What are the treatment options for low AMH?
Only a low AMH cannot decide what treatment you should have. Age is the most important factor to decide the mode of treatment. We also have to check your duration of infertility, previous pregnancy (if any), condition of your tubes and also partner’s sperms.

If all other factors are favourable and you have only low AMH, a short period of Ovulation Induction (OI- Giving medicines to stimulate the ovaries to release the eggs) and IUI (Intra-uterine insemination- partner’s sperms are inserted inside your womb through a small catheter) can be tried. If these fail, you may need to consider IVF.

Is IVF done as the last resort?
A 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, rather than OI or IUI. IVF should also be considered if your tubes are blocked or partner’s sperm count is very low.

In IVF, your eggs are stimulated with hormones and are then collected in the laboratory. The eggs are then “fertilized” with the sperms to produce the embryos, which are then transferred inside your uterus. However, in small number of women with low AMH, the chance of obtaining eggs is reduced and even if, eggs are obtained, these may not be of good quality. If pregnancy does not result and embryos are not of good quality, then you may be offered “Egg Donation-IVF”.

“Egg Donation”- What is it actually?
In women with low AMH, egg donation is usually done as a last resort. Here, the eggs are collected from another woman (donor), who has been checked to ensure that she is healthy and does not contain any diseases like HIV, hepatitis or thalassaemia. These eggs are then fertilized with your husband’s sperms and the embryo is inserted inside your uterus. The process will remain confidential, that means except you and your husband, nobody will know that donor-egg has been used.However, before using donor eggs, we usually advise the couples to try IVF (if required) with self-eggs.

What to do if previous IVF failed?
In case of low AMH, if you had good number of healthy embryos produced from your own eggs, the excess embryos can be frozen. So, if the first embryo-transfer fails, you still have your own embryos for transfer in future.

But if you had small number of embryos and all have been transferred (none remained for freezing), we have to review whether the quality of the embryos was good or not. As only one healthy embryo can give rise to pregnancy, if embryos were of good quality (Grade A), then you can try second IVF with your own eggs. However, if embryo quality was not good (Grade B or poorer), it’s better to think about egg-donation.

What is the chance of success?
The chance of success depends on your age, duration of infertility and your response. In general, the chance of pregnancy after each cycle of IUI is 15-20% (out of 100 women having IUI, 15-20 can conceive after 1st cycle) and after IVF, it is 30-40%. However, the chance is slightly lower in women with POR.

Is there any risk in pregnancy?
Every pregnancy carries some risk of miscarriage, abnormalities in the baby, premature delivery and growth problems. The mother can suffer from diabetes, high blood pressure (Preeclampsia) and bleeding. All these risks are slightly increased in women who conceive with POR. However, majority of these women will have uncomplicated pregnancy.

Is there no chance of natural conception?
In women who attain menopause before 40 years, 10% can conceive spontaneously, without any treatment. In women with low AMH but having menstruation, this chance of natural conception is even higher. So, low AMH does not always mean that you have to go for OI, IUI or IVF. But it again depends on your age and other factors.

What medicines can be tried? Or anything else?
Some medicines may be tried to improve ovarian response. DHEA (dehydroepiandrosterone) showed some positive results. In some women, testosterone gel or antioxidants, vitamin D3 etc can be helpful. However, whether the medicines are actually helpful, is a matter of debate and it needs further research.

Conclusion
Al low AMH does not always mean that you cannot become mother. Most of the women conceive either spontaneously or by medicines or by IUI. Few of them require IVF. Donor-IVF is usually used as a last resort.

What treatment can be done in Azoospermia?

If the pituitary gland is found to be defective, the treatment gives excellent results by hormone replacement, which will improve the sperm count and you can father your baby by natural conception. However, in other cases, it may not be possible to improve your sperm count by any medicines, still you can father your baby using your own sperms.

Is there any role of surgery?

If the problem is due to adequate sperm production but blockage in the sperm conducting duct, surgery can be done to relieve the obstruction, to help you to father your baby by natural conception. However, the results of the surgery are not always satisfactory. But sperms can be collected and frozen at the time of surgery for future use, in case the surgery fails.

What is the actual treatment?

