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A to Z of Infertility !

NOGS 20-21 & AMOGS PAC INITIATIVE

VOLUME - 3 1
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DR. AMOGH CHIMOTE DR. RIJU ANGIK CHIMOTE
Sr. No. Topics Page No.

01 INFERTILITY ( MALE AND FEMALE, UNEXPLAINED) 06

02 INVESTIGATIONS IN A FEMALE 13

03 INVESTIGATIONS IN MALE 16

04 TUBAL TESTING MTHODS 20

LAPAROSCOPY AND HYSTEROSCOPY IN

05 23
INFERTILITY

06 WHAT IS IUI( INTRA UTERINE INSEMINATATION) 27

07 WHAT IS IVF (IN -VITRO FERTILIZATION) 33

08 PCOS AND INFERTILITY 42

09 ENDOMETRIOSIS AND INFERTILITY 46

10 COVID-19 AND INFERTILITY 50

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 WHAT IS INFERTILITY?

• What is infertility?
- Couples who have not conceived after one year of regular unprotected
sexual intercourse
- Couples who are worried about their fertility should be informed that
84% of couples in the general population will conceive within one year if
they do not use contraception and have regular sexual intercourse. Of
those who do not conceive in the first year, about half will do so in the
second year (cumulative pregnancy rate 92% after two years and 93%
after three years).

• How common is infertility?

- Infertility is a global health issue, affecting approximately 8-10% of
couples worldwide Reproductive Health Outlook.

• What are the types of infertility?

a) Primary: couple is unable to conceive after one year of regular
unprotected intercourse
b) Secondary Infertility: Inability to become pregnant or to carry a baby
to term after previously giving birth to a baby.
c) Unexplained infertility: It is an idiopathic infertility in the sense that
its cause remains unknown even after an infertility work-up for male
as well as female. 6
• When should you go to the doctor?
- After trying for more than a year to conceive
- Menstrual complaint ( infrequent/ frequent/ heavy flow /scanty flow/
dysmenorrhea)
- Loss of libido(both male/female)
- Premature ejaculation/impotence/difficulty in establishing Intercourse
(male)
- Vaginismus (female)
- Age more than 35 years ( both male/female)

• What are the cause of Infertility?

• The causes of infertility can be broadly divided into male , female and
both. Male and female infertility contribute 40% each while 20 % are
unexplained causes . The most common cause of female infertility is a
problem with ovulation. The most common cause of male infertility is a
problem with sperm cells and how they function. Other factors that may
affect fertility include age, lifestyle, and health conditions.

• Sometimes no cause of infertility is found. This is called unexplained

infertility.

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 • Here is a list of reasons leading to infertility
Causes in Male
Sr.
Male causes Reasons
No.
1 a) Undescended testis
b) Genetic / dna damge
c) Prior infection ( e.g Mumps, adenovirus)
d) Trauma/ Injury to the testis or groin region
e) Surgery for testis or groin region
f) Varicoceles ( enlarged veins of the testis
Low /abnormal Sperm
that increases blood flow and heat which
count
affect the number and shape of sperm)
g) Exposure to toxic substance(
pesticides/radiation/ chemotherapy)
h) Addictions ( alcohol/ marijuana/ ganja/
tobacco/ steroid for body building)
i) Working in hot/ warm environment
2 Ejaculation of semen during sexual intercourse
Premature ejaculation
before or immediately after penetration
3 Damage/injury to Direct injury or trauma to the testis or penis
reproductive organs
4 Semen entering the bladder instead of
emerging through the penis during orgasm.
Retrograde ejaculation
Generally common in uncontrolled diabetes
mellitus
5 Cutting and ligating the vas deferens as a
Vasectomy
permanent method of sterilization
6 Age related changes in quantity and quality of
Age sperms, generally seen above the age of 35
years. 8
 Causes in females
Sr no Causes Reasons / Consequences
Hormone disorder can create a great havoc and
asynchrony which has a cascading effect leading to
infertility
a) Thyroid hormone: Either too much thyroid
hormone or too little thyroid hormone can
interfere with the menstrual cycle or cause
1. Hormonal issues infertility
b) Hypothalamus pituitary ovarian axis( HPO) :
ranges from improper levels of various
hormones like Follicle stimulating hormone(
FSH) Luteinizing hormone ( LH) , Oestrogen ( E2)
, progesterone ( P), Testostosterone leading to
infertility
a. Benign ( non Cancerous tumors) like polyp/
fibroid/ adenomyoma/
b. Blocked tube( Infection/ tuberculosis/ Pelvic
inflammatory disease/ endometriosis/adhesions)
2 Structural issues c. Small or blocked cervix
d. Half/double uterus or cervix
e. Irregular / septate uterine cavity
f) Adhesions ( Bands of scar tissue)
Diminished egg quantity/quality , premature
menopause or cessation of ovulation (release of
3 Ovarian factor egg) primary ovarian insufficiency

Poor egg quality and quantity with increasing age

4. Age generally seen by the age of 30 years, more 9
common above 35 years
• What are the common causes of infertility?
- Factors common to both males and females
 Poor diet that is lacking in nutrients
 Athletic overtraining
 Stress
 Too much exposure to certain chemicals and toxins (for example,
tobacco smoke, alcohol, marijuana, pesticides, radiation, and
chemotherapy)
 Sickle cell disease
 Kidney disease
 Celiac disease
 Diabetes

• How does age affect fertility?

- For healthy couples in their 20s or early 30s, the chance that a woman
will become pregnant is about 25 to 30 percent in any single menstrual
cycle. This percentage starts to decline in a woman’s early 30s. It
declines more rapidly after age 37.
- By age 40, a woman’s chance of getting pregnant drops to less than 10
percent per menstrual cycle. A man’s fertility also declines with age, but
not as predictably.

• What are the probable signs of female infertility?

Irregular or absent menstrual periods
History of pelvic infection
Two or more miscarriages
History of using an iud for birth control
Sterilisation reversal
Difficulties with sexual intercourse 10
Chronic pelvic pain
Breast discharge
History of sexually transmitted disease
Excessive acne or facial hair.

• Are lifestyle changes responsible for infertility in male and female?

- Life style changes are one of the most important parameter which
affects the fertility potential of any individual.

• What life style modifications can help in improving chances of

pregnancy?
- Life style changes are required in both men and women to have a
better chance at achieving pregnancy. The following are some of the
changes which may improve the fertility potential.
- Stop smoking. Smoking affects the development and quality of
sperm, decreases the sperm count and reduces the volume of
semen. higher risk of impotence (erectile dysfunction).
- Stop alcohol intake. Drinking alcohol affects sperm count, increases
the number of abnormally shaped sperm, Keep them cool.
- Increase your intake of folic acid ( for females)
- Raising the temperature of the testicles can decrease sperm
production and motility (the quality of movement).

