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https://www.drmajorumafertility.com/

Dr Major Uma Maheshwari Murugesan - Infertility & IVF Specialist, Apollo Fertility, No. 75, S Block, 6th Avenue, Anna Nagar, Chennai, Chennai (2025)

16/08/2025

Egg retrieval is the most important step in IVF & fertility preservation by egg freezing.

The eggs are retrieved after a period of controlled ovarian stimulation that usually lasts for about 10 days. During this duration, hormone injections are given to make multiple ovarian follicles grow.

The egg retrieval procedure is planned usually after 36 hours after the trigger injection. Trigger injection is meant to make the eggs mature.

On the day of the procedure, the lady is admitted to the hospital in fasting status.

Egg retrieval is a minor surgical va**nal procedure done on daycare basis under intravenous sedation or short general anesthesia.

A thin delicate long hollow needle is attached to the va**nal ultrasound probe & under the guidance of transva**nal scan, the o***y is gently entered through the va**na. All big ovarian follicles are punctured one by one & the follicular fluid containing the egg is brought out of the body with help of a suction device connected to the needle. Each follicle contains one egg & follicular fluid.

The collected follicular fluid with the eggs is then immediately handed over to the waiting embryologist. The embryogist then proceeds to sift the fluid & pick the eggs, introduce the s***m, to do either conventional IVF or ICSI, as the case may be, to achieve external fertilization of all available mature eggs.

This process takes about half an hour.

Most women feel only mild discomfort & can return to routine activities soon after.

In certain cases under specific circumstances, egg retrieval can also be done abdominally under ultrasound or laparoscopic guidance.

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03/08/2025

Women are born with a finite number of eggs, the Ovarian reserve

With advancing age, the Ovarian reserve starts depleting. There are higher chances of the remaining eggs, being of lower quality & competence. The eggs are more likely to have chromosomal abnormalities

The success rate of IVF - the "Take home baby rate" decreases with increasing age

Diminishing Ovarian Reserve & advancing age can make it harder to retrieve enough good quality eggs for IVF/ ICSI, producing fewer good quality embryos

Despite a successful IVF, the incidence of miscarriage is higher in this age group

The need for likely multiple IVF cycles jacks up the cost of fertility treatments

Older women are likely to have embryos with chromosomal abnormalities. Such embryos do not implant. Preimplantation Genetic testing will identify healthy embryos with normal chromosomes & the best implantation potential. Laser Assisted hatching & Embryo glue can be used @ Embryo transfer

In women with muItiple IVF failures due to poor ovarian response & egg quality, IVF with Donated eggs can be offered, to improve the chances of conception

In & after late 30s, women are likely to have diabetes, hypertension, dyslipidemia, hypothyroidism, obesity, fibroids & adenomyosis, which may affect IVF success rates & pregnancy outcomes.

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31/07/2025

Growing ovarian follicles produce increasing levels of Estrogen, which then induces a sudden increase in release of LH from the Pituitary gland in Brain. 36 hours after the LH surge, ovulation happens - Rupture of a fully developed dominant follicle, releasing the mature egg contained within. This egg is now available to start a pregnancy, if it gets fertilized by a s***m & the resulting embryo implants.

The LH surge not only initiates ovulation but also matures the egg contained within the dominant follicle. LH surge is also responsible for the changes that halve the chromosomes from 46 to 23 in the mature egg. LH surge detaches the egg stuck to the inside of the follicle wall to the follicular fluid.

The trigger injection in an IUI cycle or an IVF cycle is either hCG injection or GnRh analogue injection.

The hCG hormone injection works like the LH & is active for a longer duration.

The GnRh analogue injection makes the Pituitary release LH & is short acting.

In IUI cycles, typically ovulation trigger injection is given when the dominant follicle(s) is 18 - 25mm in size, the endometrium is 3 layered, atleast 8mm thick. The trigger injection is preferably given parallel to the endogenous LH surge. The approximate time of the endogenous LH surge can be estimated with color doppler scan. The ovulation trigger injection is given to time the IUI, approximately 24 - 40 hours later, to coincide with ovulation. The GOAL of ovulation trigger injection in an IUI cycle is to ACHIEVE OVULATION.