In most cases the men are offered a special type of IVF (In Vitro Fertilization) using the technique called ICSI (Intracytoplasmic sperm injection). In standard IVF, your wife will be given some injections to mature her eggs, which will be collected under anaesthesia through the vagina using ultrasound. These eggs are then mixed with the sperms in the laboratory and the embryos, thus produced, are either directly put inside your wife's uterus or some may be frozen and kept for future use.In ICSI, the sperms collected from your body are directly injected, under the microscope, inside the eggs.

How sperms are collected?

If any obstruction in your sperm-conducting passage is suspected, 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 or TESE (see below) are done to collect the sperms. If there is problem in sperm production, there may still be some sperms found inside the testes. These can be collected using small needle (TESA- Testicular Sperm Aspiration), or a small cut in the testes (TESE- Testicular Sperm Extraction); all under anaesthesia. In all cases, sperms can be frozen for future use.

What are the chances that sperms can be collected from the body?

If there is obstruction, the chance is nearly 100%. That means, out of 100 such men, almost all cases, sperms can be obtained from his body. If it’s due to inadequate sperm production from the testes, then the chance of collecting sperms is 50-60%.

However, in small number of cases, the sperms collected from your body may not be of good quality. In that case, you may be offered using donor sperms; it is never used without consent from you and your partner.

When donor sperm is used and how?

If a man cannot afford ICSI, donor insemination is an alternative. But it is done only with consent from both husband and wife. The process will remain confidential and the identity of the donor is not revealed. Donor is tested for diseases like STI, HIV, Hepatitis B or C, thalassaemia etc. Usual attempt is taken to choose donor having blood group and skin colour similar to those of the husband.

How can a man know that he is having azoospermia?

Unfortunately, in most of the cases, the men are not aware that he is having azoospermia. However, if you have any problems in genital organs since birth, any operations (particularly hernia), infections (mumps, tuberculosis, STI), injury, then he should be alert. Men treated for cancers (by chemotherapy), taking anabolic steroids, having problems in pituitary gland or liver diseases are at high risk. Men, having inadequate body hair, sexual dysfunction and varicocele should also discuss this issue with their doctor.

The semen test shows no sperm. What should I do?

A single report is not conclusive. This is, because, sperm production requires 3 months and it needs cool temperature than rest of the body. This is why, men have their testes hanging outside the body in the scrotum. Thus, today's semen analysis reflects a man's health 3 months before. Again, the results can vary from one laboratory to another.

So, we usually advise repeating the test after few days, preferably from a second laboratory. Sometimes, careful examination may reveal few sperms, that can be used for ICSI.

The repeat test also showed azoospermia. What is the next step?

The next step is to find out the cause. Your doctor may ask you some questions and with your permission, may check your body areas (hair growth, breast development, penis, scrotum, testicular size etc). Doctor can advise you some tests like ultrasound of your testes, or sometimes of your prostate gland. Some hormonal tests are advised (blood tests- LH, FSH, Testosterone, prolactin etc) and in some occasions, karyotyping and Y chromosome Microdelection (chromosomal analysis).

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, which then travels down the tubes into the uterus and then the pregnancy starts. Tubal factor accounts for 20-25% cases of female infertility. It’s more common in secondary infertility (women who conceived earlier).

What are the reasons for tubal blockage?
Often, the exact cause is not known. Infection is the commonest cause. The infections may be due to sexually transmitted infection (STI), particularly Chlamydia infection or infection from bowel or appendix. Tuberculosis is very common in our country and can affect the tubes, silently, without affecting any other parts (not even the lungs) of the body. Endometriosis is also a common reason for tubal blockage. Any pelvic surgery (surgery in ovaries, tubes, uterus, even appendix) can block the tubes by “adhesion”. This means the tube may be open but attached to the bowel or rotated on itself, so that the tube cannot pick up the eggs from the ovaries. Sometimes fibroid of uterus can compress the tube and cause blockage. Women, with previous history of ectopic pregnancy, are at risk. Uncommonly, some abnormalities, present since birth can block the tubes.

