Mr. and Mrs. X,24 yrs. visited our clinic with Primary Infertility of 1 year and severe dysmenorrhoea.
A 23 yrs. old unmarried girl, visited in Nova IVF Fertility centre with severe Dysmenorrhoea. She was diagnosed on USG as having Right Unicornuate uterus with Left side functioning rudimentary horn with Hematometra.
Hematometra is a medical condition involving the collection or retention of blood in
the uterus secondary to obstruction or atresia of the lower reproductive tract, the uterus, cervix, or vagina which would otherwise provide outflow for menstrual blood.
During Laparoscopy Left tube and ovary were removed due to left ovarian endometriotic cyst. Hematometra was drained and Left rudimentary uterine horn removed. Cystoscopy was done to check the patency of both ureters. Later she came in OPD after 3 years with 7 weeks of natural conception.
What is a unicornuate uterus?
A unicornuate uterus is a form of congenital uterine abnormality of the Mullerian duct where only one half of the uterus is formed. It is often about half of the average size and much smaller than a healthy uterus. It has only one functioning fallopian tube, instead of the usual two functional fallopian tubes. The uterus’s other side may be absent or have what is called a rudimentary horn, which does not communicate with the ovary. In a rudimentary horn, the fallopian tube might be blocked towards the end and may not open near the ovary to allow the ova to come in during the ovulation process.
A unicornuate uterus that has a non-communicating rudimentary horn can be associated with gynecological and obstetric complications such as infertility, hematometra, endometriosis, urinary tract anomalies, abortions, ectopic pregnancies, and preterm deliveries. Reproductive outcome and pregnancy management need comprehensive condition management and IVF treatment mostly.
In many cases, women with uterine abnormalities do not have any symptoms and are not aware of these malformations before facing pregnancy/pregnancy issues.
A couple of Mr & Mrs. S approached our clinic with 5 yrs of married life and Husband having a history of azoospermia. He had undergone testicular biopsy outside in which no sperms were retrieved. The couple was advised ICSI with micro TESE.
Micro TESE is a procedure where a biopsy of the testes is taken under magnification using an operating microscope. It is helpful in patients where the routine biopsy has not succeeded in finding sperms.
In the first stage, the lady underwent IVF stimulation with the retrieval of 23 eggs which were frozen. Under microscopic magnification, viable sperms were retrieved and the vitrified eggs were thawed. ICSI was done using these warmed eggs and sperms and 5 blastocysts were obtained. Of these 1 was transferred which resulted in the birth of a healthy male child; presently 6 months of age, the couple has 4 more embryos cryopreserved for future pregnancies.
A couple Mr. And Mrs. C underwent IVF at our center for the tubal blockage. Mrs. C had a history of Pulmonary tuberculosis. She had 8 embryos; all of which were frozen due to fluid in the uterus (endometrial cavity). The first embryo transfer was negative. They were advised removal of both tubes (salpingectomy) before the next transfer. Despite Salpingectomy, there was the recurrence of endometrial cavity fluid and suspected adhesions in the uterus. The patient was advised hysteroscopy for the same. After adhesiolysis, the fluid collection continued to persist in subsequent cycles of endometrial preparation. The patient underwent roller ball cauterization of ostia and natural cycle FET which resulted in good endometrium with no fluid accumulation. Mrs. C has an ongoing twin pregnancy of 9 weeks
Mr. and Mrs. K approached our clinic with a history of 4 recurrent miscarriages and 4 failed IVF cycles. The investigations had revealed an abnormality (translocation)in the husband’s karyotype which was a possible explanation for the abortions. The couple was counselled for IVF with PGT-SR (genetic testing of the embryos for the involved defect). The lady underwent IVF and 8 embryos were tested of which 4 were normal. The couple opted for a single embryo transfer and has an ongoing pregnancy of 8 weeks.
A 23-year-old married lady, Mrs. Deshmukh (name changed), visited Nova IVF Fertility centre to consult about her primary infertility issue. She was married for five years and had been trying to conceive over these years. Primary infertility is a condition in which a couple is unable to conceive naturally even after having unprotected sexual intercourse for over a year.
The lady had congenitally anomalous pelvic organs, i.e. a right unicornuate uterus [ i.e only one half of the uterus is developed since birth ] , and had undergone a vaginoplasty when she was 13 years old.
As this was the case of primary infertility, i.e. the patient had never conceived, and with the past complications and surgery, Dr. Banker advised her examination under anesthesia to assess her pelvic organs before planning treatment. Her examination revealed stenosed (shrunken) upper vagina and sonography revealed ovaries which were high up and difficult to access vaginally. Hysteroscopy was also done in the same sitting and presented a narrow tubular cavity of the right horn.
Hysteroscopy allows the doctor to look inside the uterus to correctly diagnose any uterine issues. A hysteroscope is a thin tube that is inserted into the vagina to examine the cervix and inside of the uterus.
Treatment and outcome
Because of her stenosed upper vagina and high placed ovaries, she was advised IVF with laparoscopic ovum-pick up by Dr. Banker, resulting in the retrieval of 24 oocytes. The laparoscopic ovum pickup technique involves the insertion of three instruments into the woman’s abdomen through three tiny incisions and retrieval of eggs. The laparoscope is inserted through a small incision at the lower edge of the navel which enables us to see the ovaries and the follicles containing the eggs. Carbon dioxide is blown to inflate the abdomen and provide clear visibility as well as working space. From a small second incision, usually on one side of the stomach, the instrument is inserted to hold the ovaries in place. A third incision, on another side of the abdomen, is made for collecting the eggs. This procedure is usually carried out on a day-care basis.