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- Well-balanced diet. There is no special eating plan for maximising
your fertility. A sensible diet that includes plenty of fruit, vegetables,
grains, meat, poultry and seafood is advised.
- Stay in a healthy weight range. Overweight men and women may
have decreased fertility. If you are overweight, losing weight may
help increase your sperm count.
- Exercise with caution. Exercising heavily every day may interfere
with the regularity of the menstrual cycle. For men, prolonged
cycling can cause damage to the groin and there is also the risk of
damage to the testicles from contact sport
- Cut back on caffeine: caffeine may interfere with the natural
ovulation process and even a modest amount of coffee (one or two
cups daily) may decrease fertility and affect sperm count
- Avoid using lubricants. They often contain chemicals that can
damage or kill sperm.
- Avoid toxins.

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 INVESTIGATIONS IN FEMALE

• What are the various investigations done for a female patient ?

- Thorough History
- Pelvic examination

- Transvaginal ultrasound( TVS)

- Routine pathology and Hormone evaluation

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• What should I expect during my first visit for infertility?
- The first visit with a fertility specialist usually involves a detailed medical
history and a physical exam. You will be asked questions about your
menstrual period, abnormal vaginal bleeding or discharge, pelvic pain,
and disorders that can affect reproduction, such as thyroid disease. You
and your partner will be asked about health concerns, including
Medications (both prescription and over-the-counter) and herbal
remedies
Illnesses , including STIs and past surgery
Birth defects in your family
Past pregnancies and their outcomes
Use of tobacco, alcohol, and illegal drugs
Use of marijuana (recreational or medical)

- You and your partner also will be asked questions about your sexual
history, including
• Methods of birth control
• How long you have been trying to get pregnant
• How often you have sex and whether you have difficulties
• If you use lubricants during sex
• Past sexual relationships.

• Why is pelvic examination required?

• Pelvic examination is done to evaluate the uterus labia majora/minora ,
vagina or the cervix for any infection or pathology.

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• What does TVS tell me?
- Transvaginal scan or TVS tells you about anatomical pathologies of the
uterus and the adnexa as well as the ovary and helps to predict when
ovulation will occur by viewing changes in the follicles.

• Is TVS painful?
- TVS may cause mild discomfort similar to a pelvic examination .

• What hormones are tested?

- This can also be called as baseline hormone evaluation
AMH ( ANTE MULLERIAN HORMONE) to check of egg reserve
FSH ( FOLLICLE STIMULATING HORMONE) to check of egg reserve
LH ( LEUTENIZING HORMONE)
PROLACTIN ( high levels may cause no ovulation)
THYROID STIMULATING HORMONE ( TSH) abnormal levels indicate
faulty menstrual pattern
TESTOSTERONE ( generally high in PCOS)
INSULIN ( high level indicates high ovarian resistance to meds)
PROGESTERONE ( to check for ovulation)
17 HYDROXY PROGESTERONE ( 17 OHP)

• When is the best time for baseline hormone?

- Generally the baseline hormone evaluation is done between day 2 to
day 5 of your menstrual cycle before 12 pm (Noon)

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 INVESTIGATIONS IN MALE

• What are the various investigations done for a male patient ?

- Thorough History
- Routine pathology
- Semen analysis

- HOS TEST

- DNA Fragmentation Index( DFI)

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 PHYSICAL EXAMINATION : evaluation of size of testis, pathologies of penis
and testis
• Why is thorough history necessary ?
- A good history helps us in diagnosing the following problems leading to
infertility in male
- Impotence – inability to maintain an erection sufficient for sexual
intercourse
- Failure to ejaculate, premature ejaculation or ejaculating backwards into
the bladder (retrograde ejaculation)
- Presence of other diseases, such as diabetes and multiple sclerosis, can
cause erection and ejaculation difficulties

• What is semen analysis?

- Semen analysis is the evaluation of husband’s semen for the following
parameters
Volume
Viscosity
Odour
Liquefaction
Fructose level
Sperm count
Sperm morphology
Motility

• Sample collection method

- Sample is collected after 3 to 5 days of abstinence after proper cleaning
and collecting the sample by masturbation in a wide mouth sterile
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container properly labelled with all details of the patient.
• Can I collect my sample at home?
- Home sample collection is usually avoided but can be accepted if the male
partner cannot deliver the sample at the hospital in a sample collection
room.
- In such cases the semen sample should be brought within 30 min to the
hospital. The sample container should be kept at body temperature while
transportation.

• What Investigations are required in case of low sperm count?

- Ultrasound: An ultrasound examination of the testes and prostate can be
useful. An ultrasound probe (slim wand) is placed on the testicles to
provide a picture of the testes and the epididymis. It is also useful for
diagnosing varicocele (swollen varicose veins of the scrotum).
- Vasography: While not used very often these days, a vasography may be
useful in diagnosing an obstruction in the vas and abnormalities of the
seminal vesicles and the ducts that leadout into the back of the penis.

• Testicular biopsy
- This involves the removal of a small sample of the tissue from a testis
using either a general or, more commonly, local anaesthetic.

• How does a man present with a varicocele?

• Most commonly, he has a completely asymptomatic varicocele found
during evaluation for infertility. Young men (or their primary doctors)
sometimes find a mass in the scrotum either during self-exam or routine
exam. Less commonly, a varicocele is found when evaluating a man
suffering from pain in the scrotum.

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• What are some causes of sperm not maturing?
- Some treatable conditions that can cause maturation arrest include
varicoceles or hormonal problems. In many cases, though, it might
be an undetectable genetic defect.

• What can a man do to improve the morphology (shape) and

motility (movement) of his sperm?
- Semen morphology is thought to have the least effect on fertility of
all of the parameters. Unfortunately, in most cases, there is no clear
or specific treatment.
- In rare cases, there may be a genetic/production problem causing
the sperm shape defect. This is usually not treatable.
- Patients are prescribed various vitamins, such as Co enzyme Q10,
lycopene, Vitamin D, Folic acid. In general, we recommend a healthy
lifestyle with lots of vegetables and a balanced diet with exercise.

• What can be done in the case of low sperm motility and pus cells?
• Low motility and pus cells can be from multiple causes. Patients
should have a physical exam, hormonal testing by a fertility specialist
and possibly specific testing to quantify pus cells. Based on the
findings, treatment may include one or more of many routes,
including medicines, vitamins, antibiotics, anti-inflammatory
medications or surgery.

