This is a technique where we use a special camera to look into your uterus from down below. We do not make any incisions anywhere.
It is usually done when we need to make sure that the inside of your uterus (cavity) is normal. This is very important before an IVF because the success rate depends on a normal cavity. We also may do a gentle curette ie scrape the lining of your womb if necessary and if it is abnormal.
We can also see if there are growths called polyps or fibroids inside the uterine cavity. If possible, we will remove them to make your uterine smooth and normal.
Before the procedure, you will be advised some blood tests. You need to avoid food and drink for 6 hours before the procedure.
This is done under general anesthesia
The hysteroscope is a thin long instrument with a camera at one end.
We first dilate the cervix (opening of the uterus)
We next distend the uterine cavity with saline as we look inside to see clearly
It takes not longer than 5 – 10 minutes to complete the procedure
This is a day procedure. You will be asked to come in the morning and can get back home by evening. You will be able to get back to work in a day.
You may feel a bit drowsy and sick soon after the procedure. This will settle in a few hours.
You may have vaginal bleeding which usually settles within a week
This is a very safe operation, but every operation and anaesthetic carries a small risk.
Occasionally the dilator is pushed through the wall of the uterus into the abdominal cavity. This sounds very alarming but all that is usually done is to extend the hospital stay another day or two.
An infection of the womb and tubes can follow a hysteroscopy. We usually give you antibiotics to prevent this from happening.
Intra Uterine Insemination Information
Here, we collect semen from the male partner and process (called sperm wash) it by separating the fast, active sperms from debris and dead sperms. We then confirm that the follicle has ruptured and that the egg has been released by doing a scan. After confirmation, we place the washed sperms inside the uterus bypassing the cervix. Therefore, the aim is to place active sperms closer to the egg to facilitate fertilization.
This is when a woman fails to produce an egg regularly on her own. The most common reason is polycystic ovary syndrome. Here, we usually assist egg growth and release by oral medication and/or injections. This is called ovulation induction. We usually advise intercourse when egg release has been confirmed by scan for up to 12 consecutive months. If they still fail to become pregnant, the next step is IUI.
Very often, IUI is advised when the sperm count is moderately low with poor motility. Another reason may be sexual dysfunction wherein the male partner is unable to participate in normal intercourse.
This is a condition where the lining which is within the uterine cavity (called endometrium) begins to grow in other places – namely the inside of the abdomen, covering the ovaries etc. Endometriosis can be of varying severity and is diagnosed by a laparoscopy. Endometriosis reduces your chance of conceiving and we often advise IUI to increase your chance to conceive.
Nearly 30% of couples who are investigated because they have not conceived have no identifiable problem. They have regular periods, they have normal fallopian tubes and the male partner has a normal sperm count/motility. This is termed ‘unexplained infertility’. These couples also need treatment to conceive and we often advise IUI
In certain situations where the male partner has a medical problem like cancer requiring chemotherapy, we will be able to freeze the sperms before treatment to preserve sperms. We can then use it by IUI later. Similarly, in men travelling overseas we could freeze the sperms for use during IUI
Men who have no sperms may choose to have donor sperms. This will require IUI too. In other cases, men may carry a genetic disease and yet choose to have sperm donation to prevent passing on the problem to their offspring.
This should be started at least a month before starting treatment. This is advised because it reduces the risk of spina bifida in your baby.
We advise you to eat a balanced diet with plenty of vegetables and fruit.
Both smoking and inhalation of smoke (passive smoking) should be avoided.
How a normal pregnancy occurs…….
Normally, after intercourse sperms will be deposited high up in the vagina near the opening to the uterus called the cervix. From here they have to swim up through the uterus to meet the egg.
The egg, after release from the ovary will be picked up by the fallopian tube.
The egg will be transported through the tube by contractions of the muscle coat of the tube.
The sperms have to travel into the tube to meet the egg. The tube is where fertilization occurs. The fertilized egg, which will later form the baby will then be transported to the uterus where further growth will occur.