Thoughts in the Time of Corona


It is hard to live peacefully for the so-called modern human civilization. Everyday we are earning fresh problems regarding social, political, economic and various other sectors. Along with this, nature is also organising natural surgical strikes and making the whole situation imbalanced. In that list, the latest addition is Corona virus. Falling behind all the known nightmares like, racism, wars, recession etc. this extremely infectious disease snatches the international headline. At present the global public health emergency is COVID-19.

In this article I'm going to discuss about the prophylactic scope of Homoeopathy. Though the efficacy of homoeopathic prophylactic remedies for various conditions has not been proved by controlled studies and statistical records, yet homoeopathy has reportedly been used for prevention during the epidemics of Cholera, Spanish Influenza, Yellow fever, Plague, Scarlet fever, Diphtheria, Typhoid etc. Sutherland writes, "If the Homoeopathic school is to put up an effective opposition to the growing demand for modern preventive medicine, it must be able to search for and present facts which will constitute irrefutable proof of the arguments we present."
In case of epidemics, the best prophylactic will be the remedy (Genus Epidemicus) obtained by examining typical symptoms from the accurate observations of the first few cases. To find the exact genus epidemicus we have to observe the cases and accumulate the proper symptomatology of the patients. Epidemic diseases are so called contagious in nature and they come with fixed group of symptoms. Dr. Kanjilal giving two alternative says, "It goes without saying that, the best prophylactic remedy is the constitutional similimum of the individual. It is proved by experience that persons strictly following the homoeopathic line in their medical measures, rarely fall victims to any epidemic disease. The next line of defense is the similimum of a particular epidemic - the so called Genus Epidemicus." Dr. Kanjilal clearly clarifies that to approach an epidemic with the homoeopathic concept of individualization and to approach with a genus epidemicus are completely two different paths. They both can't be fitted in the same bracket. So, in a nutshell our goal is to form the antibody. Which is induced by homoeopathic drugs. The drug that most closely simulates the disease in all its clinical aspects is more likely to be a prophylactic than one less similar.
The subject of Nosodes provides a most interesting study to the homoeopath and yet, strangely, the Nosodes seem to have received much less attention that they deserve, in spite of their great utility and efficacy when indicated in practice. Nosodes are most abused, unused, and misused of all the remedies in the homoeopathic Materia Medica. Some physicians use when routinely, others use them rarely or not at all. I personally believe that Nosodes are going to play a very significant role to combat against COVID-19.
Nosodes have been compared to vaccines and even called oral vaccines. Pierre Schmidt writes, a Nosode is "a medicine derived from pathological tissue or secretions containing the specific virus of the sickness." Boger writes : "When our late confrere, Dr. H.C. Allen, pointed to the nosodes as the most important of remedies in arousing reaction, he did the greatest thing of his busy life."
Now, the most important part is that - to fight against COVID-19 homoeopaths have the immense opportunity to discover an Autogenous Nosode from the secretions of the patient. For instance, Green reports a case of eczema which was cured by a potency made from the discharge itself, after Graph., Petr., Mez., Sulph., etc., had failed. Why it is not applicable for Corona virus now? What will be the best prophylactic remedy than that? The effectivity of the nosodes in preventing infectious diseases seems to have been established. Samuel Swan has reported a number of instances where the administration of Variolinum has apparently prevented the onset of smallpox. Wheeler has conducted scientific experiments with potencies of Diptherotoxin and has shown that the drug in potency has the power of altering the Schick reaction. Hering, Swan, Burnett, and others did much along this line. Hering proposed the employment of the diluted saliva of a rabid dog for hydrophobia in 1833, antedating Pasteur. Swan antedated Koch in the discovery of Tuberculinum. Koch introduced Tuberculin in 1890. Burnett began his work with this remedy (under the name of Bacillinum) in 1885 and obtained results never dreamed of by Koch. Various other reports are also to be found in the literature which seem to prove that the various nosodes have prevented specified diseases. Of course in some cases, a drug which has produced a similar symptom picture also appears to have acted as a prophylactic, but between the two, the similar drug and the nosode, the nosode is apparently preferred, because of its greater similarity and easier selection. So, in COVID-19, the nosode prepared from COVID-19 will seems to have a very definite effect in producing prophylaxis. Incidentally, the preventive virtues of nosode of COVID-19 will seems to be safer too. (Literature provides the same prophylactic example in between tuberculosis and Tuberculinum. On the contrary though BCG is claimed absolutely safe, in the British Medical Journal, there are instances of children who were adversely affected by BCG vaccination.) Yingling writes long time ago, "What shall we say of the Nosodes, remedies derived from morbid tissues and secretions containing the specific virus of diseases? Some twenty of the animal and four of the vegetable nosodes are now used with success. The list may be extended largely. We, of this society, all know and appreciate their use and value. It would be impossible today to get along without them. Our usefulness would be wonderfully curtailed and menaced."
