Email : info@acimc.org
  Contact : +92-304-111-2229/BABY
WhatsApp : +92-309-333-2229/BABY

Select Language: English English اردو اردو

All Posts in Category: Blog

How Long Should I Rest for After Embryo Transfer

Embryo transfer is a simple procedure, where the embryo is transferred into a woman’s uterus using a catheter. This procedure is the final step of IVF (In Vitro Fertilization), where the egg is injected with the sperm to form an embryo after fertilization. The purpose of embryo transfer is to facilitate conception once an embryo is made.

HOW LONG SHOULD I REST FOR AFTER EMBRYO TRANSFER

Once a doctor performs an embryo transfer, the most common concern of the couple is for how long should the woman rest for.

A simple answer to this is ‘no bed rest is required’, now some people are of the opinion that bed rest means resting till the pregnancy test date that is for 2 weeks while others think it’s for a day or two. According to studies, even half an hour rest after an embryo transfer is considered enough, but this is not accepted by a number of doctors who perform embryo transfer.

Hence, currently there is no such documented evidence to prove whether bed rest or continuing normal activities after the procedure will make a difference in the outcome.

When the embryo(s) are transferred there is not much a couple can do that would affect the outcome of the transfer. Hence any advice given by the doctors is according to the physical and mental state of the patient.

Some couples prefer resting for a few days for their own satisfaction, however others give priority to returning to normal activities after the transfer. In both cases, again it’s the couple’s choice as well as the mental and physical state of the woman. So your doctor may ask you to rest for at least twenty-four hours and others may suggest you to resume to normal activities as soon as possible depending on your condition and preferred choices. For example some women are professionals and have to resume to their job after the procedure, in such cases the doctors would not ask her to take any further days off unnecessarily. Some women want to keep themselves busy so they don’t think too much and worry about the outcome of their IVF treatment, while others cherish this time and like to think about the embryo that has been transferred.

Lastly, again conception is a natural event and there is not much impact of physical activity on conception and embryo implantation.

And it primarily depends on the genetic quality of eggs.

Having discussed this there are still a few things we tell our patients after an embryo transfer, these dos and don’ts include;

DON’T:

  • Lift heavy objects
  • Perform excessive exercises, mild walk and gentle movement is acceptable
  • Consume too much caffeine
  • Perform intercourse
  • Go for hot baths, it’s better to stick to showers till the pregnancy test, hot environment may damage the transferred embryo
  • Discuss your IVF procedure with those who have had a bad experience, it will only give you negative energy and increase your anxiety level.

But DO:

  • Talk to your husband/partner and share what you feel
  • Get support from your family and loved ones
  • Things that makes you happy, be it a hobby, listening to music or any other activity
  • Stay calm and relax
  • If you want to offer namaz, sit on a chair and pray
  • Think before resuming work, if it’s a hectic job then try avoiding it, if it involves a lot of travelling then also consider not resuming immediately.

Consult your doctor immediately if you face any difficulties coping up with the anxiety of embryo transfer, be it before or after the procedure. Or if you don’t find answers to the questions that may come to your mind.

 

By- Dr. Alvina Arslan Meer

ART Coordinator (MBBS) and Online Counselor

Read More

When Should Laparoscopy be Advised

LAPAROSCOPY

Laparoscopy is a procedure where a camera is used to find out the internal condition of a patient’s abdominal organs. In addition, it allows the doctor to also perform repairs with in the abdomen if needed, without making a larger incision. In situations where infertility is the major reason to perform this procedure, laparoscopy can be used to diagnose infertility as well as treat it.

When should Laparoscopy be advised

Procedure

Laparoscopy is a surgical procedure that involves insertion of a laparoscope and other surgical instruments, through small incisions in the abdomen. One, two or three small incisions are made in the abdomen for laparoscope insertion, laparoscope is a thin fiber optic tube that is fitted with a camera and light.

Whether or not laparoscopy should be advised is a difficult decision to make when it comes to infertility patients. Some doctors are in favor however some feel otherwise.

Laparoscopy would be advised in the following conditions:

It is usually advised when other infertility testing have not helped in reaching a diagnosis for infertility, or if the symptoms point us towards this procedure.

  1. If a patient experiences severe pelvic pain at any time
  2. When there is a suspicion of pelvic inflammatory disease or infection
  3. If you experience severe menstrual cramps
  4. If the surgeon or doctor is suspecting endometriosis
  5. When your doctor is suspecting ectopic pregnancy, it needs to be ruled out immediately or it can be life threatening
  6. If you experience Dyspareunia; pain during intercourse
  7. When pelvic adhesions are suspected

Occasionally, during diagnostic laparoscopy, if your surgeon finds an abnormality that needs fixing then he/she may remove, repair or treat the problem right away.