In IUI, sperms which are made more active by a special preparation are placed inside the uterus after egg release is confirmed by scan. This will increase the chance of becoming pregnant.
Usually after a scan and blood tests on Day 2/3 of the cycle, the patient will be started on tablets and/ or injections which will stimulate egg formation.
Eggs grow within fluid filled sacs called follicles. By doing internal scans from day 6 or so we can assess growth of these follicles. When the follicle reaches a suitable size, we will give an injection which will help the follicle to burst and release the egg.
At this time, we obtain a sample of semen and process it by a special process in the lab. This makes the sperms very active.
We perform ‘intrauterine insemination’. This causes no pain and is not done under anaesthesia. We insert a very thin tube into the uterus. The prepared sperms are then injected gently inside the uterus through the tube.
With the sperms being placed closer to the egg, the chance of pregnancy is improved.
IUI has a success rate of 12 – 15 % at best. But with repeated and consecutive attempts (a maximum of four to six depending on the reason for IUI) the success rate will rise to approximately 45 -50%.
It is unnecessary to rest after IUI. Resting does not increase your chance of getting pregnant.
We will do a urine pregnancy test 16 days after the IUI if you have not had a period by then.
Tubal Factor Infertility
The fallopian tubes are also called tubes. There is a pair of tubes attached to the uterus on both sides reaching up to the ovaries. Approximately about 10cm long, the fallopian tubes are not directly attached to the ovaries. Instead, the tubes open up into the peritonial (abdominal) cavity, very close to the ovaries.
Once the egg has been released from the ovary, the tube picks up the egg using fingerlike projections. Once within the tube, tiny hairs inside the tube help to sweep the egg towards the uterus.
After intercourse, sperms are deposited high in the vagina. They swim from there through the uterus to meet the egg within the tube. It is within the tube that fertilization takes place. The embryo which is formed then travels slowly to reach the uterus. The inner lining of the tube is specially made to make sure the embryo remains healthy throughout its journey in the tube.
Damage means that either one or both tubes are blocked. Sometimes they may not be completely blocked but may have internal scarring or destruction of the inner lining.
Tubal damage is usually caused by an infection which has spread up from the vagina, through the uterus and into the tubes. This is commonly known as pelvic inflammatory disease.
Less often, tubal damage may be due to endometriosis or adhesions which may form following operations on the uterus or ovaries.
- The most common infection is an organism called Chlamydia.
- When the infection gets into the tubes it causes an intense inflammatory response. Bacteria, white blood cells and other fluids (pus) fill the tubes as the body tries to fight the infection.
- Finally, the body wins and the bacteria are destroyed.
- However, during the healing process, the delicate lining of the tubes can be permanently damaged. The end of the tube, near to the ovaries, may become partially or completely blocked. In badly damaged tubes, the blocked tube may fill with fluid and is called a hydrosalpinx. Scar tissue or adhesions may form around the outside of the tubes and the ovaries.
- Most women will be offered a test called a hysterosalpingogram.
- This is an x-ray test
- A small amount of a special dye is injected through a small catheter placed in the cervix into the uterus.
- If the fallopian tubes are open, the dye flows into the tubes and then spills out into the abdominal cavity.
- This can be seen on the x-rays taken whilst the examination is being performed.
b) Laparoscopy and Tubal Dye Tests
- This may be offered to women who have a greater risk of having tubal damage or it may be done after a hysterosalpingogram has indicated that there may be damage to the tubes.
- It can also be used when history and examination are suggestive of other problems including endometriosis or ovarian cysts.
- Laparoscopy is performed under a general anaesthetic in the operating theatre.
- A small telescope is inserted through a small cut in the umbilicus and with the help of another instrument inserted through a small incision in the lower abdomen.
- The uterus, tubes and ovaries are seen directly. Dye is injected through the cervix to check for tubal blockage.
