Sperm Bank

The Female Evaluation

The infertility workup of the female partner has undergone several changes over the years but the basics have remained the same. The well-orchestrated female workup can be completed in a single menstrual cycle. At the end of this workup, along with the male data, the clinician should be able to plot a definitive course of treatment. The workup will be divided between female patients who are ovulatory by history and those that are not. Ovulation is presumed if the female has had regular menses every 26-32 days for the last six months. It is important to organize the workup to prevent unnecessary testing. The female workup should start with an initial intake that includes a thorough history, physical examination and a transvaginal pelvic ultrasound. Important historical details include those that might indicate previous exposure to STDs (such as a history of abnormal pap smears), recurrent pregnancy loss and the duration of infertility. Physical examination and pelvic ultrasound will identify patients that have gross pathology requiring surgical treatment prior to further fertility evaluation. For example, a dermoid cyst requiring surgery would allow the surgeon to evaluate tubal patency at the time of surgery rather than ordering an HSG.

Ovarian Reserve Testing
After the initial intake, the next step in the evaluation of the ovulatory female is the evaluation of ovarian reserve. The level of ovarian reserve and the age of the female partner are the most important prognostic factors in the fertility workup. Ovarian reserve is evaluated with a cycle day three FSH and estradiol level. On the third day of bleeding, a simple blood test yields a lot. Normal ovarian function is indicated when the FSH is <10 mIU/mL and the estradiol is <65 pg/mL. If the FSH is >15 mIU/mL, the patient will require egg donation. If the FSH is 10-15 mIU/mL or the E2 is >65 pg/mL, the more sensitive clomiphene citrate challenge test (CCCT) should be performed to further define ovarian reserve.

Tubal Patency
The next step in the ovulatory patient is to confirm tubal patency. This has been done traditionally with the hysterosalpingogram (HSG) and nothing has really improved on this. The HSG is performed at the outpatient radiology department. It involves injecting dye into the uterus and monitoring its "flow back" through the fallopian tubes. Blockages appear as concentrations of dye at the point of the obstruction. This test should be done in the follicular phase of the cycle after bleeding has stopped and before possible ovulation. The ordering physician should personally review the films to confirm findings of the study. Loculation of spill and tubal phimosis indicate that laparoscopy may be helpful. If large hydrosalpinges are identified, they should be clipped or removed laparoscopically prior to in vitro fertilization. Several large studies as well as a recent metanalysis, have confirmed the pregnancy rates with IVF are reduced by half in the presence of hydrosalpinges and that the rates are normalized with salpingectomy. The exact etiology of the phenomenon is not known.

Confirmation of Ovulation
Confirmation of ovulation is unlikely to be helpful in women when a careful history is consistent with ovulation. If there is doubt, a cycle day 21 progesterone with a level greater than 4 ng/mL is indicative of ovulation with most conceptions cycles having levels greater than 10 ng/mL. Alternately, sonographic confirmation of follicle rupture with serial ultrasound can be performed. Some programs use the basal body thermometer (BBT) to predict ovulation. The BBT measures the slight rise in temperature that occurs immediately prior to ovulation. Most physicians prefer to use the urinary ovulation predictor kits as they are more accurate and easy to administer.

Anovulatory Patients
The apparently oligomenorrheic patient should have the cause of their anovulation evaluated thoroughly prior to the initiation of treatment. The initial physical examination should note the presence or absence of goiter, acanthosis nigricans, striae, normal secondary sexual characteristics, Turner’s stigmata, galactorrhea, hirsuitism and abnormalities of the reproductive tract. Ultrasound should note the thickness of the endometrial lining as well as whether the ovaries are polycystic in nature. An endometrial biopsy should be considered if the uterine lining measures greater than 15mm.

Endocrine Evaluation
In anovulatory patients, the initial laboratory evaluation should include random levels of FSH, LH, prolactin, TSH, DHEAS and testosterone. Insulin resistance should be considered in patients that have any of the following: obesity, hirsuitism or acanthosis nigricans on physical exam; polycystic ovaries on ultrasound; inverted FSH/LH ratio or androgen excess on laboratory examination. Evaluation for insulin resistance can be accomplished simply with a 12 hour fasting serum insulin level. A 12 hour fasting serum insulin level of more than 10 mIU/ml signifies hyperinsulinemia in that PCOS subject.