Along with diagnostic purposes, laparoscopy is also performed for surgical purpose, following are the conditions where your surgeon might use the surgical approach of this procedure;

  1. Fallopian tube blockage, a blocked fallopian tube is a common cause for infertility in a lot of patients, this can be fixed laparoscopically by either repairing the tube or unblocking it. Your surgeon will make this call depending on your case, if you are young and tubal blockade is the only problem then this tubal repair may help you in conceiving naturally, however if due to any reason your only option is IVF (In Vitro Fertilization) then going straight to IVF and skipping laparoscopy is a better choice.
  2. If Hydrosalpinx is suspected, hyrdosalpinx is a condition where the fallopian tubes are blocked due to infection or ay kind of fluid buildup. Either a small part could be repaired or removed or an entire tube can be removed depending on the extent of tubal damage and or tubal blockage.
  3. Endometriosis deposits, these deposits are believed to cause infertility because they lead to an inflammatory reaction which causes scar tissues and adhesions along with pain. Some surgeons believe that removing these deposits laparoscopically may improve success rates for pregnancy, others however do not agree and hence this is controversial.
  4. Fibroids that cause pain, fibroids are muscular wall tumours present in the uterus. These may contribute to infertility by blocking the fallopian tubes or distorting the uterine cavity, they vary from small, seed-sized tumors to larger, grapefruit-sized tumours. Hence in some cases removing a fibroid may help the infertile couple.
  5. Ovarian drilling, another commonly done procedure using laparoscopy is ovarian drilling, its mostly done in patients suffering from polycystic ovarian syndrome who may benefit from ovarian drilling. This procedure involves making small punctures in the ovary, laparoscopically. The number of punctures may vary from 3 to 8, this helps women with PCOS to ovulate on their own when ovulation induction through fertility drugs have failed.
  6. An ovarian cyst, like a fibroid an ovarian cyst may also cause blockage of the fallopian tube and causes pain. The cyst can be removed laparoscopically giving higher chances of pregnancy once the blockage caused by an ovarian cyst is removed. However, care must be taken when removing an ovarian cyst, if a large cyst is removed it may cause a decrease in ovarian reserve, at times it is better to get this cyst removed by an ultrasound guided needle aspiration. Make sure you discuss it with your doctor.

Importance of laparoscopy in infertility:

A laparoscopic procedure allows your surgeon to not only diagnose the cause of infertility, by looking what’s inside the abdomen but also helps to biopsy any suspicious cyst or growths.

As discussed earlier, laparoscopy can be performed to remove any scar tissue, fibroids, ovarian cysts and endometrial deposits along with other surgical treatments performed laparoscopically. All these contribute to help one get pregnant naturally or through fertility medications.

After laparoscopy, your surgeon will suggest you appropriate options depending on the findings of the procedure. This varies from patient to patient, for example if your tubes were repaired or a fibroid was removed then you may be able to get pregnant naturally. Of course your surgeon would be the best person to lay down the options for you since he would have had seen the condition inside your abdomen himself.

 

By- Dr. Alvina Arslan Meer

ART Coordinator (MBBS) and Online Counselor

Read More

How to Manage Stress During IVF Treatment?

Many factors contribute to stress during IVF treatment and hence it’s an important topic to discuss about. These stresses include emotional stress, strain caused between relationships, financial cost involved, and the time it takes for the entire process, the loss of work, side effects of the medications used and other concerns regarding this process.
These stresses can be managed easily during the IVF treatment journey if the following steps are followed, before, during and after IVF.

HOW TO MANAGE STRESS DURING IVF TREATMENT?

Before Starting IVF Treatment:

Before IVF treatment starts one must complete all the prerequisites as advised by the doctor in order to avoid any mishaps during the treatment. It is understood that there are a lot of different emotions when a couple is going through infertility, they may feel nervous as well as excited. In order to calm yourself down it is important that you ask your doctor any questions you may have before starting the treatment.

Here is a list of the common concerns:

  • Money: Most couples are concerned about the cost of IVF treatment, it is advisable to discuss the payment options, total payment and any additional costs beforehand, managing your finances before the treatment commences is how to handle this stress. Because IVF is an expensive procedure, this stress should be taken care of by talking to your doctor as well as the concerned administrative department of your Infertility Center. Most often the additional costs that a couple is asked to pay for is freezing and storage of eggs, sperms or embryos. Besides freezing if the embryo transfer is to be done under general anesthesia then it costs additional charges. Also if the current cycle gets unsuccessful due to any reason, then payment may be needed if the couple wants to go for additional cycles.
  • Time: Second most common concern is the time it takes for the complete IVF treatment process. Some couples come from out of country, some are working individuals and some have more kids to manage, so their concern is the total time required. IVF treatment can take around two weeks to up to one month, along with that when treatment is commenced, you will be asked to come in to the clinic every day for almost two weeks. This is required because every alternate day, blood test and scan is required to keep track of the follicle size and hormone levels. These two factors tell us about the ovarian response of the female, if we get the desired response it indicates that the cycle is going well. Before beginning one should keep this schedule in mind to avoid any undesired circumstances.

During IVF Treatment:

Once treatment starts a couple goes through multiple phases, emotionally, physically as well as mentally, especially if it’s the first cycle they are going through. Handling them is easy if the female has a strong support system.

  • Personal relationship: It’s important to choose who to share your treatment details with, not everyone has to know you are going through IVF treatment. Best way to handle this is by choosing your husband as your partner to share the treatment details with given that your husband and you have a strong relationship. Strong enough to handle the pressure caused by this treatment, which requires time and commitment by your partner. For those patients who don’t feel comfortable with anybody else, they can share with their doctors.
  • Avoid Stressors: During treatment it is advisable to avoid stressors in life, as well as any major lifestyle changes. These include changing your job or shifting houses or traveling plans etc. Stress cannot always be avoided so it’s better to stay prepared for something unexpected, so that nothing comes as a surprise to you.
  • Stress relieving tips: A light exercise is advised to patients, regular yoga, any hobby that the patient must have should be taken up to release stress, meditations, health spa and staying humorous should be practiced.