- There are three possible treatments:
- Tubal surgery to repair the tube if the damage is minimal.
- IVF – to by-pass the blockage in badly damaged tubes
The most appropriate treatment depends on a number of factors including:
- The degree of tubal damage
- The age of the female partner
- Presence of other fertility problems (male or female).
With increasing success rates of IVF, fewer women would now be recommended tubal surgery. Furthermore, tubal surgery may unblock the tube but may be unable to restore normal tubal function.
This depends on the condition of the tubes at the time of surgery. If you have not conceived within one year of the operation, it is unlikely that your operation has been successful. Also, pregnancy after tubal repair can occur in the tubes – an ectopic pregnancy.The chance of this happening can be as high as 5 – 25%
This will depend on your age, duration of infertility and also on whether other problems are also present. Our centre has a pregnancy rate of about 42%. Unlike after surgery, the chance of an ectopic pregnancy is small – 1-3%. IVF is more expensive than tubal surgery. You will know whether you are pregnant in two weeks after the procedure.
Male Infertility Information
We do a test called a semen analysis. This is done after you have abstained from intercourse for 2-3 days. We look at your semen sample under a microscope to check if you have adequate numbers of sperms which move and look normal. We say that your semen test is satisfactory if – you have more than 15 million sperms, and if more than 50% move rapidly and more than 4% have a normal appearance.
Abnormal sperm parameters can cause delay in conception and very low numbers are associated with infertility.
In about 40% of infertile couples the male is either the only reason or also contributes to the infertility with the female.
Yes. Some men have no sperms at all in their semen. This is called azoospermia.
Often it is difficult to find a reason. These men are said to have idiopathic defects- i.e: no cause identifiable.
The known causes of disordered sperm production are –
Infections of the testes ( mumps) and sexually transmitted infections
Certain medicines like – sulfasalizine (taken for bowel inflammation), Phenothiazines ( taken for psychiatric illnesses) ,immunosuppressants ( taken after transplant surgery) and medicines used to treat cancer
Diabetes, thyroid and other endocrine defects.
Injury to the testes or operations to that area
Varicocele – this is an increase in the size of the veins inside the scrotum making the testes warmer by increasing its blood flow. As stated earlier, this can result in reduction in sperm production.
Being overweight, smoking and excess alcohol can reduce sperm numbers and activity
This may be because of no production or may result because of blockage of the duct system described above. Production may not occur when there are certain hormone defects or when the man has an abnormal number of chromosomes. The duct system may be blocked by damage due to infection or a part of the duct may be absent from birth. Very often, we cannot identify a reason for absent sperms
This depends on how severe the problem is.
With a slight reduction in sperms an IUI (intrauterine insemination) will be advised. Here we do a ‘sperm preparation’. By this process, the dead and inactive sperms and bacteria if present are removed and the good sperms are made very active. These sperms are then placed within the woman’s uterus. This procedure increases your chance of getting pregnant.
With very few sperms we may advise an IVF or an ICSI. For further information please read the booklet on IVF and ICSI
When no sperms are present in the semen, we will examine the testes to see if they are of normal size. Then we usually advise a hormone test (FSH) which will give us an idea as to whether you may have sperms within your testes or not. Of course, the only test which can confirm this is a testicular biopsy.
If sperms are present, we can do a small surgical procedure (read about TESE and MESA in booklet) wherein we can remove them from the testes and use them to fertilize the egg.
If however you cannot afford the above procedure or we do not find sperms in your testes, you can choose to have donor sperms.
Using sperms from the semen, nearly 75% of eggs are fertilized. This falls to about 70% when sperms from the epididymis are used and to about 65% when sperms from the testes are used. Though the chance is lesser, it is important to remember that it is the only chance of you having your biological child.
Another reason may be sexual dysfunction. A few men may have a problem with ejaculation and therefore be unable to have intercourse. Any doubts regarding this can be discussed in detail with your doctor.