In an IVF cycle, hCG or GnRha or both injections together are given usually after 10 - 14 days of ovarian stimulation when at least 3 - 5 follicles have reached 17 - 18mm size. Endometrial thickness though observed, is not the deciding factor. In an IVF cycle, there should NOT be an endogenous LH surge. Trigger injection in an IVF cycle is given to ACHIEVE EGG MATURATION & not for ovulation. This is so, because, if follicles ovulate, the eggs are lost & cannot be successfully retrieved out of body. Surgical Egg retrieval is planned 34 - 36 hours after the trigger injection.

The choice of the trigger injection in an IVF cycle depends upon the patient characteristics & the type of stimulation protocol

27/07/2025

After the ovarian stimulation & egg retrieval in an IVF cycle, freezing the entire set of embryos, for a deferred Embryo transfer cycle later is termed as Freeze all strategy.

This is revolutionary as this strategy separates IVF into two parts - ovarian stimulation - egg retrieval & the embryo transfer part done later on.

This can be either a Preplanned strategy or a last moment Rescue strategy.

The development of a safer, effective & advanced method of embryo freezing called Vitrification & full functional recovery at thawing has made this possible.

Preplanned freeze all strategy is adopted when the lady has a risk of ovarian hyperstimulation syndrome, embryos are to be biopsied for PGT, prior diagnosed adenomyosis / fibroid(s) / hydrosalpinges needing treatment before embryo transfer & couple convenience.

Rescue freeze all is when a situation unexpectedly arises at the end of ovarian stimulation/ at egg retrieval, that rules out a possibility of a fresh embryo transfer. Thin endometrium, endometrial polyp, endometritis, persistent fluid collection in uterus, premature rise in progesterone hormone level & slow / poor growth of embryo on D5 post IVF / ICSI are some of the indications.

During the ovarian stimulation phase & immediately after egg retrieval, estrogen hormone peaks & makes the endometrium less embryo friendly. Freeze all strategy allows embryo transfer later on in a natural cycle or a mildly medicated, more physiological cycle with near normal hormone levels.

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20/07/2025

A Frozen Embryo Transfer (FET) is a protocol in IVF where frozen (vitrified) embryo(s), created in a prior IVF ovarian stimulation cycle is/ are thawed & transferred into the uterus after endometrial preparation, in a later menstrual cycle.

The embryos can be transferred into the uterus either fresh, in the same cycle, 3 / 5 days after the retrieval (Fresh embryo transfer) or in any of the subsequent menstrual cycles. Till such time, the embryos are maintained in a frozen state (vitrification).

An FET cycle is typically 3 to 4 weeks long & culminates in the Embryo transfer procedure.

The advent of modern technique of safe, effective embryo freezing, thawing & full functional recovery have made frozen embryo transfer cycles possible.

Deferred embryo transfer allows the IVF cycle to be divided into 2 parts, making the process more convenient, flexible, physiological & safer without affecting the success rates.

In a frozen ET cycle, the endometrium - the uterine lining needs to be prepared adequately to allow implantation & pregnancy. Initially only Estrogen hormone & later progesterone hormone also, are required for endometrial preparation.

The source of both hormones utilized for endometrial preparation can be self produced by ovaries or externally supplied in the form of replacement / supplementation.

During ovarian stimulation phase & immediately after the egg retrieval procedure, the level of estrogen hormone is many times higher than what is found in a natural cycle, making the endometrium less friendly to the embryo. In such a situation, cancelling fresh transfer & planning an FET in a later cycle, when hormone levels are in the normal range, gives a better outcome.

The deferment allows time for preimplantation genetic testing of embryos, as the result of this analysis takes time. While the results are awaited, the embryos are maintained frozen.

Once embryos are created & preserved, a properly planned FET allows a relaxed time frame, enough for treatment of any of the following conditions like adenomyosis, hydrosalpinges, chronic endometritis, uterine fibroids, endometrial polyps, thin endometrium etc.

In women with PCOD / PCOS, frozen embryo transfer is a universally accepted & followed norm, as the risk of severe ovarian hyperstimulation is nil.

In situations where during the ovarian stimulation phase, unforeseen complications like premature rise of progesterone hormone is observed, thin endometrium is observed or the uterus shows persistent fluid collection, plan for fresh embryo transfer is cancelled & an FET is planned at a later stage after addressing the issues.

FET allows the future utilization of any extra embryos frozen, at the time of a past successful IVF - ET, typically for further family expansion.

FET is a boon for women undergoing fertility preservation (embryo preservation) for cancer treatment. After a successful cancer treatment, the embryos created prior, can then be transferred into the prepared uterus.