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 TUBAL PATENCY TESTS

Tubal patency tests are a set of test dynamic and physiological to determine
the patency of the tube. ( tube is open or blocked). These are imaging
techniques which may or may not require anaesthesia.

• What are the various tubal patency test?

- The various tests are as follows :
- Hysterosalpibgography( HSG)( most commonly used test under x ray)
- Sonosalpingography ( SSG) ( newer test done by Ultrasound)
- Laparoscopy ( under anaesthesia , gold standard)
- Hysteroscopic bubble test or parryscopy ( under anaesthesia)

• How is HSG done?

- HSG is done in a hospital, clinic. It is best to have HSG done in the first half
(days 5–12) of the menstrual cycle. This timing reduces the chance that
you may be pregnant.
- During HSG, a contrast medium ( dye) is placed in the uterus and fallopian
tubes. The dye shows up in contrast to the body structures on an X-ray
screen. The dye outlines the inner size and shape of the uterus and
fallopian tubes. It also is possible to see how the dye moves through the
body structures.
- The following are the steps fro HSG
• Usually anesthesia is not required for this procedure.
• You’ll be asked to lie down with your back on the table and your knees
20
bent and your feet spread under a C arm / X ray machine
• Once you are ready, the doctor will gently insert a speculum into your
vagina, so that the cervix can be seen.
• You may feel a little discomfort at this point.
• The cervix is then cleaned with an antiseptic solution.
• A small catheter is inserted in the cervix which may cause a small tug and
the position is confirmed under the x ray
• A small amount of dye is injected in the catheter and the uterine cavity and
the tube are visualized which is then captured on the x ray.
• If the tubes are blocked then the dye spillage will not be seen indicating
blocked tubes, if tubes are open the dye will be seen surrounding the
uterus from the outside

• What should I expect after the procedure?

- After HSG, you can expect to have a sticky vaginal discharge as some of the
fluid drains out of the uterus. The fluid may be tinged with blood. A pad
can be used for the vaginal discharge. Do not use a tampon. You also may
have the following symptoms:
- Slight vaginal bleeding
- Cramps
- Feeling dizzy, faint, or sick to your stomach

• What are the risks associated with HSG?

- Severe problems after an HSG are rare. They include an allergic reaction to
the dye, injury to the uterus, or pelvic infection. Call your health care
provider if you have any of these symptoms:
- Foul-smelling vaginal discharge
- Vomiting
- Fainting
- Severe abdominal pain or cramping
- Heavy vaginal bleeding 21
- Fever or chills
• How is SSG performed?
- SSG is procedure is similar to HSG but instead of x ray an ultrasound
probe is inserted in the vagina and Normal saline is injected in the
catheter placed in the cervix.
- If the tubes are open then the flow of the normal saline shows the
filling of the tubes and spillage of the fluid is seen in the pelvic cavity.
- If the tubes are blocked then no spillage can be seen in the
ultrasound.

• What are the instructions after the procedure?

- After the procedure you will be asked to rest in a recovery room for a
while.
- You can have a light meal if you wish and head home in about two
hours.
- While you can resume your normal daily routine you may experience
a little discomfort.
- You can resume normal activities and diet after the procedure.

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 LAPAROSCOPY AND HYSTEROSCOPY

Laparoscopy and hysteroscopy is an invasive diagnostic test for finding

and treating the cause of infertility at the same time. It a procedure which
is done under anaesthesia but a day-care procedure which means you
will be discharged on the same day.

• How is laparoscopy done?

- Laparoscopy is usually performed on an outpatient basis under general
anesthesia. After the patient is under general anesthesia, a needle is
inserted through the navel and the abdomen is filled with carbon
dioxide gas.
- The gas pushes the internal organs away from the abdominal wall so
that the laparoscope can be placed safely into the abdominal cavity to
decrease the risk of injury to surrounding organs such as the bowel,
bladder, and blood vessels.
- The laparoscope is then inserted through an incision in the navel.
Occasionally, alternate sites may be used for the insertion of the
laparoscope based upon physician experience or the patient’s prior
surgical or medical history.

• Why should I undergo Diagnostic laparoscopy?

- Your doctor can see the reproductive organs including the uterus,
fallopian tubes, and ovaries for presence of any pathology like a fibroid,
infection, structural abnormality, adhesions. Additionally, a solution
containing blue dye is often injected through the cervix, uterus, and
fallopian tubes to determine if they are open. If no abnormalities are
noted at this time, one or two stitches close the incisions. If defects or
abnormalities are discovered, diagnostic laparoscopy can become 23
operative laparoscopy.
• What is operative Laparoscopy?
- If there is a suspicion of pathology in the reproductive organs the
surgeon inserts additional instruments such as probes, scissors, grasping
instruments, biopsy forceps, electrosurgical or laser instruments, and
suture materials through two or three additional incisions. Operative
laparoscopy includes management of certain pathologies such as
removing adhesions from around the fallopian tubes and ovaries,
opening blocked tubes, removing ovarian cysts, and treating ectopic
pregnancy. Endometriosis can also be removed or ablated from the
outside of the uterus, ovaries, or peritoneum. Fibroids if on the uterus
can also be removed.

• What are the chances of complication in a case?

- When all possible complications are considered, one or two women out
of every 100 may develop a complication, usually of minor consequence.

• What are the risks of laparoscopy?

- There are certain risk ranging from mild to severe. These are as follows
- Vascular injuries: injury to a major/ minor blood vessel (Severe)
- Injury to adjacent organs sucj as bowel, bladder, ureter (Severe)
- Hematomas of the abdominal wall can occur near the incisions.
(Moderate)
- Pelvic or abdominal infections may occur. (Moderate)
- Allergic reactions, nerve damage, and anesthesia complications rarely
occur (Mild)
- He risk of death as a result of laparoscopy is very small (around 3 in
100,000)
- Postoperative urinary retention is uncommon
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- Venous thrombosis is rare
• What is Diagnostic Hysteroscopy?
- Hysteroscopy is a useful procedure to evaluate women with infertility,
recurrent miscarriage, or abnormal uterine bleeding.
- A diagnostic hysteroscopy is used to examine the uterine cavity , and is
helpful in diagnosing abnormal uterine conditions such as internal
fibroids, scarring, polyps, and congenital malformations.

• How is Diagnostic Hysteroscopy done?

- It is a procedure done under anaesthesia or sedation in which a small
Hysteroscope (a long, thin, lighted, telescope-like instrument ) of
roughly 3 mm is inserted in the vagina and normal saline is used to
dilated or balloon the vagina. The scope is then advanced in the cervix
then into the uterine cavity slowly and the entire tract evaluated for any
abnormality.
- Skin incisions are not required for hysteroscopy.
- The procedure takes 3 to 10 min depending on the skill of your doctor.