Polycystic Ovary Syndrome
Polycystic ovary syndrome (PCOS), formerly known as the Stein-Levanthal syndrome, is a condition where at least two of the following occur, and often all three:
- At least 12 follicles (tiny cysts) develop in your ovaries. (Polycystic means ‘many cysts’.)
- The balance of hormones that you make in the ovaries is altered. In particular, your ovaries make more testosterone (male hormone) than normal. When male hormones are increased, you often tend to get pimples, have excess hair growth on the face(upper lip/chin) and also lose scalp hair.
You do not ovulate each month. Some women do not ovulate at all. (In PCOS, although the ovaries usually have many follicles, they do not develop fully and so ovulation often does not occur.) If you do not ovulate then you do not have a period every month. Most women with PCO have infrequent, irregular periods.
PCO is very common problem. Research studies of women who had an ultrasound scan of their ovaries found that up to 1 in 4 young women have polycystic ovaries (ovaries with many small cysts). However, many of these women were healthy, ovulated normally, and did not have high levels of male hormones.
It is thought that up to 1 in 10 women have polycystic ovary syndrome (PCOS) – that is, at least two of: polycystic ovaries, a raised level of male hormone, reduced ovulation. However, these numbers may be higher.
The exact cause is not totally clear. Several factors probably play a part. These include the following:
Insulin is a hormone that you make in your pancreas (a gland behind your stomach). The main role of insulin is to control your blood sugar level. Insulin acts mainly on fat and muscle cells causing them to take in sugar (glucose) when your blood sugar level rises. Another effect of insulin is to act on the ovaries to cause them to produce testosterone (male hormone).
Women with PCOS have what is called ‘insulin resistance’. This means that cells in the body are resistant to the effect of a normal level of insulin. More insulin is produced to keep the blood sugar normal. This raised level of insulin in the bloodstream is thought to be the main underlying reason why PCOS develops. It causes the ovaries to make too much testosterone. A high level of insulin and testosterone interfere with the normal development of follicles in the ovaries. As a result, many follicles tend to develop but often do not develop fully. This causes problems with ovulation: hence period problems and reduced fertility.
It is this increased testosterone level in the blood that causes excess hair growth on the body and loss of the scalp hair.
Increased insulin also contributes towards weight gain.
Luteinising hormone (LH)
The hormone – LH is made in the brain. It makes the ovaries produce eggs and also increases the production of male hormone – testosterone. A high level of LH is found in about 4 in 10 women with PCOS. A high LH level combined with a high insulin level means that the ovaries are likely to produce too much testosterone.
Your genes are also important. One or more genes may make you more prone to develop PCOS. PCOS may run in some families and often sisters tend have PCOS. Males who have the PCO gene can have early baldness and oily skin.
Being overweight or obese is not the underlying cause of PCOS. However, if you are overweight or obese, excess fat can make the symptoms worse. Women with PCOS tend to have fat accumulation in their tummy- appearing ‘apple shaped’. This is called central obesity. Losing weight, although difficult, can help improve symptoms and help the establishment of regular periods.
These occur in about 7 in 10 women with PCOS. You may have irregular or light periods, or no periods at all.
You need to produce an egg each month to become pregnant. Women with PCOS may not ovulate each month, and some women do not ovulate at all. PCOS is one of the commonest causes of not being able to conceive.
Effects of too much male hormone
- Excess hair growth occurs in more than half of women with PCOS. It is mainly on the face, lower abdomen, and chest. This is the only symptom in some cases.
- Acne (pimples) may persist beyond the normal teenage years.
- Loss of scalp hair (similar to ‘male pattern baldness’) occurs in some cases.
- Weight gain – about 4 in 10 women with PCOS become overweight or obese.
- Depression or poor self-esteem may develop as a result of the other symptoms.
