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Apr24
Pcos- Infertility- How to Treat?
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. Majority of the women can keep the disease under control with lifestyle changes (diet and exercise), rather than medicines. These can also help to prevent the long-term consequences.

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 to reduce the level of insulin.

Treatment of fertility depends on your age, duration of infertility and other fertility factors. Usually the first line of treatment is OI (Ovulation Induction). The next lines are IUI (Intrauterine Insemination) and IVF (In Vitro fertilization) respectively.

What is Ovulation Induction?
Medicines (tablets, injection) are given to help your eggs grow and rupture. In the first cycle, it is important to see (by ultrasound) whether eggs are growing or not. If the eggs rupture, the chance of pregnancy per cycle is 15% and after 4-6 cycles of OI, it is nearly 50-60%. That means, out of 100 women who had ovulation, 15 can conceive after one month.

How IUI is done?
IUI is one step ahead of OI. Here along with medicines given for OI, husband’s sperm is collected, processed (“preparation”) and then inserted inside the uterus. The success rate is 15-20% per cycle.

When IVF is advised?
If a woman fails to conceive after 4-6 cycles of IUI, if the age is on higher side, there is long duration of infertility or additional problems like sperm defects or tubal blocks, IVF is advised. The success rate is 40-50% per cycle. But caution should be taken as these women are at risk of developing OHSS (Ovarian hyperstimulation syndrome- excessive response by ovaries) and twin pregnancy. Frozen embryo transfer reduces the risk.

Is there any role of laparoscopy?
Only very few women who fail to ovulate with any medicines, sometimes laparoscopy is done where some cysts are punctured using electric current (laparoscopic ovarian drilling- LOD). Additionally, LOD can be done for women requiring laparoscopy for other purposes (like pain, testing the tubes). However, LOD carries risk of ovarian damage and therefore, should be done in selective patients.

Conclusion-
PCOS is common but majority of the women can do well with life style changes. The chance of pregnancy after treatment is higher for women with PCOS than for other women.


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Apr24
PCOS is not disease of CYSTS
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 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.

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. The main problem in PCOS is not the “cysts”, rather cysts are arising because of hormonal problems.

Presence of polycystic ovaries does not always mean 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.

It is a quite common condition, affecting 2 to 26 in every 100 women.

What causes PCOS?
The exact cause of PCOS is not yet known but it often runs in families.

The symptoms are related to abnormal hormone levels:

1.Testosterone is a hormone that is produced in small amounts by the ovaries in all women. Women with PCOS have slightly higher than normal levels of testosterone

2. Insulin is a hormone that controls the level of glucose (a type of sugar) in the blood. If you have PCOS, your body may not respond to insulin (“insulin resistance”), so the level of glucose is higher. To try to prevent the glucose levels becoming higher, your body produces even more insulin. High levels of insulin can lead to weight gain, irregular periods, fertility problems and higher levels of testosterone.

Is PCOS related to other diseases?
Effect of PCOS is not limited to the ovaries. Women with PCOS are more prone to develop diabetes, high blood pressure, heart disease, stroke, depression and mood swings, snoring and daytime drowsiness and sometimes, cancer in the lining of the uterus (endometrium). The risks are higher for obese women.

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 can be cured?
Unfortunately, there is no cure for PCOS. However, it can be kept under control. Majority of the women can keep the disease under control with lifestyle changes (diet and exercise), rather than medicines. These can also help to prevent the long-term consequences.

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, which help to keep insulin level normal.

Treatment of fertility depends on your age, duration of infertility and other fertility factors. Usually the first line of treatment is OI (Ovulation Induction). The next lines are IUI (Intrauterine Insemination) and IVF (In Vitro fertilization) respectively.

Is any special precaution required in pregnancy?
Women with PCOS are at higher risk of developing miscarriage, diabetes (gestational diabetes mellitus- GDM), high blood pressure (preeclampsia), growth problems, premature delivery during pregnancy. Therefore, screening for GDM should be done along with regular scan under specialist supervision throughout pregnancy.

Conclusion
PCOS is common but majority of the women can do well with life style changes. The chance of pregnancy after treatment is higher for women with PCOS than for other women. Proper care should be taken before and during pregnancy.


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Apr24
Low Amh- What to Do?
What is meant by less number of eggs?
A woman is born with finite number of eggs in her ovaries. This is called “Ovarian Reserve”. In every month, number of eggs are destroyed and this is unavoidable. However, in some women, this process of destruction is accelerated and this is called “Poor ovarian reserve (POR)” or “Less number of eggs”.

