What is Infertility?

What is the incidence of infertility worldwide?

My husband and I have an active sex life, we are both healthy, and my periods are regular. Why are we still unable to conceive?

Is infertility exclusively a female problem?

How can I determine my fertile period?

What are the most common causes of infertility?

My gynecologist has done an internal examination and said I am normal. Do I still need to get tests done to determine why I am not conceiving?

What is the general progression of infertility treatment?

Do painful periods cause infertility?

What treatment options do infertile couples have?

My periods come only once every 6 week Could this be a reason for my infertility?

How successful is infertility treatment?

My husband's blood group is B positive and I am A negative. Could this blood group "incompatibility" be a reason for our infertility?

Are there particular factors influencing the success of a treatment?

After having sex, most of the semen leaks out of my vagina. How can we prevent this? Should we change our sexual technique? Could this be a reason for our infertility?

What about success rates of IVF?

My colleagues at work tell me that if we "work" hard at getting pregnant, and want it enough, we definitely will ! In fact, my mother in law is even suggesting that the fact that I am not conceiving means that subconsciously I do not wish to have a baby (because it may interfere with my career) and this psychological barrier is the reason for our infertility.

Are there particular health risks for women undergoing infertility treatment?

My grandmother says that if I just pray and have faith, I will definitely conceive. How far is this true?

What is Ovarian Hyper Stimulation Syndrome(OHSS)?

My husband refuses to get his semen tested. He says the fact that it is thick and voluminous means it must be normal. Is that true?

How do multiple births occur?

My sister conceived only after 6 years of marriage. Does this mean I will also have difficulty conceiving?

What are the common local side effects?

My doctor just did a physical examination for me, and he feels that the reason for my infertility is that my uterus is tipped backwards, and this prevents the sperm from swimming into the uterus. He is advising I have surgery to correct this problem. Should I go ahead?

Can ovulation induction increase the risk of ovarian cancer?

My husband says we should be having intercourse every day to achieve pregnancy. Is this true?

What about the health risks for children born following infertility treatment?

My friends say I should have sex exactly on the day I ovulate to get pregnant. How can I do this?

How important is counseling to the patient undergoing infertility treatment?

My sister in law is advising me to keep a pillow under my hips during and after intercourse. Will this increase my chances of conceiving?

What is the duration of one IVF or ICSI cycle?

My mother feels I am too tense, and that if I just relax, I'll get pregnant. Is that true?

What is Extra Uterine Pregnancy (EUP)?

I just had a HSG (X-ray of the uterus and tubes) done, and this shows my tubes are blocked. I've never had symptoms of a pelvic infection, so how could my tubes get blocked?

What is timed sexual intercourse?

My doctor has advised me to take fertility drugs . I don't want to take them because I am scared that if I do , then I'll have a multiple birth.

What is Egg donation?

My husband's sperm count varies every time we test it! How do we determine what the "real" sperm count is?

What is PCOS?

I have no problems having sex. Since I am virile, is my sperm count normal?

What is Embryo Reduction?

I don't think infertility treatment should not offered in India, because there are too many babies in this country already. Why should we exacerbate the population problem by producing more? In any case, IVF treatment is too expensive for India to be able to afford it.

What is Cryopreservation?

My semen analysis report shows I have no sperm in the semen (azoospermia). Is this because I used to masturbate excessively as a boy?

Is Intra Uterine Insemination suitable for every infertile couple?

My wife is frigid and does not enjoy having sex. Could this be the reason for her infertility?

What is TESE or MESA?

What are the causes of damaged fallopian tubes?

What is Cystic Fibrosis and Male Infertility?

What is Endometriosis?

What does Sperm Preparation mean?

What is Reproductive Surgery?

What does Laparoscopy involve?

Why is Progesterone used for IVF?

What is the best route for progesterone administration during an IVF cycle in terms of efficacy and side effect profile?

What is Infertility?
Infertility, whether male or female, can be defined as 'the inability of a couple to achieve conception or to bring a pregnancy to term after a year or more of regular, unprotected intercourse'.

How can I determine my fertile period?
Your fertile period is the time during which having sex could lead to a pregnancy. This is the 4-6 days prior to ovulation (release of a mature egg from the ovary). Women normally ovulate 14 days prior to the date of the next menstrual period.

