but is associated with low success rate than iui done along with ovulation induction.

Is tvs necessary before iui?

Tvs is, undoubtedly, uncomfortable for the woman. But it gives better picture than ultrasound done conventionally. Now, the question is, whether ultrasound monitoring is at all needed or not. Tvs directs the doctor how eggs are growing and at what number and size and when they are likely to rupture. Moreover, the rupture can also be confirmed by tvs. Again, the uncommon side effect of ovulation induction can be detected by tvs. That is called ohss (ovarian hyperstimulation syndrome) where excessive eggs can grow inside the ovaries and this can lead to collection of fluid inside abdomen and lungs and can turn very serious. Although very rare, it can be detected by tvs and early actions can be taken to prevent the progress of this condition.

In rare cases, where tvs cannot be done or patient declines, only option is to check urine by lh kit to predict the likely timing of ovulation and at that time iui is planned. However, it is less accurate than tvs monitoring and is associated with less success.

What, if eggs are not growing in the ovaries?

In some women, particularly those who are overweight, aged or some cases of pcos, eggs may not respond initially to one medicine. There are various forms of ovulation induction medicines (tablets, injection). If one is not working, your doctor can try increasing the dose of that medicine or add or replace it with other medicines. Please remember, it's difficult to predict what medicine will be best suited for a particular patient. So, it's basically a trial and error process.

What is done on the day of iui?

As timing is important, the couples are requested to stick to the timing, advised by the doctor. The husband will be asked to collect the semen by masturbation, using clean technique (to avoid contamination by germs in the semen container). The semen is then prepared by the embryologist and will be checked to see the final number of sperms and their motility and morphology.

The wife is asked to lie down in the iui table. After cleaning, a sterile speculum (instruments to separate walls of the vagina to see the cervix) is introduced inside the vagina and then 0.4-0.6 ml of the prepared semen is inserted inside the uterus with the help of a small catheter (fine tube). Iui done, under ultrasound guidance, gives better result than iui done without it. The patient is asked to lie down few minutes after taking out the catheter and the speculum. The medicines are advised and then they can go home.

Is iui painful?

Most women feel little discomfort during iui but it should not be painful. If there is technical difficulty while putting catheter inside the uterus, your doctor will discuss it with you and in the next cycle, will plan management to solve this issue.

What happens if husband cannot collect semen?

Collection of semen in unfamiliar environment is understandably a matter of discomfort and seems awkward. Proper counseling and maintenance of privacy can help. Stress-free approach is needed. If it fails, do not hesitate to inform your doctor. Some medicines can help. But in those, who are unable to masturbate, there are some instruments, like ejaculator, can help to solve this problem.

What happens if sperm count is low?

Iui can be successful if sperm count is minimum more than 5 million per ml and there is reasonably good morphology and motility. If not, ivf or icsi would be the better option. But iui can serve as trial also. That means before putting the semen, the prepared sperms can be examined and it can be predicted what is the success rate of iui in this particular case and whether ivf or icsi would be needed. In rare occasions, where sperm count is extremely low but the couple do not wish for ivf or icsi, pooled semen iui can help- where the semen is collected in number of occasions and is preserved and the final pool is used for insemination, to give a reasonable success rate.

When donor sperm is used and how?

If a man does not have any sperms or too few sperms to do iui, ivf or icsi is not affordable, donor iui is an alternative. But it is not done without consent from both husband and wife. The donor is not known to the couple or the doctor and no identity of the donor is revealed. No relative or friend can serve as donor. Donor semen is frozen semen, collected 6 months ago and the donor is tested for diseases like std, hiv, hepatitis b or c. Usual attempt is taken to chose donor having blood group and skin colour similar to those of the husband. But remember, it's only given after discussion and written consent by the couple.

Can a couple have intercourse in the cycle where iui is advised?

Intercourse around iui increases the number of sperms available at the time of ovulation.

When should one check for pregnancy?

Usually if period does not come within 18 days after iui, pregnancy test is advised. It can be done at home. If negative, then the cause of not having periods is sorted out.

What is the chance of success after iui?