• When is the appropriate time for hysteroscopy?

- Hysteroscopy is generally performed soon after the bleeding stops after
menses to day 12 of your menses.

• What is operative hysteroscopy?

- Use of instruments to treat the pathologies in the cervix and the uterus
is called as an operative hysteroscopy.
- It is generally done for the following pathologies
- Polyp
- Adhesions
- Uterine anatomical defects 25
- Cervical adhesions
- Scar tissue removal
- Determining tubal patency.

• What are the risks of Hysteroscopy

- Complications of hysteroscopy occur in about two out of every 100
procedures. Perforation of the uterus (a small hole in the uterus) is the
most common complication.
- Although perforations usually close spontaneously, they may cause
bleeding or damage to nearby organs, which may necessitate further
surgery.
- Uterine adhesions or infections may develop after hysteroscopy.
- Serious complications related to the fluids used to distend the uterus
include fluid in the lungs, blood clotting problems, fluid overload,
electrolyte imbalance, and severe allergic reactions.
- Severe or life-threatening complications, however, are very uncommon.
Some of the complications above may prevent completion of the
surgery.

• What should I expect after a hysteroscopy

- Following hysteroscopy, some vaginal discharge or bleeding and
cramping may be experienced for several days.
- Most physical activities can usually be resumed within one or two days.
- You should ask your physician when to resume sexual intercourse.
- If a Foley catheter is left in the cavity, it is usually removed after several
days.
- Estrogen may be prescribed for several weeks after surgery.
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 INTRA UTERINE INSEMINATION

• What is intrauterine insemination?

- It is a form of artificial insemination A procedure where sperm are placed
into the female reproductive system by a means other than intercourse.
Intrauterine insemination (IUI) is the most common form of AI used and
involves placing sperm into the female’s uterus through a catheter or a
small tube. IUI is usually one of the first techniques used to assist a couple
who is having difficulty becoming pregnant.

• Which Factors Control the Success Rates of IUI?

- IUI success rates vary considerably and depend on many factors like:
- Age of the woman
- Use of any type of ovarian stimulation (drugs are given to stimulate
ovulation)
- Duration of infertility
- Cause of infertility
- Number and quality of motile sperms (the ability of the sperm to move)

• Who Might Benefit with IUI?

- IUI can help in cases where the man has low sperm count, or poor motility
where the sperms are unable to reach the egg.
- Because sperm is placed directly inside the woman's uterus, IUI can also
help couples who are unable to have intercourse because of disability,
injury, or difficulties such as premature ejaculation (where a man ejaculates
27

early).
- It is also recommended for women with mild endometriosis (tissue that
looks and acts like the lining of the uterus grows outside of the uterus in
other areas like ovaries, bladder, etc.).
- Is often used as the first line treatment for couples with "unexplained
infertility".
• When is IUI not recommended?
- IUI is not recommended for women who have severe disease of the
fallopian tubes, tubal disease, a history of pelvic infections, a low
ovarian reserve, or moderate to severe endometriosis.
- While severe male factor infertility does not necessarily preclude
couples from undergoing IUI, it does significantly reduce their odds of
success, making IVF the preferable option.

• What is a pre-IUI workup?

- A pre-IUI workup is when we make sure you are in good health, your
hormone levels are normal and that your uterus can support a
pregnancy. Prior to the IUI procedure, we will monitor your eggs
through ultrasound and/or blood testing in order to determine the best
time for injection.

• What is done in IUI?

- In the procedure, warmed and ‘washed’ (treated) sperm are introduced
into the woman’s uterus through a tube. Sperm can be provided by the
woman’s husband or partner (artificial insemination by husband – AIH)
or sperm provided by a known or anonymous sperm donor (artificial
insemination by donor – AID or DI). The procedure is done around the
time of ovulation to give the best chance of conception. Hormonal
(fertility) medications might be used in along with the treatment to
enhance conditions for a pregnancy.
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• What is the entire procedure of IUI ?

OVULATION MONITORING SEMEN SPERM

INSERTION
INDUCTION OVULATION COLLECTION PREPARATION

• OVULATION INDUCTION
- There are four different ways your doctor may choose to conduct
IUI depending on your individual situation:
- Without hormonal medications
1. In a natural cycle
2. With hormonal medications
3. Clomiphene/IUI
4. Follicle stimulating hormone – FSH/IUI
5. Follicle stimulating hormone with human chorionic
gonadotrophin – FSH/ hCG /IUI

• MONITORING OVULATION
- Throughout this first stage, your response to FSH will be carefully
monitored for ovarian hyperstimulation syndrome (OHSS) and to
gain a clearer picture of what is happening to the follicles so the
right timing and dose can be determined. This monitoring will be
done through regular Transvaginal ultrasounds, blood tests and
urine tests

29
• SEMEN COLLECTION
• Artificial insemination by husband (AIH)
- On the day of the insemination, the male partner will be required to
produce a sample of semen by ejaculating into a sterile container. Two to
three days’ abstinence from intercourse/masturbation is preferred prior
to the sample collection day. Clinics often provide a room so that this
sample may be produced in private, but some men prefer to collect the
semen at home and deliver it to the clinic. As it is being used that day it
must not be frozen or refrigerated, and it needs to arrive promptly at the
clinic – within a half an hour.

• DONOR INSEMINATION (DI)

- IUI can also be done using donor sperm, either from an anonymous or a
known sperm donor (known as DI or donor insemination). Insemination
with donor sperm is used when
- no male partner
- male partner does not produce sperm,
- sperms are of very poor quality
- high risk of passing on genetic diseases.
- Sperm are usually frozen ahead of time and screened for sexually
transmitted diseases (e.g. HIV/AIDS/Hep/Hep C) and any genetic
disorders. The semen selected for a couple closely matches, as much as
possible, the male partner’s characteristics, e.g. eye and hair colour,
height and build.

30
• SPERM PREPARATION
- The semen is prepared in a laboratory for the next stage. In the woman’s
body, the cervix acts as a filter for the sperm, so only the motile sperm
pass through. In the same way, during the IUI procedure the semen is
‘washed’ and filtered, removing any mucus and non-motile sperm. In
other words, a concentrated solution containing the most active sperm
is inserted. Unwashed sperm must not be placed in the uterus as severe
allergic reactions can occur.
- Donor sperm are usually screened for diseases and genetic defects
before being frozen. The samples are thawed and the most active sperm
are separated as required.