What are the most common causes of infertility?
The most common causes of female infertility are ovulatory disorders and anatomical abnormalities such as damaged fallopian tubes. Less frequent causes include, for example, endometriosis and hyperprolactinemia. Causes of male infertility can be divided into three main categories: Sperm production disorders affecting the quality and/or the quantity of sperm; anatomical obstructions; Other factors such immunological disorders. Approximately a third of all cases of male infertility can be attributed to immune or endocrine problems, as well as to a failure of the testes to respond to the hormonal stimulation triggering sperm production. However, in a great number of cases of male infertility due to inadequate spermatogenesis (sperm production) or sperm defects, the origin of the problem still remains unexplained.

Do painful periods cause infertility?
Painful periods do not affect fertility. In fact, for most patients, regular painful periods usually signal ovulatory cycles. However, progressively worsening pain during periods (especially when this is accompanied by pain during sex) may mean you have endometriosis.

My periods come only once every 6 week. Could this be a reason for my infertility?
As long as the periods are regular, this means ovulation is occurring. Some normal women have menstrual cycle lengths of as long as 40 days. Of course, since they have fewer cycles every year, the number of times they are ‘fertile’ in a year is decreased. Also, they need to monitor their fertile period more closely, since this is delayed (as compared to women with a 30 day cycle).

How successful is infertility treatment?
When talking of success rates for any type of infertility treatment, one should bear in mind that the average chance to conceive for a normally fertile couple having regular unprotected intercourse is around 25% during each menstrual cycle. It is estimated that 10% of normally fertile couples fail to conceive within their first year of attempt and 5% after two years. Comparable to normal fertility rates, effective treatments can be expected to have, on an average, up to a 25% success rate per cycle of treatment, and may therefore need to be repeated several times before a pregnancy is achieved. Simple ovulation induction to compensate for hormonal imbalances has a very high success rate; more than 80% of women suffering from such disorders are likely to conceive after several cycles of treatment with drugs such as clomiphene citrate or gonadotropins.

My husband's blood group is B positive and I am A negative. Could this blood group 'incompatibility' be a reason for our infertility?
There is no relation between blood groups and fertility.

Are there particular factors influencing the success of a treatment?
In any type of infertility treatment, important factors need to be taken into account when referring to success rates. The age of the woman and the duration of the couple's infertility are likely to influence the success of treatment. In women, fecundity decreases as age increases, particularly after 40 years of age. When the woman is being treated, her chances of conceiving can be lessened if her partner also has infertility problems (eg poor quality sperm).

After having sex, most of the semen leaks out of my vagina. How can we prevent this? Should we change our sexual technique? Could this be a reason for our infertility?
Loss of seminal fluid after intercourse is perfectly normal, and most women notice some discharge immediately after sex. Many infertile couples imagine that this is the cause of their problem. If your husband ejaculates inside you, then you can be sure that no matter how much semen leaks out afterwards, enough sperm will reach the cervical mucus. This leakage of semen (which is called effluvium seminis) is not a cause of infertility. In fact, this leakage is a good sign - it means your husband is depositing his semen normally in your vagina! Of course, you cannot see what goes in - you can only see what leaks out - but the fact that some is leaking out means enough is going in!

What about success rates of IVF?
Overall, success rates for IVF have steadily improved over the last ten years. Birth rates for IVF vary according to the expertise of the centers practicing this technique. However, centers in Europe have reported pregnancy rates after one cycle of IVF equal or superior to 25%. In 1993, the French IVF registry (FIVNAT) reported a pregnancy rate of 25.4% per embryo transfer on a total of 23,025 oocytes retrieved. Based on such results, after three to four cycles of IVF, a woman under 40 whose partner does not have any fertility problems could reasonably expect to give birth. Again, in general, success rates may vary from one center to another, since they are influenced not only by the level of expertise of the medical team but also by the characteristics of the patients treated. A clinic treating a large number of women over 40 is likely to report lower success rates than a clinic having a majority of patients under 35.

My colleagues at work tell me that if we 'work' hard at getting pregnant, and want it enough, we definitely will! In fact, my mother in law is even suggesting that the fact that I am not conceiving means that subconsciously I do not wish to have a baby (because it may interfere with my career) and this psychological barrier is the reason for our infertility.
Unlike many other parts of your lives, infertility may be beyond your control. Don't blame yourself if you are not getting pregnant - it's a medical problem which often needs appropriate medical treatment. The attitudes you are encountering are often born out of ignorance - and are a kind of ‘victim-blaming’ - ignore them!

