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Reproductive Medicine

Reproductive Medicine: The field of reproductive medicine has witnessed a technological revolution in the last decade. Applications of new techniques based on a better understanding of reproduction have made it possible to fulfill the dream of motherhood for many.
Team Of Specialists:
Dr. Kiran Arora
Dr. Parul Prakash
Dr. Sarabpreet Singh

Department Of Reproductive Medicine & Infertility Treatment at Artemis Hospital, Gurgaon

Reproductive Medicine

The field of reproductive medicine has witnessed a technological revolution in the last decade. Applications of new techniques based on a better understanding of reproduction have made it possible to fulfill the dream of motherhood for many. No experience can parallel the thrill of helping to create human life. Infertility treatment however is not easy and to offer the best to the patient, one has to keep in constant touch with new developments. Artemis has started its ART services under the expert guidance. It is committed to provide the most advanced treatments available worldwide.

Comprehensive Fertility Program:

Counseling and psychological support are an integral part of the IVF treatment program, helping patients cope with the inevitable stress associated with IVF. Artemis IVF centre is sensitive to the many difficult decisions couples face while undergoing infertility evaluation and treatment. Therefore, providing accurate information to patients through patient education is one of our highest priorities. Free consultation with the Psychologist is available for all patients going through the IVF treatment.

Our IVF Centre located in the heart of Delhi-NCR in Gurgaon always welcomes your questions about our program, because it is committed to providing the best medical care and fertility treatment to a fully informed group of patients. We think of each couple as members of our team working towards a common goal – your successful pregnancy.

Facilities Available:

Endoscopic Procedures
•Diagnostic & Operative Laparoscopy
•Diagnostic & Operative Hysteroscopy
•Hysteroscopic Tubal Recanalisation, Sonography
•3-4 Dimensional Ultrasonography
•Diagnostic & Interventional Sonography
•Embryo Reduction
•Sono Salpingography Andrology
•Computer Assisted Semen Analysis and sperm Morphology
•Sperm Fragmentation Test
•Sperm preparation for Normospermic and Male infertility patients
•In-Vitro fertilization, ICSI, TESA, IMSI
•Laser assisted ICSI
•Blastocyst Transfer
•Laser Assisted Hatching
•Pre implantation genetic diagnosis
•Sperm & Embryo
•Oocyte & ovarian tissue

Special Services At Artemis:

I. Andrology Service: Recent surveys have shown that male infertility is probably the largest single cause of infertility. At least half of all human infertility is male factor related. A full assessment of the male, detailed analysis of the seminal plasma and sperm function tests are important for a comprehensive evaluation. Currently, knowledge of sperm function and its relation to infertility is rudimentary. Since specific tests to determine the fertilizing ability of the sperm are not available a treatment schedule has been developed. Success of these treatments is based on large clinical trials. Intrauterine insemination is the first step in the treatment ladder and ICSI with ejaculated and testicular sperm is at the top end. Artemis has the latest equipment to do a computer based analysis of sperm motility and morphology. This assessment allows us to give you a possibility score on fertilization, implantation and early pregnancy loss with your sperm.
Intracytoplasmic Morphologically Selected Sperm Injection (IMSI): Intracytoplasmic morphologically selected sperm injection (IMSI) is a new development that may improve assisted reproduction pregnancy rates. It magnifies sperms up to 6,000 times compared to the standard 200 to 400 times magnification associated with traditional fertilization approaches. IMSI makes it possible to discard sperm whose nuclei have an abnormal shape or contents. Using IMSI the optimal sperm is identified and used for fertilization. The IMSI procedure may be a potential alternative to those couples whose semen analysis shows abnormal morphology.

IMSI is known to give better pregnancy rate and lower abortion rates in patient with male factor in fertility.

Sperm DNA Fragmentation Test: Sperm DNA Fragmentation (SDF) is an important piece of information about seminal quality. An SDF value that exceeds a threshold value of 30% suggests sub-par sperm quality. The SDF value confers clinicians the power to make informed decisions in their daily practice and take action based on quantitative results. It is an established fact that the probability of pregnancy is more if fragmentation is low

– Unknown etiology fertility failure
– Embryo loss – Repetitive miscarriage
– Best donor selection
– Selection of best seminal samples prior to vasectomy or oncology treatment
– To distinguish which couples are suitable for treatment by IUI
– To assess the efficacy of medical interventions or treatment of infectious diseases and varicocele.

II. Assisted hatching: Before implantation, in the normal situation, the embryos must hatch from its shell to attach to the womb. In some cases e.g. women over 35 years, women with polycystic ovaries, and the outer shell of the egg (the zona pellucida) may become hardened. Hardening of the zona pellucida hinders embryo hatching. The zona pellucida is thinned or opened to facilitate hatching of the early embryo using the help of enzymes, chemicals or Laser. At Artemis, all three techniques are available though we prefer to use laser assisted hatching as it reduces the chances of embryo damage.