AFTER IVF TREATMENT

After IVF Treatment:

Once the process of embryo transfer has taken place the most stressful period starts. This period takes its toll on most couples because this is the time when the fate of their pregnancy is being decided. It is better to decide what to do during this time beforehand, plan a schedule for yourself in such a way that you don’t sit idle during the waiting period. Of course strenuous activities won’t be advised during this time since your embryo has been transferred and so you need to be careful.

IVF Treatment Result:

If Positive: First pregnancy test is performed after 2 weeks of embryo transfer, if it is positive you will still be monitored closely and get regular pregnancy tests in the initial period and then will be asked to come for a scan.

If Negative: In this case don’t count it as a failed cycle, instead the infertility team would have a better idea of what protocol to follow and what changes to make in the following cycles. In this case you can meet your consultant without fee and plan your next cycle of IVF.

 

By- Dr. Alvina Arslan Meer

ART Coordinator (MBBS) and Online Counselor

Read More

Myths About Infertility

Myths About Infertility

MYTH #1 Infertility Issues are a Woman’s Problem Only.

This is the first and the foremost myth, not only in Pakistan but worldwide. No doubt the percentage of female infertility conditions is higher as compared to male infertility, however the involvement of males in infertility issues is not negligible in fact it accounts for 30% of infertility factors in males.

FACT: According to the American Society for Reproductive Medicine, 30 percent causes of infertility are due to male factors, 35 percent due to female factors, 25 percent due to both partners and 15 percent due to unknown causes.  So we could say males are almost equally responsible for causing infertility as the females.

 

MYTH #2   Birth Control Pills Cause Infertility.

Some women believe taking birth control pills leads to infertility or takes longer to conceive than those who haven’t taken the pills. These women have in mind that since birth control pills alter the hormonal levels within their body, it may change the normal functioning capacity of their reproductive system and lead to infertility.

FACT: Taking contraception will never cause infertility, however different types of contraception have different time spans for fertility to return back to normal. Mostly implants or injections take several months, but pills, patches, rings and IUDs bring the fertility back to normal almost immediately.

Myths About Infertility

MYTH #3   Women Suffering from PCOS or Endometriosis are Unable to Conceive.

Poly-cystic ovarian syndrome and endometriosis are one of the leading causes of infertility in our country, females with these disorders are of the opinion that they can never conceive because they often face difficulties in conceiving and on their doctor’s visits or scans, and they are diagnosed with PCOS and endometriosis.

FACT: Out of the 50% of women facing infertility, around 20% have PCOS and 10% have endometriosis. Although these conditions do not meet the optimal requirements for pregnancy, they still do not fall in the category of infertility. All these women need is assistance, to help them conceive. Hence these women are advised to consult a doctor even when they are not yet ready for conception, in order to have an understanding of how to improve their chances of conceiving as well as have a basic knowledge of what to expect from their reproductive health system.

MYTH #4   Irregular Menstrual Cycles Mean a Women is Infertile.

Having irregular menstrual cycle is no doubt very frustrating for a woman who’s trying to conceive, reason being she doesn’t know the exact day or days of her ovulation, in fact at times she may not ovulate at all.

FACT: A variety of reasons contribute to irregular cycles, most common reasons are stress, over exercise and other serious problems like endometriosis. It is true that women who have irregular menstrual cycle have difficulty in conceiving; however irregular periods do not mean that the fertility is impaired.

Myths About Infertility

MYTH #5    A Female Doesn’t have to Worry about her Eggs Until she is 40 Years old.

A lot of women believe that the age bracket of 35 to 40 is when they should start worrying about their eggs. Some also think egg quantity can be improved with medications, this is impossible by any means as a female has an egg reserve when she is born, this reserve only declines with time and cannot be improved.

FACT: Every female is born with a certain number of eggs; this number is approximately 1-2 million at birth. So by the time female reaches puberty this number decreases to half its original number. This ovarian reserve of eggs continues to decline with age, and declines quite rapidly in the late 20s and 30s, reaching a noticeable decline after age 35. Not only the quantity but the quality of eggs also decreases with time.

MYTH #6    Taking an Appointment from a Reproductive Health Doctor or Infertility Specialist Means You will have to go for IVF Treatment.

Couples tend to think that going to an infertility specialist means they will have to go for a test tube baby immediately or eventually. At times they have been to so many gynecologists and failed to conceive, and hence they think that IVF is their only option.

FACT: Basically reproductive health specialists also called infertility specialists are there to educate couples about their fertility potential. First thing these specialists do is get the appropriate tests done for the couple. This includes blood tests like AMH; that tells about the ovarian reserve, hormonal profile that includes FSH, LH, PROLACTIN, ESTRADIOL and TSH, as well as Tran’s vaginal ultrasound on the required days. Semen Analysis is an important parameter that is checked by most specialists to identify male infertility problems as well as sperm quality and quantity. Once these baseline infertility tests are performed, the specialists then give you the possible options which may include medications, timely intercourse procedure, and intra uterine insemination and if nothing works or if the circumstances are such that IVF is the only option then only patients are given the option of IVF.

 

By- Dr. Alvina Arslan Meer

ART Coordinator (MBBS) and Online Counselor 

 

Read More

Testicular Biopsy

TESTICULAR BIOPSY

TESTICULAR BIOPSY

A testicular biopsy is a test used to perform for male infertility, it is a procedure where a small sample of tissue is taken from the testes and examined under microscope for the presence of sperms and also to look for the cause of low sperm count and/or abnormal quality of sperms.