Are there particular health risks for women undergoing infertility treatment?
Along with their intended benefits, drugs used to treat infertility may on occasion cause side effects. In ovulation induction, close monitoring of follicular growth is crucial to ensuring successful treatment. Monitoring techniques (such as ultrasound scan and blood tests) and adequate use of treatment protocols help the physician to avoid ovarian hyperstimulation syndrome (OHSS) and minimize the risk of multiple pregnancy. Current treatment protocols have been designed to reduce the risk of multiple births and OHSS.

My grandmother says that if I just pray and have faith, I will definitely conceive. How far is this true?
Believing in god can help you to maintain a positive outlook - but sheer will and blind faith won't overcome a physical problem like blocked tubes or absent sperms.

What is Ovarian Hyper Stimulation Syndrome (OHSS)?
Ovarian Hyper Stimulation Syndrome (OHSS) is a side-effect that can occur during infertility treatment with ovulation inducing drugs. Symptoms of this syndrome may include ovarian enlargement, accumulation of fluid in the abdomen and gastrointestinal disorders (nausea, vomiting, diarrhea). Severe cases of OHSS are however very rare (1-2% of cases).

My husband refuses to get his semen tested. He says the fact that it is thick and voluminous means it must be normal. Is that true?
Semen consists mainly of seminal fluid, secreted by the seminal vesicles and the prostate. The volume and consistency of the semen is not related to its fertility potential, which depends upon the sperm count. This can only be assessed by microscopic examination.

How do multiple births occur?
Multiple births occur more frequently after infertility treatment than in the normal population. About 80% of pregnancies achieved following simple ovulation induction with gonadotropins result in single births, the remaining 20% being multiple pregnancies, mostly twin pregnancies. New treatment regimens carefully adapted to the patient's response help to decrease the risk of a multiple pregnancy. After IVF, one pregnancy out of four is multiple (20% twin pregnancies and 3-4% triplets). In IVF centers, physicians now frequently choose to replace a maximum of three embryos after fertilization, to further reduce the chance of multiple births.

My sister conceived only after 6 years of marriage. Does this mean I will also have difficulty conceiving?
If your mother, grandmother or sister has had difficulty becoming pregnant, this does not necessarily mean you will have the same problem! Most infertility problems are not hereditary, and you need a complete evaluation.

What are the common local side effects?
Common local side effects experienced by patients who receive gonadotropins by intramuscular injection include skin redness, swelling and bruising. Pain and discomfort sometimes reported after intramuscular injections are now likely to be lessened with the availability of gonadotropins produced by recombinant DNA - or genetic engineering-techniques, which are administered by subcutaneous injection.

My doctor just did a physical examination for me, and he feels that the reason for my infertility is that my uterus is tipped backwards, and this prevents the sperm from swimming into the uterus. He is advising I have surgery to correct this problem. Should I go ahead?
About one in five women will have a retroverted uterus. If the uterus is freely mobile, this is normal, and is not a cause of infertility. This is not an indication for surgery!

Can ovulation induction increase the risk of ovarian cancer?
Ovarian cancer is a rare disease; the chance of a young woman developing an ovarian malignancy during her lifetime is lower than 1.5%. A number of factors have been found to increase the risk of ovarian cancer, including genetic predisposition and dietary habits. Scientific studies carried out in the last few decades have demonstrated that infertility itself is a risk factor for ovarian cancer. There is evidence that each pregnancy reduces the risk of a woman contracting ovarian cancer (this risk could be reduced by more than 25% by a first pregnancy). No epidemiological study has ever established a causal link between ovulation promoting drugs and ovarian cancer. An extensive study on this issue, reporting on more than 2,600 women treated between 1964 and 1974 and followed for an average of twelve years, found no association between ovulation inducing drugs and ovarian cancer.

My husband says we should be having intercourse every day to achieve pregnancy. Is this true?
Sperm remain alive and active in woman's cervical mucus for 48-72 hours following sexual intercourse; therefore, it isn't necessary to plan your lovemaking on a rigid schedule.

What about the health risks for children born following infertility treatment?
Regarding children born following treatment with ovulation promoting drugs, the incidence of birth defects has never been found to be higher than that in the normal population.