Symptoms typically begin in the late teens or early 20s. Not all symptoms occur in all women with PCOS. For example, some women with PCOS have some excess hair growth, but have normal periods and fertility. Symptoms may also change over the years. For example, acne may become less of a problem in middle age, but hair growth may become more noticeable.
Possible long-term problems of PCOS
If you have PCOS, over time you have an increased risk of developing type 2 diabetes, diabetes in pregnancy, a high cholesterol level, and possibly high blood pressure. For example, about 1 in 10 women with PCOS develop diabetes at some point. These problems in turn may also increase your risk of having a stroke and heart disease in later life.
If you have no periods, or very infrequent periods, you may have a higher than average risk of developing cancer of the uterus (womb).This risk is however small.
Tests may be advised to clarify the diagnosis, and to rule out other hormone conditions.
- Blood tests may be taken to measure certain hormones. For example, a test to measure testosterone and LH which tend to be high in women with PCOS.
- An ultrasound scan of the ovaries may be advised. An ultrasound scan is a painless test that uses sound waves to create images of structures in the body. The scan can detect the typical appearance of PCOS with the many follicles (small cysts) in slightly enlarged ovaries.
Also, you may be advised to have regular checks of blood sugar, blood pressure, and blood cholesterol to detect any abnormality as early as possible. Exactly when and how often the checks are done depends on your age, your weight, and other factors. After the age of 40, these tests are usually recommended every year.
There is no cure for PCOS. We cannot replace your polycystic ovaries with normal ovaries. However, symptoms can be treated, and your health risks can be reduced.
Losing weight helps to reduce the high insulin level that occurs in PCOS. This has a knock-on effect of reducing male hormones. This then improves the chance of you producing an egg and also improves any period problems, you chance of conceiving and may also help you to reduce hair growth and acne. The increased risk of long-term problems such as diabetes, high blood pressure, etc, are also reduced.
Losing weight can be difficult. A combination of eating less and exercising more is best. Advice from a dietician, and help and support from a practice nurse, may increase your chance of losing weight. Even a moderate amount of weight loss can help.
Treating hair growth
Hair growth is due to the increased level of testosterone – the ‘male’ hormone.
- Unwanted hair can be removed by shaving, waxing, hair removing creams, electrolysis, and laser treatments. These need repeating every now and then, although electrolysis and laser treatments may be more long lasting.
- A cream called eflornithine may be prescribed to rub on affected areas of skin. It works by counteracting an enzyme (chemical) involved in making hair in the skin. Some research trials suggest that it can reduce unwanted hair growth, although this effect quickly wears off after stopping treatment. It is called vaniqua cream
Drugs taken by mouth can also treat hair growth. They work by reducing the amount of testosterone that you make, or by blocking its effect. Drugs include:
- The combined contraceptive pill – Novelon. There are many pills to choose from, but all have some effect of reducing hair growth.
- Cyproterone acetate is an ‘antitestosterone’ drug. This is commonly combined with oestrogen as a special contraceptive pill called Krimson 35. Krimson 35 is commonly prescribed to regulate periods, to help reduce hair growth, to reduce acne, and is a good contraceptive.
Tablets taken by mouth to treat hair growth take 3-9 months to work fully. You need then to carry on taking them otherwise hair growth will recur. Removing hair by the methods above (shaving etc) may be advised whilst waiting for a tablet to work.
The tablet Krimson 35 will reduce pimples. But if the problem is too severe, you may get additional advice from a skin specialist.
Treating period problems
Some women, who have no periods, or infrequent periods, do not want any treatment for this. However, your risk of developing cancer of the uterus (womb) may be increased if you have no periods for a long time. Therefore you must have a period at least once every two months.
Therefore, some women with PCOS are advised to take the contraceptive pill as it causes regular ‘withdrawal bleeds’ similar to periods. If this is not suitable, another option is to take progestogen hormone for five days every month which will cause a monthly bleed like a period.
Problems with getting pregnant
The chance of becoming pregnant depends on how often you ovulate. Some women with PCOS ovulate now and then, others not at all.