Which patients should undergo testicular biopsy?

In the evaluation of male infertility, the first step is to perform a semen analysis, if this test detects low sperm count, absent sperm count or an abnormality in the sperms then further testing is required in order to identify the cause of these abnormalities.

Next comes the blood testing for sex hormone levels and if the hormone levels come out normal then testicular biopsy should be performed as advised by the infertility specialists.

The testicular biopsy helps us assess the production and maturation of sperm cells in the testes.

Male reproductive system

We must first have a brief idea about the male reproductive system and the organs involved in formation and transport of sperms.

The male reproductive system consists of primary sex organs the testicles, scrotum and penis, and a few accessory organs.

Testicles are two oval shaped organs located outside the body in a pouch like sac of skin covering, called the scrotum. These are responsible for making the primary sex hormone, testosterone, and for generating sperms. Within the testicles are coiled tubes called seminiferous tubules which are responsible for producing sperms. The sperms pass from testicles to epididymis, where the sperms mature and are stored. They are released into the vas deferens by contractions, when sexual arousal occurs.

The vas deferens transports mature sperms into the urethra, the tube that is responsible for carrying urine and sperms outside the body, should ejaculation occur. The opening of urethra is at the tip of penis, and once a male reaches sexual climax, the semen which contains sperms is expelled from the penis.

Near the base of the bladder are sac like pouches called seminal vesicles, that are attached to the vas deferens, these seminal vesicles provide a sugar rich fluid (fructose) to the sperms, which is the source of energy that allows them to move.

The primary hormones responsible for the male reproductive system to function normally are Follicle-stimulating hormone, luteinizing hormone and testosterone.

For spermatogenesis (formation of sperms), the follicle stimulating hormone is necessary, and luteinizing hormone is required for stimulation of testosterone production, which in turn is required for sperm formation.

Uses of testicular biopsy:

  • To determine if the problem of sperm production is caused by a blockage
  • Extract sperms to use them in the IVF procedure, in instances where sperms are not present in the semen
  • To diagnose testicular cancer
  • To determine the cause of a testicular lump.

Process of testicular biopsy

There are two commonly used techniques to perform a testicular biopsy:

  • Needle biopsy: this is performed under local anesthesia where a sample of testicular tissue is obtained using a specialized syringe or needle.
  • Open biopsy: this can be performed under local or general anesthesia, here a small cut is made into the scrotal skin and a piece of testis is taken out using a blade.

Following are the details of commonly performed testicular biopsies:

A testicular biopsy is an out patient procedure, usually performed at your doctor’s clinic or a hospital. It takes 15 to 20 minutes. The patient is supposed to stay still during the procedure and hence is offered a sedative, some doctors prefer a general anesthesia.

The patient is asked to lie on his back and the scrotal area is cleaned to remove any bacteria. A local anesthesia is used to numb the skin of the scrotum.

Percutaneous biopsy: A percutaneous biopsy also called fine needle biopsy is a procedure where a thin needle is inserted into the scrotal skin. This needle has a syringe at its end which is used to collect the testicular tissue. This percutaneous procedure does not require any incision or stitches.

A variant of this fine needle biopsy is a Core needle biopsy where a hollow, spring-loaded needle is used to extract testicular cells sample called a core sample, the process of extraction makes a loud snapping sound and it is a larger sample as compared to the fine needle sample.

Open biopsy: An open biopsy is also called a surgical biopsy where your doctor starts by making a small 2 to 3 cm cut into your scrotal skin and the testes, then a small tissue sample is taken out for examination. The cuts are then stitched using absorbable sutures.

Complications of testicular biopsy:

The procedure of testicular biopsy is generally painless and risk-free, however in a few instances patients develop;

Testicular infection.

Prolonged bleeding from the site of biopsy.

Formation of a blood clot.

A mind swelling, pain and discoloration is normal. However, you should immediately call your doctor if any of the following occurs:

Severe bleeding that causes staining of large portions of your dressing.

Fever that is more than 100F.

Severe pain and swelling.

 

By- Dr. Alvina Arslan Meer

ART Coordinator (MBBS) and Online Counselor

Read More

How Many Sperms are Required to Fertilize an Egg

HOW MANY SPERMS ARE REQUIRED TO FERTILIZE AN EGG

When a couple is trying to conceive but are not successful in doing so, and the main problem is male infertility then the most commonly asked question arises; how much sperm is required to fertilize an egg? The answer to this is quite simple only one sperm is needed to fertilize an egg!

The next question our patients ask is; then why do we need millions of sperms in the semen of a male?

Well, the answer to this question is not simple; for every sperm that completes its journey in reaching the egg, there are millions of sperms that don’t survive this journey!

The journey of the sperms towards an egg is explained as follows:

The 40 to 150 million sperms normally found in an ejaculate increase the chances of fertilizing an egg in the Fallopian tube, few sperms will reach a mature egg with only one being successful in entering the egg and eventually fertilizing it. This journey of reaching an egg from the vagina, may take half an hour to days, depending on sperm quality and the ability to swim.

The path of these sperms from the vagina to the egg is a long and difficult one. Once sperms have been introduced into the vagina, they start swimming, first to the cervix then towards the Fallopian tubes in an attempt to fertilize an egg, they split their direction with some travelling towards one Fallopian tube while others swim towards the other tube. Now at a given time, only one Fallopian tube has a mature fertile egg that should be fertilized for pregnancy to take place. This way even if good amount of sperms reaches one of the Fallopian tubes they are left without an egg to fertilize. Whereas the sperms in the other tube, where an egg is present, compete against each other to penetrate it. The egg is protected from the sperms by being surrounded with a thick layer of cells called the corona radiate.