My friends say I should have sex exactly on the day I ovulate to get pregnant. How can I do this?
Although having sexual intercourse near the time of ovulation is important, no single day is critical. So, don't be concerned if intercourse is not possible or practical on the day of ovulation.

How important is counseling to the patient undergoing infertility treatment?
The physician helps the infertile couple find the most appropriate therapeutic path to overcome barriers to conception, but, before a treatment is started, patients need to be aware of all its aspects, including its constraints. Beyond the medical expertise, infertile couples are also looking for counseling and support. From a psychological point of view, infertility is often a hard condition to cope with. During treatment and before a pregnancy is achieved, feelings of frustration or loss of control usually experienced by the infertile couple are likely to be exacerbated. Management of infertility includes both the physical and emotional care of the couple. Therefore, support from physicians, nurses and all people involved in treating the infertile couple is essential to help them cope with the various aspects of their condition. Offering counseling and contact with other infertile couples and patient associations can provide help outside the medical environment.

My sister-in-law is advising me to keep a pillow under my hips during and after intercourse. Will this increase my chances of conceiving?
Sperm are already swimming in cervical mucus as sexual intercourse is completed and will continue to travel up the cervix to the fallopian tube for the next 48 to 72 hours. The position of the hips really doesn't matter.

What is the duration of one IVF or ICSI cycle?
One complete IVF or ICSI cycle takes approximately 15 to 16 days. From Day 1 or 2 of menses the stimulation of the ovaries start by muscular or subcutaneous injections of hormones. The mean stimulation period is 12 days, depending on the reaction of the ovaries. The ovum pick up takes place within two days after stopping the stimulation (usually on day 13). Now the real IVF or ICSI follows in the laboratory. When fertilization occurs, embryos are transferred into the uterus (usually on day 15) and drugs supporting the uterus are given. After approximately 13 days a pregnancy test will show whether the IVF treatment has been successful or not.

My mother feels I am too tense, and that if I just relax, I'll get pregnant. Is that true?
If pregnancy has not occurred after a year, chances are there is a medical condition causing infertility. There is no evidence that stress causes infertility. Remember, all infertile patients are under stress - it's not the stress which causes infertility, it's the infertility which causes the stress!

What is Extra Uterine Pregnancy (EUP)?
When a pregnancy is not located in the uterus it is called an Extra Uterine Pregnancy (EUP) or ectopic pregnancy. The most common place for an EUP is the fallopian tube but sometimes the ectopic pregnancy is located elsewhere, such as in the cervix, the ovary or in the abdomen. EUP is a rare disease and occurs in 1% of all pregnancies. With IVF treatment the risk can increase. Risk factors for EUP are a history of infection of the tubes (salpingitis), chlamydia infection, Pelvic Inflammatory Disease (PID), former EUP, operation on the tubes or in the lower abdomen, endometriosis and appendicitis. The symptoms of ectopic pregnancy are often similar to those of a normal miscarriage and may include a positive pregnancy test together with or without vaginal bleeding and abdominal pain. Although it is not common, the possibility of EUP has to be considered in patients with the symptoms and one (or more) of the risk factors for EUP. Diagnosis is made by questioning the patient on the risk factors, physical examination, vaginal ultrasound and laboratory findings. Depending on the size and the location of the EUP, different treatments can be given. Mostly the ectopic pregnancy will be removed surgically but occasionally medical treatment or expectant treatment is offered when the pregnancy is very small and thorough control of the patient is possible.

I just had a HSG (X-ray of the uterus and tubes) done, and this shows my tubes are blocked. I've never had symptoms of a pelvic infection, so how could my tubes get blocked?
Many pelvic infections have no symptoms at all, but can cause damage, sometimes irreversibly, to the tubes.

What is timed sexual intercourse?
To increase the chance of getting pregnant spontaneously, timed sexual intercourse is recommended. This means that sexual intercourse, or coitus, has to be taken place around the time of ovulation, which is the most fertile period of a woman. To detect the approximate time of ovulation a temperature curve of several menstrual cycles can be made. The woman takes her body temperature each morning before getting out of bed, starting on the first day of the menstruation until the start of a new period. The body temperature rises around 0.5 degree Celsius after the ovulation. This is mostly about 14 days after the first day of the period and when no pregnancy occurs the temperature drops to normal again; with pregnancy the temperature stays high. One can also use urine or saliva tests to detect the ovulation. The time of ovulation can sometimes vary a few days each month, even in a regular menstrual cycle. Also, if the circumstances are right, sperm can live inside the women for a few days and sperm quality can decrease with high sexual activity. Therefore it is best to have intercourse 3-4 days before the expected ovulation and every other day until 2-3 days after the expected ovulation with no necessity for higher frequency. When tests are used to detect ovulation it is advised to have sexual intercourse on the day of a positive test.

