How can one know that the Fallopian tubes are blocked?
Unfortunately, most women do not have signs or symptoms suggesting tubal block. However, if you had previous infections in pelvis, tuberculosis in any part of the body, previous ectopic pregnancy, appendicectomy or gynaecological surgery, or feel severe pain during periods or during intercourse, there is a chance of tubal blockage.

How the tubes are tested?
Whether tubes are open (“patent�) or not, is usually checked by a special X-ray, called Hystero-salpingogram (HSG), in which a contrast material will be given through the neck of the uterus (cervix). It is cheaper and easily available. However, some women can feel discomfort during HSG. Usually some pain-relief medications are given during the procedure.

Another method is Saline Infusion Sonography (SIS) or SSG, in which water is inserted inside the uterus with the ultrasound probe put inside the vagina (TVS). It is more accurate than HSG and causes less discomfort. Both HSG and SIS are done in out-door basis, without any need of anaesthesia.

When Laparoscopy is advised?
If HSG or SIS 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 SIS 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 SIS 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.

Why Sperm analysis is done?

Sperm analysis is an essential part of evaluation of an infertile couple. In most cases, this is the only test, a male partner requires. However, a single abnormal semen analysis does not always mean that there is any abnormality in the man.

In a man, 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. If, for any reason (for example, high fever, tight underwear, hot tub bath etc), the man's health was abnormal 3 months ago, the semen analysis may become abnormal. Again, the results can vary from one laboratory to another.

Is there any difference between semen and the sperms?

Semen consists of 2 parts- the sperms and the fluid ("seminal plasma"). The sperms cannot be seen by the naked eye. The fluid that you can see, is the semen. So, semen and the sperms are not the semen.

How semen is tested?
In the laboratory semen is tested for certain parameters like- volume (amount of semen), liquefaction (time needed for semen to become liquid), colour, appearance etc. The sperms are checked for total count, motility (ability of the sperms to move), morphology (the appearance of the sperms), vitality (whether sperms are living or not) etc. It is important for the laboratory to follow WHO 2010 criteria for semen analysis (not the older criteria like 1992). Sometimes, some special tests may be done on the semen depending on your scenario.

How semen collection and analysis is done?
The easiest and the most commonly used method is masturbation. You should collect it in the laboratory in a room with adequate privacy and comfort. Of course, for most of the men, it seems awkward to collect semen in unfamiliar environment, away from home. Usually most laboratories provide a separate room where you can bring your partner with you.

Is any preparation required?
Please maintain abstinence for 3 to 5 days (not more than 5, not less than 3). That means you should avoid intercourse and masturbation for 3-5 days prior to the test. This is because, both long term (more than a week) and short (less than 2 days) period of abstinence can lead to false results regarding quality and quantity of the sperms. Get relaxed. Wash your hands properly before the collection. It's important to collect all the semen in the collection pot and not to spill a portion outside.Do not hesitate to tell your doctor if you feel any problem.

In the next video, we will discuss what to do if you feel problem during semen collection in the laboratory.

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).