• INSERTION
- On the day of ovulation, sperm insertion will take place with fresh or
thawed sperm. For those using fresh sperm, you will be asked to return
to the clinic one to two hours after the delivery of the sperm sample for
the insertion process. This simple procedure is done without anaesthetic
and is rather like having a pap smear, with a similar level of discomfort
involved. An instrument called a speculum is inserted into the vagina so
that the cervix (neck of the uterus) can be seen. A narrow tube attached
to a syringe is gently pushed through the cervix into the uterus. The
sperm are then injected into the uterus. It is usually not painful but
occasionally some mild cramping or discomfort may occur. You will be
asked to remain lying down for around 10–20 minutes and then you will
be able to resume your normal routine.

• When is the best timing for an IUI?

- Ideally an IUI should be performed within 6 hours of ovulation. Typical
timing would be to have a single IUI at about 36 hours post-hCG, If two
IUIs are scheduled, they are usually spaced at least 12 hours apart
between 24 and 48 hours after the hCG. 31
• What is the success rate for IUI?
- The overall success rate of IUI is between 15-20 percent per cycle and the
rate of multiple gestation pregnancies is 23-30 percent.

• How long does washed sperm live?

- Washed sperm can live 24-72 hours; however, it does lose potency after 24
hours. Washed Sperm can live up to 5 days in fertile mucus, 2-3 days being
pretty common.

• Do I need to rest after an IUI?

- Most people don’t need to, but if you had cramping or don’t feel well
afterward it is better to rest for a while and continue your routine activities.

• What should I avoid after an IUI

- You should avoid lifting heavy weights and heavy workout. Continue your
routine activities and avoid intercourse for at least 24 hours.

• Can the sperm fall out?

- Once the sperm is injected into the uterus, it does not fall out. There can,
however, be increased wetness after the procedure because of the catheter
loosening mucus in the cervix and allowing it to flow out.

• How high a sperm count is needed for IUI?

- A count above 10 million washed sperms appears necessary for success,
Higher success rates are with washed counts over 20-30 million.

• How many IUIs should I try before moving on to IVF?

- One might do 2-3 IUIs on oral ovulogens (Chlomephene citrate/ letrozle)
before moving on to 2-3 cycles with injectables( rFSH/ hMG). If one doesn’t
have success after 3 good ovulatory cycles on injectables with well-timed
IUI, it would be time to consider IVF.

• How to Know if Pregnancy Has Occurred After IUI?

- Approximately 2 weeks after IUI, a pregnancy test would be advised by
32 the

doctor to confirm the pregnancy.

 IN VITRO FERTILIZATION ( IVF)

• What is IVF or test tube baby?

- In vitro fertilisation (IVF) literally means ‘fertilisation in glass’. You may
have also heard the term ‘test tube babies’ but these days the
procedure involves placing an egg and sperm together in a plastic dish
to fertilise, rather than in a test tube.
- IVF refers to a technique of assisted reproduction where the egg and
sperm are fertilised outside of the body to form an embryo. This
embryo is then transferred to the uterus to hopefully implant and
become a pregnancy.
- The first IVF baby, Louise Brown, was born in 1978 in the United
Kingdom.
- The technique was originally developed to treat infertility caused by
blocked or damaged fallopian tubes but is now used to treat a wider
variety of infertility problems.

• When Is IVF Indicated?

- IVF was originally developed for women with blocked fallopian tubes or
missing tubes and is still used to treat those conditions. It is also used
when infertility cannot be explained and with the following ovulatory or
structural causes:
- Problems with ovulation
- Endometriosis
- Fibroids
- Polycystic ovarian syndrome
- Cervical problems.
- Advanced maternal/paternal age
- Severe male factor
33
- Previous failed treatment ( IUI)
• What is IVF procedure?
- Starting IVF can be a very long and ardouring time – it is another step
closer to becoming parents. Naturally, you will feel hopeful about a
successful outcome but you also need to prepare yourself for around
two months of medications, numerous procedures and testing.
- Please also bear in mind that the success rate of modern fertility
treatments is high, but for the majority of couples, multiple treatment
cycles may be necessary.
- The basic stages involved in the IVF procedure are detailed below. The
whole process up to the embryo transfer stage will usually take six to
eight weeks.

Stage 1: Stage 2: Stage 3: Stage 4: Stage 5: Stage 6:

Ovarian Egg Fertilisat Embryo Embryo Luteal
stimulation (oocyte) ion develop transfer phase
and retrieval ment support
monitoring [Egg Pick
Up]

• Stage 1
- Ovarian stimulation and monitoring
- Baseline hormone evaluation will be done on day 2 of your cycle along
with a transvaginal sonogram to determine the total number of
available eggs in that particular cycle.
- Depending on your reports injection of recombinant FSH ( rFSH) or a
mixture of FSH and LH ( hMG) will be started
- You will be called on 6th day of starting the injection, for ultrasound
(USG) to monitor the growth of follicles and depending on that dose34of
the injection may be reduced or increased.
- Injections will continue till 4 follicles reach 18 mm and a final injection
called the trigger is given
- Egg collection is done between 34 to 36th hour of the trigger

• Stage II
- Egg retrival/pickup
- This a procedure performed under anaesthesia. Just like routine TVS
scan the probe is inserted along with a long needle.
- The ovaries are visualized with the follicles and the needle is inserted in
the follicle and all the fluid inside the follicle is aspirated and the fluid is
then immediately sent to the embryology lab
- In the embryology lab the embryologist examines this fluid under the
microscope for presence of egg, once the egg is visualized it is kept in a
separate dish .
- This procedure continues till all the follicles are aspirated and the eggs
retrieved.

• Stage III
• Fertilization
- About two hours before egg pick up, a semen sample is collected from
the male partner. Two to three days’ abstinence from
intercourse/masturbation is preferred prior to the sample collection
day. The sperm sample is usually produced by masturbation at the
clinic. The sperm is processed to select the strongest, most active
sperm. This is called ‘sperm washing’. The sperm are then placed with
the eggs in an incubator set to the same temperature as a woman’s
body. The next day, the eggs are examined under a microscope to
determine whether fertilisation has occurred The resulting embryos
will be either transferred to the uterus two to five days later, or frozen
35
for later transfer.
• Stage IV
• Embryo Development
- This is a process of monitoring the growth and development of the
fertilized egg and is done by an embryologist who examines and logs
the information on the growth, quality and number of embryos growing
at a proper rate.
- The various stages of embryo development are
- Zygote : A single sperm penetrates the mother’s egg cell, and the
resulting cell is called a zygote.
- Morula : When the zygote reaches 16 or more cells, it is called a morula.
- Blastocyst: The morula continues to divide, creating an inner group of
cells with an outer shell. This stage is called a blastocyst and consists of
approximately 100 cells

• Stage V
• Embryo transfer
- Embryo transfer is not a complicated procedure – rather like a pap
smear – and can be performed without anaesthesia. Two to five days
following egg pick up, the embryo is placed in a catheter (a soft tube)
and transferred to the uterus via the vaginal opening. The number of
embryos transferred depends on a woman’s age, cause of infertility,
pregnancy history and other factors. Generally one, or occasionally two,
embryos will be transferred to the uterus. If more than 2 embryos are
formed then the remaining embryos are frozen and can be used in case
the first cycle fails.