My doctor has advised me to take fertility drugs. I don't want to take them because I am scared that if I do, then I'll have a multiple birth.
Although fertility drugs do increase the chance of having a multiple pregnancy (because they stimulate the ovaries to produce several eggs) the majority of women taking them have singleton births.

What is Egg Donation?
Women with no or not properly working ovaries can, in some cases, get pregnant through egg donation. In this procedure another woman will be the egg donor. This woman will have an IVF stimulation and ovum pick-up. After the ovum pick-up the collected eggs will be fertilized with sperm of the partner of the recipient woman ie donor acceptor. The embryos are then transferred into the uterus of the recipient. If a pregnancy occurs the recipient and her partner will have a child which is biologically only half their own.

My husband's sperm count varies every time we test it! How do we determine what the 'real' sperm count is?
Even a normal (fertile) man's sperm count can vary considerably from week to week. Sperm count and motility can be affected by many factors, including time between ejaculations, illness, and medications. There are other factors which affect the sperm count as well, all of which we do not understand.

What is PCOS?
Poly Cystic Ovary Syndrome or PCOS is an ovulation disorder, which affects 4-6% of all women. Several factors contribute to the disease. At this moment researchers think that the cause of the disease is genetic. The major features of this syndrome are irregular or no menstruation, hirsutism and acne due to high levels of male hormones, obesity (40-50%), high insulin levels with risk of developing diabetes and large polycystic ovaries shown on ultrasound. Women with PCOS usually present at fertility clinics for counseling. To increase fecundity the treatment possibilities are mostly focused on regulation of the menstrual cycle. For this, several drugs are used (clomiphene citrate, metformin, gonadotropins) and weight loss is strongly advised. In many cases the cycle will be ovulatory and regulated by these treatments. Furthermore at this moment it is being investigated whether electrocoagulation of the large ovaries can give (long-term) regulation of the cycles.

I have no problems having sex. Since I am virile, is my sperm count normal?
There is no correlation between male fertility and virility. Men with totally normal sex drives may have no sperms at all.

What is Embryo Reduction?
Assisted Reproductive Therapy (ART) has caused an increase in multiple pregnancies. This situation is especially seen in ovulation induction and Intra Uterine Insemination. In order to prevent the risk of severe premature birth and handicaps as well as risks for the mother, embryo reduction is sometimes performed. The number of embryos in the uterus is reduced and the remaining pregnancy has a better chance of normal development and delivery. Of course this is not an easy decision for either the patients or the doctor. With careful guidance of the patient during treatment and good counseling when the patient is at risk for a large multiple pregnancy, many triplets or higher order pregnancies may be avoided.

I don't think infertility treatment should be offered in India, because there are too many babies in this country already. Why should we exacerbate the population problem by producing more? In any case, IVF treatment is too expensive for India to be able to afford it.
The right to have children is a fundamental right of every human being and a very basic biological urge. Just because a neighbor has too many children should not deprive the infertile couple of their right to have their own. IVF and related technologies are undoubtedly expensive, but, then, so is heart surgery. Yet, no one objects when over Rs 1 lakh are spent to try to salvage the heart of a 70-year-old man (whose life expectancy in any case is only about 5 years and is not extended by the surgery). Why then should medical technology not be used to help couples in their thirties (with their whole lives ahead of them) have their own baby? In fact, IVF is a much more cost-effective use of medical resources than a number of other accepted surgical procedures (such as joint replacement surgery or kidney transplants).

