Female factors:

Tubal factors::

• This was the initial indication for referral of the couple for ART
• In fact, the World’s FIRST test Tube baby was conceived for this indication
• Cases where microsurgical tubal re-anastomotic surgeries have failed or are unlikely to benefit the patient
• Tubal Blockages due to Genital Tuberculosis, Non tuberculous infections, post-surgical adhesions, bilateral hydrosalpinx, H/O failed tuboplasty, H/O ectopic pregnancy, bilateral salpingectomy etc.

Uterine factors:

• Mullerian Agenesis or Congenital Uterine Anomalies
• Women with severe intra-uterine adhesions ( More than 40 percent of the Uterine Cavity obliterated )
• Multiple Uterine Fibroids or Severe uterine adenomyosis
• Hysterectomized patients can expect family building through a process of Gestational Surrogacy or Uterine Transplants

Ovarian Factors:

• Polycystic Ovarian Disease
• Hypogonadotropic Hypogonadism
• Premature Ovarian Failure
• Congenitally Absent ovaries
• After oophorectomy through Donor Oocyte option
• After pelvic irradiation or Chemotherapy for Malignancy
• Severe Ovarian Endometriosis

Cervical Factors:
ONLY IF….

• Surgically unsurmountable Cervical Causes

ENDOMETRIOSIS:
One of the very important causes for referral for ART ..

• Women with moderate to severe endometriosis
• Those in whom medical or surgical therapies have failed
• Mild to Moderate endometriosis with other contributory factors

Counselling needed for the option of family building through the use of Donor oocytes in cases of:

• Premature Ovarian Failure
• Severely Diminished Ovarian reserve
• After Radio or Chemotherapy for Malignancies
• Transmissible Genetic Disorders
• Bilateral oophorectomy done

MALE FACTORS:
SEMEN ABNORMALITIES

• Low concentration of Spermatozoa less than 2 million per ml on two consecutive occasions 3 months apart
• Severe Oligoasthenospermia
• Severe Necrozoospermia
• Severe pyospermia
• Obstructive Azoospermia through Sperm Retrieval Techniques ( TESA, PESA, TESE, Microsurgical Sperm extraction )

IMMUNOLOGICAL FACTORS
Failed Immune suppression for Anti sperm Antibodies in either Male or Female

UNEXPLAINED INFERTILITY
These are the couples where no identifiable cause can be found in either the Male or Female partner
Couples with prolonged Unexplained Infertility more than 2 years would benefit from referral to ART

So What are the various Assisted Reproduction Techniques ?

Sometimes the Nature needs just that little help !

• Ovulation Induction with “ Timed Relations “
• Ovulation Induction with IUI
• IVF
• ICSI
• IMSI
• Laser Assisted Hatching
• TESA, TESE, PESA, Microsurgical Testicular Sperm Retrieval, Micro-TESE
• Preimplantation Genetic Testing for Aneuploidy , PGT-A, PGD - Preimplantation Genetic Diagnosis
• In Vitro Maturation of oocytes ( IVM )

METHOD OF CHOICE:-

The Choice of the Assisted Reproduction Technique needed is made based on..

• Clinical Profile of the couple
• Duration and Severity of the problem

Intra Uterine Insemination ( IUI ) Common Indications for IUI are

• Failure to conceive with 6 cycles of ovulation induction
• Suboptimal Semen parameters ( Sperm concentration less than 8 million/ ml and forward progressive motility less than 5%
• Oligoovulation
• Unexplained Infertility
• Endometriosis
• Coital difficulties

Indications for using Donor Sperm in IUI

• Non obstructive Azoospermia
• Seropositive Husband and Sero negative wife
• Husband has a history of transmissible Hereditary Disorder
• Husband has Severe oligospermia but the couple does not want to undergo IVF/ ICSI

Common Male Factor Causes

• Severe Oligo asthenospermia
• Obstructive Azoospermia with normal FSH
• Erectile Dysfunction

INDICATIONS FOR ICSI or IMSI WITH EJACULATED SPERM

• Severe Oligoasthenospermia
• Fertilization failure with IVF
• Poor motility Spermatozoa

INDICATIONS FOR DONOR OOCYTE OPTION:

• Gonadal Dysgenesis
• Gonadal Agenesis
• Premature Ovarian failure
• After Chemo or Radiotherapy for cancers
• Poor responders to ovarian stimulation
• Resistant Ovary Syndrome

PATIENT SELECTION FOR REFERRAL FOR ASSISTED REPRODUCTION TREATMENTS SHOULD BE BASED ON THE FINDINGS OF BASIC CLINICAL ASSESMENT ANDINVESTIGATIONS AS TO THE CAUSE OF INFERTILITY

Common Indications for IVF and Embryo Transfer
Common Female Factor Causes:

• Bilateral Tubal Block
• Severe PCOS not conceving with Ovulation Induction and IUI
• Endometriosis
• Adenomyosis
• Diminished Ovarian Reserve
• Advanced Age

UNEXPLAINED INFERTILITY

When individually both Male and Female partners are normal but still there is no conception

INDICATIONS FOR ICSI / IMSI WITH EXTRACTED SPERM:

• Obstructive Azoospermia with normal FSH
• Non obstructive Azoospermia
• Anejaculation
• Retrograde ejaculation
• Congenital Bilateral Absence of Vas Deferens

INDICATIONS FOR PGT - A (Preimplantation Genetic Testing for Aneuploidy) & PGD Preimplantation Genetic Screening and Preimplantation Genetic Diagnosis:

• Repeated IVF Failures
• Recurrent miscarriages
• To screen and weed out embryos with chromosomal abnormalities in elderly women or those with transmissible genetic disease in either the male or female partner
• When either Male or Female partner has balanced chromosomal translocation
• To screen out embryos with Genetic Disorders like Sickle Cell Anaemia, Thalassemia, Duchenne Muscular Dystrophy, Cystic Fibrosis,Huntigton’d chorea etc