Infertility

What is Infertility?

Infertility is defined as the inability of a couple to conceive after one year of unprotected sex. It affects as many as 1 in 6 couples or 10% to 15% of reproductive-age couples. The monthly conception rate of couples at peak fertility is 20% to 25%. 60% of couples conceive within 6 months, 80% within 12 months, and 90% within 18 months.

Why is infertility on the rise?

The prevalence of infertility is on the rise as women are postponing childbearing for social, economic, professional, or psychological reasons. Stress, smoking, alcohol, toxic chemicals and drug exposure, and nutritional deficiencies or excesses can all negatively affect fertility.

What are the causes of infertility?

One-Third of infertility cases can be attributed to male factors.  One-Third of infertility cases can be attributed to female factors.  One-Third of infertility cases are caused by a combination of factors in both partners.

Treatment is individualized for each patient after assessing them thoroughly in terms of history, examination, and the previous treatment taken. Unnecessary investigations and unindicated procedures are avoided.

When do you evaluate the couple for infertility?

We evaluate the couple normally after one year of unprotected intercourse. However, early evaluation and treatment are indicated in women with Age > 35 years
Hypo /Oligomenorrhea and Amenorrhoea,  Known or suspected uterine/tubal disease, endometriosis, or diminished ovarian reserve,  Suspected or infertile partner. One-third of women who delay pregnancy until after the age of 35 years and at least half of the women who delay until after 40 years will have some difficulty in conceiving.

Infertility Testing & Evaluation

Evaluation begins with detailed documentation of the history and physical examination of both partners. Adequate counseling is an integral part of the management.

As a routine, it is suggested to do:

• Haemogram with HPLC (to rule out thalassemia or other hemoglobinopathies)
• Blood sugar (fasting )
• Rubella IgG
• Endocrinology profile including S.TSH and S.Prolactin (These are the treatable causes of infertility)
• Mountoux and Chest X-ray in suspected cases of tuberculosis.

Treatment is individualized for each patient after assessing them thoroughly in terms of history, examination, and the previous treatment taken. Unnecessary investigations and unindicated procedures are avoided.

Female Infertility Evaluation

The female partner is specifically assessed for ovarian reserve,  tubal patency, and one basic transvaginal ultrasound  The various tests are described below:

1. Ovarian Reserve Assessment

Each woman is born with a fixed number of eggs. Ovarian reserve tells us the number of eggs a woman has or in other words, it's the quantitative measure of eggs. It is related to the reproductive potential. The more the number of eggs, the better the chances of conception.

(a) Age: Age is a very good indicator of ovarian reserve. The oocyte number and quality decline with age. The fertility peaks at 20-25 years of age and the number of eggs declines sharply after 37 years of age.

(b) Biochemical Tests:

• Serum Anti Mullerian Hormone (S.AMH): She is evaluated for ovarian reserve by S.AMH. AMH is secreted by the developing follicles of 2-9 mm. It is quite a good indicator of ovarian reserve. In fact, S.AMH is more sensitive and specific than the antral follicular count (AFC) on ultrasound as it also reflects pre-antral and small antral follicles (<2 mm), which are hardly seen in an ultrasound. It has many advantages over other markers of ovarian reserve, like it can be done during any day of the cycle unlike AFC and S. FSH which can only be measured during the first five days of the cycle and its values are stable from one cycle to another.
• Follicle Stimulating Hormone (S.FSH ): is also commonly used for measuring ovarian reserve. S.FSH >12 IU/L indicates poor ovarian reserve. S. FSH is measured on day 2 /3/4 of the cycle.
• Inhibin B: It's a hormone secreted by the preantral follicles. With advancing age, the number of follicles decreases hence there is a decrease in Inhibin – B levels. It's an ovarian hormone that inhibits FSH release. 
• Estradiol: Day 3 E2 levels < 50pg/ml combined with normal FSH indicates good ovarian reserve, good response to stimulation, and better pregnancy rates. High E2 levels on day 2/3 of the cycle suggest the premature selection of follicles. This may occur as the ovary ages, or when ovarian follicular cysts remain from a prior menstrual cycle. These follicular cysts may interfere with egg selection in the current cycle and might lead to poor response to fertility treatment.

(c) Ultrasound Imaging

• Antral Follicular Count (AFC): The antral follicular count describes the total number of follicles measuring 2-10 mm in both ovaries. AFC is assessed preferably during the early days of the cycle. A total AFC count of < 5, indicates poor ovarian reserve.
• Ovarian Volume: Ovarian volume of < 3 ml, predicts poor response to ovarian stimulation. Ovarian volume has a limited value for predicting ovarian reserve.

