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Infertility & IVF


Infertility & IVF


Thank you for selecting "ARKA IVF CENTER" for your In-Vitro Fertilization (IVF) Programme.

This information directory is designed especially for you to help you better understand the steps that will be taken during the course of the programme. The entire treatment cycle from the initial consultation to the end of the programme is covered and explained here.

We are committed to guide you along the various milestones and make your experience with us a fulfilling one.

With best wishes,

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Dr Sandhya Avagadda M.S - Arka IVF Hospital

Dr Sandhya Avagadda M.S

Gynae Lap. Surgeon and Infertility Specialist Arka IVF Centre Baggu Sarojini Devi Hospital Srikakulam, AP, India.

Introduction and Indications for In- Vitro Fertilization (IVF)

Introduction of IVF

One in six couples experience some level of difficulties in achieving pregnancy. Infertility is defined as not able to get pregnant despite having frequent, unprotected sex for atleast a year.

Louise Brown was the first baby in the world to be conceived by In Vitro Fertilization (IVF). She was born on 25 July 1978. Durga, who was born on 3rd October,1978 was the first in India and second in the world to be conceived by IVF. There are now more than six million babies after IVF treatment worldwide.

IVF is recommended for couples who have tried other methods of fertility treatment without success, or for those who are not suitable for other methods.

IVF involves retrieving good quality eggs from the woman for insemination with her husband’s sperm in the laboratory. The resulting embryos are then transferred back into the womb for implantation.

We, at Arka IVF Centre, Srikakulam are sincerely committed to help couples overcome infertility. Doctors, embryologists, medical technologists, nurses, psychologists and other allied health professionals here work together as a team to provide our couples with the necessary support and assistance in a friendly and personalized manner.

Indications for IVF

IVF is an elective therapy for couples that have been otherwise unable to conceive naturally.

Indications for enrolment into an IVF programme may include, but are not limited to the following:

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Preparation for the IVF Programme

A. First Consultation

When you first meet with the IVF specialist, you will be asked to answer questions relating to your relevant medical & surgical history, previous fertility investigations, allergies, etc.

Physical examination will include a general survey, vital signs, listening of the heart and lungs with a stethoscope, as well as examination of the breast, abdomen, cervix, uterus and ovaries for the women.

Examination of the man will include examination of the penis and scrotum when indicated by a General surgeon/Andrologist.

If you have undergone any medical investigations in other healthcare institutions or any IVF cycles previously, it would be helpful to bring all the medical and laboratory reports as you may not need to repeat some tests.

B. Other Investigations

Blood test for Serum Follicle Stimulating Hormone (FSH), Luteinising Hormone (LH), Estradiol, Testosterone, Prolactin, and thyroid function tests.

Serum Anti-Mullerian Hormone (AMH). This is to assess ovarian reserve.

Blood Group, FBS, PPBS, S.creatinine, clotting and bleeding time, CBC, CUE.

Thalassemia Screen.

Pap smear (If this has not been done within the last 3 years).

Endocervical swab for Chlamydia.

Blood tests for infections:

Semen Analysis: This is done after abstinence from ejaculation or intercourse for at least 3-6 days. Semen can be collected at home and brought to the Andrology lab within 2 hours. Alternatively, there is a collection room within the hospital.

Blood tests for infections:

Infection screening is a mandatory requirement for all patients enrolling in IVF programmes. The test results for HIV and the rest of the disease are valid for 6 months and 1 year respectively.

Upon completion of the investigations, you will meet the IVF specialist again to review the results.

C. Pre-IVF Counselling

Pre-IVF counselling is essential to couples going for the IVF programme. Pre-IVF counselling can be done at our clinic prior to starting the programme.

At the counselling session:

Our clinic staff will assist with your enquiries. Should there be additional need, a return visit to the attending IVF specialist may also be scheduled after the pre-IVF counselling.

Psychological counselling is also offered tocouples considering an IVF programme, as there are many important issues to be considered in the psychological welfare of the couple during what can be an extremely emotional and stressful time in their lives.

D. IVF Planning

The IVF treatment cycle will last for approximately four to six weeks. It usually starts on the preceding menstrual cycle of the planned IVF programme. Our nurses at OPD and Arka IVF centre will inform you of the key dates and steps to be taken with regards to medications and appointments at the clinic.

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Overview of IVF schedule

Step 1: Stimulation and monitoring of ovarian response

There are various different IVF stimulation protocols. Your IVF specialist will decide which protocol is most appropriate for you. The details of the protocol that has been chosen for you are attached at the back of this booklet.

