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 When we go to retrieve sperm from a male, first we must understand is this male producing high numbers of sperm but the system is blocked, or is he producing very low numbers of sperm. That is crucial in determining what type of procedures is used to retrieve or obtain the sperm from the male. below are some methods of sperm retrieval techniques.

» Assisted Reproduction Techniques

» ICSI (Intracytoplasmic Sperm Injection)

» Surgical Sperm Retrieval

» Microsurgical Retrieval of Epididymal Sperm

» Non-obstructive Azoospermia and TESE

» Non-Surgical Sperm Retrieval

» Congenital Bilateral Absence of Vas Deferens

» Electroejaculation

» Ejaculatory Duct Obstruction

» Percutaneous Sperm Aspiration

A. Non Surgical Sperm Aspiration 

1. Testicular Sperm Aspiration -TESA 
In TESA performed in our clinic under local Anesthesia , one can easily and quickly obtain adequate numbers of sperm for ICSI in many men who have no sperm in their semen because of vasectomy or other causes of blocked ducts; in men who cannot ejaculate including men with spinal cord injury. Men who lack living sperm in their ejaculate frequently have at least some sperm in the testicles, where sperm are made. Testicular sperm can fertilize if they are injected directly into the eggs through a process called ICSI (Intracytoplasmic Sperm Injection.)

TESA is performed under sedation, and is painless and rapid. A tiny needle is used to extract sperm directly from the testis. While the ejaculate normally contains 100 million to 300 million sperm, aspiration of as few as 100-200 sperm by NSA have been enough to achieve pregnancy when it is combined with ICSI. Prior to the development of TESA, men with no sperm in their ejaculate had to undergo surgery to remove sperm either from their testes or from tubes connected to the testis. Non-surgical sperm aspiration is rapid, does not require hospitalization, is pain-free when done under sedation, and recovery is virtually immediate. 

The technique will be immensely helpful to men who have had vasectomies and later decide that they want to have children. It is possible to reverse a vasectomy by having bypass surgery, but the operation is frequently not successful, especially for men with long-standing vasectomies. Additionally, sperm quality after vasectomy reversal is often reduced and ICSI is required even if sperm appear in the ejaculate. For many men, non-surgical sperm aspiration eliminates the need for vas reversal surgery. Men who cannot ejaculate due to spinal cord injuries or neurological conditions like multiple sclerosis can also become fathers through the new technique. There is also a large group of infertile men who simply have no sperm or only dead sperm in their semen although their ducts and ejaculatory process are normal, and who can have testicular sperm obtained through NSA. 

2. Percutaneous Epididymal Sperm Aspiration - PESA 
In this the sperms are directly aspirated with the aid of a small needle mounted on a syringe. The skin is not cut open .The aspirate is given to the laboratory, where the sperms are identified and ICSI is performed. PESA will also help infertile men who lack sperm in their semen because the route out of the testes has been blocked by prior infection or congenital lack of development (Congenital Bilateral Absence of Vas Deferens CBAVD), as well as men who have had their prostates removed and can no longer ejaculate but make sperm. 

NSA must be done with ICSI because testicular sperm cannot enter eggs by themselves. The female partner receives a series of medications to increase the number of eggs created by the ovary as in a conventional IVF cycle. When the eggs grow to adequate size, they are extracted non- surgically at the Institute under sedation, and NSA is scheduled the same day. After egg retrieval and sperm aspiration, our embryologists will inject each egg with a single sperm. Two days after the procedures, definite information regarding fertilization of the eggs and the number of embryos will be available. Embryos will be transferred back to the uterus two or three days following fertilization; additional embryos may be cryopreserved (frozen), as requested. It should be noted that for some men a single NSA procedure may yield enough sperm to permit sperm freezing for several subsequent ICSI attempts. 

B. Testicular Sperm Extraction - TESE 
There is a particular group of males who have no sperms in their semen. Also standard testicular biopsy procedure, done in the past , have shown no spermatogenic activity. In recent times, many such males, have undergone the procedure of TESE. The biopsy specimen thus obtained, has been meticulously searched for sperms, over 2 to 6 hours, sperms obtained, ICSI performed and pregnancies achieved. As many as 10 -30% men with established testicular failure, have fathered kids with this technique. We at the IVF Odisha Fertility Centre are doing all the above procedures in our lab, with a high pregnancy rate.

What is artificial insemination with Donor sample (AID) or Donor Insemination (DI)?

In as many as 30 % of infertile couples the male is responsible for infertility. A significant percentage of these males do not father children despite various treatments including ICSI. The solution is inseminating their wives with semen of another male (donor) at the time of her ovulation. This procedure is called AID or DI.