• Stage VI
• Luteal Phase Support
- The luteal phase is the two week period between the embryo transfer
and the pregnancy test. It is usually recommended that you take it easy
for a couple of days after the transfer.
36
- After 48 hours, you can resume your normal activities – these will not
affect implantation.
- The corpus luteum (the follicle after the egg is released) does not
produce the hormones oestradiol and progesterone to prepare the
uterus for embryo implantation as it would in a natural cycle. This is due
to the treatment prior to egg collection and the collection process itself.
In order to ensure there is adequate progesterone present, you will be
prescribed progesterone as a vaginal gel or in the form of injections or
tablets to help keep the endometrium (the lining of the uterus) in
optimal condition for implantation. After approximately 16 days, you
will return to the clinic or your doctor for a blood test to determine
whether a pregnancy has occurred

• Are the injection used in IVF treatment very painful?

- The idea of daily injections can be overwhelming. The initial injection of
rFSH are administered by a very small gauge needle and are
subcutaneous. Theses injection are as painful as being stung by an ant.
- Some patients might be given injections of progesterone which can be
painful for which analgesic cream can be administered.

• Is egg retrieval procedure painful?

- Because anaesthesia is used for egg retrieval, patients feel nothing
during the procedure. Patients may feel some minor cramping in the
ovaries that can be treated with appropriate medications.

• How long does egg retrieval take?

• Egg retrieval typically takes 30- 45 minutes, depending on how many37
follicles are present.
• Will the egg retrieval damage my ovaries?
- No, there is no damage to the ovary with egg retrieval procedure. Of
course there are short term risks such as infection or bleeding which can
occur, but thankfully these are extremely rare events. Studies have
shown that ovaries seem to be unaffected by stimulation and egg
retrieval.

• Is bleeding expected after the egg retrieval?

- Light spotting and cramping are common after an egg retrieval. This
bleeding is most likely the result of needle punctures in the vaginal wall.
Bleeding and cramping should be minor and will most likely be less
intense than your regular period.

• What is done with any "leftover" embryos?

- Embryos that have developed to the blastocyst stage but are not
transferred during the transfer cycle will be cryopreserved (frozen) if
that is your wish.

• How long do out of town patients have to stay for IVF treatment?
- Generally the patients need to stay in town for a period of 3 weeks if
stimulation is to be started at the hospital where egg retrieval is done. If
the stimulation is done at the home town under the guidance of the
fertility specialist the patient has to come for egg retrieval procedure
and stay for a week i.e till the day of embryo transfer. ( day 3 to day 5 of
egg retrieval procedure).

• How soon can a patient from out of town travel back after embryo
transfer?
- Most of the out of town patients return home the day after the embryo
transfer All types of travel are safe. Sitting for an extended period of
time will not affect chances of pregnancy. We recommend that patients
traveling by air drink plenty of fluids, as circulated air can be quite dry,
38
and dehydration should be avoided.
• How successful is IVF?
- The average IVF success rates using one’s own eggs begins to drop
around age thirty and dips rapidly in the mid 30s and early 40s, due to
lower egg quantity and quality. The general global statistic shows that
the pregnancy rate with IVF varies between 32 to 45 %
- In addition to age, success rates with IVF vary with respect to one’s
height, weight, infertility diagnosis, sperm count, and reproductive
history, such as the previous number of pregnancies, miscarriages and
births.

• Are there any side effects associated with IVF?

- Fertility medications can cause
- Mood swings,
- Headaches,
- Hot flashes,
- Abdominal pain,
- Bloating.
- In very rare cases, fertility medication may induce ovarian hyper-
stimulation syndrome (OHSS).

• What are the symptoms of OHHS?

- Nausea or vomiting
- Shortness of breath
- Decreased urinary frequency
- Feeling faint
- Significant weight gain within three to five days
- Severe stomach pain and bloating 39
• How many times can a couple try IVF treatment?
- There is no limit for it. However, many IVF attempts can reduce the
possibility of pregnancy. In some cases, several attempts are
performed until we get a pregnancy.

• Does the number of embryos transferred influence the possibility

of pregnancy?
- There is hardly any difference in the chances of pregnancy if 1 or 2
blastocyst are transferred. If an embryo ( day 3 ) more than 3
embryo are transferred chances of having multiple pregnancy
increases.

• Is there a higher risk of miscarriage in IVF treatment?

- The risk of miscarriage is a little higher after IVF treatment. This risk
is not linked to the treatment itself but to the patient’s ability of
becoming pregnant.

• Is bleeding normal in the early stages of pregnancy?

- No matter what type of pregnancy, bleeding is always abnormal.
The patient should always consult physician. However, with IVF,
bleeding is more common due to the risk factors and may not lead
to miscarriage.

40
• Should patients follow a diet before treatment?
- There are not enough studies about this subject but some
research have shown that a significant number of successful
treatments were those of patients who followed a diet based on
vegetables, fish organic oil etc., prior to their cycles.

• Should patients lose weight before treatment?

- Losing weight can increase the chances of pregnancy in patients
with PCOS. Overweight ladies may have extended treatment
periods and increased possibility of miscarriage.

41
 POLYCYSTIC OVARIAN SYNDROME

• What is PCOS?
- Polycystic ovary syndrome (PCOS) is a hormonal disorder common
among women of reproductive age. Women with PCOS may have
infrequent or prolonged menstrual periods or excess male hormone
(androgen) levels. The ovaries may develop numerous small follicles and
fail to regularly release eggs.

• What are the Symptoms of PCOS

- Signs and symptoms of PCOS vary. A diagnosis of PCOS is made when
you experience at least two of these signs:
- Polycystic ovaries. Your ovaries might be enlarged and contain follicles
that surround the eggs. As a result, the ovaries might fail to function
regularly.
- Difficulty in becoming pregnant (usually because of a lack of ovulation)
(Infertility)
- Ultrasound appearance of ovarian cysts (polycystic ovaries)
- Periods that are absent (amenorrhoea) or infrequent (oligomenorrhoea)
- Excess of male hormones, causing symptoms such as hairiness
(hirsutism) or acne
- Weight gain and an increase in fat, especially around the abdomen or
tummy area
- Prediabetes or diabetes
- Abnormal levels of blood fats (lipids, such as cholesterol and
triglycerides).
42
• Why does it occur?
- It is believed to be linked to both lifestyle factors and genetics – in other
words it may run in the family and/or be affected by lifestyle factors
such as body weight.
- Insulin resistance can be caused by genetic factors or lifestyle factors
(such as being overweight) and is commonly a combination of both.