If you do not ovulate but want to become pregnant, then fertility treatments may be recommended by a specialist and have a good chance of success. But remember, you are much less likely to become pregnant if you are obese. If you are obese or overweight then losing weight is advised in addition to other fertility treatments.
There are many medicines which can be given if you wish to get pregnant. For further details please read the booklet on Ovulation induction
Preventing long term problems
A healthy lifestyle is important to help prevent the conditions listed above in ‘long-term problems’. For example, you should: eat a healthy diet, exercise regularly, lose weight if you are overweight or obese, and not smoke. For advice on food, please contact any of our staff.
Summary of Polycystic Syndrome PCOS
Polycystic ovary syndrome (PCOS) is common. It can cause period problems, reduced fertility, excess hair growth, and acne. Many women with PCOS are also overweight. Treatment includes weight loss (if you are overweight), and lifestyle changes in addition to treating the individual symptoms.
Egg Donation Information
Some women are unable to conceive because they do not have enough eggs or their egg quality is poor. Unfortunately, there is no tablet or injection to increase egg numbers or improve quality. Therefore some women are forced to consider this form of treatment.
Eggs form in the ovary when the woman is a baby in her mother’s uterus. The eggs do not increase in number after a baby is born. On the other hand, their numbers keep on decreasing after birth. At birth, a female baby will normally have two million eggs and this number decreases to 300,000 to 500,000 at puberty. After 35 years, this decrease is rapid and eventually at menopause, no eggs remain in the ovary and hence periods stop altogether.
Some women may have less numbers of eggs at birth or they may get exhausted very soon. Some women may choose to delay having a child until after 35 years and may find that sometimes as a result of this natural decline in egg number, have very few or no eggs. These women may require donor eggs.
A few women may have no eggs at all from birth. Some women may have had treatment for cancer or a problem called endometriosis as a result of which their eggs may have been destroyed completely.
We measure the levels of certain hormones in your blood. They are FSH (Follicle stimulating hormone) and AMH (anti mullerian hormone) If the levels are altered it will mean that your ovaries have lesser number of eggs. Also on scan, your ovaries may be smaller in size and have fewer numbers of antral follicles (fluid filled sacs which contain eggs). Antral follicles can be counted by doing a scan on day two or three of your cycle
Women with fewer good quality eggs are still able to become pregnant with their own eggs but the chance of becoming pregnant is very small: usually less than 1:100 per year.
As stated earlier, the chance of conceiving is smaller when you have few eggs. If you do conceive and if the egg is of good quality then you have a good chance of continuing your pregnancy. If the egg is not of good quality, then your chance of miscarriage increases.
Injections will only increase the growth of existing eggs. They will not produce new eggs.
This is where egg donation is useful. We will obtain eggs from a donor and fertilize them with your husband’s sperms. The embryo which is formed will be transferred into your uterus. If the embryo attaches itself to the inner lining of the uterus, it will grow the same way your eggs would have.
Couples often ask us to arrange egg donors. These women will remain anonymous. They are selected carefully by our unit .The are young, healthy and usually between 20 and thirty years of age. They have one or two children, so we are certain that they have good fertile eggs.
Alternatively, couples sometimes bring in egg donors who are known to them.
The egg donors who are recruited by us will remain anonymous always. They will be unknown to you and you will remain unknown to them.
A detailed history will be taken to ensure that they have good health. Hereditary diseases in their lineage are excluded by taking a detailed history. All donors will be screened for infections including Hepatitis b and C, HIV, syphilis, cytomegalovirus, etc. Donors can also have a chromosome check and a thalassemia screen if requested by recipients.
We can match your blood group and physical characteristics as best as possible. However, it is easy to understand that matching cannot be perfect and has limitations.
Often there is a more than just an immense concern about having an egg donor – a genetically different mother’s eggs growing as your baby.
This link is an excellent real life account of a mother who had a successful egg donation.