The next mission for the sperms, after swimming to an egg is to break this barrier of cells surrounding the egg. Out of these sperms the healthy sperms contain enzymes that can break down this barrier. However, many sperms are required to break down this barrier in order for one of them to penetrate the egg and fertilize it. Therefore, the one sperm that is successful in penetration is the healthiest sperm; this is nature’s way of ensuring that only the healthiest sperm fertilizes the egg, and in turn leads to a healthy pregnancy and a healthy baby.

So, even if just one sperm fertilizes the egg, this entire process requires millions of sperms to complete the task.

For men who have a low sperm count, below 20 million, are considered less fertile as compared to those with a normal sperm count, because low sperm concentration means less number of sperms travelling towards the egg and even less sperms reaching the egg.

The sperms once being released into the vagina can live for up to three to five days in the female reproductive system.

They eventually die if not encountered with a mature egg, however if the women is in that period of her menstrual cycle where the ovulation has happened and the egg is available for being penetrated, the fertilization takes place in most cases. Once penetration occurs, the eggs form a thick layer around them, this layer is called zona pellucida and serves as a blocking mechanism for other sperms to enter the egg. The cervical mucus also thickens.

Then the process of embryo-genesis begins where the haploid sperm (23 chromosomes) and the haploid egg (23 chromosomes) fuse to form a diploid 46 chromosomes zygote. Here the genetic material and sex of the baby is settled. This zygote then continues to divide as it travels through the Fallopian tube and into the uterus for eventually being implanted in the uterine wall, at this stage its called a blastocyst and starts receiving its nutrition from the mother. Here it divides further and the pregnancy commences.

Finally when all goes well and the baby is born, we can say that, that one sperm has been successful in making a baby boy if the sperm contributed its Y chromosome, or a baby girl if the sperm contributed its X chromosome!

Also, ‘bravo to that sperm!!’

 

By- Dr. Alvina Arslan Meer

ART Coordinator (MBBS) and Online Counselor

Read More

WHO standards of Semen Analysis

Semen Analysis

What is Semen Analysis?

Semen Analysis is an important diagnostic tool for the evaluation of male fertility, by examining the male semen and the sperms present within. The test is necessary for those wanting to conceive or for those verifying the success of vasectomy.

This investigation is carried out according to WHO guidelines, focusing more on the concentration, morphology and motility of the sperm(s).

Indications for Semen Analysis

  • Infertility
  • Follow up after Vasectomy
  • Hypogonadism
  • Prior to donations for artificial insemination
  • Storage of semen before radiotherapy

Semen Analysis explained according to WHO criteria:

A complete semen analysis should include ejaculate volume, sperm count, concentration, motility and morphology.

Ejaculate volume; A semen volume of 2 to 5 milliliter is considered normal, according to WHO the lower limit is 1.5 mL. A decreased ejaculate volume maybe seen in congenital bilateral absence of the vas deferens, ejaculatory duct obstruction, primary testicular dysfunction and retrograde ejaculation. These conditions cause a low volume of ejaculate with no sperms.

Ph; the pH of an ejaculate as stated by WHO should be between 7.2 – 7.8.  any pH value not falling in this range is considered harmful to the sperms, affecting their motility and hence their ability to penetrate the egg. An acidic pH (<7.2) of the semen is most commonly due to a blockage of the seminal vesicles, which functions to provide an alkaline solution (fructose) to the ejaculate. In the absence of which the acidic prostatic fluid predominates.

Total sperm count and Sperm concentration; if there is a complete absence of sperm on standard microscopic semen analysis after centrifugation of the semen sample then a repeat test should be done. If no sperm is detected on both the tests, then it is labeled as azoospermia.

A sperm concentration of less than 20 million per milliliter is labeled as oligospermia and a concentration of less than 5 million per milliliter is labeled as severe oligospermia.

However recently WHO revised this criterion and the following concentrations that divide oligospermia into three classes are also considered now;

  • MILD: concentrations between 10 million – 15 million sperm per mL
  • MODERATE: concentrations between 5 million – 10 million sperms per mL
  • SEVERE: concentrations less than 5 million sperm per mL

Motility of sperms; WHO has a cut off value of 50% for sperm motility. The sperms are graded according to their motility;

  • Motility IV or Grade A: Sperms that fall in this category are the ones with progressive motility, they move fast in a straight line and are the strongest.
  • Motility III or Grade B: These sperms move in a non-linear direction, they do move forward but in a curved or crooked motion.
  • Motility II or Grade C: These move in a non-progressive manner, which means they do move their tails but do not progress forward.
  • Motility I or Grade D: Sperms in this category fail to move at all and are labeled immotile.

Morphology of sperms; according to WHO a semen sample with at least 30% or more with normal morphology can be considered normal. While WHO standard for Kruger strict is 4% or more.

In Vitro Fertilization (IVF), uses morphology of sperms to predict the success rates of fertilization.

Fructose level; fructose is an important carbohydrate produced by seminal vesicles, its function is to provide energy to the sperms for swimming. WHO verifies the normal value for fructose level as 13 mmol per sample. Since fructose is provided by seminal vesicle, an absence of it would indicate an abnormality in the seminal vesicle.