• Can PCOS be treated?

- There is no known cure for PCOS and it is thought that once you have it,
you always will. But you can work together with your doctor to manage
your symptoms and change your lifestyle so that you can have a healthy
life.

• How PCOS affects your body

- Having higher-than-normal androgen levels can affect your fertility and
other aspects of your health. Following are the effects of PCOS
Infertility
- Metabolic syndrome
- Up to 80 percent of women with PCOS are overweight or obese. Both
obesity and PCOS increase your risk for high blood sugar, high blood
pressure, low HDL (“good”) cholesterol, and high LDL (“bad”)
cholesterol.
- Together, these factors are called metabolic syndrome, and they
increase the risk for heart disease, diabetes, and stroke.
Sleep apnea
- This condition causes repeated pauses in breathing during the night,
which interrupt sleep. Sleep apnea is more common in women who are
overweight — especially if they also have PCOS.
43
Endometrial cancer
- During ovulation, the uterine lining sheds. If you don’t ovulate every
month, the lining can build up. A thickened uterine lining can increase
your risk for endometrial cancer.
Depression
- Both hormonal changes and symptoms like unwanted hair growth can
negatively affect your emotions. Many with PCOS end up experiencing
depression and anxiety.

• How is PCOS diagnosed?

- Doctors diagnose PCOS if women have at least two of three main
symptoms —
- High androgen levels
- Irregular periods
- Cysts in the ovaries.
- A pelvic exam, blood tests, and ultrasound can confirm the diagnosis.

• How does PCOS cause Infertility?

- In PCOS the egg may not be released in every cycle which leads to
infertility.
- Further because of hormonal dysregulation the endometrium (lining of
the uterus) may not be ready to accept the embryo and hence there can
be failure of implantation

• How can I get pregnant if I have PCOS?

- PCOS can make it harder to get pregnant, and it can increase your risk
for pregnancy complications and miscarriage. Weight loss and other
treatments can improve your odds of having a healthy pregnancy. 44
• How can I manage the symptoms of PCOS?
- Management of symptoms of PCOS can be done with the help of
medicines and lifestyle modification. Here are a few simple methods to
manage PCOS by life style modification.

Symptoms Treatment
Weight loss options include:
Obesity, weight gain • changes to diet
• exercise
Cosmetic treatments, i.e. Waxing, bleaching, laser,
Hirsutism (hairiness) electrolysis
• Weight loss
Acne • Topical creams( consult your doctor)
weight loss
Insulin resistance • Changes to diet
Diabetes • Exercise
• Medications
Irregular and/or heavy periods • Weight loss
• weight loss
Infertility
• medications

• What are my options for getting pregnant if I have PCOS?

- There are multiple options of getting pregnant if you suffer from PCOS.
Theses are :-
- Weight loss
- Life style and diet modification
- Medications ( Hormonal preparations)
- Laparoscopic ovarian drilling
- IUI with medication ( Ovulation Induction)
- IVF

45
 ENDOMETRIOSIS

• What is endometriosis?
- Endometriosis occurs when the tissue that normally lines the inside
of the uterus (the endometrium) grows in other places of your body
where it doesn’t belong, such as on the ovaries, fallopian tubes,
outside surface of the uterus, bowel, bladder and rectum.

• How common is Endometriosis?

- Any female , from puberty to menopause, is susceptible to
endometriosis.However you are more likely to develop the condition
if you have the following risk factors:
- Have not had children
- Are overweight
- Have heavy or prolonged periods
- Had your first period at an early age, i.e. before 12 years of age
- Have a family history of endometriosis, e.g. mother, sister, aunt.

• What causes it ?
- Hereditary: It is not known exactly what causes endometriosis,
although it does tend to be hereditary, i.e. run in families.
- Retrograde Menstruation: This means that women menstruate
‘backwards’ through the fallopian tubes and into the pelvis, rather
than through the vagina and out of the body.

46
• What are the symptoms of Endometriosis?
- Pain: The most common symptom of endometriosis is pelvic pain. The
pain often correlates to the menstrual cycle.
- Bleeding: Heavy, prolonged, irregular inter cycle
- Bowel or bladder symptoms, bleeding or discomfort
- Irregular bowel activity, including diarrhea
- Bloating
- Tiredness
- Infertility
- Emotional problems (e.g. depression, anxiety)
- Premenstrual symptoms, including mood swings and irritability.

• How does endometriosis affect pregnancy?

- Up to 50% of women with infertility problems have endometriosis.
Some women with mild endometriosis symptoms don’t even know
they have the condition until they have trouble becoming pregnant.
- In some cases, the fallopian tubes are damaged or have scar tissue due
to the formation of endometriosis, and this can stop the flow of the
egg down the tube. It also makes it more difficult for the sperm to
travel along the tube to the egg, lowering the chance of conception..
- Other possible reasons for infertility include chocolate cysts (
endometriosis of ovary) affecting ovulation, and eggs that don’t
develop properly and are less likely to be fertilised.
- It is also thought that the body produces toxins, which affect the
sperm, and the developing embryo.

• How does pregnancy affect endometriosis?

- Pregnancy can relieve the symptoms of endometriosis – because you
are no longer menstruating – but it is not a cure in itself. For many
women, the symptoms usually return after giving birth or within a few
years after childbirth. Most women can delay the return of the
symptoms by breastfeeding, as long as the feeding is frequent enough
47
and intense enough to suppress the menstrual cycle.
• How is endometriosis diagnosed?
- Endometriosis is a difficult entity to diagnose and it requires
experience and proper technique to diagnose it on imaging. The
diagnosis is done based on the following –
 History:
- History of painful menses. Heavy bleeding or irregular bleeding
- Painful sexual intercourse.
- Pain while defecating
 Examination : a Per vaginal examination may help in diagnosis . while
performing the examination any pain or tenderness in the vagina or the
pelvis is indicative of either endometriosis or pelvic inflammatory
disease.
 Imaging : Good 2 d TVS can also help in diagnosing endometriosis
especially chocolate cyst.
MRI : 3d scan
 Laparoscopy : It is the gold standard of diagnosing endometriosis

• What is a Chocolate cyst?

- A chocolate cyst is an ovarian cyst filled with old blood. These cysts,
which doctors call endometriomas, are not cancerous, though they
usually mean that a person’s endometriosis is severe enough to
complicate their fertility.