Oocyte Retrieval (Follicle Puncture)

The first IVF baby was born as a result of collecting an egg by laparoscopy. Patrick Steptoe had pioneered the use of the laparoscope in gynaecology - a procedure which is now used extensively but was considered in the late 1970's to be 'a dangerous procedure'. Patrick Steptoe and Robert Edwards achieved the first IVF birth on July 25th 1978, although they had achieved an ectopic pregnancy some time before that. That pregancy was the result of a single egg being collected. The photographs on the right (taken by Patrick Steptoe down the laparoscope) shows a single follicle as a shiny structure towards the bottom left of the ovary. We ocassionally have to yet resort to laparoscopic oocyte retrievals when the ovaries are not accessible with transvaginal ultrasound eg. Meyer-Rokitansky-Kustner-Hauser Syndrome.
Oocyte retrieval is performed approximately 34-36 hours after the hCG injection, immediately before each follicle releases its oocyte. Oocyte retrieval involves a short procedure (lasting 20 to 45 minutes depending on the number of follicles having reached maturity) which is performed transvaginally under ultrasound control (the same way as during the ultrasound monitoring during the stimulation phase). There is therefore no incision or scar involved since the needle is inserted in each follicle by puncturing the ovary directly through the lateral wall at the top of the vagina. Each follicle is punctured and emptied of its fluid by aspiration. The eggs are collected through the vagina under ultrasound control, using a fine needle that is passed through the vagina into the ovary. Fluid from the follicles is sucked through the needle into a test tube and is passed immediately to the adjacent laboratory where the scientist checks for eggs under the microscope. After each aspiration, the sterile test tube containing the aspirated fluid is forwarded to the IVF laboratory, which will do a microscopic search of the fuid for the presence of oocytes. Most eggs are reasonably easy to find as a jelly like mass of cells known as the cumulus surrounds them(see picture). The eggs are then placed in culture fluid (a water based salt solution with added nutrients) in special dishes and put into the incubator at body temperature. If no oocyte is identified, repeated rinsing of the follicle with some millilitres of culture medium generally permits recovery of the oocyte. Oocyte retrieval can be done under a light general anesthesia (usually Propofol) at Rotunda.
The procedure takes 15-30 minutes and most women will have one or several eggs recovered. It is rare for no eggs to be found. After OPU the woman usually remains in the recovery area for about two hours before discharge. Due to the drugs used during the procedure, driving for the next 24 hours is not advisable. Your co-ordination and perception may be impaired and insurance companies may decide not to cover claims that occur during this time. It is not unusual to have some vaginal bleeding, from where the needle passes through the vaginal wall, for the next 24 hours. Mild lower abdominal cramping for the next day or two, due to swelling of the ovaries, is also common and paracetamol can safely be used.

Fertility Tests

Laparoscopy
The laparoscopy is a common outpatient surgical procedure that allows the physician to view reproductive organs such as the tubes, ovary, and uterus, and diagnose conditions causing infertility including endometriosis and tubal blockage(see picture). The laparoscope is a small "telescope like" instrument that is placed through a small incision in the abdomen, usually at the belly button(see picture). Small operative tools are inserted through another small incision at the pubic hairline. The laparoscope usually does not produce noticeable scarring. The abdomen is filled with gas causing it to expand making the internal organs more accessible. Reproductive surgeons undergo extensive advanced microsurgical training with the laparoscope. They are able to perform many, if not most, fertility operations using the laparoscope, which dramatically reduces recovery time, pain cost, and adhesions/scarring. Fertility specialists will usually treat conditions such as endometriosis during the diagnostic laparoscopy. This is one reason that a specialist should perform the laparoscopy when infertility is suspected.

Hysteroscopy
The hysteroscopy is an important tool in the study of infertility, recurrent miscarriage, or abnormal uterine bleeding. Diagnostic hysteroscopy is used to examine the inside of the uterus, also known as the uterine cavity, and is helpful in diagnosing abnormal uterine conditions such as internal fibroids, scarring, polyps, and congenital malformations(see picture). A hysterosalpingogram (an x-ray of the uterus and fallopian tubes) or an endometrial biopsy may be performed before or after a diagnostic hysteroscopy. The first step of diagnostic hysteroscopy involves slightly stretching the canal of the cervix with a series of dilators. Once the cervix is dilated, the hysteroscope, a narrow lighted viewing instrument, similar to but smaller than the laparoscope, is inserted through the cervix and into the lower end of the uterus(see picture). Carbon dioxide gas or special clear solutions like normal saline or glycine are then injected into the uterus through the hysteroscope. This gas or solution expands the uterine cavity, clears blood and mucus away, and enables the physician to directly view the internal structure of the uterus. Diagnostic hysteroscopy is usually conducted at Rotunda under propofol anesthesia. Diagnostic hysteroscopy is usually performed soon after menstruation because the uterine cavity is more easily evaluated and there is no risk of interrupting a pregnancy. A mock transfer or trial transfer may also be done at this time.

