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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

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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

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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 

 

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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 

 

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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.

 

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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.

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Delayed Embryo Transfer

During the course or struggle of infertility, the most important process is of embryo transfer and even more crucial is the right time for this process to be performed. Thus, it is very important for our infertility specialists to choose the right time for embryo transfer, that being the time with which our patients could benefit the most and have the highest chance of conceiving.

Embryo transfer is the technique performed at many infertility clinics including Australian concept infertility Center with the help of our infertility specialists as well as the embryologists, who work as a team to transfer the embryo with in a female uterus.

However, when this technique is delayed for different reasons, the major reason being patient welfare then it is called ‘delayed embryo transfer’

In delayed embryo transfer the fertilized embryo of our IVF (in vitro fertilization) patient are frozen so that they can be used in the future and be transferred in the female uterus when the conditions are feasible.

What is an embryo?

As a normal method of sexual reproduction in human beings, when an egg cell and a sperm cell, from a female and a male body respectively are fertilized they form a single celled organism called zygote, this zygote then undergoes cellular division to form an organism called embryo, which undergoes further growth and eventually forms into a fetus.

When this process of fertilization takes place outside a women’s body, and in a petri dish inside a lab, it is called in vitro fertilization (IVF). An egg is retrieved from a female body after closely monitoring her ovulatory process and a sperm is retrieved from a semen sample of a male, these are then manually combined to form an embryo. The sperm is directly injected within the cytoplasm of an egg and this procedure is called intra cytoplasmic sperm injection (ICSI).

The in vitro fertilization process is given approximately five days for the embryo to divide and grow in size, it goes through the division cycle of two-cell, four-cell and eventually eight-cell embryo. The formation of an eight-cell embryo on day three of in vitro fertilization is considered a very good sign and points towards higher chances of success.

What actually is Embryo transfer and delayed embryo transfer?

Once an embryo is formed ‘in vitro’, it can be used in the following ways;

Either it can be transferred to the female uterus during the same ovulation cycle in which her eggs were retrieved and fertilized, this is called a fresh cycle embryo transfer. This includes all the stages of egg retrieval, fertilization, culture in lab for several days and embryo transfer during one menstrual cycle.

Or they can be frozen and used later for transfer and eventually implantation, this is called a delayed embryo transfer. This involves the freezing or cryopreservation of good quality embryos for future use, these frozen embryos can be used in the next cycle or after months and even after years, embryos frozen for as long as 10 years have also been reported to be successfully implanted!

Depending on a female’s condition during the egg retrieval cycle, the infertility specialists and embryologists decide whether to go for a fresh cycle embryo transfer or a delayed embryo transfer.

Considering the enhanced and improved techniques of embryo freezing now, many specialists opt for freezing all good quality embryos and use them once the recipient female’s uterus and ovaries have returned to a normal condition seeing that she has undergone intense hormonal stimulation during the ovulatory process and during the egg retrieval procedure.

What happens after the embryo is transferred?

Most couples ask this question, of course concerned about the fate of the new baby they just helped making, with an IVF treatment. They want to know the chances of them becoming parents with this embryo.

Well once the embryo is transferred to a women’s uterus, the final hurdle for the embryo to overcome is to get implanted! And this depends on the egg quality, sperm quality and then the embryo quality that resulted from the fertilization of the former two.

A brief description of what happens to an embryo after being transferred;

-The blastocyst continues to divide and emerges from its shell,

-It then starts to attach itself to the uterine lining,

-Once the blastocyst invades the uterine lining the process of implantation occurs and the women may experience some bleeding or spotting, however no bleeding doesn’t mean you have not conceived,

-The embryo then digs deeper and starts getting blood supply from the maternal blood vessels,

-As it continues to grow, a hormone called human chorionic gonadotropin (HCG) is released in the blood stream,

-More HCG is released when fetal development is in full swing and the placenta has developed,

-This is when one can take the home urine pregnancy test, around the 9th day of transfer however we at Australian concept infertility medical Center prefer you wait till 10-12 days for a blood beta-hcg test which is much more reliable. We give our couples a date to come and get tested for pregnancy and we love to give our couples the good news ourselves!

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What is Polycystic Ovarian Disease ?

 

One of the most common hormonal disorder associated with the female ovaries is POLYCYSTIC OVARIAN DISEASE, commonly called as PCOD. It causes infertility, hence has become a growing concern for females trying to conceive.

Role of ovaries in a female reproductive system.