• How is endometriosis treated?

- Treatment of endometriosis depends on the severity of the disease. It
is generally managed with a combined modality of lifestyle
modification, medicines and or surgery.
48
Grade of endometriosis Involvement Treatment

Superficial ovary/ uterus and Life style modification and

Grade I
tube not involved drugs

Tubes and uterus may be Drugs for pain relief and

Grade II
involved hormonal pills

Drugs for pain relief and

Grade III Uterus tubes ovaries involved hormonal pills and Surgery for
fertility enhancement

Uterus tubes ovary and

Grade IV Fertility enhancing Surgery
surrounding organs involved

49
 COVID-19 AND INFERTILITY

• I hear that elective medical procedures in my geographic area are

stopped and IVF and other fertility treatments considered ‘elective’?
- A: It was stopped initially during the pandemic for a couple of months
but now all the treatments have been resumed.
- No one providing your care believes that any fertility treatment is
elective. Infertility is a disease, and treatment of infertility is medically
necessary. There is a distinction between a treatment that cannot be
postponed even for a few days (such as surgery for a ruptured
appendix), and treatment that is time sensitive and extremely
important (such as IVF) but not a medical emergency.

• Am I at risk of contracting COVID-19 at my appointment?

- We are taking all possible precautions to protect our patients and staff,
including:
1. Having patients wait in their car in the parking lot until the treatment
room is ready
2. Pre-screening the patient by phone when they arrive at our clinic to
determine potential risk
3. Checking patient temperature at the door prior to entering. Patients
with a temperature of 100 degrees or higher are not allowed into the
clinic
4. Staff are wearing masks
5. Staff temperature is checked twice daily
6. Frequent cleaning of high touch surfaces throughout the day
50
7. Good hand washing for all employees
8. Physical distancing in the clinic

- However, we all face the possibility of infection whenever we leave our

homes, and we cannot guarantee that you face no risk of contracting
the virus. This is because the virus is contagious long before any
symptoms show.
- If you do not need to physically be in the office, we offer telehealth
consultations by phone instead.

• Is it safe to undergo ultrasound for ovulation study now?

- As we said,we are taking utmost precautions to clean the machine
after every use,spacing the appointments,changing the disposables
after every patients. We have also reduced the number of ultrasound
visits to reduce the risk of exposure.

• Can my clinic prevent me from getting infected by screening patients

and staff?
- As anyone who has been through fertility treatment or has prepared to
begin fertility treatment knows, multiple clinic visits and procedures
are required. Unfortunately, even if a clinic tries to screen patients and
staff to lower the risk of novel coronavirus exposure in the fertility
clinic, there is no way to guarantee prevention of exposure. COVID-19
is now spreading through communities and is not limited to those who
have traveled to certain countries. People who have the novel
coronavirus are contagious days before they develop any symptoms.
The virus can be in the air that they breathe out and the air you
breathe in. This risk is reduced by wearing masks and by increasing
physical distance between people. However, even these precautions
aren’t foolproof and do not guarantee your safety.
- We wish we could screen in a way that could eliminate risk, but we
honestly cannot.
51
• Can I proceed with fertility treatment if I meet diagnostic criteria
for COVID-19?
• If you meet diagnostic criteria for treatment you will have to be 14
days symptom free before being allowed to proceed with fertility
treatment.

• Will postponing my IVF treatment affect my ability to have child?

• A: It is extremely difficult to consider postponing your treatment.
Most people have gone through tremendous loss and grief by the
time they get to the place where they are doing an IVF cycle. In
addition, navigating the cost and insurance coverage aspects is
daunting. Now that you are at this point in your family building,
you are dealt a huge unknown with the COVID-19 pandemic, and
how you should proceed, or start, this medical treatment. It should
be somewhat helpful to hear that there is no evidence that
delaying treatment for a month or two will ultimately affect your
ability to have a child, even if you have concerns about advanced
age and / or diminished ovarian reserve (low egg supply).

• Is there a risk that my cycle could be cancelled if I proceed with

treatment now?
• A: As health care professional we are taking all the necessary
precautions but during the course of the treatment if any of the
doctors or staff members become positive we can continue your
cycle at another fertility clinic after your covid testing so that your
treatment cycle does not get cancelled.
• If you become covid positive during treatment cycle,we shall do
the ovum pick but freeze your embryos/eggs and do a frozen thaw
embryo transfer.
52
• My IVF cycle was planned but my husband is tested COVID positive
and I am under home quarantine. What can I do now?
- Consider scheduling a consultation and begin to prepare for your
treatment cycle. Some people may want to use this time to focus on
improving their general health through efforts such as smoking
cessation or weight loss that may improve fertility treatment success.
It’s a good opportunity to focus on nutrition and reduce or eliminate
habits that are detrimental to overall health.

• I have been diagnosed with cancer and chemotherapy is

recommended. Can I still attempt to freeze my eggs (or sperm if
male)?
- Yes! People facing an urgent need for fertility preservation can proceed
during the pandemic, if this is deemed to be reasonable after
consultation with their doctor .

• Are my eggs and embryos going to be safe during the COVID-19

pandemic?
• Yes. There is no immediate threat to the safety of cryopreserved eggs,
sperm or embryos. Clinics have policies and procedures to maintain
the liquid nitrogen tanks containing frozen embryos, eggs, and sperm.
We will continue to do so during this time of crisis. That is always and
will continue to be a op priority. We have reached out to our supplier
of liquid nitrogen and they do not anticipate any disruption of
deliveries. We have obtained extra reserves to be safe.
• Please ask your doctor if you have any questions about the systems in
place at your provider’s clinic.

• Are you checking to see if my egg donor or gestational carrier are at

risk of being infected with COVID-19?
- Yes. We are following the recommendation and tracking updates as it
relates to third party reproduction. We are asking all tissue donors if
they have, in the last 28 days: 53
traveled to areas with COVID-19 outbreaks, as defined by CDC
lived with individuals diagnosed with or suspected of having COVID-
19 infection; or
been diagnosed with or suspected of having COVID-19 infection
Furthermore, we are advising our third party agency partners to
making sure they are also following the FDA’s guidance.

• I read on the internet that some scientists are suggesting the

COVID-19 might disrupt sperm production. Is that true?
• At this time, there is no evidence to support this speculation. For all
intents and purposes, this paper was intended to warn the medical
and scientific community to investigate, and not intended to be a
public health pronouncement. We are monitoring case reports when
come from trusted sources like the CDC and WHO. In
the meantime there is no evidence that sperm counts are
compromised by those who are infected, and there is no
recommendation to bank sperm. We will update this section as we
learn more.

54