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May21
A rare case of atypical lipoma in retropharyngeal space review of literature
http://dx.doi.org/10.18203/issn.24545929.ijohns20194956


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Apr25
How to maintain your bone & joint health while in a lock-down Scenario
The covid-19 virus has brough the whole world to a lockdown. India is no exception to this and we are now in a lockdown. Which means no going out of your home for except for essential things which is long time which can adversely affect the human body, if proper precautions are not taken. So we at bone and joint care thought of suggesting some tips and precautions to help you maintain your physical health while in the lockdown.

Precautions:

Cooking or cleaning utensils requires standing for a long period of time this can put immense load no the hip and knee joint leading to joint pain. Hence, when cooking or cleaning always try to shift your weight between legs while standing
Avoid bending forward and sweeping rather use standing position and use long broom. Bending forward and doing this activities take toll on back muscle and make it prone to injuries.

If you intend to be the couch potato this lockdown or going to sit in front of the PC while working from home, try to get up from sitting position every 40-45 minutes and if you can muster the courage stand up and perform some simple stretches. as shown below

TIPS:

Get your daily dose of Vitamin D: Vitamin D is essential to maintain bone & joint health Staying at home means minimal to no exposure to sun at all. Sunlight is essential to maintain the Vitamin D levels of the body. If possible, Try to get some sunlight for atleast 15-30 mins. If you have joint pain this is essential… you can also consult an orthopaedic for vitamin D supplements. Be warned – self-medication and overdose can cause complications.

Try Simple Exercises for 20-30 minutes every day or atleast alternate days to maintain your joints and muscles. You don’t have to go all pro like the celebrities or follow any regime. Just even simple exercises, even the ones taught in school PT classes should suffice.

If exercise is not your piece of cake Just Walk in your house or the building compound from one end to the other 30- 60 minuses will keep your health in check until the lockdown ends. (maintain proper distance and sanitary precautions like a mask and alcohol rub is essential)

This long lockdown period is going to take toll on your mental health aswell. Hence, try to do yoga or meditation to keep your mental health in check. So keeping your mind well exercises is as important as your body.
Yes it’s just that simple to maintain your health while in the lockdown. We hope that by following these simple steps will help you get back to normal life after lockdown without any joint pain.

So keep smiling..

Source: https://boneandjointcare.co.in/how-to-maintain-your-bone-joint-health-while-in-a-lockdown/


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Apr24
Sperm Abnormality- Donor Sperm is NOT needed
Often we see men are coming to us with abnormal semen analysis report showing very low ("Oligospermia") or absent ("Azoospermia") sperm count or very poor "motility" (ability to move) of the sperms. They ask, if they require sperm donor. The answer is "NO".

Two things must be remembered-
1) Semen Report must be REPEATED from an AUTHENTIC LABORATORY after ABSTINENCE of 3-5 days. This is important, as the sperm count varies day to day. It takes almost 3 months to produce the sperms. therefore, if today you wear very tight underwear or you have high fever, your sperm count (checked after 3 months from today) will be low. As a result, a SINGLE ABNORMAL SEMEN ANALYSIS report does NOT HAVE ANY SIGNIFICANCE. You need to repeat it.

2) Both Male and Woman should be seen together. What treatment is required, actually depends on the reports of both the partners, their age and duration of infertility. Moreover, the pregnancy will ultimately happen on the woman. That's why, we need to see both together.

Unfortunately, in many of such cases, medicines cannot work. Still, you can become biological father using your own sperms. Initially you can take medicines. but even after taking medicines, sperm counts remain abnormal, you should consider IUI or IVF.

That means, we may not be able to improve your sperm count in most of the cases, but we can definitely help you to become the biological father of your baby.
What is IUI (Intrauterine Insemination) ?
Medicines (tablets, injection) are given to your wife to help her eggs grow. By ultrasound, we see whether eggs are growing. If the eggs about to rupture, husband’s sperm is collected, processed (“preparation”) and then inserted inside the uterus. The success rate is 10-15% per cycle. That means out of 100 couples trying IUI, 10-15 can conceive after the first cycle. You can try maximum 3-4 cycles of IUI.