In one cycle, chance of success is around 20-25%. Most of the couples conceive after 3rd or 4th cycle of iui. The chance of pregnancy after 6th cycle is low, so, usually iui beyond 6 cycles is not advised.

The factors where iui gives better results include unexplained infertility, sexual dysfunction of any of the partner, pcos and male subfertility (low sperm count or motility)

What happens if iui fails?

As said earlier, you should think about further treatment, if 3rd or 4th cycle of iui fails. There is no use of doing iui beyond 6 cycles, unless natural intercourse is not possible and the age is favourable. Ivf gives better result.

Is there any harmful effect of iui?

Very few harmful effects have been noted, for examples, hazards of ovulation induction (ohss lt; twin pregnancy), pain, infection and discomfort. As mentined, if raw semen is given, unusual allergic reaction can happen.

How iui is being done in your particular centre by Dr. Sujoy dasgupta?

We believe in patient's autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We try to take nominal charges and help couples to collect medicines (particularly injections) at lower prices than mrps.

After thorough evaluation of both the partners, we plan for ovulation induction drugs, with consent from them and advise them to come for tvs. After each day tvs, we explain the progress and probable timing of iui.

On the day of iui, after requesting the couple to maintain punctuality, we advise the husband to collect semen, in comfortable atmosphere, maintaining the privacy. If there is problem in semen collection, we provide support to him and address his issues in sensitive way.

Our expert trained embryologist then prepares the semen. We always encourage the couples to see the condition of raw and prepared semen under microscope to maintain the transparency. 

We advise the woman to fill up the bladder (to take water and not to urinate) to facilitate the passage of iui catheter. Unlike other places, we perform iui inside ot to prevent unwanted infection. 

Again we maintain our uniqueness in the sense that we perform it under ultrasound guidance. The ultrasound guidance has been scientifically proved to increase the success rate of iui. Moreover, we show the woman in the ultrasound (real time) how the catheter has been put inside the uterus (to make sure that we are not doing ivi or have placed it in wrong position). This also helps to reduce patient&#x2019;s anxiety and uncertainty. After that, our nurse takes care of the patient and observes her when she takes rest. 

Then we advise the post-iui medicines and advise them what to expect and when they can go home. Again, this time we try to answer all questions the couples can ask.

Conclusion

Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Often we find that patients planning for treatment and in the mean time, they conceive naturally. That means even without treatment, there is some chance of pregnancy. Of course, it's stressful situation for both the partners. Stress affects conjugal relationships and lead to many couples avoiding conjugal life. Indeed stress can affect the hormone levels in females and affects sexual performances in males. It's easier for us to advise you to stay stress-free but is difficult to practice. Nevertheless, try relaxation as much as possible. Think that majority of the couples ultimately conceive by some form of treatment. Have faith in yourself and have faith in your doctor.

1 person found this helpful

Health Quote of the Week

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
Health Quote of the Week

Eating 6 dates daily during the last 4 weeks of pregnancy produces a more favourable delivery outcomes.

4 people found this helpful

Health Quote of the Week

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
Health Quote of the Week

Lentils + fortified grain foods = birth defect prevention.

1 person found this helpful

Today is 3rd day of my period doctor suggested to take umom as well as clofert 100 mg is help to get good egg development pls suggest me we r taking treatment for past 5 months my hormonal profile as well as my tube r healthy ,my husband semen analysis is also normal I've pcos doctor suggest me reduce weight. I reduced around 20 kgs now my period will appear around 29 days to 37 days. But I've the problem to get pregnant.

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
Today is 3rd day of my period doctor suggested to take umom as well as clofert 100 mg is help to get good egg develop...
With clofert taken for 6 months, chance of pregnancy is only 75%. Make sure that ovulation has been confirmed in scan. If no pregnancy by 6 months, you should consider other medicine or possibility IUI.
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Hi Doctor! I'm going to discuss my friend problem. He has a problem with erection of his dick it get hard but don't get straighter it'll get hard by south direction.