To understand clearly what exactly is Polycystic ovarian disease one must know the function of the female ovaries as well as the knowledge of its role in reproduction because ovaries are a very important organ in a female’s reproductive system. Not only that, they are also very important in terms of fertility. Every normal female has a pair of ovaries in her lower abdomen, these are the female reproductive glands situated on either side of the uterus and connected to the uterus through the Fallopian tubes. The function of these ovaries is to form the ova or eggs and release them (eggs) into the uterus every month. They are solid, ovoid structures each measuring about 1 centimeter in thickness, 3.5 cm in length and 2.5 cm in width. As mentioned earlier ovaries are the reproductive glands and hence release hormones mainly; estrogen and progesterone. This release of hormones is under the influence of hypothalamus and is triggered by it.

Estrogen and progesterone are extremely important for a normal growth of the female reproductive system as well as for fertility. They regulate the female menstrual cycle, the growth of secondary sexual characteristics in a female at puberty as well as the ovulation process.

What is ovulation?

When a girl hits puberty, the ovulation occurs, it is a process in which one egg is released from an ovary each month, the ovaries usually take alternate cycles to release an egg.

The pituitary gland receives a signal from the hypothalamus to release two hormones, Follicle Stimulating Hormone (FSH) and Luteinizing hormone (LH) called the gonadotropic hormones. One should bear in mind that a female or a baby girl is born with an egg reserve, which means that she is born with all the eggs of her lifetime and these eggs are contained in the follicles that are found inside the ovaries. So at puberty each female starts her menstrual cycle with approximately 400,000 eggs. These eggs mature within a follicle before they are released and this release is under the influence of FSH and LH. The FSH causes growth of an egg while the LH Is responsible for the release of an egg from the ovary.

What happens to the egg after being released from an ovary?

Once the follicle ruptures, the egg is released from the ovary and captured by the fallopian tubes and guided through to the uterus through the muscular contractions of the tubes. It is during this time and within 24 hours of egg release that fertilization of the egg with a sperm can take place in order to form an oocyte which later undergoes multiple cell divisions to form an embryo. If an egg is not fertilized within 24 hours of its release it begins to degenerate.

POLYCYSTIC OVARIAN DISEASE

It should be much easier to understand PCOD now that we have some knowledge about the ovaries, the ova and the hormones involved.

As the name suggests PCOD occurs when the ovaries develop multiple cysts, (poly means many) making the ovaries look bulky or enlarged because these are not the functional cysts that disappear instead they remain and occupy a large area of the ovaries. Therefore, the development of these cysts hinders the normal function of an ovary of releasing an egg in turn causing infertility issues because as discussed earlier the process of ovulation is essential for a female to conceive and get pregnant.

It not only affects the ovulation process but also disturbs the menstrual cycle causing irregular periods and infertility. In addition to this the presence of these cysts causes hormone imbalance as well, increased number of cysts cause the release of a hormone called androgen instead of estrogen, androgen is a male hormone and it is the main reason why females with PCOD have facial hair and chest hair, because the male hormone follows the male hair distribution pattern.

Symptoms of PCOD?

Not all women with PCOD have the same symptoms but irregularity of menstrual cycle is the most common symptoms, other symptoms include; Acne, irregular periods or complete absence of periods, excessive hair growth and at unusual places, pelvic pain, weight gain, mood swings and the most important infertility!

What causes of PCOD?

The exact cause of PCOD is yet to be discovered, but some factors play an important in leading to this condition, they include;

Heredity, if a mother has multiple cysts in her ovaries, the daughter is most likely to inherit it.

Excess androgen production, androgens are male hormones but are found in excess in a PCOD female.

Insulin resistance, if a human body resists insulin then there is excess production of insulin in the body this in turn leads to excess androgen production and eventually difficulty in ovulation.

In our society, infertility is a very serious concern as it determines the future of a female.

Thankfully today we have infertility specialists and infertility centers like Australian concept infertility center where it is not impossible to have a baby even if you are suffering from Polycystic ovarian disease, thanks to our infertility specialists and our expertise in assisted reproductive techniques. We treat PCOD with medications and in some cases use the assisted reproductive techniques, if required, which include ICSI, IVF, TEST TUBE BABY. We are making it possible for our PCOD patients to conceive and have a life that they imagined with their own children.

 

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Sperm Freezing for Cancer Patients

The diagnosis of Cancer is becoming extremely common in our world as the time passes, and hence is becoming a major issue for us to solve, not only that it is also occurring at earlier ages than expected! Which leaves very little time for men to be able to react before their sperm count decreases. This is because they are too busy fighting the battle that they often tend to ignore the fact that they will want kids in the future. And for that the most important thing one needs is a Sperm! And an egg of course. But thinking of the male perspective sperm quantity and quality is very important, which starts declining not only when the person has cancer but also because of the multiple treatments and medications he undergoes to cure it, chemotherapy and radiotherapy being the main culprits!