(d) Proactive Tests:

Clomiphene Citrate Challenge Test (CCCT): In contrast to the static measurements of ovarian reserve mentioned previously, the clomiphene citrate challenge test (CCCT) is a dynamic approach.
When undergoing CCCT, the first step is to measure day 3 FSH and E2. Then 100 mg of clomiphene is administered on cycle days 5 through 9, and FSH and E2 measurements are repeated on cycle day 10. In general, a high day 10 FSH suggests poor ovarian reserve. Clomiphene stimulates follicles to grow which causes E2 secretion. This E2 via a negative feedback mechanism causes suppression of FSH secretion from the pituitary. In patients with poor ovarian reserve, there is poor follicle growth hence low E2 which in turn causes more production of FSH.

2. Transvaginal Sonography

Infertility evaluation is incomplete without transvaginal sonography. It is usually done to evaluate the uterus and the ovaries. The uterus is evaluated for size, shape, and position and is especially looked for any mass like fibroid, polyp, adenomyosis, or any adhesions in the endometrial cavity. Simultaneously the ovaries are assessed for the antral follicular count and ovarian volume to rule out any ovarian mass like endometriosis. Tubes are generally not seen on ultrasonography unless they are diseased and dilated as in hydrosalpinx.

 3. Evaluation of Tubal Patency

Hysterosalpingography: It is the most common procedure to evaluate the patency of fallopian tubes. This procedure visualizes the uterine cavity and the fallopian tubes under fluoroscopic guidance in an X-Ray Room.

Sonosalpingography: It is another method for evaluating tubal patency. It is a reliable, simple, and well-tolerated method to assess tubal patency in an outpatient setting

Laparoscopy: It is the best technique for diagnosing tubal and peritubular disease. It is a patient-friendly, daycare surgery, the patient is admitted in the morning and is discharged the same day. Laparoscopy combined with hysteroscopy usually completes the pelvic evaluation.

a. Hysterosalpingography (HSG)

This procedure visualizes the uterine cavity and the fallopian tubes under fluoroscopic guidance in an X-Ray Room.

A radio-opaque dye is instilled into the uterine cavity via the cervix. The filling of the uterine cavity and the bilateral filling of the fallopian tubes and spilling into the abdominal cavity are seen on the screen. In case one or both tubes are blocked, it shows the site of the blockage.

 It can also show abnormalities of the size and shape of the uterus which may be there by birth like bicornuate, septate, or arcuate uterus, or if any polyp or submucous fibroid is present.

When and How is it done?

It is usually performed between days 6 – 11 (usually after cessation of menstrual flow and before ovulation) of a menstrual cycle. It's done in an X-Ray room. Antibiotic prophylaxis and a pain killer are usually given for three days, starting one day before. The patient is called after a light breakfast at 11 a.m. Anesthesia is not routinely needed but may be used in selected patients (in that case patient comes fasting). After a detailed written informed consent, the patient is taken to an X-ray room where she is asked to lie down on her back in a dorsal position with her knees folded up.

Under all aseptic conditions, 2 – 3 ml of a radio-opaque, water-soluble dye injected through the cannula into the uterine cavity is sufficient to delineate the uterine cavity. Further, 3 – 4 ml is sufficient to demonstrate bilateral tubal patency or tubal obstruction. Usually, 3 – 4 X-ray images are taken during the entire process for a permanent record of the result.

The patient is kept under observation and allowed to go 3 – 4 hours after the procedure.

What are the risks and hazards of the procedure?

• It is a very short and safe procedure with minimal risk of complications like:
• Pain is usually avoided by giving an Injection of Buscopan, half an  hour before the procedure
• Allergic reaction to the dye
• Endometrial infection (Endometritis)
• Fallopian tube infection (Salpingitis)
• Perforation of the uterine cavity

What are the contraindications of the procedure?

The procedure should not be performed:

• In the presence of genital infection
• If the patient is sensitive to Iodine

b. Sonosalpingography (SSG)

It is another method for evaluating tubal patency. It is a reliable, simple, and well-tolerated method to assess tubal patency in an outpatient setting. Like HSG it is also performed from day 7 to day 11 of a regular 28 days menstrual cycle under antibiotics and painkillers.