How can I know that I have less number of eggs?
Blood results can show low AMH and high FSH. The most definitive test is checking for the eggs (AFC- Antral Follicular Count). It must be kept in mind that a single result is not confirmatory. In short, we have to look into age, AMH and AFC together.

What are the treatment options?
Only a low AMH or low AFC cannot decide what treatment you should have.

We also have to consider your age, duration of infertility, previous pregnancy (if any), condition of your tubes and partner’s sperms. If all other factors are favourable and you have only low AMH and AFC, a short period of Ovulation Induction (OI) and IUI (Intra-uterine insemination) can be tried. If these fail, you may need to consider IVF.

Is IVF done as the last resort?
Low AMH does not always mean that you need IVF. However, if your age is on the higher side or duration of infertility of long, IVF may be the better option for you.

We always encourage the women to try IVF with your own eggs first. If that fails, then ONLY consider donor eggs.

What is the chance of success?
It depends on your age, duration of infertility and your response. In general, the chance of pregnancy after each cycle of IUI is 15-20% and after IVF, 30-40%. However, the chance is slightly lower in women with POR.

Is there no chance of natural conception?
In women who have menopause before 40 years, 10% can conceive spontaneously. In women with POR, this chance of natural conception is even higher. So, POR does not always mean that you have do OI, IUI or IVF.

What medicines can be tried?
Some medicines may be tried to improve ovarian response, like DHEA, testosterone gel or antioxidants, vitamin D etc. However, whether the medicines are actually helpful, is a matter of debate and it needs further research.


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Apr24
Fallopian Tube Block
What is Fallopian Tube(s)?
Fallopian tubes (commonly called “the tubes”) are the structures that are connected to the both sides of the uterus. Inside the tube, the sperms and the egg meet (“fertilization”) to form the embryo.

How the tubes are tested?
1. Hystero-salpingogram (HSG)- by a special X-ray, using a contrast material.

2. Saline Infusion Sonography (SIS) or Sonosalpingography (SSG)- water is inserted under ultrasound guidance- more accurate, causes less discomfort.

What are my options if tubes are found to be blocked in HSG?
You still can consider SIS as a second test to check tubal patency. However, if SIS also shows the “block”, then there are simply two options. You can consider laparoscopy or go for IVF straightforward.

When Laparoscopy is advised?
If you are at younger age, other fertility factors normal and the infertility is of shorter duration, laparoscopy may be the suitable approach for you. If laparoscopy confirms the patency of the tube(s), you can try for pregnancy naturally. Sometimes, attempt can be made to remove the block by laparoscopy.

When should I go for IVF?
If the conditions of your ovaries or partner’s sperms are not satisfactory, your age is on the higher side, or infertility is of long duration, directly going for IVF would be the better option for you. If tubes are found blocked in laparoscopy, you need IVF. Again, if you fail to conceive within 6-12 months’ time after laparoscopy, even when the tubes were found open, you may need to consider IVF.


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Apr24
Abnormal Sperm Report- What to Do?
Semen Report is Abnormal?
If a single semen analysis report is abnormal, that does not mean that there is great problem. You need to repeat it from authentic laboratory.

What are different types of abnormal sperm reports seen?
Sperm count low (Oligospermia)

Abnormal Sperm Motility (Asthenozoospermia)

Azoospermia (Zero Sperm Count)

Abnormal Morphology (Terayozoospermia)

Pus Cell very high

Should you take any medicines?
Medicines work ONLY in mild to moderate cases. Even then if you want to continue medicine WITHOUT active treatment, sperm counts may decrease further.

Can any Injections help?
ONLY if there is hormonal imbalance, gonadotrophin injections can help. But please DO NOT TAKE TESTOSTERONE injection or tablet, because it will further lower down sperm count. Testosterone should NOT be taken even if your blood level of Testosterone hormone is low.

Are any other tests needed?
If the report is severely abnormal, you may need some tests to find out the cause. These include

Physical examination- Doctor may examine your private areas including testicles and penis.
Ultrasound- of scrotum and prostate gland
Hormone tests in blood- Testosterone, FSH, LH, sugar etc.
Chromosomal tests- Karyotype, Y chromosome microdeletion etc.
When to go for IUI, IVF or ICSI?
It depends on severity of the abnormalities in sperms and the condition of your wife's fallopian tubes and ovaries. In mild cases, IUI can be tried. In severe cases, you should NOT delay IVF-ICSI.