When IUI can be done?
If the sperm count is mildly/ moderately low, IUI can be tried. However, for doing IUI, at least one fallopian tube of your wife MUST be open. Moreover, the success rate of IUI is higher if your wife's age is less than 35 years, she is having good number of eggs in the ovaries and you are not trying for pregnancy for long time.

What is IVF (in vitro fertilization)?
Your wife will be given some injection (gonadotrophin) to promote growth of the follicles (fluid filled sacs in the ovaries containing eggs). Injections are NOT painful and are needed to be taken under the skin. She has to come to TVS (ultrasound by putting probe in the vagina) follicular study regularly to see if the follicles are growing. Usually, injections are needed for 10-12 days. After that, under anaesthesia, eggs are collected from her body by inserting small needle. The eggs are then fertilized with the sperm to produce the embryos. The embryos are then transferred after 2-3 days (Fresh Transfer) or after 2-3 months (Frozen Transfer). The success rate of IVF is 40-50%. That means out of 100 couples undergoing IVF, 40-50 can conceive after the first cycle.

When IVF should be done?
If you have tried IUI for 3-4 cycles and failed, you should consider IVF. If your wife's fallopian tubes are blocked, her age is on the higher side, she is having less number of eggs in the ovaries and you have been trying for pregnancy for longer time, you should NOT delay IVF.

What to do if the sperm count is severely low?
In that case, you require a special type of IVF, called ICSI (Intracytoplasmic Sperm Injection). Here, the sperms collected from you, will directly be injected inside the eggs collected from your wife to form the embryo. It increases the success rate.

What to do if there is no sperm (Azoospermia)?
There is also no need to use donor sperms. You can father your own baby using your own sperms, collected from your testicles, by small needle (TESA- Testicular Sperm Aspiration). Those sperms can be used for ICSI.

Donor sperms are used for IUI ONLY when your sperm count is very low, you require IVF-ICSI but unfortunately you cannot afford. Donor sperms can ONLY be used after taking consent from BOTH the husband and the wife.
Conclusion-
In most of the case, you can become biological father of your own baby using your own sperms by IUI or IVF. If the problem is mild, IUI can be tried. In case of severe problem, you should not delay IVF. Donor sperm is not usually needed.


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Apr24
Sperm Problems- IUI or IVF- What to do?
Often we see men are coming to us with abnormal semen analysis report showing very low ("Oligospermia") or absent ("Azoospermia") sperm count or very poor "motility" (ability to move) of the sperms. Naturally, they are very much worried and want to know whether medicines can be helpful.

Two things must be remembered

1) Semen Report must be REPEATED from an AUTHENTIC LABORATORY after ABSTINENCE of 3-5 days. This is important, as the sperm count varies day to day. It takes almost 3 months to produce the sperms. therefore, if today you wear very tight underwear or you have high fever, your sperm count (checked after 3 months from today) will be low. As a result, a SINGLE ABNORMAL SEMEN ANALYSIS report does NOT HAVE ANY SIGNIFICANCE. You need to repeat it.

2) Both Male and Woman should be seen together. What treatment is required, actually depends on the reports of both the partners, their age and duration of infertility. Moreover, the pregnancy will ultimately happen on the woman. That's why, we need to see both together.

Unfortunately, in many of such cases, medicines cannot work. Still, you can become biological father using your own sperms. Initially you can take medicines. but even after taking medicines, sperm counts remain abnormal, you should consider IUI or IVF.

What is IUI (Intrauterine Insemination)?
Medicines (tablets, injection) are given to your wife to help her eggs grow. By ultrasound, we see whether eggs are growing. If the eggs about to rupture, husband’s sperm is collected, processed (“preparation”) and then inserted inside the uterus. The success rate is 10-15% per cycle. That means out of 100 couples trying IUI, 10-15 can conceive after the first cycle. You can try maximum 3-4 cycles of IUI.

When IUI can be done?
If the sperm count is mildly/ moderately low, IUI can be tried. However, for doing IUI, at least one fallopian tube of your wife MUST be open. Moreover, the success rate of IUI is hiogher if your wife's age is less than 35 years, she is having good number of eggs in the ovaries and you are not trying for pregnancy for long time.