III. Blastocyst Transfers: Embryo is cultured for 5 days in-vitro till it grows to form a blastocyst. In a natural conception the embryo enters the uterine cavity at this stage of development. Blastocyst transfer helps to improve pregnancy rate and reduces the chances of multiple pregnancy, however a larger number of good quality embryos (at least 3- 5) are required to be able to take the patient to blastocyst transfer, since some embryos may not survive for longer periods in in-vitro culture.

In Vitro Egg maturation A procedure useful for women with polycystic ovaries in whom high or low ovarian response to stimulation drugs is always a problem. Eggs are collected without or with minimal ovarian stimulation and then matured in the laboratory. After maturation ICSI is done for fertilization.

Pre implantation genetic diagnosis Procedure involves taking a biopsy (1-2 blastomeres) from an 8 cell embryo and then testing it for genetic disorders. This is useful in patients where there is history of recurrent miscarriages, previous IVF failures, history of genetic disorder in previous pregnancies or in the family.

IV. Gamete (Egg & Sperm) Donation & Embryo Donation Facilities for gamete donation are available. Detailed screening of the donor is carried out prior to his/her acceptance into the program. Anonymity of both the donor and recipient is maintained.
a) Donor Insemination (DI) All donors are very carefully screened for sexually transmitted diseases, Hepatitis B & C. A detailed history is obtained to rule out current or past diseases and inherited disorders. Donors are matched as closely as possible for physical characteristics to the male partner of women receiving the donor sperm. Donor anonymity is maintained as per ICMR regulations / ART bill.

b) Egg Donation Some women are unable to produce their own eggs due to hormonal deficiency, genetic predisposition or other medical conditions. Others choose to have egg donation because they carry a genetic illness, which may be passed on to any babies born or they have poor quality eggs or recurrent miscarriages. Through egg donation these women have the opportunity to give birth. The patient receiving the donated eggs (the recipient) is treated with hormones to prepare the lining of the uterus to receive the embryos. Eggs are recovered from the donor who has to go through ovarian stimulation to form multiple eggs and then these are recovered under anaesthesia under ultrasound guidance. The entire procedure is carried out vaginally. The sperm from the recipient’s husband is used to inseminate the eggs (either by IVF or the ICSI technique). The resulting embryos are transferred two/three days later to the recipient’s uterus.
c) Embryo Donation Some couples, for a variety of reasons, are unable to produce their own genetic gametes (i.e. sperms or eggs). In such cases both donor sperms and donor eggs can be used to produce a donor embryo. The woman’s uterus is prepared with hormonal tablets to receive the embryo.

V. Surrogacy (renting a womb) Surrogacy involves implantation of the couple’s embryo into the uterus of another woman, who agrees to give birth to the child so conceived. Artemis runs an efficient and ethical surrogacy programme.

VI. Cryopreservation (Freezing and Storage)
a) Cryopreservation (freezing and storage) of embryos Following IVF maximum of three/four embryos are transferred in each cycle. The remaining embryos may be frozen for embryo transfer at a later date. Only good quality embryos are frozen since they have a better survival rate on thawing .It is important to note that even good quality embryos may not survive the freezing and thawing process. We currently are using the latest technique in cryopreservation called ‘vitrification’.
b) Frozen Embryo Replacement (FER) The replacement of frozen embryos is preferably carried out after treatment with hormone replacement therapy (HRT) or in a spontaneous ovulatory cycle. Zona thinning/hatching in these embryos improves implantation rates. You can opt to have this procedure.
c) Cryopreservation (freezing and storage) of sperm The preservation of sperm by freezing is now a fully accepted routine procedure. Most, although not all, semen samples can be frozen/preserved for long periods and thawed without loss of fertility. In patients going through an IVF/ICSI cycle, semen is cryopreserved prior to cycle commencement. This is important because at times (generally due to stress or sudden illness) the husband is unable to give the sample on the day of egg retrieval. This facility also allows women to continue with their treatment cycles when the partner is not available.
Oocyte and Ovarian tissue freezing has been started in Artemis for Fertility Preservation in Cancer patients.

Frequently Asked Questions:

Does The Women’s Age Have An Effect?

Yes, age has a very important effect. There is a gentle but steady decline in establishing a pregnancy after the age of thirty in Indian Women.

How Many Attempts Should We Have?

Every couple is different and the answer to the question will inevitably depend on the specific treatment you have had and the results of preceding treatment cycles. It is believed that IVF success optimizes in three cycles. Decisions on how to proceed will be discussed in detail with you during your consultation or at a review appointment.

What About My Particular Infertility Problem?

 There are differences in success rates depending on the cause of infertility, for example, tubal factors, endometriosis and male factor, unexplained or anovulatory infertility. You will have detailed discussions regarding your special circumstances.

How Many Times In A Cycle Will I Have To Come To The Clinic?