Ultrasound
Ultrasound measurements have many applications in the infertility evaluation and are also used for monitoring during in vitro fertilization stimulation cycles. The transvaginal ultrasound (through the vagina) is used frequently because it allows the physician to view the ovaries, uterus, and many other internal organs. The ultrasound produces images similar to an x-ray; however, sound waves are used instead of radiation. Many times dense structures, such as uterine fibroids, are clearly visible on transvaginal ultrasound. The ultrasound is also able to show the follicles on the ovaries as they develop and are ovulated(see picture). The fertility specialist must know the number and size of the follicles during drug-stimulated IVF cycles as this information helps in adjusting medication dosages. Ultrasound is used to measure the width of the endometrium, which must thicken and become more vascular to accept a developing embryo(see picture). It is also used as a means to document pregnancy by visualizing the fetal heartbeat.

CV of the Year

I really loved this Fwd. Please click on the image to magnify it. Enjoy a good laugh & have a happy weekend friends:)

Eggs From Heaven

After a night of drinking, Brian crept into bed beside his wife who was already asleep. He gave her a peck on the cheek and fell asleep. When he awoke he found a strange man standing at the end of his bed wearing a long flowing white robe.

"Who the hell are you?" demanded Brian, "and what are you doing in my bedroom?"

The mysterious Man answered, "This isn't your bedroom and I'm St. Peter".

Brian was stunned, "You mean I'm dead!!! That can't be, I have so much to live for, I haven't said goodbye to my family.... you've got to send me back right away".

St Peter replied, "Yes, you can be reincarnated but there is a catch. We can only send you back as a dog or a hen."

Brian was devastated, but knowing there was a farm not far from his house, he asked to be sent back as a hen. A flash of light later, he was covered in feathers and clucking around pecking the ground.

"This ain't so bad" he thought until he felt this strange feeling welling up inside him.

The farmyard rooster strolled over and said, "So you're the new hen, how are you enjoying your first day here?"

"It's not so bad," replies Brian, "but I have this strange feeling inside like I'm about to explode".

"You're ovulating," explained the rooster, "don't tell me you've never laid an egg before."

"Never," replies Brian. "Well just relax and let it happen."

And so he did, and after a few uncomfortable seconds later, an egg pops out from under his tail. An immense feeling of relief swept over him and his emotions got the better of him as he experienced motherhood for the first time. When he laid his second egg, the feeling of happiness was overwhelming and he knew that being reincarnated as a hen was the best thing that had happened to him..ever!!!

The joy kept coming and as he was just about to lay his third egg he felt an enormous smack on the back of his head and heard his wife shouting, "Brian, wake up you drunken bastard, you're shittin' in the bed."