What is IVF (in vitro fertilization)?
Your wife will be given some injection (gonadotrophin) to promote growth of the follicles (fluid filled sacs in the ovaries containing eggs). Injections are NOT painful and are needed to be taken under the skin. She has to come to TVS (ultrasound by putting probe in the vagina) follicular study regularly to see if the follicles are growing. Usualy, injections are needed for 10-12 days. After that, under anaesthesia, eggs are collected from her body by inserting small needle. The eggs are then fertilized with the sperm to produce the embryos. The embryos are then transferred after 2-3 days (Fresh Transfer) or after 2-3 months (Frozen Transfer). The success rate of IVF is 40-50%. That means out of 100 couples undergoing IVF, 40-50 can conceive after the first cycle.

When IVF should be done?
If you have tried IUI for 3-4 cycles and failed, you should consider IVF. If your wife's fallopian tubes are blocked, her age is on the higher side, she is having less number of eggs in the ovaries and you have been trying for pregnancy for longer time, you should NOT delay IVF.

What to do if the sperm count is severely low?
In that case, you require a special type of IVF, called ICSI (Intracytoplasmic Sperm Injection). Here, the sperms collected from you, will directly be injected inside the eggs collected from your wife to form the embryo. It increases the success rate.

Whether IUI or IVF/ ICSI will be done using your sperms or donor sperms?
We always encourage the couples to become biological parents. Therefore, we always prefer using your own sperms. Donor sperms are used for IUI ONLY when your sperm count is very low, you require IVF-ICSI but unfortunately you cannot afford. Donor sperms can ONLY be used after taking consent from BOTH the husband and the wife.

What to do if there is no sperm (Azoospermia)?
There is also no need to use donor sperms. You can father your own baby using your own sperms, collected from your testicles, by small needle (TESA- Testicular Sperm Aspiration). Those sperms can be used for ICSI.

Conclusion-
In most of the case, you can become biological father of your own baby using your own sperms by IUI or IVF. If the problem is mild, IUI can be tried. In case of severe problem, you should not delay IVF. Donor sperm is not usually needed.


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Apr24
Sperm Abnormal- Can Medicines Help?
Often we see men are coming to us with abnormal semen analysis report showing very low ("Oligospermia") or absent ("Azoospermia") sperm count or very poor "motility" (ability to move) of the sperms. Naturally, they are very much worried and want to know whether medicines can be helpful.

Two things must be remembered
1) Semen Report must be REPEATED from an AUTHENTIC LABORATORY after ABSTINENCE of 3-5 days. This is important, as the sperm count varies day to day. It takes almost 3 months to produce the sperms. therefore, if today you wear very tight underwear or you have high fever, your sperm count (checked after 3 months from today) will be low. As a result, a SINGLE ABNORMAL SEMEN ANALYSIS report does NOT HAVE ANY SIGNIFICANCE. You need to repeat it.

2) Both Male and Woman should be seen together. What treatment is required, actually depends on the reports of both the partners, their age and duration of infertility. Moreover, the pregnancy will ultimately happen on the woman. That's why, we need to see both together.

What medicines should I take if the second semen analysis report is also abnormal?
It all depends on how abnormal the report is. In case of mild abnormalities, we give medicines called "Antioxidants" (special types of minerals and vitamins that act on the sperms) for 2-3 months and ask to repeat the test again to see if there is any improvement. At the same time, some life-style changes are advised. These include avoidance of smoking and alcohol, reducing weight, avoidance of using tight underwear, prolonged sitting and driving.

However, if the problem is severe, you can take antioxidants. But it is more IMPORTANT to do some tests to FIND OUT THE CAUSE. Sometimes, we can find the cause like diabetes, which if controlled, can improve your sperm count without any other treatment.

What tests are required?
You may need physical examination of your genital organs by the doctor. You may be advised some blood tests for hormones (Testosterone, FSH, LH, Sugar etc). Some ultrasound examination of your testicles or prostate gland may be advised. In severe cases, some genetic testing (blood test to see if there is any chromosomal problem) may be needed.

Can any medicines help if there is severe problem?
In most of the cases, medicines cannot help. You can take antioxidants but SHOULD NOT RELY solely on it. In most cases, you will require IUI or IVF. However, there is ONLY ONE CASE where medicines can ACT DRAMATICALLY. That is if there is problem in the pituitary gland (situated in the brain). In that case, taking gonadotrophin injections for 3-6 months will significantly improve your sperm count.