What is Cryopreservation?
Cryopreservation means preserving in a frozen condition. The best known cryopreservation is of semen. This is mostly done in case of cancer of the testicles before treatment of the cancer. Furthermore cryopreserved semen is used in donor insemination. It is also possible to freeze fertilized eggs after IVF or ICSI. If more embryos are left after an IVF or ICSI procedure they can be frozen and transferred another time. In this way there is another chance of a pregnancy while only one IVF or ICSI cycle is performed. For human oocytes cryopreservation is much more difficult. Only in very few experiments this is done successfully. The attention of researchers now is on developing a way to freeze ovarian tissue and after thawing, to obtain the oocytes in it. This procedure is not yet fully refined but when it is it can offer great opportunities in the future.

My semen analysis report shows I have no sperm in the semen (azoospermia). Is this because I used to masturbate excessively as a boy?
Masturbation is a normal activity which most boys and men indulge in. It does not affect the sperm count. You cannot ‘run’ out of sperms, because these are constantly being produced in the testes.

Is Intra Uterine Insemination suitable for every infertile couple?
No. In Intra Uterine Insemination (IUI) processed semen is directly put into the uterus. It is a technique used for couples with fertility problems based on specific causes. These causes are

IUI can be performed either in a spontaneous ovulatory cycle (cervical hostility) or in a cycle with ovarian stimulating hormones (idiopathic subfertility and male subfertility/sperm antibodies). The stimulation is mostly done with clomiphene citrate or gonadotropins.

My wife is frigid and does not enjoy having sex. Could this be the reason for her infertility?
There is no connection between sexual pleasure and fertility. Don't forget that even a woman who gets raped can get pregnant! And don't forget that the commonest reason women do not enjoy sex is because their husbands are unskilled lovers! Maybe you should improve your sexual technique, and spend more time in foreplay and in pleasuring your wife!

What is TESE or MESA?
TESE (Testicular Sperm Extraction): Sperm collected out of the testicles after operation. MESA (Microsurgical Epididymal Sperm Aspiration): Sperm collected out of the epididymis after operation.TESE or MESA is a technique developed for patients with no sperm cells in their sperm due to an undeveloped or obstructed spermatic cord. The cause of obstruction can be a former sterilization or an infection of the epididymis. When the testicles make no sperm cells at all, of course TESE or MESA is not possible. If sperm cells are obtained, an ICSI procedure (Intra Cytoplasmic Sperm Injection) will follow. ICSI is like IVF; only now one sperm cell is injected into each egg to fertilize it and make an embryo.

What are the causes of damaged fallopian tubes?
In the beginning In Vitro Fertilization (IVF) was developed for patients facing infertility due to damaged fallopian tubes. Later on the indications to perform IVF were broadened, for example, unexplained infertility and male infertility. Nowadays tubal damage still accounts for a large number of all IVF treatments. The main cause is abdominal infection. This is mostly due to sexually transmitted diseases (for example chlamydia or gonorrhea) but complicated appendicitis or Pelvic Inflammatory Disease (PID) can also cause damaged tubes. Other causes are abdominal operations (gynecological operations, Cesarean section, sterilization or other) and internal diseases like Crohn's disease. Affected patients can have fertility problems and are at risk for having a pregnancy located in the tubes (ectopic or tubal pregnancy).

What is Cystic Fibrosis and Male Infertility?
Men who have cystic fibrosis often have a congenital anomaly in the male genital tract. The vas deferens, the tube connecting the testicle and epididymis to the ejaculatory duct, is congenitally absent. This makes it impossible for the sperms to pass through the penis. Using testicular sperm aspiration, the urologist can obtain sufficient sperm to allow excellent success with IVF and ICSI (intra cytoplasmic sperm injection). Insufficient numbers of sperm are obtained to make intrauterine insemination an effective option. As cystic fibrosis is a recessive genetic disorder, abnormal gene contributions from both parents are necessary for this disorder to be present. Both copies of the gene are abnormal in men with CF. While persons carrying a single copy of an abnormal gene do not have this condition, when paired with a partner with CF, they have a 50% chance of CF in their offspring. This makes testing the female partner advisable. If the woman tests normal, the children will be carriers for an abnormal gene and although they will not likely have CF, it is advised that their spouses be checked for CF gene abnormalities.

