When IVF Treatment is Required?
Dr Parag Hitnalikar MD, FNB
Who should go for IVF?Weather IVF is the right treatment for me? Am I the right candidate for IVF? Will IVF succeed in me? What should I do before going for infertility treatments?
These are the questions faced by a couple when pregnancy is not happening in spite of all the efforts.
It is very natural for couples to get confused because they are not able to take a decision regarding the best treatment for them.
Before discussing who should opt for assisted reproductive technology, let us first see what the most important things for fertility are. When you understand the important requirements for the conception, it’s easier to decide if you require IVF or not.
Normal Sexual Activity
Life is becoming very fast and competitive. There are a lot of issues in maintaining a good diet and take out time for exercise. This is taking a toll on sexual activity in a couple.
According to many researchers, the average number of sex per week by a couple is going down. This is also adding to performance anxiety, which is difficulty in having sex when it is recommended.
Normal Cervical Function
Cervix is the portion where the vagina ends and uterus starts. It is also called as the mouth of the uterus. Its main function is to provide passage to the sperm and store sperm. It contains cervical mucus, which is a good medium for sperm to swim.
The life span of sperm is increased because of the cervix as sperm are stored here and are released into the uterus as and when required. But if the cervix is hostile for sperm, pregnancy will not occur.
Normal semen parameters
It is very important to have normal semen parameters for natural conception. All the sperm parameters such as semen count, motility, and morphology are important. Good semen is the one that has good sperm count, most of the sperm are actively moving and most of the sperm are structurally normal. Any of these parameters if abnormal can affect the chances of pregnancy.
The uterus has got two fallopian tubes, which collect the eggs from ovaries and keep it till it gets fertilized by sperm. The internal lining of tubes is customized specifically for moving the egg from ovary to uterus. Apart from that, the tube also contracts and relaxes periodically, which propels the egg to the uterus. If the fallopian tubes are damaged, it is highly unlikely for the pregnancy to occur.
Normal egg production
Every month, one egg is formed in either of the ovaries. This egg then gets released into the tubes, where it is fertilized by sperm. The formation and release of the egg are controlled by various reproductive hormones. Because of abnormal hormonal secretions or other factors such as endometriosis, PCO, pelvic disease; egg may not be produced or get released into the fallopian tubes.
Adequate egg reserve
Each woman is born with a certain number of eggs in her ovaries. It is like a fixed deposit in a bank, where we can only remove the amount but can not deposit any.
Every month, many eggs are recruited and only one of them gets released.Hence the number of eggs also called ovarian reserve, gets diminished continuously. The poor the egg reserve, the poor are the chances of conception.
It is not only adequate to have eggs stored in the ovaries but equally important is the process of egg development and release. Many women have adequate eggs in the ovaries but the process of egg development and release is hampered because of hormonal disturbances.
Mating of egg and sperm
When the egg is released in the tubes, what is crucial is that the egg gets fertilized with a sperm. Although millions of sperm are deposited in the vagina after intercourse, only very few are going to reach the fallopian tubes. Even fewer are going to reach the egg. Out of the sperm reaching the egg, only one sperm will get inside the egg and forms an embryo.
Development of embryo
For the development of an embryo, the process of fertilization is very important. Fertilization is the process in which the sperm binds to the outer covering of eggs, penetrates the covering and enters the egg. This is followed by subsequent events for the embryo formation. Many microscopic factors are important for fertilization such as the presence of certain chemicals in sperms, the binding capacity of egg cover and so on.
Implementation of embryo
It is not just adequate that a good embryo develops until it sticks to the lining of the uterus and forms the pregnancy. After the embryo is formed, it migrates to the uterus and finds a suitable place for it to stick and get the necessary blood supply. Only then can a healthy pregnancy develop.
The interaction or cross-talk between the embryo and endometrial lining is very important as no matter how good the embryo is, it’s useless without implantation.