It’s a non-invasive procedure done under ultrasound guidance. After obtaining informed consent, the patient is made to lie down in an ultrasound room, the vagina is cleaned with antiseptic solution. A sterile speculum is introduced into the vagina and a pediatric Foley’s catheter is introduced into the uterus through the speculum which is retained in situ by inflating 2 ml of saline. Normal saline is then installed into the uterine cavity, if the tubes are patent, the flow of saline is observed as a shower at the fimbrial end. Apart from tubal patency, this is an excellent test to diagnose sub-mucous polyp or intrauterine adhesion. It is as accurate as HSG in evaluating tubal patency but if the tube is blocked, it doesn’t give the site of blockage.

Advantages of Sonosalpingography

• It is a very short and safe procedure with minimal risk of complications
• It’s an outpatient, noninvasive procedure
• There is no radiation hazard
• It also helps in diagnosing uterine anomalies like sub-mucous polyps and intrauterine adhesions
• There is no allergic reaction as no dye is used
• The site of blockage cannot be detected
• It requires expertise in ultrasonography
• The findings are subjective

c . Laparoscopy

It is the best technique for diagnosing tubal and peritubal disease. In today's era of excellent ultrasonography combined with very high sensitivity and specificity of HSG, Laparoscopy is preferred when there is associated pelvic pathology like endometriosis, fibroid, or blocked tubes on HSG or Sonoslpinography where corrective surgery can be performed in the same sitting. Thus it is used more as a therapeutic modality for correcting pelvic pathologies rather than just a diagnostic tool.

Laparoscopy

Laparoscopy or Key Hole surgery is commonly known as a procedure that allows the surgeon to visualize the abdominal and pelvic organs clearly on a TV screen. It’s a patient-friendly daycare surgery, the patient is admitted in the morning and is discharged the same day. Laparoscopy combined with hysteroscopy usually completes the pelvic evaluation.

Where is Laparoscopy Indicated?

1. Diagnosing tubal pathologies in infertile women and at the same time corrective procedures can be done for tubal blockages like Fallopian Tubal Recanalization, Neosalpingostomy, Fimbrioplasty, Correction of hydrosalpinx.

2. Tubal Sterilization.

2. Hysterectomies   -(Removal of Uterus )

3. Corrective and pelvic resurrection and restoring pelvic anatomy  for Endometriosis

4. Myomectomy ( Removal of Fibroid )

5. Ovarian cyst removals like Endometriosis or Dermoid cyst.

6. Adhesiolysis as in chronic pelvic pain or in  Pelvic  Inflammatory Disease.

7. Surgeries for prolapse uterus and bladder neck suspension.

8. Radical Surgeries for Gynaecological Malignancies like ovarian cancer, Endometrial cancer.

How is it done?

Laparoscopy is a surgical procedure done under General anesthesia in Operation Theatre. One, two, or three very small cuts are given in the abdomen, through which a laparoscope and specialized surgical instruments are introduced. A laparoscope is a thin, fiber-optic tube, fitted with a light and camera. The pelvic organs are visualized on the TV Monitor, and the surgery is proceeded depending on the case.

Advantages of Laparoscopy in Infertility?

Laparoscopy involves very small incisions with far less postoperative discomfort and a rapid recovery time

• Along with the tubes, it allows visualization of all pelvic pathologies like fibroids, endometriomas, and peritubular and periovarian adhesions.
• It also allows careful assessment of the external architecture of the tubes and in particular, visualization of the fimbria.
• Identified abnormalities like tubal obstruction, pelvic adhesions, and endometriosis can be corrected simultaneously.

Disadvantages of Laparoscopy

• It is an invasive procedure requiring anesthesia.
• It requires advanced training, great skill, and excellent hand-eye coordination.

Complications of Laparoscopy

The overall complication rate is 0.2%-10.3%. However, the complications are still less in the hands of expert surgeons and most of them are minor and treatable. The various complications that can occur are bleeding from the port site, subcutaneous emphysema, hernia at the trocar entry, post-operative shoulder pain, and bladder and bowel injury. We are proud to say that our complication rate is fearless.

Male Infertility  -

What is Male Infertility?

• Male infertility is quite common these days. One-third of the cases are caused by male infertility.  The sperm count may be low, or nil or the sperm may have decreased motility or they may be abnormal in shape. The main cause is low sperm count. We follow  WHO 2010  criteria for semen analysis  (mentioned below).
• Semen analysis is the foremost simple and diagnostic investigation for male infertility. 
•  Semen Collection is preferable to be done at IVF Centre only.

It requires

• Abstinence for 2 to 3 days
• Sample collection preferably by masturbation at the center.  
• Keep the sample at body temperature (37oC)
• Avoid normal condoms or lubricants