Semen Analysis

Summary of WHO Criteria for a Normal Semen Analysis;

According to WHO, an ejaculate is considered normal if at least 1.5ml of ejaculate contains more than 15 million sperms per milliliter of semen. Out of these at least 32% should swim in a forward direction, and at least 4% should have a normal shape. Given that these criteria are met, a man is considered fertile.

In order to be certain, the ejaculate should be evaluated twice.

Apart from the findings of semen analysis, an ejaculate should not contain more than 1 million white blood cells and microorganisms per mL ejaculate.

If the semen analysis is abnormal and does not meet the WHO criterion, then further intervention is required.

The WHO criteria changes at times however the sperm concentration criteria have been the same for a long time now, which is; there should be at least 15 million sperm cells per mL and the ejaculate volume should be at least 1.4 mL.

Semen Analysis

By – Dr. Alvina Arslan Meer

ART Coordinator (MBBS) & Online Counselor 

 

Read More

Difference Between Azoospermia and Oligospermia

 

In simple words and in a lay man’s language this could be explained as; azoospermia meaning ‘no sperm’ and oligospermia meaning ‘not much sperms’.
However, in medical language it is explained as follows;

Azoospermia:

Azoospermia is a medical condition where there is a complete absence of sperms in the semen sample of a male, given the sample is centrifuged. At least two semen samples should be studied before diagnosing a male with azoospermia. It affects about 1% of male population and accounts for 20% of male infertility cases.

Oligospermia:

Oligospermia is a condition where the amount of sperms required in a male’s ejaculate to conceive is less than the minimum level for conception. This condition is also called oligozoospermia. The cut off value, according to WHO is 20 million sperms per milliliter, any sperm count less than this value is labeled as oligospermia. It is the most common cause of decreased chances of conception and infertility in men.

CAUSES : 

Both these conditions are caused by a vast majority of factors, both congenital and acquired.

Causes of Azoospermia:

Congenital absence of the Vas Deferens

Epididymitis

Ejaculatory duct obstruction

Undescended testes at birth

Young syndrome

Trauma or surgery of the scrotum

Vasectomy

Primary testicular failure (Klinefilter syndrome)

Chromosomal abnormality causing genetic infertility; this condition requires karyotyping

Micro deletion of the Y chromosome

Unexplained genetic infertility

Secondary testicular failure (Kallman syndrome)

Pituitary/Hypothalamic tumor

Hyperprolactinemia; high level of prolactin in males

Unexplained gonadotropic hormones deficiency, these hormones are required for spermatogenesis

Cancer treatment; which includes chemotherapy, radiation and surgery

Drug induced pituitary suppression; drugs like glucocorticoids, anabolic steroids and alcohol

Testosterone supplements

Congenital adrenal hyperplasia

Varicocele

Organ failure due to severe illness (kidney or liver failure)

Sickle cell anemia

Hemochromatosis

Diabetes mellitus

Pesticide/toxin exposure; for example in hot tubs and baths

Sperm autoimmunity

Causes of Oligospermia:

Certain medical conditions leading to oligospermia include:

Varicocele: This is caused by dilatation of testicular veins which increases testicular temperature and further disrupts spermatogenesis. For sperm production to take place the temperature of the testicles should not rise because if it rises then it affects the production of testosterone, the male hormone required for sperm production and the high temperature also causes damage to the sperm’s DNA.

Sexually transmitted diseases; it leads to infections and hence the sperm count

Medications; some medicines like beta blockers, blood pressure control medicines and antibiotics cause ejaculation problems and decrease the sperm count

Problems with ejaculation; retrograde ejaculation or those caused by cancer, injuries, past surgeries, tumors

Hormonal imbalance: gonadotropic releasing hormone, FSH, LH and Testosterone, all are required for healthy sperm production

The lifestyle of a male also accounts for a few factors responsible for Oligospermia, these include:

High testicular temperature: most often caused by placing laptop on the lap/near the genitals, sitting frequently and wearing tight clothing

Obese males; being overweight or obese has negative effects on sperm production as well as on hormonal production

Substance abuse and alcohol: drugs like cocaine and marijuana cause decreased sperm production. Excessive alcoholism and smoking cigarettes have the similar negative effects.

Environmental exposure; exposure to some chemicals and metals causes decreased sperm production, these include cleaning agents, pesticides, painting material and heavy metals like lead.

TREATMENT

Treatment of azoospermia:
The treatment depends mainly on the cause of azoospermia.

Blockage: if the sperms are absent due to blockage then microsurgery is the option given to patients, it involves removing the obstruction for example in vas deferens or by passing it, allowing the sperms to pass through.

Hormonal imbalance: if the cause of absent sperms is lack of hormones then administration of the required hormones is the option given to patients.

However for men who have unexplained infertility and other issues are advised to undergo In Vitro Fertilization process in which the sperm(s) if any present in the testes are extracted directly using sperm retrieval procedures. The sperm is then used, to be injected directly into the female oocyte (egg) in a lab, a process called ICSI (Intra Cytoplasmic Sperm Injection)
These procedures are used depending on the infertility diagnosis and are as follows;

TESE: Testicular sperm extraction.

Micro TESE.

MESA: Microscopic Epididymal Sperm Aspiration.

PESA: Percutaneous Epididymal Sperm Aspiration

Testicular Biopsy.

Treatment of Oligospermia:
Oligospermia is much easier to treat as compared to azoospermia, but again the treatment depends on the cause of oligospermia;

Varicocele: the treatment involves surgically ligating the dilated spermatic veins.

