Laser Assisted Hatching

This process causes thinning of the outer shell, zona pellucida of the embryo before transferring them into the womb. This helps the embryo to hatch out easily during implantation. It may increase the chances of pregnancy in some but not all IVF.

Why Assisted Hatching?

In natural conception, as soon as an egg is fertilized by a single sperm, the outer wall of the egg, zona pellucida thickens to prevent the entry of other sperms. This fertilized egg travels down the fallopian tube to reach the uterus, the fertilized egg hatches or comes out of this thick zona pellucida and implantation takes place in the uterus 6-7 days after fertilization. Assisted hatching is based on the same principle, when an egg is fertilized by the sperm in a laboratory, it forms an embryo which is covered by zona pellucida. With assisted hatching, a small hole is created in zona pellucida on day 3 or day 5 before embryo transfer which allows the embryo to hatch out of the zona pellucida and attach to the walls of the uterus.

Who are the couples that require Assisted Hatching?

All IVF patients don’t require assisted hatching. Assisted hatching has demonstrated the potential for improving embryo implantation rates, and clinical pregnancy rates in selected patient groups undergoing IVF. Assisted hatching is recommended for:

• Women above 37 years
• Women with elevated FSH on day 3 of their menstrual cycle
• Couples with failed IVF cycles or Unexplained infertility
• Couples whose embryos have a particularly thick zona pellucida

What are the methods are used for Hatching?

• Hatching using acid Tyrode’s solution – The embryo is stabilized using a holding pipette, and a small hole is created in the zona pellucida, using another pipette which contains acidified Tyrode’s solution. The embryos are returned to the incubator till the embryo transfer.
• Hatching via mechanical means – Such as partial zona dissection (PZD) using a glass microneedle.
• Hatching with a laser diode – A 15 – 20 µ hole is made, Using a 1.48-micron infrared diode laser, laser hatching takes less time, less exposure to toxic chemicals and, lesser mechanical force is required. Even the size of the gap can be controlled as it is computer operated. However, it requires great skill and precision to do laser hatching. The specifically designed laser system includes the laser, which serves as the energy source to create an opening in the zona pellucida and a computer which allows the operator to precisely control the laser energy output, laser pulse duration, and the gap size.

Is assisted Hatching always safe?

Assisted Hatching is a newer technique and requires expertise, the success depends on embryologist experience. It is important to discuss this with your fertility expert before getting it done.WHO criteria for normal semen values:-

The various semen abnormalities may be-

                        Oligospermia                           -When the semen count is < 15 M/ml

                        Azoospermia                            – No sperm in the ejaculate

                        Aspermia -                               When there is no ejaculate

                        Asthenospermia          -         When the sperm motility is less

                        Teratospermia -           When the sperms are abnormal in shape.

                        Oligoaesthenoteratozoospermia – When the semen count is low, the motility is less and they are abnormal in shape.

How to proceed with abnormal semen analysis? 

We perform a repeat semen analysis 2 months after the first report.  If the previous report mentions azoospermia, we confirm  Azoospermia by centrifugation of a semen specimen at 3,000 g *15 min and examining the pellet under high power. Many times we have observed sperms in centrifuged samples, where the previous reports have mentioned azoospermia.

 We have an integrated team of Urologists, Psychologists, and endocrinologists, and the male partner is evaluated by a urologist who takes a detailed history and examines the male partner. Confidentiality is maintained.

A thorough history is taken, noting occupational history or any exposure to high temperature and environmental toxins, any prolonged illness or surgery done before, history suggestive of any sexually transmitted diseases, coital frequency, or any ejaculatory dysfunction.

His weight and height are taken and his genitalia are examined for Testis, Epididymis, Vas Defrens, and Prostate.

What are the tests done in case of  Azoospermia or severe Oligospermia?

In most cases, the history and examination are suggestive of diagnosis, and tests are done according to the diagnosis.  Only minimal and indicated tests are done and unindicated and unnecessary tests are not done at our center.

To confirm the diagnosis, we usually do

• Hormone Testing – S.FSH, S.Testerone, S.Prolactin to categorize whether it's the testicular, testicular, or post-testicular cause of Azoospermia.
• Genetic Profile – Karyotype is done to rule out  Klienfelter‘s syndrome, Y chromosome microdeletion, and Cystic Fibrosis Gene Mutation.
• Imaging – Scrotal, Trans-rectal ultrasound is done and any abnormality of the testis, testicular volume, vas defrens, or prostate is noted.
• Post Orgasmic Urine analysis – It is done to rule out retrograde ejaculation. The presence of any sperms in the urine confirms Retrograde Ejaculation.
• Semen Culture – To rule out any infection causing abnormal semen analysis.