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12/07/2025

In human reproduction, the Endometrium & the Embryo represent the soil & the seed respectively.......

A healthy endometrium is fundamental for a successful pregnancy.

The endometrium is the innermost layer inside the uterus & is made up of two distinct layers.

The first layer @ the base - the Stratum basalis. This layer stays relatively unchanged. This layer contains Stem cells.

The second layer is dynamic, the Stratum functionalis. (the functional layer) It responds to the monthly cyclic changes in hormone levels, produced by the ovaries. This layer periodically sheds, grows back, matures & sheds again if there is no conception. The dynamism of this layer is the result of the replenishment growth / regeneration from the basal layer.

It is this functional layer of the endometrium where the blastocyst embryo attaches & grows if conception happens.

The Endometrial regeneration requires Estrogen hormone & maturation requires both Estrogen & Progesterone hormones.

The endometrium has stores of energy source, hydration, blood supply to allow nourishment & growth of the embryo.

If conception has not happened, this layer will break down & shed due to decreasing hormone support leading to periods.

Endometrium needs to be of a certain thickness & certain character to allow a successful implantation.

The endometrium needs to have an adequate blood supply to be able to support the implanted embryo.

Any Endometrial disease - infection / inflammation / damage to the basal layer / dysfunction affects the fertility potential negatively irrespective of all other factors.

The fully prepared endometrium remains receptive to the embryo for only a few hours called the receptivity window.

Endometrium is inhabited by a mix of friendly bacteria that has a positive role in embryo implantation.

Endometrium also produces certain biochemicals that play an important role in immune modulation. These biochemicals facilitate / may impede implantation of embryo.

There are various modalities to assess the endometrium like ultrasound scan, direct visualization by hysteroscopy & biopsy study of various types.

The process of embryo implantation requires a "cross talk" between the endometrium & the embryo. This is the part that is beyond human control.

The complex nature of the underlying process of the implantation, makes Embryo implantation the rate limiting step of human reproduction.

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29/06/2025

Despite all the modern advancements in the science & technology of IVF - Embryo transfer, the embryo implantation is the narrowest bottleneck - the success rate / the "Take - home baby rates" being approximately 35% per embryo transfer procedure.

The Implantation involves a "Dialogue / interview" between the embryo(s) & the endometrium. This is observed to be beyond human control.

Endometrial scratching is a pre IVF - Embryo transfer procedure involving an intentional disturbance to the superficial layer of the lining of the uterus (endometrium), often in the cycle preceding an IVF - ET / ET cycle.

It is believed to improve the chances of embryo implantation, hence very relevant in current times.

Some studies have found that Endometrial scratch (ES) may increase pregnancy / live birth percentage, especially in women with multiple failed IVF - Embryo transfer cycles.

ES is believed to trigger an exaggerated healing & pro - implantation immune response in the scratched endometrium, potentially improving the endometrial ability to allow implantation. ES stimulates the production & release of certain biochemicals that enhance endometrial growth, blood flow aiding repair & regeneration of the endometrium.

It is primarily used as an add-on treatment for women undergoing IVF - Embryo transfer, who have past history of repeated implantation failures.

ES is a brief OPD procedure without needing any anesthesia. Mild painkillers can be given to alleviate any discomfort.

A long, thin, sterile, single use plastic biopsy instrument called the 'Pipelle' resembling a ball point pen refill, is inserted through the cervix into the uterus, with a partially full bladder & sometimes a USG guidance. One end is inside the uterus & the outer part is outside for handling.

The Pipelle is moved to create a mini suction effect inside the uterus that disturbs the endometrium.

ES procedure may cause temporary menstrual cramps like pain, bleeding, dizziness etc.

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22/06/2025

The technique of Embryo transfer has a great impact on the success of IVF.

A Mock Embryo Transfer (ET) is a practice trial run of the embryo transfer procedure, performed before / during an IVF cycle, that helps prepare for the actual ET procedure.

It is a minor OPD procedure usually causing none to minimal discomfort. So, anesthesia is not needed.

During Mock / Trial ET, the conditions / prerequisites are all the same as during the actual ET, except for the fact that there is NO embryo involved.

The principle of Mock ET is "A road travelled prior is a known road."

This preparatory procedure helps the IVF doctor in assessing the path to the uterine cavity space - the cervical canal, its curvature, direction, angle & the position of uterus et cetera. These individual characteristics vary from woman to woman.