Monitoring Follicular Growth You will need to come to the clinic at intervals to monitor your follicular development during this period. This is achieved by transvaginal ultrasound scan and hormone blood tests.

What are follicles?

Blood tests will be done to measure the Serum Estradiol levels, which can help the IVF specialist to monitor your response to the stimulation medications and to make appropriate adjustments in the dosage of the medications.

The male partner should start prophylactic antibiotics-Oral Doxycycline 100 mg capsules, twice a day for 10 days, on the day that the female partner starts stimulation injections. This is to reduce the chance of infection in the semen.

Important note:

Inform the doctor if you are on any medication.

Step 2: Triggering Ovulation

When an appropriate number of follicles have reached a certaincriteria, you are ready for Oocyte retrieval.

The schedule for Oocyte retrieval will be co-ordinated and arranged by IVF clinic. You will receive instructions regarding medications, timing of administration, and the necessary preparations or procedures prior to admission for Oocyte retrieval.

An injection will be administered 36 hours prior to the Oocyte retrieval to trigger ovulation. This medication aids in the final maturation of the eggs and assists in ovulation.

Important note:

The trigger injection must be administered at the instructed time as it can affect the outcome of the Oocyte retrieval.

Step 3: Oocyte Retrieval (Egg Collection)

Preparation for Oocyte retrieval:

This is an outpatient day surgery procedure.

Fasting is required, i.e. no food and drink for at least six hours prior to the scheduled procedure time.

Medications may be taken with sips of water.

Please report to the clinic at least two to three hours before the scheduled procedure. Do bring these documents:

Letter of admission.

IVF Programme Appointment Card.

Identity Card

Please remove all jewellery, nail polish, perfumes, make-up and contact lenses on the day of Oocyte retrieval.

Do arrange for an adult companion on that day.

After admission, you will be escorted into the day surgery operation theatre after you have emptied your bladder.

The anaesthetist will review you and explain the route of anaesthesia to be given.

Important note:

Please mention to the team if you have any known medical illness. Allergy, or adverse reactions to anaesthetic agents or sedatives.

The Procedure

Oocyte retrieval takes 15-20 minutes on average. It is done under general anaesthesia with transvaginal ultrasound guidance.

A needle is passed through the vaginal wall into the ovaries under direct visualization with the ultrasound, to aspirate the follicles.

The follicular fluid is passed to the embryologists for examination. They will inform the IVF specialist how many eggs have been collected at the end of the procedure.

After the procedure, you will be transferred to the recovery room for further monitoring. You will be allowed to eat and drink four to six hours later, and can be discharged after being reviewed by a member of the team.

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Operative risks and complications include:

Post Oocyte retrieval

There are no dietary restrictions.

You may carry on with your usual daily routine although strenuous exercise and sexual intercourse are to be avoided.

Avoid swimming, hot steam, saunas or tub baths.

Prophylactic antibiotics will be given for seven days to minimise the risk of infection.

Luteal phase support

For fresh embryo transfers,on the morning after the Oocyte retrieval, you will start on a progesterone gel applied vaginally/injectable progesterone that helps to prepare the lining of the womb for embryo implantation. This is carried on until pregnancy test result is known.

Depending on the types of stimulation protocol, you may be instructed to use other medications following Oocyte retrieval.

Collection and preparation of sperm on the morning of the day of Oocyte retrieval:

Please submit fresh semen samples following an abstinence period of three to six days.

The sample can be collected at home and brought to the hospital within two hours. Alternatively, preferably, it can be produced at the sample collection room in the IVF complex.

The sample would then be prepared for the insemination of the collected eggs.

To help alleviate and ease the stress for a time like this, we provide a semen storage service (as back-up) prior to the Oocyte retrieval day.

Step 4: Fertilization and Embryo Culture

The embryologist will identify the eggs in the aspirated follicular fluid and assess their maturity. All the mature eggs will be inseminated with the sperm. Fertilization may be achieved through:

IVF-inseminate the egg with prepared sperm for natural Fertilization (or)

Intra Cytoplasmic Sperm Injection (ICSI) - injection of a single sperm into each mature egg.

You will be notified by the embryologists of the outcome of Fertilization on day3/day5 after the Oocyte retrieval. Accordingly either fresh cycle is done or all embryos frozen if an FET cycle is planned. Poor quality embryos will be discarded.

Important note:

In case of failure to retrieve mature Oocyte, or failure to fertilise after insemination, embryo transfer wound not be possible. An appointment will be scheduled to discuss the outcome with the IVF specialist.