What's the problem if medicines are taken for long time?
As such, medicines will not harm. But if you take medicines despite the fact that your sperm count is not improving, you can land up in azoospermia. This is because, in male having severe oligospermia, there is a tendency that sperm count may further decrease over time. Therefore, relying on medicine will INDIRECTLY HARM you. Rather, you should think of IUI or IVF.

Can Testosterone be taken?
Even if your testosterone is low, if you start taking tablet/ injection of testosterone from outside, your SPERM COUNT WILL DECLINE FURTHER. Therefore, under any circumstances, if you want to become father, you SHOULD NOT TAKE TESTOSTERONE. Sometimes, after hormonal tests, we can advise tablets like Letrozole, which can help to improve the testosterone level, indirectly.

IUI or IVF- What to do?
If the sperm count is mildly/ moderately low, IUI (Intrauterine Insemination) can be tried. however, if its severely low, you should go for special type of IVF (in vitro fertilization), called ICSI (Intracytoplasmic Sperm Injection). All of these will be done using your sperms only.

What to do if there is no sperm (Azoospermia)?
You need some investigations to find out the cause. If there is pituitary gland problems, injections can be helpful. In most of the other cases, no medicines can help. But you can become the biological father of your baby using your own sperms, collected from your testicles, by small needle (TESA- Testicular Spwerm Aspiration). those sperms can be used for ICSI.

Conclusion-
In most of the case, we may not be able to improve your sperm count by medicines. Taking medicines years after years, can rather be harmful. In most cases, you can become biological father of your own baby using your own sperms.


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Apr24
Polycystic Ovary in USG does NOT always mean PCOS
Sometimes women are coming to us with ultrasonography (USG) report showing "PolyCystic Ovaries" and they are thinking that they have PCOS.
What is PCO (Polycystic Ovary)?
Polycystic ovaries have more number of follicles (fluid-filled spaces containing the eggs), which appear like cysts. However, the “cysts” in PCOS are not tumours.

What is polycystic ovary syndrome (PCOS)?
PCOS is hormonal disorder where there are irregular periods, excessive hair growth on face or body (“hirsutism”), loss of hair on head, oily skin, acne and weight gain along with polycystic ovaries found in ultrasound. The main problem in PCOS is not the “cysts”, rather cysts are arising because of hormonal problems.

The symptoms vary from woman to woman. Some women have very few mild symptoms, while others are affected more severely by a wider range of symptoms.

When a woman is said to have PCOS?
A diagnosis is made when you have any two of the following:

1.irregular, infrequent periods or no periods at all

2.an increase in facial or body hair and/or blood tests that show higher testosterone levels

3.an ultrasound scan that shows polycystic ovaries.

Therefore, if you have PCO in USG but you do NOT have irregular periods and you don't have excessive hair growth etc, then you DO NOT have PCOS. You just have polycystic Ovaries.

It is a quite common condition, affecting 2 to 26 in every 100 women. Unfortunately, there is no cure for PCOS. However, it can be kept under control.


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Apr24
IVF in PCOS- When it is needed
Women with PCOS have good number of eggs inside the follicles but they cannot be released (Ovulation). As a result, sperms cannot meet the eggs, leading to infertility. Unfortunately, there is no cure for PCOS. However, it can be kept under control. You should aim to keep your weight to a level that is normal.

Is IVF ONLY treatment for PCOS?
Treatment of PCOS-Infertility depends on your age, duration of infertility and other fertility factors. Usually the first line of treatment is OI (Ovulation Induction). If patient fails to conceive with OI, then IUI is offered. If IUI also fails, then ONLY IVF is usually advised. Therefore, majority of the women with PCOS conceive without IVF; especially if they are young (age less than 35 years), infertility duration is short, husband;s sperm condition is OK and Fallopian tubes are alright.

When IVF is suggested for PCOS?
If your age is on the higher side (age more than 35), infertility duration is of longer time, husband's sperm reports are not good or your fallopian tubes are blocked then you should consider IVF. Moreover, if you tried OI several cycles (4-6 cycles) with oral tablets and injections and also tried IUI 3-4 cycles, the chance of pregnancy is low, without IVF. Therefore in that case, you should seriously consider IVF.