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
Hi Doctor! I'm going to discuss my friend problem.  He has a problem with erection of his dick it get hard but don't ...
Erectile dysfunction (ed) occurs when the man is unable to achieve or maintain his erection of penis to meet his or his partner's sexual satisfaction. The problem is often faced by newly married men. Fortunately with experience, most of them are able to overcome this problem. Again it is increasingly common with increased age. So, what are the causes. In some male, it is psychological, caused by anxiety, depression, stress, marital disharmony etc. Use of alcohol and smoking will aggravate the problem. Psychological causes can happen at any age but more common at younger age. But in some cases, it is associated with serious diseases, especially at old age. It has been seen that in apparently healthy male ed is the first sign of heart disease. So, if you have ed, make sure that i's not caused by your heart problem. Again diabetes is another important cause. Excessive weight gain will also cause hormonal imbalance and thus problems in erection. Some hormone may also cause ed like thyroid, prolactin and even testosterone (male sex hormone). If you have chronic diseases like liver or kidney disease, it may also lead to ed. Diseases of nerves and spines should also be kept in mind. Sometimes, infections or tumour in private parts (prostate, testis etc) will also add to ed. Other diseases of penis like abnormalities in blood vessels can also be responsible, especially in young guys. Apart from these, some surgeries in abdomen and some drugs (like drugs to lower blood pressure, antidepressants, hormonal drugs etc) will also cause ed. Now, what you can do? If you want to suffer silently, you will land up in other problems like problem in sexual life, problem in family relationships, depression and even inability to make your partner pregnant. But do all men with ed have to go to doctor? Initially, the men should try life style modifications like avoiding smoking and alcohol; avoiding stress and anxiety; making good understanding with partner and also reducing weight. The partner should also have sympathetic attitude to the husband who is having ed. But if still the issue is not resolved you have to consult doctor. It's not a mater of hesitation or embarrassment, as you may think. Rather it is needed to ensure that you are healthy. So, your doctor will talk to you, will check you and try to find out if any cause is there or not (like heart disease, diabetes, hormones etc). He may order some basic tests to ensure that everything is alright. After that he will advise you the treatment. If the cause is found, treatment of the cause (like diabetes) may cure ed. Even if no cause is found, ed can be treated by various ways. But should you try the drugs shown in television or newspaper? Remember, drugs used in ed have important side effects and we advise drugs only when it is absolutely necessary. In most cases simple measures like stress reduction, exercise help. Sex counseling of both the partners helps a lot. And if still ed persists, we advise drugs. There are variety of drugs, all are having own advantages and disadvantages. Particularly sildenafil group of drugs can affect heart and retina. So, we always practice caution before prescribing such drugs. And when patients are advised such drugs we advise to inform us when he feels eye problems, chest pain, fainting or even painful persistent erection of penis (" priapism"). There are other drugs that can be applied directly over penis. Testosterone group of drugs are prescribed only in selective cases as they have serious side effects and even they can reduce the size of your testes. In some cases where drugs cannot be given or drugs fail, we advise penile implants or artiificial pump to maintain erection. Finally in very few cases, where blood vessels of penis is blocked, we can cure it by some operations. So, if you feel ed, don't get depressed. At the same time don't feel embarrassed to take medical help. Today's embarrassment may harm you in future. So, get cured and enjoy your personal life.
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I get my periods on 28 of every month. But this time due to consumption of emergency contraceptive pill in 12 September, my periods got preponed to 22nd September. I had to take another emergency contraceptive on 26th September due to unprotected sex. And again today I am bleeding a lot. I have no Pms or thyroid issues and my monthly date is 28 of every month without any changes.

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
I get my periods on 28 of every month. But this time due to consumption of emergency contraceptive pill in 12 Septemb...
It may be side effect of I pill. Wait for period. Check pregnancy test 3 weeks after last unprotected intercourse.
3 people found this helpful
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I can not ejaculate while having however while masturbating I am able to do so. Also the erections are not hard as they used to be. Need help.

