Dr Abri de Bruin

Welcome! Please see this website as an educational reference for patients. My practice strives to offer comprehensive and individualized care in minimal access surgery, endometriosis and infertility.

1. Definition

A couple that has had unprotected intercourse for a period of 12 months and not conceiving


2. Basic tests

On the husband

A complete semen analysis.

If you would like to have one done prior to the appointment, you can phone Genesis Reproductive Center at Kloof on 012 3674378

If you previously did it, please see if you can give me a report or at least when and where it was done.

On the wife

  • Hormone profile done on day 2/3 of your period.  This will include LH, FSH and estradiol levels
  • Progesterone levels on day 22 of your period in some instances
  • Blood group
  • Rubella antibodies to see if you have been immunised against German measels
  • Other tests will be individualised
  • Trans-vaginal ultrasound - This is to evaluate the uterus and ovaries

HSG

  • This is a test to check if the tubes are patent and is done in a limited number of patients for specific reasons

Hysteroscopy

  • This is a procedure where a camera is inserted in the uterus to evaluate the inside of the uterus.
  • In the old days a procedure named a D&C was done, but that only gives you tissue to examine, but no information on the uterus or small polyps or fibroids that can be the cause of abnormal bleeding or infertility
  • The procedure can be done in theatre as well as in the rooms, depending on the indication for the procedure

Laparoscopy 

This procedure is where a camera is inserted through the umbilicus (belly button) and the pelvis (uterus, ovaries, tubes) can be evaluated

What we want to know is the following:

  1. Are there any signs of endometriosis? - this will then be removed at the same time
  2. What is the relation between the ovaries and the tubes? - this is very important as the distal part of the tubes (fimbriae) needs to be free from the ovary to pick up the egg during ovulation
  3. Are there any adhesions of the ovary to the pelvic sidewall? - this can clarify pain and possibly recurring cysts
  4. Is the uterus normal? - sometimes born abnormalities of the uterus is seen this way
  5. Are the tubes patent? - a very important finding if present or not
Blocked tube

Blocked tube

End of tube restored and patent

End of tube restored and patent


3. Important to remember:

If all the tests have been done and you are still not conceiving, please remember the following:

  1. we do not know if the follicle that you make contains an egg
  2. we do not know what is the quality of the egg
  3. we do not know if the tube picks up the egg
  4. we do not know if the sperm fertilises the egg
  5. we do not know how the embryo develops
  6. we do not know if there was a problem with implantation of the embryo into the uterus

4. Can we determine these factors?

Yes we can, but unfortunately only by doing an IVF.  During this procedure one can see how many of the follicles contained eggs, what the quality of the eggs are, if the sperm fertilises the egg and the development of the embryos


5. Do we need to do this as a firtsline option?

No, if there are no clear indications to do an IVF, one can start with less invasive and less costly treatment options


6. Treatment options

  1. Timed intercourse
  2. Intra-uterine insemination
  3. IVF
  4. ICSI

Timed intercourse

This is where we monitor the growth of the follicle, either in a natural cycle or with ovulation induction with medication, and at the time when the follicle reaches the correct size, ovulation will be triggered by an injection and the times of having planned intercourse is then planned

Intra-uterine insemination

Exactly the same as with timed intercourse is followed, but now the husband gives a semen sample and the sperm is prepared and inserted into the uterus with a small 1mm plastic catheter at the correct time

IVF/ICSI

  • In this procedure, different protocols can be followed.  This includes a short protocol with a flare-up stimulation or with an antagonist
  • The other alternative is to use the long protocol with downregulation.
  • The decision of which protocol to follow is based on the individual couple and their specific diagnosis
  • The bottom line is that both ovaries are stimulated to produce a number of follicles.
  • This is achieved by taking daily injections of specific hormones.  During the stimulation, usually two different injections will be taken.  These injections are usually taken by the patients themselves
  • These follicles are then stimulated till the leading follicle reaches 18-20mm and the others are around 14mm
  • When the time is right, the patient arrives at the fertility unit (Genesis Reproductive Center)
  • Here the husband gives a semen sample that will be used.  3 days of abstinence will be required
  • The wife is given conscious sedation and under sonar guidance the follicles are aspirated (a needle inserted into the follicles) and the follicle fluid is given to the embryologist
  • The embryologist will then evaluate the fluid for oocytes (eggs).  Not all follicles contain eggs, so you may have 12 follicles and after aspiration we might have less eggs
  • The quality of the eggs are also evaluated
  • Then in IVF the eggs are placed with sperm of your husband and natural fertilisation takes place
  • In ICSI, a single sperm is injected into a single egg.  This is done for all the eggs
  • The development of the embryos are then evaluated and a decision is taken by the embryologist and your doctor on whether to transfer the embryos on day 3 or 5 following the retrieval of the eggs
  • The transfer is not painful at all - as uncomfortable as a PAP-smear.
  • You should please have a full bladder as the embryos are transferred into the uterus under ultrasound guidance.
  • Following the transfer, you will continue with your medication till the day of the pregnancy test.  This is done 7 or 10 days following the transfer
  • If you have a positive test, then you will have to repeat the test after 48 hours to make sure that the value doubles.
  • If it does, you then start with your pregnancy vitamins, continue with the progesterone and make an appointment for 5 weeks later for an ultrasound to confirm the pregnancy.

Other treatment options

Other possible treatments available includes the following:

1.  donor sperm - this can be used in either inseminations or IVF

2.  donor eggs

  • there are 2 options here, either using a known donor, or going through a donor agency

3.  surrogacy

  • again either a known surrogate or a surrogate through an agency
  • when doing the surrogacy route, it is important to remember that the initial process will take a few months
  • it is subject to high court approval and the treatment will only start following the issue of the order from the high court
  • this needs to be discussed with Dr de Bruin in detail as he needs to tell you about the tests necessary to be done on both the husband and wife and husband of the surrogate and the surrogate herself.
  • Psychological evaluation of all 4 parties will also be necessary
Image Source: anjungsainssmkss.files.wordpress.com/2011/05/sperm1.jpg

Image Source: anjungsainssmkss.files.wordpress.com/2011/05/sperm1.jpg

woman-holding-pregnancy-test.jpg

PROPERTY OF DR ABRI DE BRUIN 2015