The 24 oocytes were fertilized by IVF in the laboratory, and seven blastocysts were formed and frozen. The patient further underwent a frozen embryo transfer of a single embryo given her anomalous uterus and was thrilled to have a positive pregnancy result
What is a unicornuate uterus?
A unicornuate uterus is a form of congenital uterine abnormality of the Mullerian duct in which only half of a uterus is formed. It is often about half of the average size and much smaller than a healthy uterus. It also usually has only one functioning fallopian tube, instead of the usual two functional fallopian tubes.
What is a Vaginoplasty, and why could it be performed in children?
Vaginoplasty may be performed in children or adolescents with vaginal malformations, disorders of sex development, or intersex conditions. Vaginoplasty includes specific procedures including vagina creation, initiating vaginal dilation, clitoral reduction, labiaplasty, etc.
Usually, after vaginoplasty repairs, women can give birth, but the pregnancy may need to be monitored and managed carefully. Also, such women are at risk of prolapse.
A couple, Mr. and Mrs. Rathod (name changed) had a history of primary infertility for 13 years. Primary infertility is defined as a condition in which a couple is unable to conceive naturally even after having unprotected intercourse for over a year.
During this time, they attempted fertility treatments from various other clinics and underwent 4 failed IVF cycles with 8 embryo transfers.
With a lot of hope, the couple then decided to visit the Nova IVI Fertility, Ahmedabad for their last attempt at IVF.
Visit at Nova
Upon visiting Nova, Dr. Banker did a thorough medical evaluation of their condition – repeated IVF Failure] and advised them to undergo a couple of advanced tests to find a possible cause [ whether in sperm, egg or uterus] to decide the appropriate course of action to increase their chance of pregnancy. For Mrs. Rathod, these tests included Endometrial Receptivity Analysis (ERA) along with Endometrial Microbiome Assessment (EMMA) and Analysis of Infectious Chronic Endometritis (ALICE) to check the receptivity [ acceptance status ] of the uterus and Mr. Rathod was advised DNA Fragmentation Index (DFI), which would determine the quality of his sperm. The couple was also advised to undergo Pre Genetic Testing-Aneuploidy (PGT-A) on the embryos to ensure the selection of a healthy embryo for transfer.
Mrs. Rathod’s EMMA revealed that her endometrium had ultra-low biomass and there was a lack of lactobacilli. Her ALICE test revealed the absence of endometrial infection.
Mr. Rathod’s DFI was 44% which is why they were advised to also undergo MACS (Magnetic Activated Cell Sorting) technique for sperm selection. If sperm DNA fragmentation is found to be high, the MACS technique is used to sort the good quality sperm from the rest. This helps in selecting the healthiest sperm which subsequently results in a good quality embryo. This technique helps to improve IVF outcomes.
IVF cycle and way forward
As advised by Dr. Banker, the couple underwent 2 cycles of IVF to pool more embryos for testing. In these 2 cycles, 5 embryos were formed and biopsied. Of the 5 formed embryos, only 1 was found to be normal on Pre-Implantation Genetic Testing – Aneuploidy and was chosen for transfer.
She was given lactobacilli supplementation for a month, to prepare her uterus suitably for hosting the embryo according to the EMMA report. The ERA result was suggestive of early receptive endometrium, and hence the embryo transfer was planned after 6 days of administering progesterone accordingly. With the above-mentioned fertility care program, Mrs. Rathod finally conceived after the transfer of a single healthy embryo.
The couple was delighted with the results, and they were immensely grateful to the Nova team for their guidance in their fertility journey.
A couple, Mr. and Mrs. XX had a history of primary infertility for 6 years with very low ovarian reserve. Primary infertility is defined as a condition in which a couple is unable to conceive naturally even after having unprotected intercourse for over a year.
Poor ovarian reserve is a condition of low fertility characterized by a low number of remaining eggs in ovaries with reduced chances of conception.
During this time, they attempted fertility treatments from various clinics in the UK and underwent 5 IVF cycles with 5 embryo transfers before coming to us.
With a lot of hope, the couple then decided to visit the Nova IVF Fertility under Dr. Banker.
Visit at Nova
Upon visiting Nova, Dr. Banker did a thorough medical evaluation of their condition and advised them to undergo a couple of tests to assess the right treatment course like AMH, AFC measurement.
Even after knowing very low chances of success, the couple wanted treatment with their own eggs only. They were planned for the ICSI cycle.
A good number of such women with a low ovarian reserve may conceive with their own eggs if they are given individualized treatment that is tailored for their profile. Such patients should be counselled appropriately for an aggressive approach toward achieving fertility. The sooner the treatment is started, the better the chances of pregnancy
IVF cycle and way forward
As advised by Dr. Banker, the couple underwent ICSI.
1 The first cycle resulted in the retrieval of 2 eggs with complete fertilization failure.
2. The second cycle was cancelled after some days of injections due to inadequate response.
3. In the third cycle, a different protocol was used, which resulted in the retrieval of 2 mature eggs, and 2 [ day 3] embryos were transferred.
Finally, she has conceived with a single pregnancy.
The couple was delighted with the results, and they were immensely grateful to Dr. Banker and Nova team for their guidance in their fertility journey.