What should you do before IVF?
First of all please remember, the success rate of IVF is only 40-50%. That means out of 100 couples undergoing IVF, 40-50 can conceive after the first cycle. Some may need additional cycles. Keep your weight normal. reducing weight helps to improve success rate of IVF.

How IVF is done?
You will be given some injection (gonadotrophin) to promote growth of the follicles (fluid filled sacs in the ovaries containing eggs). Injections are NOT painful and are needed to be taken under the skin. You have to come to TVS (ultrasound by putting probe in the vagina) follicular study regularly to see if the follicles are growing. Usually, injections are needed for 10-12 days. After that, under anaesthesia, eggs are collected from your body by inserting small needle. The eggs are then fertilized with the sperm to produce the embryos. The embryos are then frozen and are transferred after 2-3 months.

Why embryos are not transferred in the same cycle and are frozen?
In PCOS, there is a risk called, OHSS (Ovarian Hyperstimulation Syndrome), where excessive number of focllicles can develop, leading to fluid accumulation in tummy and chest. It may turn serious, sometimes. Therefore, if we freeze the embryo, the OHSS severity decreases. At the same time, during IVF, we give some medicines to reduce the risk of OHSS, ask to come for regular monitoring and request the women to take protein rich diet and plenty of water.

Overall, the success rate is higher in PCOS, after IVF, compared to other causes of infertility.


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Apr24
PCOS-Infertility- When to do Laparposcopy
The basic problem in PCOS (Polycystic Ovary Syndrome) is that there are numerous eggs in the ovaries but they do not grow and Ovulate (release of eggs).

The first line of treatment in PCOS is weight control. Medicines like Metformin or Inositol can be added, if needed.

The second step is OVULATION INDUCTION (OI)- giving MEDICINES, ORALLY (Clomiphene or Letrozole) so that the eggs grow and get released ("Ovulation"). But while taking medicines, its important to see if the medicines are able to induce ovulation, by TVS Follicular Study.

What to do if the oral medicines are not working (you are not ovulating with oral medicines?)
In that case, we have 2 options-

1) Injection Gonadotrophin

2) Laparoscopy

Laparoscopic Ovarian Drilling (LOD)-
By Laparoscopy ("Microsurgery", putting camera inside the abdomen by key-hole), some of the follicles ("Cysts") are burned using electric current.

The Advantages of Laparoscopy are-
a) Any other possible diseases and causes of infertility can be detected (diseases of the tubes, endometriosis etc).

b) If the woman is having pain/ endometriosis/ cyst etc, these can be treated at the same time.

c) After laparoscopy, the chance of spontaneous conception increases (without need of frequent visits to the doctors).

The Disadvantages of Laparoscopy are-
a) If LOD is done in over-enthusiastic manner (many cysts are burned), it will damage the ovaries and the woman can land up in PREMATURE MENOPAUSE.

b) There is risk of anaesthesia and surgery.

c) The "Adhesion" (abnormal attachment between the organs) caused by Laparoscopy may further increase the risk of INFERTILITY.

So, LOD is done ONLY IF-
i) If the weight of the woman is normal;

ii) LH and AMH both are very high; and

iii) There was no response (Ovulation) with oral medicines.

All these 3 factors MUST be present before LOD.
Otherwise, LOD will do more harm than benefits.


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Apr24
PCOS-Infertility- If oral tablets fail
The basic problem in PCOS (Polycystic Ovary Syndrome) is that there are numerous eggs in the ovaries but they do not grow and Ovulate (release of eggs).

The first line of treatment in PCOS, therefore, is Ovulation Induction (giving medicine to grow and release the eggs). This has to be done VERY CAREFULLY. If medicines are ineffective, eggs won't grow. On the other hand, slight increase in dose can cause many follicles to grow, leading to serious complications like OHSS (Ovarian Hyperstimulation Syndrome- ovaries enlarge, water can accumulate in various body parts) and Multiple Pregnancy (Twin, Triplet etc). That's why we must do TVS Follicular Scan to see if eggs are growing and whether there is chance of OHSS or not.

The first line of agents in Ovulation Induction (OI) are usually oral tablets like CC (Clomiphene Citrate) and Letrozole. Sometimes we add Metformin tablet to improve the response to the oral medicines.