Do you need TESA/ TESE?
Even when there is no sperms in semen, sperms can be collected from your body, from your testicles by inserting fine needle and that can be used for ICSI.

When Donor Sperm is required?
In most cases donor sperm is not needed. It is used when no sperms can be obtained or when you cannot afford ICSI.


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Apr24
Pcos-Infertility- What Treatment Do You Need
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 “cysts” in PCOS are not tumours. The main problem in PCOS is not the “cysts”, rather cysts are arising because of hormonal problems. Presence of polycystic ovaries does not always mean PCOS.

Is PCOS related to other diseases?
Women with PCOS are more prone to develop diabetes, high blood pressure, heart disease, stroke, depression and mood swings, snoring and daytime drowsiness and sometimes, cancer in the lining of the uterus (endometrium).

Why PCOS increases the risk of infertility?
Women with PCOS have good number of eggs inside the follicles but they cannot be released (Ovulation).

How PCOS is treated?
You should aim to keep your weight to a level that is normal. Treatment of fertility depends on your age, duration of infertility and other fertility factors. Usually the first line of treatment is OI (Ovulation Induction). Medicines (tablets, injection) are given to help your eggs grow and rupture. The next lines are IUI (Intrauterine Insemination) and IVF (In Vitro fertilization) respectively.

Is there any role of laparoscopy?
Only very few women who fail to ovulate with any medicines, some cysts are punctured using electric current (laparoscopic ovarian drilling- LOD). It should be done ONLY in selective cases. Otherwise it will do more HARM than GOOD.

Is any special precaution required in pregnancy?
Women with PCOS are at higher risk of developing miscarriage, diabetes (gestational diabetes mellitus- GDM), high blood pressure (preeclampsia), growth problems, premature delivery during pregnancy.


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Apr24
Should Fallopian Tubes be removed before IVF?
Sometimes, people who came for IVF, are asking whether the Fallopian tubes need to be removed before IVF.

Normally, what happens inside our body?
The sperms, deposited in the vagina during sexual intercourse, are travelling through the uterus into the Fallopian tubes (attached on the either side of the uterus), where the eggs released from the ovaries ("Ovulation") are also entering. Thus, inside the tube, the egg and the sperm meets ("fertilization") to produce the embryo, which then comes down inside the uterus. The embryo then attaches to the uterus and gives rise to pregnancy.

We need to understand how IVF is done.
By giving some medicines (injections) in the body, the eggs in the ovaries are grown and then they are collected with a fine needle from the ovaries. The sperms are collected from the male partner. In the laboratory, the eggs and sperms are fertilized to produce the embryo. The embryo is then transferred back inside the uterus, where it can give rise to pregnancy. Thus, basically what happens inside the fallopian tubes are done in the laboratory. Therefore, we are bypassing the function of the fallopian tubes during IVF.

So, IVF can be done whether the fallopian tubes remain open (Sperm problems, low egg counts, endometriosis, unexplained infertility, ejaculation problems, azoospermia) or blocked (in HSG, SSG and/or Laparoscopy). So, there is NO NEED OF REMOVAL OF THE TUBES BEFORE IVF.

However, there is one exception.
That is hydrosalpinx, where there is swelling of the fallopian tubes (one or both the tubes) because of accumulation of fluid. That fluid can come down from the tubes into the iterus and can damage the embryo transferred after IVF. In that case, the diseased fallopian tube is doing more harm than good. Therefore, the diseased tube MUST be removed before IVF. So, in most cases, IVF can be done keeping the Fallopian tubes inside the body.


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Apr24
Opening Blocked Fallopian Tube- Hysteroscopic Tubal Cannulation (Under Laparoscopy)
What are the options if tubes are found blocked in HSG?
You still can consider SSG (Sonosalpingography) or SIS (Saline Infusion Sonography) as a second test to check tubal patency. SSG is an option before you take the final decision. However, if SSG also shows the “block”, then there are simply two options. You can consider laparoscopy or go for IVF straightforward. It depends on your age, other fertility factors (condition of the sperms and ovaries), duration of infertility and your wish.

Why and how Laparoscopy is done?
If HSG or SSG show both the tubes are blocked, then the only way to confirm the blockage is by laparoscopy. This is, because, sometimes, the spasm of the muscles of the tube during HSG or SSG can lead to“false positive” result; that means if tubes are found to be blocked by those tests, the tubes may actually be found open actually during laparoscopy. Laparoscopy is also advised to check the tubal patency, if there are other reasons (like removal of cyst or severe pain) or when HSG or SSG could not be done for technical difficulties. Laparoscopy is done under general anaesthesia with two or three small opening (key-hole surgery) in the abdomen and a coloured material (“dye”) is introduced through the uterus.