Infections: the treatment involves an antibiotic course to get rid of the urinary or reproductive tract infections.

Hormonal imbalance: medications and hormonal replacement treatments are given to fix the hormonal imbalance.

If the couple still fails to conceive, they should visit an infertility specialist and discuss their options of assisted reproductive techniques like IUI (Intra Uterine Insemination), IVF (In Vitro Fertilization), and ICSI (Intra Cytoplasmic Sperm Injection). Further more if the cause is mainly male infertility due to no sperm in the ejaculate or due to low sperm count then the options of testicular sperm retrieval should be considered, where the sperms are aspirated or extracted from the testes and used in assisted reproductive techniques to fertilize an egg.

 

By – Dr. Alvina Arslan Meer

ART Coordinator (MBBS) & Online Counselor 

 

Read More

PGD vs PGS

PGD vs PGS

OVERVIEW
PGD (Pre genetic Diagnosis) and PGS (Pre Genetic Screening) are two different genetic tests, used by the doctors to investigate whether the In Vitro Fertilized embryo is suitable for implantation in the uterus and will result in a successful pregnancy or not.
Embryos with abnormal chromosomes or genes often result in either miscarriages, a failed treatment cycle or a child with a chromosomal or a genetic disorder.

PGD is performed to detect genetic defects or single gene mutations within the embryos, hence preventing certain genetic diseases to be passed on to the child.
Whereas PGS is performed to detect whether the embryo consists of any chromosomal abnormalities and if it has a normal number of chromosomes or not.

Pre Genetic Diagnosis

PGD is a technique performed prior to implantation of an in vitro fertilized embryo. It is performed on the embryo to detect any DNA change or mutation of a particular gene, called a single gene disorder or a Mendelian disorder. These disorders particularly pass from the parents to offspring and hence are important to be detected before implantation into the mother’s uterus is performed. The occurrence of single gene mutation is rare, however if both the parents are carriers of that particular genetic mutation then the chances of their offspring inheriting the disease are high. Therefore, PGD allows the parents to choose disease free and healthy embryos.

Steps involved in PGD technique:

  • After the IVF process of egg retrieval and fertilization in a laboratory takes place, the embryo starts to divide into multiple cells.
  • Around day 5 of cell multiplication, a few cells from the embryo are removed micro surgically for examination and the embryos are frozen.
  • Then DNA evaluation is performed on the cells of each embryo to check for inheritance of a particular genetic mutation.
  • When the PGD technique labels the embryos mutation-free, the embryo(s) are transferred in the uterus and couples are asked to wait for implantation and a positive pregnancy result.
  • If there is an excess of embryos that are mutation-free, they are frozen safely to be used later for implantation, whereas embryos with mutation(s) are destroyed.

Who is a candidate for PGD?

  • Carriers of single gene mutation disorders
  • Carriers of sex linked genetic disorders
  • Parent(s) with chromosomal disorders
  • Women aged 35 years and above
  • Women with more than one failed attempt of fertility treatment
  • Women with recurrent pregnancy loss

Following diseases can be detected using PGD:

  • Cystic fibrosis
  • Sickle cell anemia
  • Myotonic dystrophy
  • Tay-sachs
  • Thalassemia
  • Fragile X syndrome

Pre Genetic Screening

PGS is a technique performed prior to implantation of an in vitro fertilized embryo. It is performed on the embryo to check for the chromosomal normalcy i.e. the normal number of chromosomes. A normal human contains 23 pairs of chromosomes that makes a total of 46 chromosomes. PGS evaluates the embryo for any addition of chromosomes or a missing chromosome, unlike PGD that is used to detect specific genetic disorders. Therefore, PGS allows the detection of genetic syndromes that are caused by chromosomal aberrations due to numerical alterations.

Steps involved in PGS technique:

  • Initial steps are the same as in PGD, after cellular multiplication the cells from an embryo are removed micro surgically to be examined.
  • The DNA from these cells is then evaluated to check for a possible chromosomal abnormality.
  • Only the embryos that are disease-free are labelled as fit for transfer in the mother’s uterus.
  • Additional embryo(s) are frozen to be used in the future, whereas the diseased embryos are destroyed.

Who is a candidate for PGS?

  • Either parent with a family history of chromosomal abnormalities
  • If the sperm is at risk of carrying a chromosomal disorder
  • Women aged 35 years and above
  • Women with more than one failed attempt of fertility treatment
  • Women with recurrent pregnancy loss

Following diseases can be detected using PGS:

  • Down syndrome
  • Edward syndrome
  • Patau syndrome
  • Klinefelter syndrome
  • Turner syndrome

 

SUMMARY

PGD

                                PGS

Checks for genetic disorders by evaluating an embryo for specific genetic mutation or a DNA change.

 

 

Can detect single gene mutations.

 

 

Performed to detect cystic fibrosis, myotonic dystrophy, sickle cell anemia, tay-sachs etc.

 

 

Can be used for gender selection.

               

 

 

Methods used in PGD; Fluorescent in situ hybridization(FISH), polymerase chain reaction(PCR) etc.

 

Checks for genetic abnormalities by evaluating an embryo for chromosomal alterations numerically.

 

 

Does not detect single gene mutations.

 

 

Performed to detect Down syndrome, turner syndrome, klinefelter syndrome etc.

 

 

Can be used for gender selection.