What is the treatment of male infertility?

The treatment is specific to the cause.

In general,

Patients are advised 

1. Lifestyle modification

2. Medical Treatment

3. IUI

4. Assisted Reproductive Techniques (ART )

5. Surgical treatment

• Lifestyle Modification 

• Weigh Reduction for Obesity
• Decrease alcohol &Smoking
• Loosely fitted undergarments
• Avoid Occupational exposure to heat, sauna, or hot tub use and use of anabolic steroids

Medical Treatment

The drugs work in cases like

A. Hypogonadotropic Hypogonadism.

Hypo-gonadotropic hypogonadism(HH)- It’s a condition where 2° sexual characters are absent, the testis is small and there is azoospermia. The levels of  FSH, LH & Testosterone are very low.

Treatment for these patients is simple. Injections of hCG(1,000-2,000 IU) IM are given twice or thrice weekly along with FSH injections for 6-24 months. Testicular growth occurs in almost all and spermatogenesis occurs in 80—95% of patients without undescended testes.

B. Pyospermia - Antimicrobial therapy is given in cases of panspermia; where there are  ≥106 /ml of peroxidase-positive white blood cells  (WBCs ). However, it only eradicates microorganisms.  It has no positive effect on inflammatory alterations and/or cannot reverse functional deficits or anatomic and secretory dysfunctions.

C. Coital infertility- like Anejaculation or Retrograde Ejaculation

• Sympathomimetic drugs such as pseudo-ephedrine, vibrator, and electro-ejaculation are used for anejaculation
• Sympathomimetic drugs and recently macro plastique injection of the bladder neck are used for retrograde ejaculation.

D. Idiopathic Male Infertility

• It occurs in ~30-45%  of infertile men. There is no demonstrable cause for abnormal semen parameters. Subnormal sperm parameters include 
  • sperm concentration < 20million /ml
  • motility < 50% motile sperm
  • normal morphology  < 30%

There is low scientific evidence for the use of bromocriptine /  hCG/HMG / αblockers  /Systemic corticosteroids. Androgens are contraindicated. Recombinant FSH, folic acid with zinc, or antioestrogens are beneficial in some patients. Antioxidants can be given empirically for 2 months.  They may work in a few idiopathic cases

IUI

IUI is a suitable alternative in

• Mild –Moderate Oligoasthenospermia where total sperm count is more than 106/ml with motility   >  30%
• Antisperm Sperm Antibodies are there or there is
• Ejaculatory Dysfunction

The pregnancy rates with IUI in male infertility are  9-20%. Four cycles of controlled ovarian hyperstimulation (COH) combined with IUI are superior to IVF and less expensive than a single IVF cycle.

Assisted  Reproductive Techniques (ART)

A. In Vitro Fertilization  (IVF ) – works well in cases of severe Oligospermia  (When the number of motile sperms is < 106/ml and also where no  Pregnancy has occurred after 3-6 cycles of IUI in Mild-Moderate Oligospermia.

B. Intracytoplasmic Sperm Injection (ICSI)- ICSI is suitable for 

• Severe Astheno&Teratospermia

• With Surgical Retrieval of Sperm

• Non-Obstructive Azoospermia
• Obstructive azoospermia is not amenable to reconstruction as in CBAVD.
• Coital infertility due to anejaculation
• Fertilization failure after conventional IVF

Surgical treatment

A. Microsurgical vasectomy reversal

Vasectomy reversal may be offered to the desired patients. Low cost,   good success rate make it more effective than IVF. Overall patency in 86 %of cases and live birth rates up to 58% are reported with vasectomy.  

B. Varicocelectomy

Varicocelectomy is of benefit only if there are semen abnormalities and the varicocele is clinically palpable in the absence of female factor infertility.  The average spontaneous pregnancy rate after varicocelectomy is 39%

C. Surgical sperm retrieval and assisted reproduction

Indications:

•  Non-obstructive azoospermia (NOA).
•  Obstructive azoospermia is not amenable to reconstruction as in CBAVD.
• Coital infertility due to anejaculation