What is "Hysteroscopic Tubal Cannulation"?
During laparoscopy, we can make attempt to remove the block by simultaneous use of Hysteroscopy. Hysteroscopy is done by inserting a small telescope with camera inside your womb (uterus) through the vagina) under the anaesthesia. During Cannulation, a small wire is passed through the hysteroscope through the womb into the tube. Laparoscope is used to see the passage of the wire through the tube. This can open the blocked tubes in many cases.Please remember, you need laparoscopy and hysteroscopy at the same sitting. So,there is no need of two operations separately.

When Hysteroscopic Tubal Cannulation is done?
If you are at younger age, other fertility factors normal and the infertility is of shorter duration, laparoscopy may be the suitable approach for you. That means, if there is good chance that you can conceive without IVF, this operation is suitable for you.

What is the next step if this operation is "Successful"?
The operation is "SUCCESSFUL" when the "blocked" tube(s) are opened by this operation. In that case, you can try for pregnancy naturally, by ovulation induction or by IUI (Intrauterine Insemination), depending on your circumstances. If you fail to conceive within 6-12 months’ time after laparoscopy, even when the tubes were found open, you may need to consider IVF.

What to do if the operation FAILS to open the blocked tube?
Unfortunately in that case, you will require IVF.

When Hysteroscopic Tubal Cannulation is NOT advisable?
If the conditions of your ovaries or partner’s sperms are not satisfactory, your age is on the higher side, or infertility is of long duration, directly going for IVF would be the better option for you. Because, in these cases, even if tubes can be opened, there is fair chance that you will require IVF. By opting for IVF directly in such cases,, you can avoid the risks and costs related to laparoscopy.

What are the RISKS involved in this operation?
This is a very safe operation. But like any other surgeries, there is small risk of complications. Majority of the women undergoing this surgery, will not face any problems. However, out of 1000 women having the surgery, 1-2 can face problems like infection, excessive bleeding, damage to the organs (ovaries, tubes, uterus, bowel, urinary tract). There is small risk that the patient may need open operation and rarely second operation. Out of the 12000 women undergoing this operation, one can have life-threatening complications.

Conclusion-
If there is good chance that you can conceive naturally, after seeing blocked Fallopian tubes in HSG and SSG, Hysteroscopic Tubal Cannulation can be a good option for you.


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Apr24
Ejaculation Problem- Fatherhood is Possible
What are the causes of Ejaculation problems?
The problem may be due to some previous surgery (in the prostate gland, hernia, in the abdomen for cancer), diabetes neurological problems, spinal cord injury, diseases of prostate, some obstruction in the sperm conducting ducts etc

What is the next step?
Please do not hesitate to inform your doctor. He/ she will ask some questions and examine you to find out the cause. Some blood tests (like sugar) may be advised. Urine test is commonly advised. In few men, the problem may be retrograde ejaculation (Semen going into bladder instead of moving forward). In that case, sperms can be found in the urine immediately after masturbation. Scrotal ultrasound examines the details of your scrotum (testes and the organs surrounding them). TRUS (Transrectal ultrasound) is advised to see the problems in the prostate gland and around, here the ultrasound probe is inserted inside the anus.

What are the treatment options?
In very few cases, some medicines can help to improve ejaculation. These can help, particularly in retrograde ejaculation. However, in most cases, medicines are not helpful. Nevertheless, pregnancy is possible and you can become the biological father of your kids.

Vibro-ejaculator can sometimes be helpful. It is a small device applied on the front part of the penis ("Glans Penis") to discharge the semen. You can collect the semen in this way and use it at home.

How sperms can be collected?
Non-toxic condom- If you have nocturnal emission (“Night fall”) you can use this condom over penis while sleeping and collect the semen and carry it to the laboratory. The sperms can be frozen for furture use by IUI/ ICSI.
Vibro-ejaculator- can help to collect the sperms, which can be frozen for future IUI/ ICSI.
Testing urine- The sperms can be retrieved from urine and can be used for IUI/ ICSI. However, you need special preparation to reduce the normal acidity of the urine.
Prostatic message- If urine test shows no sperms, inserting lubricated gloved fingers inside your anus to message your prostate gland can sometimes help.
Electroejaculation- If prostatic message fails, your prostate gland can be stimulated using a small probe inserted through the anus under general anaesthesia. However, it is not widely available.
Testicular biopsy- If all of the above method fails, sperms can be collected from the epididymis (small gland above the testis) by small needle (PESA- Percutaneous Epididymal Sperm Aspiration) or and or sometimes, by a small cut (MESE Microsurgical Epididymal Sperm Extraction). All these are done under anaesthesia. If these fail, TESA (Testicular Sperm Aspiration- a small needle is inserted inside the testes) or TESE (Testicular Sperm Extraction- a small cut is made) can be done. Sperms collected by this way, can only be used for ICSI.
In all cases, sperms can be frozen for future use.
What should be the option- IUI or ICSI?
If your wife's results are satisfactory (At least one Fallopian Tube is open, adequate number of eggs in the ovaries), IUI (Intrauterine Insemination) can be a suitable option. In IUI, your sperms can be used, if your sperm count is satisfactory.