The most important part of avoiding fertility issues in the future is banking the sperms for freezing, and this should be practiced more when children and adult men under the age 45 are diagnosed with cancer. Once they have their sperms frozen, they can in a later date or when they decide to have a family come to Australian concept infertility Center and discuss with our highly capable consultants about the next steps that should be taken. Following options would be given to our patients with the pros and cons of each discussed with the patient in detail, these include; IVF, ICSI and TEST TUBE BABY.

Now, it is understandable that it’s a difficult thing to hear when one is already going through accepting the fact that he has cancer and then your doctor tells you that your future fertility may also get compromised due to the cancer treatment that one has to undergo, it may cause further distress to a man. But these treatments along with the negative effects are the life saving techniques that a cancer patient needs to undergo.

The patients may think how does the process of sperm freezing actually works?

Well the process of sperm freezing or sperm banking involves the collection of a semen sample and freezing of the sperms which are thawed at a later time and used in one of the many assisted reproductive techniques including IVF, ICSI etc., when the patient decides to have a family but is having difficulty conceiving. This technique is called cryopreservation. There are other techniques which includes testicular sperm extraction and testicular tissue freezing but by far the most successful and the most commonly used technique is cryopreservation for male cancer patients.

One of the many side effects of cancer treatment includes sexual dysfunction especially when the cancer is of the pelvic region which includes; bladder, colon, rectal, testicular and prostate cancer, therefore it becomes extremely important for these patients to choose cryopreservation in order to preserve their fertility and ensure their families. This occurs mainly because in radiation therapy the radiation is targeted towards the pelvic region. In addition to this all other cancer patient who have undergone cancer therapies have an adverse effect to their blood vessels, nerves and hormones that control the sexual function.

Some men ask what are the ‘dangerous’ radiation doses and dangerous chemotherapy drugs to cause fertility issues?

For patients about to undergo chemotherapy and radiation, these are very common concerns and therefore should be taken in to consideration for patient satisfaction, the answer to these questions aren’t simple because it depends on the shielding technique used during radiation, the dose of radiation used, as well as the dose to the testicles. However, for total body irradiation it is a known fact that about 80% of the patient will have permanent infertility. For chemotherapy the main culprits are the alkylating agents, these agents act by preventing DNA replication by forming covalent bonds and hence stopping the growth of rapidly dividing cells as explained earlier. This again is dependent on the cumulative dose of chemotherapy drugs as well as the age of the patient. I.e. men more than 40 years of age are less likely to remain fertile after therapy.

One may have the question about how does chemotherapy and radiation therapy affect fertility?

In order to understand this one may first try to understand the mode of action of the chemotherapy drugs and radiation. Their mode of action is to stop the growth of rapidly dividing cancer cells by damaging their DNA. Now the body of course has some cells that rapidly grow as a normal mechanism of the body, these cells include gastrointestinal cells, hair follicles and some reproductive tissues along with the sperm cells. Since sperm cells are constantly dividing they are a target for chemotherapy and the radiation therapy. This means that the cancer therapy cannot distinguish between the harmful ‘bad’ cancer cells and the normal “good” body cells, destroying the DNA of all growing cells and hence causing an issue for men who have undergone these therapies and who wish to have a family in the future.

How to go about it?

It is an oncologist’s job to mention the possibility of sperm banking or cryopreservation to the patient before starting the cancer treatment. Unfortunately, some cancer patients are not aware of this possibility since their oncologist did not discuss the option of sperm banking with them. For those who are fortunate enough to have been informed by their oncologist about sperm banking are either too emotionally unstable to think about it or are physically drained to look for a clinic or schedule an appointment. While for some it is just an uncomfortable process which makes them avoid it.

Whichever the case may be with you, you can count on us and come to discuss all the possibilities, our team will sit with you, answer all your queries and give you the best options according to your needs, so even you can have a healthy baby!

Also remember Australian concept infertility medical Center gives special discounts to cancer patients, because we care for you to have a baby!

 

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Role of Prolactin in IVF Treatment

IVF

Prolactin is a chemical that is secreted by pituitary gland. This is the pea-sized gland found in the middle of brain and is responsible for triggering many body’s processes. It is found in both men and women and is released at various times throughout the day and night. Prolactin is generally released in order to stimulate milk production in pregnant women. It also enlarges a woman’s mammary glands in order to allow her to prepare for breast feeding. On the other hand, it also affects ovulation and menstrual cycles. This is why it is nearly impossible to become pregnant when a woman is breastfeeding. Prolactin inhibits two hormones: follicle stimulating hormone (FSH) and gonadotropin releasing hormone (GnRH). Both of these hormones are responsible for eggs maturation and development in the ovaries, so that they can be released during ovulation. Thus when a woman have excess prolactin level, ovulation is not triggered rendering a women infertile.

 

By -Dr. Ayesha Maqbool

ACIMC Lahore, Coordinator (MBBS)

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