Various explanation have been offered to prove that nosodes are not isopathic remedies. It has been suggested that potentization alters the nature of the original substance so that the resulting product becomes similar and not identical. But the correct reasoning seems to be that the nosode represents a product of disease in a particular individual, animal or plant. Each disease-product is the result of an interaction between a particular individual and a particular pathogenetic agent. Since these two factors and the resulting reaction cannot be exactly duplicated, the resulting product can never be identically same for any other case of disease, though the outward disease-manifestations and the disease-label may be the same. For instance, in virus diseases, it is known that the virus may mutate from time to time. The virus of the Asian Influenza epidemic of 1956 was different from the virus of the Influenza epidemic of 1918-20. The manifestation of symptomatology were also different. The mortality rate was different.
Some of the Influenzinums marked by Nelson's of London are as follows :
1. Influenzinum (the 1918 epidemic), 2. Influenza virus A Asia/57, 3. Influenza virus A England/42/72, 4. Influenza virus B Hong Kong 5/72, 5. Influenza virus A/Port Chalmers/1/73, 6. Influenza virus A (Asian) 1954, 7. Influenza virus B (Asian) 1954, 8. Bacillus Influenza 1918, 9. Influenza virus Az Hong Kong 1968, 10. Influenza virus Ar 1967, 11. Influenza virus B, 12. Influenza Co. (Combination of Az to 1918), 13. Influenza virus a1.
Similarly, when bacteria are attacked by antibiotics, these organisms are found to develop different strains which are resistant to the drugs. These are instances to show the variability in the nature of the invading organisms. No two individuals in the world are exactly alike and the reaction of each individual to a specific circumstances or agent is bound to be different from that of any other individual, however, much the reactions may appear to the alike. So, a Nosode product developed from the disease tissue of one individual will probably vary in nature and indications from the nosode product developed from the diseased tissue of another individual, though the disease entity affecting both persons may be the same. When the same nosode is prepared from the different persons, each preparation may fall under a different group; with the result, we may have a Medorrhinum of the 8th group, one of the 7th group and so on. If we were to prepare the nosode from different sick individuals, the enormous implications of this discovery can't be imagined! This is a question about the homoeopathic concept of individualization. I personally have no explanation of this last part but I'm always eager to be enlightened about that and I'm also very hopeful from my homeopathic society.
Regarding homoeopathic prophylactics the potencies to be used, and the frequency of repetition, very little authoritative information is available. Gibson states, "There is no hard and fast method for the use of potencies in prevention and the length of time protection may last is, of course, difficult to estimate. One plan is to give three doses of a 30C potency spread over a period of 24 hours. Repetition in the event of continuing danger of infection should be under the guidance of a homoeopathic physician." Wheeler and Kenyon write that a dose of the 30th potency of the prophylactic remedy will protect at least for a fortnight. Others advise one dose of the 30th once a week or the 200th once a fortnight till the epidemic passes. Grimmer considers that one dose of the 10M potency affords protection throughout an epidemic. The higher potencies seems to afford protection for longer periods as evidenced by the experiments of Dr. Paul Chavanon (under Diphtheria.)
At last there is a positive side of this Corona episode. As influenza virus had played a major role to stag the great World War One, at present Corona virus also came as a preventive medicine for our planet which is violently diseased. Obviously it's an exaggeration. But after detection of COVID-19, the display of patients, empathy, and administrative excellence shown by the government of India and other countries, we must acknowledge that. We hope that, we and our planet will be completely safe under their supervision. During this global threat over human civilization by COVID-19, causes multilayered panic among the population, the only way to cease it, if we could germinate this hope. Then we shall overcome.

Dr. Swarnadip Bhattacharyya (BHMS)
West Bengal University of Health Science