In IUI, the sperms are inserted through a small tube, inside the uterus. IUI is cheaper, but the success rate is 10-15% per cycle (out of 100 couples doing IUI, 10-15 can conceive in one month).

However, ICSI is to be done if your sperm count is very low and sperms are collected by TESA/ TESE/ MESA/ PESA. ICSI (Intracytoplasmic Sperm Injection) should also be considered if your wife's reports are not satisfactory (both the Fallopian Tubes blocked, ovaries have less number of eggs) and you have done 4-6 cycles of IUI.

ICSI is a special type of IVF (In Vitro Fertilization). In standard IVF, your wife will be given some injections to mature her eggs, which will be collected through the vagina. These eggs are then mixed with the sperms in the laboratory to produce the embryos.

In ICSI, the sperms collected from your body are directly injected, under the microscope, inside the eggs. The success rate of ICSI is 40% per cycle but it's expensive.

When Donor sperms should be used?
If a couple cannot afford ICSI but IUI using husband's sperm is not possible, Donor-Sperm-IUI is the option, if the wife's reports are satisfactory. Again if TESE sample fails to retrieve adequate amount of good quality sperms, IUI/ICSI should be done with donor sperms.


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Apr24
Hydrosalpinx (Swelling of the Fallopian Tube)
What is hydrosalpinx?
Sometimes, the Fallopian Tubes (the tubes remaining on both sides of the the uterus, where the sperms and the eggs meet to form the embryo) become swollen and contains fluid. This condition is called hydrosalpinx.

What are the reasons for hydrosalpinx?
The most common reason is PID (Pelvic Inflammatory Disease), where sexually transmitted infection (STI) can damage the tube and block it. As a result, the secretions accumulate inside the tube. Another reason is endometriosis (the lining of the uterus may lie outside the uterus and causes blockage of the tube). Previous surgery, infections like tuberculosis may also be responsible.

How hydrosalpinx is harmful?
In hydrosalpinx the inner lining of the tube is damaged. Usually hydrosalpinx is associated with blockage of the tube, so that the egg and the sperm cannot meet properly. Even if the tube is found open by HSG, because of the damage of the inner lining, the tube cannot function properly and as a result, the embryo is not formed inside the tube.

In case, a woman requires IVF, the fluid present in the hydrosalpinx, leaks inside the uterus and damages the embryo and thus leads to failure of IVF treatment.

How hydrosalpinx is diagnosed?
Sometimes HSG can show small hydrosalpinx. If it is not shown in the TVS, in most cases, nothing special is required. However, if the TVS shows hydrosalpinx, the damaged Fallopian tube must be REMOVED, because this tube IS DOING MORE HARM THAN BENEFIT.

How hydrosalpinx is removed?
The ideal procedure is laparoscopy, where by means of key-hole surgery, the diseased tube is removed (Salpingectomy). However, in some cases, it may not be possible, technically, to remove the tube. In that case, the tube is blocked by special clip.

What should be done if both the tube contains hydrosalpinx?
In that case, both the tube should be removed. But, unfortunately, in that case, the only option remaining for pregnancy, is IVF.

What should be done if hydrosalpinx is seen during or before IVF?
In that case, it's better to remove the tube after egg collection (and freezing the embryos), so that the effect of surgery on ovaries can be minimised (there is small chance of ovarian damage in few women during surgery).

However, if you had previous laparoscopy and it was not possible to remove or clip the tubes, there is an alternative option, called "Aspiration" by which the fluid inside the tube is taken out vaginally by inserting a needle under ultrasound guidance (just like egg collection) under anaesthesia. However, this is temporary measure and the fluid may accumulate later on. Therefore, it should ONLY be done in selective and difficult cases and should be done ONLY before the embryo transfer.


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