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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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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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