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
I can not ejaculate while having however while masturbating I am able to do so. Also the erections are not hard as th...
Try Kegel exercise. Stop smoking and alcohol. Reduce stress. If still not cured, consult doctor to find out the cause and treat it.
2 people found this helpful
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I want to conceive, we have already tried 3 months but no positive result. What medicine should I take? My.

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
I want to conceive, we have already tried 3 months but no positive result. What medicine should I take? My.
In 1 month of regular trying chance of pregnancy is only 15%. So do not lose heart. Try for 6 months. If no success, consult doctor to see if there is any problem in husband or wife and treat it.
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I'm doing Masturbation from last 10 years and when I will do the sex my Semen is leaking within seconds.

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
I'm doing Masturbation from last 10 years and when I will do the sex my Semen is leaking within seconds.
1. Premature ejaculation (pe) occurs when men cannot control semen flow or have excessive sensitivity. So, before treatment, you should precisely diagnose the cause of your problem. 2. It is easily curable- but needs time. Usually most cases respond to sex therapy and exercises and using few simple tips. So, men may need drug to cure this.
2 people found this helpful
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I masturbate 3 times a day. Is there any problem with it? Will I face any problem in my married life?

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
I masturbate 3 times a day. Is there any problem with it? Will I face any problem in my married life?
There is absolutely no harmful effect. There are only myths about it. One can do it whenever he/ she wants. But remember, anything in excess is not useful. If you are addicted to it, it can divert your attention and may cause loss of concentration in studies, works and family life.
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I've finished my mensuration period before 3 days and yet I've pain of it. And I was having it before 2 weeks of start. What is it mean? I got checked up approx 1 year before and Dr. found a small ovary cyst ?was that's the issue of it again or anything else bcoz im5getting that pain continuously and what I need to do to get rid of it? For now I'm taking ashokarisht from 3 days as well and Dr. prescribed me for evecare syrup so which one I prefer and anything else if required?

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
I've finished my mensuration period before 3 days and yet I've pain of it. And I was having it before 2 weeks of star...
You need to take regular hormonal drugs and also medicines during periods. this is a common problem at this age and usually gets cured by time. 3-6 months of medicine usually gives cure.
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Hi I am 25 years old and I got married 10 months back. I was 5 months pregnant. Suddenly 1 week back I got severe pain near pelvic region early morning and when we reached hospital they said the baby moved till vagina and there is no chance of baby survival. I delivered male dead baby that day but his weight was 370gms and his formation was not good as his intestine developed outside his stomach. I got ultrasound scan at my mid 4th month but they said everything was good. I too didn't felt any abnormality. I used all medicines prescribed by my doctor without fail. It was a sudden abortion without any reason. The doctor said the cervix opened and baby reached till vagina. I want to why abortion happened and why my baby development was not not good?

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
Development may not be good due to various reasons- like defects in its gene, some drugs or unknown causes. But these should have been detected by scan. Now this abortion was probably due to "cervical incompetence" where cervix opens before time. We have to rule out possible causes before planning next pregnancy and give you proper care before and during pregnancy.
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Hi Sir, I have last month date on 14th, till this date 26th I have no date. I have taken a medicine of progicare for stopping pregnancy 1 table on 19th and other 4 table on 21st, I have a very small bleeding on 22nd there after nothing. I am worrying about please help me.

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
Hi Sir, I have last month date on 14th, till this date 26th I have no date. I have taken a medicine of progicare for ...
This is likely to be side effect of that pill and it may be harmful to take the tablets before checking pregnancy. Wait for another 2 weeks and get USG done.
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I have taken eova m tablet on last period, then on 9 th day of period took HCG injection. But today my period has been started. Can I take eova in this cycle again?

MBBS (Gold Medalist, Hons), MS (Obst and Gynae- Gold Medalist), DNB (Obst and Gynae), Fellow- Reproductive Endocrinology and Infertility (ACOG, USA), FIAOG
Gynaecologist, Kolkata
I have taken eova m tablet on last period, then on 9 th day of period took HCG injection. But today my period has bee...
In one cycle, chance of pregnancy with these medicines is only 20%. So, try for at least 3 months and make sure that at least in 1st month USG has been done to check if the medicine worked or not.
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