What is Endometriosis?
Tissue histologically identical to the endometrium (the inner lining of the uterine wall) outside the uterine cavity. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported in other areas as well. Endometriosis is one of the most common problems that gynecologists currently face. It is one of the most complex and least understood diseases in our field and, despite many theories, we still do not have a clear understanding of the cause or of its relationship to infertility. Since this disorder is primarily a human disease and rare in other animal species, accumulation of the facts has been slow. Although endometriosis has been considered a pathological or separate disease entity, it may not be a disease at all. It may actually be the clinical manifestation of a more basic underlying disorder, such as a basic chemical or physiological abnormality that affects the tubal motility or immune system which could be responsible for the initiation or progression of endometriosis in patients with retrograde menstrual flow. By the same token, endometriosis may not be the cause of infertility, but the result of it. Further technological developments may be necessary in order for us to fully understand this problem.

What does Sperm Preparation mean?
Spermatozoa are ejaculated in the seminal fluid during intercourse or masturbation. During assisted reproduction the spermatozoa are extracted from the semen by a series of processes - centrifugation and washing, layering (to select the active sperm and leave the immotile or dead sperm behind) or selecting the best sperm by making them swim through a denser medium and using those that succeed.

What is Reproductive Surgery?
Reproductive surgery is a subspecialty that treats anatomical abnormalities interfering with normal reproductive function. Advanced reproductive surgery requires meticulous surgical technique for optimal results, including rapid patient recovery and avoiding the need for routine hospitalization. Reproductive surgeons treat tubal obstruction, endometriosis, uterine fibroids, scarring of the ovaries or other pelvic structures resulting from pelvic inflammatory disease (PID) in the female, and varicocele and vas obstruction in the male as well as other abnormalities.

What does Laparoscopy involve?
The laparoscope allows visual inspection of the pelvic organs through a very tiny incision. Abnormalities that lead to infertility can be treated surgically through additional small incisions to remove scar tissue, laser, coagulate, or excise endometriosis, and repair tubes blocked at the fimbrial end. Many types of female reproductive surgery can be performed laparoscopically in the outpatient setting.

Why is Progesterone used for IVF?
Progesterone is required for the success of early pregnancy. In a natural cycle progesterone is made by the corpus luteum (CL). If the CL is removed during the first 5 weeks after conception, the pregnancy will miscarry. By about 9 weeks' gestation, the luteal-placental shift takes place: the trophoblast itself makes sufficient progesterone, and the pregnancy is no longer dependent on the CL. There are 2 reasons for giving extra progesterone after an IVF.

The first is that the CLs in IVF were all disturbed by the IVF needle during egg pick-up. The CLs start as follicles containing eggs. At the retrieval, the needle is placed inside the follicle, the egg is removed; and other cells may also be removed. The follicle is mostly fluid, but it also contains tons of cells that make up the follicle and surround the egg. These are called the granulosa cells; and these are the cells that convert to CL cells after ovulation. So if the needle removes some of these cells, as is usually the case, the CL would not work as well, and less progesterone is produced.

The second is to do with IVF medication. In a natural cycle, the hormone LH is secreted by the pituitary in small doses after ovulation, as this LH helps the CL to produce progesterone. However, during an IVF cycle, most women are given Lupride, Gonapeptyl or Ovurelix to suppress a premature LH surge at ovulation. In a natural cycle or IUI, surges are fine, they cause ovulation. In IVF, we need to time the retrieval to the hour, so that a surge at the wrong time ruins everything. So we give medicines to stop LH; but this means LH is no longer available to help the CL with progesterone production as well.

What is the best route for progesterone administration during an IVF cycle in terms of efficacy and side effect profile?
Oral preparations - Oral supplementation is not recommended because although some studies have not found a difference in efficacy between oral and other routes of administration, a few studies did report lower implantation rates, lower pregnancy rates, and /or higher miscarriage rates in women receiving oral compared with IM or vaginal progesterone.

Intramuscular progesterone - The main downside of IM progesterone is local skin inflammation at the site of injection. At times, this reaction can be quite painful and can lead to induration that may persist for weeks after the injections are complete.

Vaginal preparations - Because the progesterone is first absorbed locally, intrauterine concentrations are high despite serum levels that are lower than with IM progesterone. Vaginal progesterone may be administered using compounded suppositories, tablets or 8% gel. The main side effects with vaginal preparations are vaginal irritation, discharge and dyspareunia. The principal advantage of the vaginal preparations is that they are less painful than IM injections. IM injections may be difficult for a patient to administer herself, whereas vaginal preparations can be self-administered. However, vaginal preparations must be used 2-3 times per day, whereas IM progesterone is administered once daily.