IVF treatment is recommended if
Before we go into the recommendations of IVF Treatment, we must know what is IVF. In the in vitro fertilization (IVF) procedure, we give injections to the female partner so as to produce multiple eggs. These eggs are then retrieved by a procedure called egg retrieval under anesthesia and it’s not a painful procedure.
We fertilize the eggs with the husband’s sperm and make embryos in the laboratory. We then do the embryo implantation in the uterine cavity for pregnancy to develop. The success rate of IVF depends on many factors such as the age of the female, sperm quality, condition of the uterus, associated pathologies, etc.
- Blocked or fallopian tubes
The most common indication for IVF is blocked or damaged tubes. Many infections or surgeries can damage the tubes. Moreover, many of the infections which cause damage to the tubes are bilateral, which means it affects both the tubes.
IVF treatment is the only effective treatment for these females. Surgical correction can be tried but the chances of a successful pregnancy are less and more so the chances of tubal pregnancy which is dangerous are more.
- Poor sperm parameters
Many medications are available for improving sperm quality. But whether or not it will help depends on the cause of sperm problems.
If sperm production is defective because of a deficiency of vitamins and minerals, then they are more likely to respond to treatment. But if the sperm production is defective because of a cause other than deficiency, then they are less likely to respond to medications. Moreover, most of the major defects in the sperms are not treatable.
Endometriosis is a disease in which the endometrial lining which should be present only inside of the uterus, starts growing outside of the uterus. Endometriosis if present can slowly cause damage to all reproductive organs such as ovaries, fallopian tubes, pelvic space, etc. If endometriosis is of significant severity and is not responding to normal medications, then IVF is the best option for pregnancy.
- Unexplained infertility
Amongst all the causes of infertility, unexplained infertility is responsible for around 15% of cases. When tubes are normal, sperms are normal and ovulation is occurring but still no pregnancy, it’s called unexplained infertility. Most of the time no cause is found. If conservative treatment for unexplained infertility such as timed intercourse or IUI fails, IVF is the best and the only option remaining.
- Repeated IUI failures
IUI treatment is recommended in couples with low sperm count, sexual dysfunction, unexplained infertility, etc. Those couples who do not get pregnant after 3 to 6 cycles of IUI will have reduced chances of getting pregnant with IUI. These women may require a cycle of IVF. It is important to restrict the use of ovulation drugs for less than 12 times in a woman’s life so as to reduce the chances of ovarian cancer.
- Increasing age
Increasing the age of marriage, delaying the childbearing and professional commitments is pushing the couples to avoid pregnancy for a long time after marriage. With increasing female age especially after 35 yrs, its very difficult to conceive naturally. Moreover, there is danger of ovarian exhaustion which will leave the couple with the only option of donor eggs. Hence it is better to go for IVF when the ovarian reserve is still in good shape.
The polycystic ovarian syndrome is a condition in which there is an imbalance in the reproductive hormones, which leads to anovulation. Currently, it is affecting a quarter of the women population in the reproductive group. Those women with PCOS who are not responding to ovulation induction treatment by fertility drugs or fertility medications may require IVF treatment.
- Sexual dysfunction
Severe sexual dysfunction such as erectile problems, premature ejaculation, lack of libido, vaginismus, etc can sometimes be difficult to treat. Many of these problems are psychological in origin but organ dysfunction can also lead to sexual dysfunction. Many of these couples ultimately land up for the IVF cycle.
- Genetic disease
Many of the genetic diseases may require IVF treatment. Genetic disorders can be single gene defects such as thalassemias, sickle cell anemia, cystic fibrosis, etc. Or they can be chromosomal abnormalities such as Down’s syndrome, Turner’s syndrome, Klinefelter’s syndrome, etc.
We can do genetic testing for the embryo with the help of preimplantation genetic screening (PGS) or preimplantation genetic diagnosis (PGD). After testing we can insert only normal embryo so as to get a healthy pregnancy.