This procedure is preferably done in association with a transabdominal pelvic USG scan & a full bladder.

This procedure also determines the best suited ET catheter, need to use a guide wire - the Stylet & the technique of catheter insertion.

Mock ET procedure can diagnose anatomical abnormalities / deviation / challenges that may prevent an easy & smooth embryo transfer on the scheduled day of ET.

This procedure helps in ensuring the embryo is gently deposited inside the uterus at the correct location with minimal struggle.

This procedure also prepares the woman for the actual Embryo Transfer procedure.

In a situation where the Mock ET procedure had been difficult / painful, the doctor & the woman can make an informed choice of opting for anesthesia for / at the time of ET procedure.

Studies suggest that a Mock ET may improve success rates in IVF cycles by optimizing the embryo transfer technique.

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09/06/2025

Heterotopic Pregnancy is a type of abnormal multiple pregnancy, with one fetus located in the uterus (the normal expected location) & other located outside the uterus.

In a spontaneously conceived HP, two eggs are released at the same time & each gets fertilized, & the resulting two embryos implant in different locations simultaneously, one inside the uterus (the normal location) & another outside the uterus (abnormal location), leading to Heterotopic Pregnancy.

A recent study estimated the incidence of HP as about 1/30000 in spontaneous pregnancies, increasing to 1/360 to 1/100 in pregnancies resulting from various fertility treatments.

HP after IVF - ET, occurs due to one transferred embryo implanting inside the uterus & another implanting in one of the abnormal locations simultaneously.

HPs are possible even in ovulation induction & Timed In*******se cycles / IUI cycles.

Diagnosis of Heterotopic Pregnancy can be challenging. On USG, once a pregnancy is located inside the uterus (the normal location), another pregnancy lurking simultaneously at an abnormal location can be easily missed unless specifically looked for. Diagnosis requires a very high index of suspicion.

70% of all HPs are diagnosed on USG / TVS between 5 - 8 weeks of pregnancy, 20% between 9 - 10 weeks.

The risk of heterotopic pregnancy comes from the coexistence of the ectopic pregnancy. The commonest location of ectopic pregnancy are the fallopian tubes & rarer locations can include the cervix, o***y, previous cesarean scar, or even the abdomen. None of these organs have the anatomy / functional ability to support a developing pregnancy.

As the fetus grows, the organ housing the ectopic pregnancy will eventually rupture & leading to a massive internal bleeding.

The symptoms of heterotopic pregnancy are variable & nonspecific. Approximately 50% of women / couples are unaware of the ticking catastrophe that they carry..... have no symptoms.

Symptoms are same as of ruptured ectopic pregnancy include sudden, severe / vague abdominal or pelvic pain, collapse or shock.

Risk factors - Potentially all kinds of successful fertility treatments, multiple embryo transfer, prior tubal surgery, history of Pelvic Inflammatory Disease, history of a prior ectopic pregnancy.

A Laparoscopic removal of the coexisting Ectopic pregnancy permits the intrauterine pregnancy to continue normally.

Medical management, though useful in ectopic pregnancies diagnosed early, has a limited role in the management of HP as it will harm the intrauterine pregnancy as well.

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30/05/2025

Though desired by some couples, Twin pregnancy carries significantly higher health risks for both - the mother & babies, including premature birth, low birth weight, pregnancy complications, delivery complications.

With the aim to bring down the risk of twins in IVF - ET, an elective Single blastocyst Embryo Transfer (eSET) is strongly recommended & practised.

This practice has brought down the incidence of fraternal twinning to zero.

Despite this, rarely the expectant parents & the doctor are shocked to find Twins (after eSET) at the time of first ultrasound.

These cases are IDENTICAL (MONOZYGOTIC) TWINS!!

This kind of twinning can happen when a single embryo, randomly splits into two separate embryos after the embryo transfer, inside the uterus, unbeknownst to the couple & the doctor, so diagnosed directly at USG.

Identical twins have the same genetics & therefore, are of the same gender.

A recent study has shown that twinning was observed in upto 1 - 2 % of pregnancies (1 - 2 per 100 cases) following a successful eSET.

In general population, identical twins are observed in about 0.4% (4 per 1000) of spontaneous conceptions.

The IVF/ ICSI - Single blastocyst Embryo Transfer cycle CANNOT guarantee that monozygotic twinning will not happen, as it is a natural, spontaneous & a random incident of nature.