Clomiphene Challenge Test

Women are born with their lifetime supply of eggs within the ovaries. Each month follicles, each of which contains one egg, are recruited under the influence of follicle stimulating hormone. One follicle will become dominant, develop to maturity, and be ovulated. Ovarian reserve is a measure of the “quality” of the eggs remaining within the ovaries. Ovarian
reserve naturally declines as a woman ages and approaches the menopause. However, diminished reserve can occur in younger women due to perimenopause, genetics, or for unknown reasons.
In the standard infertility evaluation, levels of the hormones FSH, LH, and estradiol are measured on day 3. An elevated FSH level on day 3 is one indication of poor ovarian reserve or that the menopause is approaching. The clomiphene citrate challenge test (CCCT) provides an additional assessment of ovarian reserve. The clomiphene citrate challenge test (CCCT) is a sensitive means to measure ovarian reserve and is often conducted if the FSH level is 10-15 mIU/mL or the E2 is >65 pg/mL. It is performed by measuring the day 3 FSH and estradiol levels, the patient takes 100 mg tablets of Clomiphene Citrate on cycle days 5-9, and her FSH is measured again on day 10. A poor CCCT test, regardless of patient age, indicates that there will be a decreased response to injectable medications in assisted reproductive technology cycles. Pregnancy success rates are lower in these women and there is an increased chance of miscarriage. The clomiphene citrate Challenge Test is routinely performed at our clinic in women aged 38 years or older regardless of how the cycle day 3 levels look. This will identify patients with incipient ovarian dysfunction. The clomiphene citrate challenge test should also be considered in women of any age with otherwise unexplained infertility as approximately 30% will show abnormalities that adversely impact their prognosis with fertility treatment.
A level from 10-12.5 mIU/mL predicts resistance to fertility medications and a diminished prognosis. At 12.5-15 mIU/mL, the prognosis is poor but pregnancies do occur with aggressive treatment. Levels greater than 15 mIU/mL indicate that infertility treatment with the patient’s own eggs is not likely to succeed and that egg donation should be offered. Patients with any FSH level greater than 10 mIU/mL should be referred to a fertility specialist for further evaluation. A poor clomiphene citrate challenge test indicates that it is unlikely that the couple will be successful using in vitro fertilization, IVF. Some clinics do not offer IVF to couples failing the CCCT test and others offer it but clearly explain the poor chance of success. Donor egg IVF is the best option for these couples.

A Cheaper Alternative To IVF

A landmark in the development of fertility treatment was announced by doctors yesterday with the birth of the first babies to be conceived using a revolutionary technique that offers a safer, cheaper alternative to IVF. The twin boy and girl, who were born on 18 October at the Radcliffe Infirmary in Oxford, were conceived using In Vitro Maturation (IVM), a method that dispenses with the use of costly fertility drugs, saving up to £1,500 (INR 120,000) on the normal price of treatment. The technique is also safer for the one in three women among those seeking fertility treatment who have polycystic ovaries, a condition that puts them at high risk of dangerous side effects from fertility drugs. Specialists said the development could make in vitro techniques available to more infertile couples by cutting the cost of treatment. Infertility is estimated to affect one in six couples in the UK but IVF costs around £5,000 (INR 400,000) a cycle and treatment is restricted on the NHS!

Tim Child, a consultant gynaecologist at the Oxford Fertility Clinic and senior fellow in reproductive medicine at Oxford University, who led the work, said: "I think it is a safer, cheaper alternative to IVF for all women. However, for many women the success rates are currently much lower. Research in the future will address this." The Oxford Fertility Clinic is the only one in the UK licensed to use the technique: 20 cycles of treatment have been carried out and four other women are currently pregnant, giving a pregnancy rate of 25 per cent. This is expected to improve with further experience. In addition, without the need for drugs, repeating the procedure would be less taxing on the woman. For standard IVF, the Oxford clinic's pregnancy rate is 45 per cent.

The parents of the babies, who have asked to remain anonymous, were delighted, Mr Child said. At birth the boy, born first, weighed 6lb 11oz and the girl weighed 5lb 14oz. "The parents are ecstatic. They have got absolutely stunning twins. They went home on Tuesday to start their new life together. It is wonderful."

In standard IVF, the woman takes fertility drugs for five weeks to stimulate production of her eggs, which are then collected direct from her ovaries under the guidance of ultrasound, before being fertilised in the laboratory. The drugs cost between £600 and £1,500, with charges often higher in London. The procedure is time consuming and uncomfortable and for the third of women with polycystic ovaries there is a one in 10 risk of severe ovarian hyperstimulation syndrome, a dangerous side-effect that in rare cases can prove fatal.

IVM avoids the use of drugs and instead involves collecting eggs from the ovaries while they are still immature. The eggs are then grown in the laboratory for 24 to 48 hours before being fertilised and replaced in the womb. The technique was pioneered by the University of McGill in Montreal, Canada, where Mr Child spent two years researching and developing it before joining the University of Oxford in 2004. It has also been used in Seoul, South Korea, and Scandinavia. To date about 400 babies have been born worldwide using IVM compared with around two million by IVF. At present the Oxford Fertility Clinic is only offering the treatment to women with polycystic ovaries, but in the long term Mr Child said he hoped to offer the procedure to all women. "When we see patients we say these are the options and it is up to them to decide. We are not offering it to women with normal ovaries at present because we don't get enough eggs from them. It depends on the number of resting follicles and with normal ovaries you don't get so many.