What to do if the oral medicines are not working (you are not ovulating with oral medicines)?
If these do not work we have 2 options-

1) Injection Gonadotropin (that carries small risk of OHSS and Multiple pregnancy, therefore, needs intense Monitoring by TVS)

2) surgery called LOD (Laparoscopic Ovarian Drilling- the electric current is used to burn few follicles in PCO). However, LOD carries surgical, anesthetic risks and also the risk of ovarian damage, if not done in proper way.

What to do if you had ovulation with oral medicines but failed to conceive?
If OI is done with oral medicine, the success rate is 15% per cycle. That means, out of 100 women taking the tablet, having regular intercourse and undergoing TVS Follicular Study, 15 will conceive at the end of one month.

It is useless to take the medicines for OI years after years. Pregnancy should happen within 6-9 cycles of OI.

If oral tablets has been tried for 4-6 months, it's better to add injections for next 3-4 months.

How to take the injections?
Injections are usually started from day 2/ 3/ 4 of the period. The number of injection depends on your response. The injections are NOT painful and need to be taken under the skin. TVS Follicular Study is done from day 8/9, once in every 2-3 days (until day 14-16) to confirm that the injection is working. You should have regular physical relationship as well.

How long injections can be taken?
How long you can take injections, depends on your age and the duration of infertility.

It is useless to take the injections for OI years after years. Pregnancy should happen within 3-4 cycles of OI.

If still pregnancy cannot happen, it's better to consider IUI or IVF.


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Apr24
Pcos-Infertility- Treatment With Medicines Only
How PCOS is related to the infertility?
Women with PCOS have good number of eggs inside the follicles but they cannot be released (Ovulation). As a result, sperms cannot meet the eggs, leading to infertility. Additionally, obesity, diabetes, high testosterone and insulin level all can be risk factors for infertility.

How PCOS is treated?
Unfortunately, there is no cure for PCOS. However, it can be kept under control. You should aim to keep your weight to a level that is normal. Losing only a small portion of weight will improve regularity of your periods, ovulation and also the chance of pregnancy.

Some women are prescribed “Insulin sensitizers” like inositol and metformin.

Treatment of fertility depends on your age, duration of infertility and other fertility factors. Usually the first line of treatment is OI (Ovulation Induction).

What is "Ovulation Induction" (OI)?
OI means taking medicines to help the follicles (fluid filled sacs in the ovaries, containing the eggs) grow and ovulate (rupture, releasing the eggs), to improve the chance of pregnancy. The medicines may be in the form of tablets or injections.

What tests should be done before OI?
The condition of your tubes (HSG), Ovaries (AMH, TVS) and husband's sperms (Semen Analysis) should be checked. In addition, blood group, Thalassemia screening and Rubella testing should be done to ensure that your baby should not have any problem during and after pregnancy. Do not conceal from your doctor, if you received any OI before.

How OI is done?
Oral tablets are usually started from day 2/ 3/ 4 of the period for 5 days. TVS Follicular Study is done from day 8/9, once in every 2-3 days (until day 14-16) to confirm that the medicine is working.

Is it necessary to undergo TVS Follicular Study while doing OI?
It is important to know whether the medicine given for OI is acting for you (ovaries are responding and ovulation is happening). If medicine is not working, then taking the same for several months, is the waste of time, money and energy. If the medicine is working in the first month, as confirmed by TVS, you can take the medicine for next few months without need of further TVS.

What's the success rate of OI?
If OI is done with oral medicine, the success rate is 15% per cycle. That means, out of 100 women taking the tablet, having regular intercourse and undergoing TVS Follicular Study, 15 will conceive at the end of one month.

When OI should NOT be done?
1. If you already tried OI for more than 6-9 months. Here OI in unlikely to succeed.

2. If both of your Fallopian Tubes are blocked. Here OI will not help.

3. If the husband has very low or absent sperm count / motility/ morphology. Here OI will not help.

How long OI can be done?
How long you can take OI, depends on your age and the duration of infertility.It is useless to take the medicines for OI years after years. Pregnancy should happen within 6-9 cycles of OI.

If oral tablets has been tried for 4-6 months, it's better to add injections for next 3-4 months.

If still pregnancy cannot happen, it's better to consider IUI or IVF.

Conclusion-
Most of the women with PCOS can conceive with simple OI only.


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