Manipulation of the outer shell of the blastocyst embryo - the Zona Pellucida, is thought to lead to division of a single blastocyst into two & the resulting twinning.

The timing of the embryo division determines whether the twins will share the amniotic sac.

Monozygotic twins usually have a Monochorionic zygosity - single placenta. Diamniotic twins have separate amniotic sacs.

Monoamniotic twins, share the same amniotic sac, hence have high incidence of complications.

Follow my profile for more information about fertility & disorders. For appointments- text 91-9363051156 to the Helpdesk WhatsApp number.

25/05/2025

Adenomyosis is a benign uterine condition which is common in women suffering from infertility.

Adenomyosis leads to enlargement of uterus. This is due to growth of ectopic endometrial tissue (normal tissue at an abnormal location) within the muscle mass layers of the uterus. These ectopic endometrial glands inside the muscle of uterus, also undergo bleeding during periods. But, such a discharge keeps accumulating within the layers of muscle as there is no exit route. (Natural exit route thru' cervix & va**na is available only for secetions / discharge from the inside of uterine cavity endometrial lining). This accumulation within the layers of uterine muscle irritates the muscle, leading to muscle hypertrophy focally around every ectopic endometrial bleeding nidus. Hence, the uterine muscle mass enlarges. Such a uterus is likely to be tender & painful before, during & just after periods.

There are a few variants of Adenomyosis. More than one variant may coexist in the uterus at any given time......

Adenomyosis is frequently found in women who have endometriosis as well......

Adenomyosis not only reduces spontaneous conception but also the success rates of all fertility treatments, as well as the "Take home baby" rates.

Adenomyosis increases the risk of heavy, painful periods, miscarriage, premature labour, abnormal placental attachment.

The negative impact on fertility is primarily due to a state of chronic inflammation of the uterus, increased local production of biochemicals called Prostaglandins & Cytokines in the uterus, hypercontractility & anatomical distortion of uterus. The junction of endometrial lining & the uterine muscle becomes thicker than normal..... The blood flow to uterus / endometrium may also be compromised.

All these factors individually & collectively create an environment less friendly / unfriendly for embryo implantation, development & nurturing pregnancy.

Management strategy is tailor-made depending upon USG / MRI features, symptoms & past history.

For appointments- text 91-9363051156 to the Helpdesk WhatsApp number.

15/05/2025

Hyaluronic Acid (hyaluronan), a high viscosity sticky biochemical substance produced in our body, chemically a carbohydrate polymer, an important component of the extracellular matrix - the cementing substance between cells, is found naturally in joints, eye, cartilage, skin & uterine secretions.

In the uterus, it is understood to increase around the time of Embryo implantation.

HA is known to stick to cell surface receptors on preimplantation embryo & in the Endometrium - the uterine lining tissue. It forms the sticky matrix between the embryo & the uterine lining, helping in implantation.

HA contributes to embryonic cell multiplication, adhesion & further development leading to "homing - in" in the uterine lining.

Hyaluronon enriched IVF culture medium, like "Embryoglue", may improve the chances of the embryo sticking to the uterine lining in a selected set of women undergoing IVF - ET cycle, increasing the live birth rates. It mimics the natural sticky condition in the uterine lining around the time of implantation.

"Embryoglue" is used to incubate the embryo(s) just before the embryo transfer procedure. It coats the embryo(s) all around. The embryo(s) are then gently deposited inside the uterus through a sterile inert fine catheter.

Though HA enriched transfer medium can give an advantage in a selected set of patients, it is not necessary for all patients undergoing ET.

It is very important to reiterate at this point that it neither guarantees implantation nor does it prevent ectopic pregnancy !!

It is safe for the woman, the uterus, the embryo, the fetus & baby born as a result, though its use may increase the cost.

Despite the advances like use of HA enriched culture medium like "Embryoglue", techniques like laser assisted hatching, Embryo implantation continues to be the rate limiting step, a bottleneck for success rate of IVF - ET.

Follow my profile for more information about fertility & disorders. For appointments- text 91-9363051156 to the Helpdesk WhatsApp number.

Dr Major Uma Maheshwari Murugesan - Infertility & IVF Specialist

16/08/2025

03/08/2025

31/07/2025

27/07/2025

20/07/2025

12/07/2025

29/06/2025

22/06/2025

09/06/2025

30/05/2025

25/05/2025

15/05/2025

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