Who can benefit from AID?
1. AID (Artificial Insemination Donor ) is generally advocated for males with low semen counts (Oligospermia or zero counts) (Azoospermia), where treatment with drugs, surgery and ART treatments like AIH, IUI and ICSI have proven unsuccessful. It is an acceptable alternative to adoption.
2. It is also suggested to males who may have a genetic disorder that could get transmitted to their progeny.
3. It may be used as a backup to the procedure of TESE (Testicular Sperm Extraction) and ICSI that is done for males with non-obstructive Azoospermia, especially when no sperms are found in the testicular biopsy. (see Nonsurgical Sperm Retrieval)

How is the Semen obtained in Semen Banking?
A donor male donates the semen after he is screened and tested as safe for various infections such as HIV, Hepatitis and other Venereal Diseases. At BabiesandUs lab, we test the donor for infections every 3 months. The semen thus obtained can be used in two ways:

1. Fresh Semen Insemination:
It is insemination where the donated semen is used within an hour of ejaculation. The semen can be placed on the cervix without processing or can be placed in the womb after processing as is usually done with IUI. This is done commonly in India. However, there is always the remote chance of a donor carrying the latent infection of HIV that may manifest itself as a positive after 2 to 3 months of the insemination. It is due to these reasons many ART units have given up this technique.

2. Frozen Semen From Semen Bank:
After collecting the semen from an HIV negative donor, it is processed, added to straws or vials. These are then stored in liquid nitrogen containers called semen banks, of -196ºC for six months. In short, it is quarantined. After 6 months the donor is retested for HIV. If the second HIV test is negative, this sample is released from quarantine and insemination takes place only at that time.

Which of the two is a better alternative?
The success rate of both fresh as well as frozen AID is almost similar. However in case of frozen AID it is important to accurately pinpoint the timing of ovulation. This is because the motility of frozen thawed sample decreases rapidly within 12 hours, in contrast to fresh insemination, where the sperms stay alive in the body for 48-72 hours.However, the biggest advantage of frozen samples are its minimal risk of HIV transmission.

What is the Success rate of AID (Artificial Insemination Donor) ?
The success rate is in the region of 15-20%. That means if 10 couples undergo AID every month, 1 or 2 couples would become pregnant every month. At the end of 6 months 5 to 6 couples become pregnant. The remaining 4-5 couples who do not become pregnant, can undergo further AID for 6 months. During this time 2 more will become pregnant. At the end of one year around 80% (8 out of 10 started couples)will acheive pregnancy. The two couples who fail to become pregnant at the end of one year can either opt for IVF/ICSI with donor sperm or go in for adoption.

Endometriosis

Posted by Published in: Category 2
endometriosisThe uterus is lined with a layer of tissue called the endometrium. Endometrial tissue normally grows only inside the uterus (womb), but sometimes it grows outside the uterus - commonly in the reproductive organs (ovaries, fallopian tubes) or on the intestines, rectum or bladder. This condition is called endometriosis.

During menstruation the uterine lining is expelled through the vagina, but blood from endometrial tissue growing outside the uterus has no place to go. As a result, monthly bleeding in this tissue leads to the growth of cysts, lesions and scar tissue and causes the surrounding area to thicken. Some women have little or no discomfort from endometriosis but others experience great pain before and/or during their menstrual cycle. The symptoms of endometriosis usually subside after the menopause.

How does it occur?
The causes of endometriosis are still not known and there is no simple cure. Estimates of how common it is range from 1 to 15 per cent of women of reproductive age. No single theory explains why some women develop the condition. Some experts suggest that during menstruation, endometrial tissue "backs up" through the fallopian tubes and then settles, and grows, in the abdomen.

However, others believe that all women experience menstrual tissue back-up. In most cases, the immune system automatically destroys abnormal tissue before it attaches in the abdomen. But if the immune system is unable to get rid of the misplaced tissue, endometriosis develops. Another theory is that remnants of a woman's own embryonic tissue, which formed while she was in her mother's womb, may develop into endometriosis during adulthood or may transform into reproductive tissue under certain circumstances.

What are the symptoms?
Some women have no symptoms. Others may experience one or more warning signs that can range from mild to severe. The type and severity of the symptoms can depend on where the endometriosis has implanted, how deeply, and how long a woman has had it; over time the extent of the adhesions build up and can cause more problems.

Common symptoms include:

• chronic pelvic pain

• very painful periods

• deep pain during sexual intercourse

• difficulty becoming pregnant

• pain during ovulation

• heavy or abnormal menstrual flow, such as premenstrual spotting/staining

• painful bowel movements, diarrhoea, constipation or other intestinal upsets during menstruation

• painful or frequent urination during menstruation

• exhaustion.