The goal of all fertility treatments is for you to deliver a healthy baby. With In-Vitro Fertilization (IVF), the chance of conceiving multiple babies is about 25% compared to a natural conception where the rate is about 1-2%.

Although having twins or even triplets may be your “dream” outcome, multiple pregnancy is associated with many health risks.

What are risks associated with multiple pregnancy?

The risks, which begin from the first trimester include:

It is important to note that healthy and fit individuals may also experience the above risks.

What a single embryo transfer and why should you choose it?

Elective single Embryo Transfer (eSET) is a procedure where one good embryo, selected from a larger number of available embryos, is placed in the womb after the eggs have been fertilised. This embryo may be from a fresh or a previous cycle. The main aim of eSET is to reduce the multiple pregnancy rate associated with replacing more than one embryo.

Who is suitable for eSET?

We will offer to women with the best chance of achieving a pregnancy. While there are many factors that influence successful conception, women who meet the following criteria are considered suitable for eSET.

Our embryologists will grade each embryo as they are growing based on a detailed assessment under the microscope and your doctor will further discuss the option of eSET with you throughout your IVF journey.

Although the desire for parenthood can be strong and you have many decisions to make, it is important to choose the option that suits your personal and practical limits. Please feel free to clarify any doubts that you may have with us so that we can help you make the best choice.

Step 5: Fertilization and Embryo Culture

Preparation for embryo transfer:

The procedure

No anaesthesia is required.

The embryo(s) are transferred into the womb using a small tube or transfer catheter, and the process is visualized and guided by abdominal ultrasound.

The embryo transfer is usually painless, although some patients may experience mild cramping. After transfer, you will be brought to the recovery room. You may be discharged from the hospital after one to two hours.

Post embryo transfer

Complete bed rest after the embryo transfer is not necessary, but it would be good to reduce any undue stress. Hospitalization leave is issued from the day of Oocyte retrieval until the day of the pregnancy test so that you can rest.

Diet may be taken as tolerated.

Alcohol and smoking is not allowed.

Refrain from swimming, tub baths, hot steam baths or Jacuzzis.

No tampons or vaginal douches.

Intercourse should be deferred until a viable pregnancy is verified.

Avoid any strenuous activities like exercise, jogging or gym training.

Please seek clearance from the IVF specialist or the staff at the clinic if you are taking any other medications.

The two weeks wait after the embryo transfer can be a difficult time filled with uncertainty and anxiety. Please try to relax and support each other throughout the wait.

Step 6: Pregnancy Test

The blood test for confirmation of pregnancy (β HCG) is done 16 days after the Oocyte retrieval.

In the event that there are equivocal results, or in the presence of vaginal spotting or bleeding, a repeat blood test may be required to confirm the results after two to three days. This will enable the clinician to determine whether the pregnancy is continuing at a normal course.

If the result is Positive

Congratulations! Additional medications and supplements to support Pregnancy will be taken.

An appointment will be made for a transvaginal ultrasound two to three weeks after a positive pregnancy test to verify how many of the transferred embryos have implanted and to confirm the presence of a singleton or multiple pregnancy. It would also aid in the evaluation of possible early miscarriage or ectopic pregnancy.

If the result is Negative

Stop using the progesterone gel suppositories (and other medications as relevant). Next menses would be expected to come within two weeks.

Don’t give up yet! Please schedule an appointment with the IVF specialist to discuss further management options.

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Risks and Complications

A. Poor Ovarian Response

There may be instances when the treatment cycle has to be cancelled, because of poor response to the stimulation regimen. If there are fewer than four developing follicles after adjustment to optimize the dosage of fertility injections, the couple and the IVF specialist might consider abandoning the IVF cycle.

In subsequent IVF cycles, the IVF specialist might put the patient on a different dosage of medications.

B. Ovarian Hyperstimulation Syndrome (OHSS)

Some patients will over respond to the Gonadotrophin injections and produce too many follicles. If this happens and treatment continued, there is a risk of developing Ovarian Hyperstimulation Syndrome (OHSS). Patients at a risk of developing OHSS are advised to take half the dose of hCG and encouraged to drink at least 2 litres of fluid daily. Their egg collection may be cancelled and they must continue on the injections until all the follicles have disappeared. Protected intercourse will also be advised until next period. After this, treatment with a lower dose of Gonadotrophin injections can be restarted.