This varies from patient to patient and also with the stage for treatment. In a DI or IUI (H) cycle, for example, the likely number of out-patient visits for monitoring is 2-4, for IVF or ICSI 4-5. During these visits egg and endometrial development are checked. Some blood tests may be advised to assess egg maturity and decide on the drug dosage. The first visit is on Day 2/3 of the cycle. At this visit an ultrasound is done to rule out any residual ovarian cysts and to check for endometrial thickness. Drug administration is withheld in case these parameters are not within the required limits.

Egg recovery is generally carried out under anaesthesia unless you opt to have it under sedation and requires you to be in hospital for half a day. For embryo transfer you are required to come in with a full bladder and you will be asked to rest for a couple of hours in hospital after the transfer.

What Are The Risks For Assisted Conception Pregnancies?

The risk of abnormalities does not appear to be significantly greater than with natural conception. With procedures like ICSI there is an increased risk of sex chromosome related anomalies. The reason for this is that in patients with severe male factor infertility the abnormality existing in the male partner is carried forward. It is important to note that some techniques are very new, and detailed follow up data is not yet available.

What Happens If Treatment Is Not Successful?

 Be assured that we shall make every endeavor to care for you and to help you cope. ART has made tremendous progress in the last few decades and there will certainly be a treatment, which would benefit you.
Is there an increased risk of malignancy? Current knowledge does not show any definite increase in malignancy. The scientific committees’ worldwide are constantly looking into this and we will keep you updated as to the results. Women in whom there is a family history of ovarian malignancy should limit the exposure to ovarian stimulation drugs.

Tubal Surgery

Before IVF became available, tubal surgery was the only way to correct tubal problems. These days surgery of the tubes has a limited place in the management of infertile couples. However, in selected cases this procedure is invaluable and both tubal microsurgery and endoscopic (key-hole) surgery can be performed.
Who is a candidate for IVF (In-Vitro Fertilization) and ART? Assisted reproductive technologies (ART) include IVF, which is the technique of fertilizing a woman’s egg in the laboratory. While it was designed originally for women with tubal diseases, IVF has been extended with equal success to infertility due to endometriosis, poor cervical mucus, unexplained factors and male infertility.

How Do I Know If ART Can Help Me?

Thorough evaluation by an infertility specialist familiar with ART is necessary to decide whether IVF or another treatment is appropriate for you. Tests previously done usually need not be repeated as long as past records are available. Alternative therapies are presented to you if another approach offers an equal or greater chance of success. These options include ovulation induction, sperm washing and intrauterine insemination, hormonal supplementation, opening of blocked fallopian tubes through endoscopy,

What Should I Expect?

IVF is a complex process consisting of several steps. First, fertility drugs are given to stimulate the ripening of several eggs. Blood tests and ultrasound examinations allow for precise monitoring of egg development. At the appropriate time, the eggs are retrieved under ultrasound guidance, a non-surgical procedure performed under light sedation or anesthesia. The sperm is then added to the eggs in the laboratory where the fertilized eggs develop for 2-3 days. In case of micromanipulation for male infertility a single sperm is injected into the egg ICSI (intra cytoplasmic sperm injection). Finally, the embryos (fertilized dividing egg) are placed in the womb by a simple non-surgical procedure similar to a pelvic examination. A mock embryo transfer is done prior to starting the cycle to ensure that we do not encounter any unexpected problem on the day of the actual embryo transfer.

Two weeks after embryo transfer, a pregnancy test is done. All this is done on an out patient basis.

What Are The Risks Of ART?

The associated reproductive procedures have so far proven remarkably safe for both – the ‘would be’ mother and her child. The spontaneous abortion rate is slightly higher than in the general population. This is not related to the procedure, it is due to inherent problems with the patient that led to infertility in the first place. There is an increased chance of multiple births, which can be limited by the number of embryos transferred. There is no difference in the pre-delivery management and the mode of delivery – vaginal/caesarean section, if all routine parameters are normal.

Progress through the IVF Treatment Cycle Unfortunately, not all couples proceed smoothly through every treatment cycle. The response of the body to fertility drugs varies not only in different patients but also from cycle to cycle in the same patient. Sometimes the treatment cycle has to be discontinued due to the following reason
1. A poor response to the drugs – less than 4 follicles
2. Failure of fertilization
3. Poor endometrial (uterine lining) growth

Some couples may not achieve fertilization with conventional IVF. These patients then have to go for a procedure like ICSI. Fertilization rates are higher with ICSI because the sperm bypasses the zona barrier. In patients showing a low response i.e. <6 eggs ICSI is advisable to ensure embryo transfer. There are numerous hurdles to cross, and we will do our very best to help you overcome each one.

What Are The Chances Of Success With ART?

The success rate (i.e. chances of taking home a baby in one treatment cycle) varies depending on a number of factors of which the most important factor is the age of the female partner. At consultation you will be advised of your specific chances. The average pregnancy rate (PR) is 35 to 40 % (PR’s vary based on the cause of infertility and age of the patient, with younger patients doing better than those over the age of 35) and 70% for oocyte donation cycles.


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