 

 

Methods used in PGS; Array comparative genomic hybridization(aCGH), quantitative real time polymerase chain reaction (qPCR), next generation sequencing(NGS) etc.

 

   

In vitro fertilization is a complex, time consuming and an expensive process, hence PGD and PGS are performed to increase the percentage of positive results of IVF. Both the tests hold immense importance and should be performed prior to implantation.

However PGD has a number of limitations and is considered an old technology where as PGS is more advanced and accurate. This is mainly because PGD test depends on single cell evaluation hence its effectiveness is questionable. In comparison PGS detects aneuploidy and mosaicism in embryos which allows scientists for the exclusion of such embryos from the Embryo Transfer and this can significantly improve success rates in IVF.

 

Read More

What is Hyperstimulation?

The purpose of infertility treatment including IVF and other assisted reproductive techniques is to increase the chances of infertility for infertile couples. This treatment is intended to stimulate the ovaries to ensure that several ovarian follicles are developed instead of just one that develops in a normal natural cycle. This helps the doctors to collect several oocytes (eggs) and eventually several embryos to be transferred into a female uterus.

OVARIAN HYPERSTIMULATION SYNDROME :

Ovarian Hyper stimulation syndrome commonly called as OHSS is a rare iatrogenic syndrome, which occurs as a result of these ovarian stimulation treatments and fertility drugs for ovulation. The most commonly used fertility drugs are the gonadotropin drugs, clomid and letrozole.

Gonadotropins includes FSH and LH and are used in injectable form whereas clomid and letrozole are taken orally. The purpose of both is to stimulate the ovaries in order to obtain increased number of oocytes at the time of egg retrieval.

WHO clinical classification:

The classification of Ovarian Hyper Stimulation Syndrome is based on the signs and symptoms experienced by the female patients, and are divided into mild, moderate and severe forms, based on the degree of their severity these are classified as the following;

Mild OHSS:

Increase in Ovarian volume, less than 5cm

Excessive steroid production

Pelvic discomfort

Moderate OHSS:

Increase in Ovarian volume, between 5cm to 12cm

Abdominal Distension

Digestive problems like nausea, vomiting and diarrhea

Severe OHSS:

Increase in Ovarian volume, greater than 12cm

Renal failure

Ascites (accumulation of excess fluid in the abdomen or peritoneal cavity)

Pleural effusion (accumulation of excess fluid in the pleural cavity, between the layers of the lungs and the rib cage)

Coagulation disorders (blood disorders leading to disruption of clot formation and hence bleeding)

This classification helps to determine the type of treatment required, should the patient experience ovarian hyperstimlutaion signs and symptoms. Normally the infertility specialists are familiar with these signs and symptoms, and hence are able to detect them in order to provide appropriate treatment required. Since these are serious complications and can be potentially life threatening if left untreated, they should be catered to very effectively.

If you experience any of the above mentioned signs and symptoms during an ovarian stimulation cycle, you should consult your doctor immediately and pay him or her a visit.

Risk Factors:

The risk of having hyperstimulation can be prevented by screening the patients for risk factors, this should be considered before starting the treatment.

The Risk Factors of having the complication of Ovarian Hyper stimulation syndrome are as follows;

Your age is 30 years or younger

You have Polycystic ovarian syndrome

Your AMH (Anti Mullerian Hormone) levels are high

You are underweight

You have a history of developing OHSS in the past

This means a younger patient with a normal ovarian reserve and with polycystic ovarian syndrome is at a higher risk of developing hyperstimulation complications than an older patient with a decreased ovarian reserve. To check for ovarian reserve, the most commonly used test by our doctors is the level of Anti Mullerian Hormone (AMH).

Prevention of OHSS

When starting the infertility treatment, your specialist doctor must take in consideration, your age, your ovarian reserve, your hormonal levels and the possibility of having polycystic ovarian syndrome, in order to avoid ovarian hyperstimulation.

Also after starting the treatment, your doctor would follow the stimulation response to fertility drugs, using blood tests and ultrasound, and so the gonadotropin doses must be tailored according to individual patient’s response. Thus, if your doctor notices an excessive response to ovarian stimulation, he or she should decrease the dose accordingly.

Although hyperstimulation occurs only after ovulation has taken place, your doctor can still look for signs that suggest increased risk during a particular cycle. If that’s the case, then in response to the fertility drugs, your ovaries will develop an increased number of follicles than expected, and the estradiol or estrogen level in your body would also be higher than normal, meaning that your chances of having OHSS in this cycle are high.

Ideally under such circumstances the doctor would cancel your treatment because pregnancy can worsen OHSS. Your doctor would cancel the insemination process and would advise you to avoid having intercourse if you were undergoing an IUI (intra uterine insemination). Whereas if you were undergoing an IVF treatment then any fertilized embryos would be frozen and saved to be transferred into your uterus at a later date, when your body allows.

An alternative to this cancellation of ovarian stimulation treatment is delaying ovulation and the process is called ‘coasting’. This is achieved by prescribing a Gonadotropin releasing hormone antagonist commonly called GnRH antagonist, that would prevent the LH surge, which is required for ovulation. This delay lowers the risk and severity of complications and increases the chances of carrying on with a successful pregnancy.

One should not exert themselves thinking of these complications, instead you should be in contact with your doctor during the entire process and inform him or her about any alarming signs. Of course your doctor would provide you with the relevant information and material, we have come across some pamphlets delivered by an infertility clinic called Australian concept infertility center, it had a lot of relevant information on hyperstimulation.

Read More