Some patients will still develop the OHSS in the few days or two weeks after egg collection. The majority will develop a minor or moderate form of the condition, their ovaries become enlarged with multiple cysts and ascites (fluid in the abdominal cavity), causing abdominal discomfort.

The most severe form of OHSS occurs only in 1.0% -1.5% of patients receiving fertility injections. It is characterized by nausea, vomiting, ovarian enlargement and ascites, causing marked abdominal pain and distension. The abdominal distension may prevent the proper movement of the diaphragm (the muscle between the chest and abdomen) so that the woman may feel extreme breathlessness. She may also feel weak and faint due to a reduction in her circulating blood volume (hypovolaemia).

In the most extreme situations, there is a reduction in the blood flow through the kidneys, resulting in a reduction in urine output. Those women who develop severe OHSS require hospital admission, usually to relieve their symptoms and to monitor their progress.

Management of severe OHSS may include aspiration of some of the ascitic fluid from the abdominal cavity. It will include maintaining the circulating blood volume by administering intra venous fluids, which will also substitute the fluids lost by vomiting.

Majority of patients (75%) with severe OHSS are pregnant. Symptoms do not persist after the first three months when the hormone production supporting the pregnancy shifts from the ovaries to the placenta (after birth). In the majority of cases the symptoms disappear within few weeks. Those patients who are not pregnant recover much quicker, usually by the time they have their next period.

The symptoms you should be concerned about are as follows:

If you have any of those symptoms please do not hesitate to contact us.

C. Multiple Pregnancy

Transferring more than one embryo increases the chances of pregnancy. However, this also increase the risk of having a multiple pregnancy.

Approximately 25% of IVF pregnancies are multiple pregnancies. These are classified as high-risk pregnancies.

Why is it a high-risk pregnancy?

With these scenarios in mind, our Arka IVF centre has adopted a stand to limit the maximum number of embryos to be transferred into the uterus. Please refer to page 11 for more information on elective single embryo transfer (eSET).

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Antagonist Protocol

A. Cycle programming

Your IVF specialist will discuss with you on the need to programme your IVF cycle. If this is recommended, you will be required to start taking progestin e.g. Norethisterone tablets on day 18 of the menstrual cycle prior to your intended IVF cycle. Your IVF specialist will advise on the number of days that you need to take the table, which is usually between 7 to 14 days.

B. Baseline ultrasound scan and blood test

These are performed five days after stopping Norethisterone (you will usually experience a period by the day of scan if you are on a programmed cycle), or on day two of your menses if you are not on a programmed cycle. The purpose of the ultrasound scan and blood test is to ensure that it is alright for you to start your daily injections of stimulation medications.

C. Injections

You will be given medications to stimulate the ovaries to produce multiple Oocyte (eggs).

Gonadotrophin, e.g. Gonal-F® or Recagon (recombinant FSH )® is given as a subcutaneous injection for 9-11 days (Refer to Annex1). The dosage may vary between different patients and cycles as treatment regimens are individualised to suit different needs. Your IVF specialist and the CHR nurses will inform you of the specific medicines you will be using.

A second medication will be started, usually on day six or seven of stimulation, to prevent premature ovulation from occurring. These medicines are called GnRH antagonists. Cetrotide® (Cetrorelix) and Orgalutran® (ganirelix) are two examples.

D. Possible Side Effects

Agonist or long protocol

A. Down-regular phase

The down-regular phase is initiated on Day 21 of the menstrual cycle. A hormonal injection, Buserelin acetate e.g. Superfact®, is given daily as a 0.5ml injection just beneath the skin for 14 days (Refer to Annex2). It is an analogue of Gonadotrophin releasing hormone (GnRH) which will “turn-off” the pituitary gland from releasing its natural its natural hormone. This will prevent premature ovulation during the stimulation phase.

Possible Side Effects

B. Onformation of down-regulation

After two weeks of Buserelin acetate injection, you will be asked to come to the clinic for a transvaginal ultrasound examination and a blood test for serum estradiol and LH levels. The results will help determine if down-regulation has been achieved, and if you are ready for the next phase of treatment.

C. Stimulation Phase

Once down-regulation has been achieved, you will be given medications to stimulate the ovaries to produce multiple eggs or oocytes. Gonadotrophin, e.g Rec FSH is given as a subcutaneous injection for 10-12 days (Refer to Annex1). The dosage may vary between patients and cycles as treatment regimens are individualized to suit different needs. During this phase, the Buserelin dosage is decreased to 0.2 ml per day. It is continued until the day of hCG e.g. Ovidrel administration.

D. Possible Side Effects

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