How is it diagnosed?
A doctor can evaluate your symptoms by discussing your medical history and performing a pelvic examination to check for cysts, unusual tenderness or a thickening of the pelvic area. This is best done when you are menstruating. An ultrasound scan may also be used to evaluate the pelvis. However, you'll need a minor, day-care key-hole surgical procedure called a laparoscopy to get a firm diagnosis of endometriosis. Laparoscopy can be carried out at any time during your menstrual cycle.

Under a general anaesthetic, a surgeon will insert a small tube with a light in it (a laparoscope) into a small cut near your navel. The surgeon fills your abdomen with carbon dioxide gas to make the organs easier to see and then checks the size, location and number of endometrial growths. Sometimes it's necessary to remove a piece of tissue (a biopsy) to reach a diagnosis. Often it is possible for the surgeon to carry out treatment at the same time as diagnosis, unless moderate or severe disease is found. Because treatment for endometriosis-associated infertility cannot begin without a definite diagnosis, you must have a laparoscopy to confirm the condition.

Can endometriosis cause a fertility problem?
Endometriosis can cause the fallopian tubes to become blocked and can damage the ovaries. It is estimated to be the cause of infertility in 3 per cent of couples, and is one of the factors behind tubal problems which cause infertility for about 17 per cent of couples. However, evidence suggests even if your endometriosis is severe, you may still have a chance of getting pregnant naturally - it depends on how the disease has affected your reproductive organs. If you know you have endometriosis and you are having problems conceiving then you should seek help sooner rather than later. Don't wait longer than six months of trying before making an appointment with your doctor.

How is it treated?
Although no certain cure exists, the two main forms of treatment for endometriosis are drug therapy and surgery. The treatment depends on:

• the severity of your symptoms

• the location and size of endometrial growths

• your plans for having children

• your age, as symptoms intensify as you grow older.

Treatment options if you're trying to get pregnant
Your doctor should refer you on to a fertility specialist who will offer to carry out a laparoscopy and dye ("lap and dye"), so that an assessment can be made of any damage to your fallopian tubes and ovaries.

You may also be offered an ultrasound scan of your pelvic organs, which can be carried out using an ultrasound probe inserted into your vagina. If your endometriosis is comparatively mild, doctors may suggest no treatment for six to 12 months to see if you become pregnant without any intervention. Your doctor will want to discuss possible treatment before the investigatory laparoscopy, as one option is for the surgeon to remove abnormal growths and tissue during this initial laparoscopy. This is a relatively simple procedure using a laser and/or surgical tool to cut away the endometrial tissue. It makes some sense to carry out the surgery during the investigatory laparoscopy, as it avoids having to go through the procedure again at a later date. Tubal flushing is an alternative to surgery for blocked fallopian tubes and also has a high success rate.

Some couples end up taking the assisted conception route. This is sometimes in preference to surgical techniques, when surgical and other interventions have not helped them to conceive, or when the disease is mild and conception hasn’t occurred naturally after about a year of trying. In the latter case, it is recommended that women with mild endometriosis are offered up to six cycles of IUI. If IUI is not successful or appropriate (such as where there is a male infertility problem as well), or when surgery has not made a difference, IVF is recommended. The overall success rate as a result of IVF is about 25 per cent, but it is lower for women with endometriosis - the reasons for this are unclear.

You won't be offered drug treatment because the drugs used usually suppress ovulation for a period of time or they may be harmful to a developing embryo. It has been shown that there is no improvement in pregnancy rates after finishing them. The exception to this is gonadotropin-releasing hormone (GnRH), which inhibits the production of hormones involved in ovulation. There is limited evidence that a 3-6 month course of GnRH prior to IVF can improve pregnancy rates for women with endometriosis.

Treatment success rates
Laparoscopic surgery can almost double the chance of pregnancy and a live birth for women with mild endometriosis compared with not having the surgery. Following surgery, rates of pregnancy for women with mild endometriosis as their only fertility problem range from 81 to 84 per cent, depending on the techniques used. Those with moderate or severe endometriosis, including damage to the ovaries, have a 36 to 66 per cent chance of conceiving after surgery. Pregnancy rates are highest within a year of surgery, since endometriosis commonly recurs in spite of the operation. Your own doctor will be able to give you more specific advice on your chances of pregnancy after the procedure. Tubal flushing is particularly successful for women with endometriosis, increasing their chances of pregnancy almost sevenfold and of a live birth fivefold.

Treatment options if you're not trying to get pregnant
If you aren't trying to have a baby and your symptoms are mild to moderate, you'll probably have regular check-ups to monitor the condition but no medical treatment. It's likely that the endometriosis will disappear when ovulation and menstruation stop after the menopause.

If you suffer only mild pain before or during your period and infertility is not a factor, over-the-counter pain relief may be enough to alleviate any discomfort.

A non-surgical option for managing the symptoms of endometriosis is to control hormone stimulation with contraceptive pills, progesterone pills or other drugs. These treatments block ovulation so that both the uterine lining and the endometrium stop bleeding each month. This in turn prevents the build-up of new cysts, scar tissue and swelling outside the uterus.

Drug therapies can also help your body heal the existing endometriosis. All the medical treatments available are equally successful at controlling symptoms, but they vary in their side effects. If you don't get on with one drug, ask if you can try another one that may suit you better.

The Mirena intrauterine system (IUS), which is a type of coil containing the hormone levonorgestrel (a synthetic progesterone), also shows promise. Several small research studies have found that using the Mirena IUS can reduce pain and control the symptoms of endometriosis for over three years. It can be used as an initial treatment or after surgery to stop the endometriosis recurring as quickly as it may do otherwise.

If your endometriosis is severe (deeply infiltrated into your organs and/or very painful), your doctor may suggest surgically removing it. This is usually carried out via key-hole, laparoscopic surgery using a laser or other instruments to cut out or destroy the endometriosis. In the worst cases, and when fertility is not an issue, it might involve removing affected organs such as fallopian tubes, ovaries or the uterus. If your uterus is removed, you can never become pregnant.

How long will the effects last?
All the current treatments offer a degree of relief from the symptoms of endometriosis but none provides a cure. Even after hormone therapy or surgery, endometriosis may recur.

How can I ease my symptoms?
It may help to record your symptoms on a calendar for three months. Make a note of the problems, as well as how they affect your work and leisure activities. Sharing this information with your doctor can help you get a speedy, accurate diagnosis.

Here are some suggestions for easing your pain:

• rest on a comfortable couch or in bed when pain strikes

• take warm baths

• put a hot-water bottle or heating pad on your abdomen

• avoid constipation by increasing the fibre in your diet

• practise relaxation exercises such as yoga, deep breathing and visualisation

• ask your doctor about prescription or over-the-counter pain relief.

What can be done to help prevent endometriosis?
A variety of treatments can help control the symptoms of endometriosis but nothing can completely prevent or cure it.
assisted-laser-hatchingCouples may face difficulty and frustration after IVF and ICSI treatments due to failure of successful implantation of healthy looking embryos into the womb.
In general, the embryos are transferred back into the womb on the second or third day, when they are in the 4 cell or 8 cell stage. Once they are placed back into the womb, they keep on growing till day 5 (5 days after oocyte retrieval). At this time the embryos are multicellular, and differentiated into an inner cell mass and an outer cover called the Trophectoderm. This embryo is called a Blastocyst. The Blastocyst starts expanding and cracks open the cover of the zona, and escapes out. This process is known as 'Hatching'.

In Assisted Hatching, a cut is given to the zona, when the embryos are at 4 cell (day 2) or 6-8 cell (day 3) stage. These embryos are placed back into the womb. The cut also called Assisted Hatching, weakens the zona, and helps in the hatching process. This in turn results in better pregnancy rates.

The cut can be made in three different ways:

1. Mechanical Hatching: In this the embryo cover is slit open mechanically with the help of a thin long drawn out glass needle. This is done with the help of a machine called the Micromanipulator.

2. Chemical Hatching: In this the zona is opened by touching it with a chemical called Acid Tyrode Solution. This is also done with the aid of the Micromanipulator.

3. Laser Hatching: This is the latest method, introduced in the world in 1992. At present the Laser beam is generated by an InGaSp Diode Laser. The zona is cut with the Laser beam by simply pressing a button on the Laser machine. Many babies have been born all over the world, following the introduction of this technique.

Which Patients benefit from Assisted Hatching?
The following group of patients are usually selected for the technique of Assisted Hatching:
1. Women patients usually between 35-38 years of age
2. Patients in whom the zona thickness is more than 15 microns
3. Patients who have had more than one attempt at IVF/ICSI and have failed to become pregnant
4. Patients who have their extra embryos frozen. The frozen thawed embryos are hatched before embryo transfer
5. Patients who are undergoing Pre-Implantation Genetic Diagnosis

Which is the Best method of Hatching-mechanical, chemical or Laser?
All the three methods give equivalent results in experienced hands. However Laser Hatching is simple to perform, easy, accurate, and reproducible and any embryologist can perform it. Hence, it is the preferred method of choice. 
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Team IVF Odisha

drpltripathy
Dr. P. L. Tripathy
Obstetrician & Infertility Specialist
  • Dr. Neeraj Pahlajani
    Obstetrician & Infertility Specialist

    dr sameerpahlajaniDr. Sameer PahlajaniInfertility Consultant & Sonography ExpertDr Dibyajit_MohantyDr. Dibyajit MohantyMD, Obs. & GynecDr Sasmita_DasDr. Sasmita DasMD, Obs. & Gynec