"On average we get four eggs from a woman with normal ovaries compared with 16 from one with polycystic ovaries. The procedure involves a process of attrition – two-thirds mature and two-thirds of those fertilise – so you need a decent number to start with." Research on developing the culture medium in which the eggs are matured in the laboratory could reduce the attrition rate so that fewer eggs are needed. The technique could then become suitable for women with normal ovaries, Mr Child said.

A second drawback of the procedure was that eggs grown in culture had a harder outer shell than those matured in the ovary and were more difficult for sperm to penetrate. The eggs had to be fertilised by ICSI – injecting a single sperm directly into the egg. "We hope to develop the culture medium so the egg doesn't mind being grown in the laboratory and we can use ordinary insemination [mixing eggs and sperm so fertilisation occurs naturally]. But in most IVF clinics, 50 per cent of patients are treated with ICSI anyway," he said. "Anything that reduces the cost of IVF, provided it is safe, means treatment could be available to more people. But this is an emerging technology – it is very early days. The most important thing is that patients get proper information so that they can make a decision on what is best for themselves."

Embryo Biopsy

Since the birth of the first baby achieved through conception outside of the human body in 1978, the principles of "in vitro" fertilization and culture have remained the same - careful establishment and maintenance of a well-controlled, sterile environment in which the normal physiology of fertilization and early development can be played out relatively undisturbed to provide healthy embryos for transfer back into the body. During the ensuing two decades, much has been learned, however, about the tolerances of such a system and how this technique can be exploited to treat a widening range of infertility cases. There have been great strides made in development of more appropriate culture media that has enabled embryos to be grown for extended periods of time in culture. Surplus embryos and possibly eggs may now routinely be cryopreserved in liquid nitrogen for use in subsequent attempts at pregnancy. Fertilization itself is no longer a hit-and-miss affair with the advent of assisted fertilization through micromanipulation. Embryos can be micro-manipulated for cell biopsy to determine their genetic status as well as aid in their ability to implant through drilling into their outer shell (assisted hatching). Embryo Biopsy is performed for preimplantation genetic diagnosis (PGD) and enables the screening of both the unfertilized egg by removal of the first polar body, or the fertilized multi-cellular embryo by removal of one or more cells either at the 6-12 cell stage(see picture) or from the trophectoderm of the blastocyst. This material can be probed for both genetic mutations or gross chromosomal errors. This technology remains in its infancy and can be of profound importance clinically, but at this time only for cases with very clear medically-defined needs. The biopsy procedure requires very exacting skills of the IVF laboratory, and the egg or embryo is not entirely free of risk during the procedure. Hence, couples whose offspring have a high chance of inheriting a genetic disorder may have their embryos screened. Women who are at risk of generating eggs with a high risk of chromosomal anomalies can benefit from having their eggs or embryos screened for chromosomal normality.

Risks Associated With Fertility Medications

The controlled "superovulation" techniques used in IVF are designed to stimulate the ovaries to produce several eggs (oocytes) rather than the usual single egg as in a natural cycle. Multiple eggs increase the potential availability of multiple embryos (fertilized eggs) for transfer and ultimately increase the probability of conception. The medications required to boost egg production may include, but are not limited to the following: Lupride/Gonapeptyl (gonadotropin releasing hormone-agonist), Antagon or Cetrotide (gonadotropin releasing hormone-antagonist), Menopur, Bravelle or Gonal-F (FSH, follicle stimulating hormone), GMH(combination of FSH and LH, luteinizing hormone), and Choragon or Ovidrel(hCG, human chorionic gonadotropin). Each is administered by injection only. Most medications are given subcutaneously (beneath the skin), though some are intramuscular injections (into the muscle). Risks associated with injectable fertility medications may include but are not limited to, tenderness, infection, hematoma, and swelling or bruising at the injection site. Risks associated with the medications may include, but are not limited to, allergic reactions, hyperstimulation of the ovaries (mild, moderate or severe), failure of the ovaries to respond and cancellation of the treatment cycle.

There are situations that can occur during a stimulation that may necessitate canceling your IVF cycle and stopping treatment for a period of time. This occurs because the ovaries produce either too many or too few eggs in response to drug stimulation protocol. Although we realize that this can be a big disappointment, at times it is necessary to discontinue the use of the medications to avoid the possibility of complications and to afford you the best chance of future success. If canceling the cycle becomes necessary, you will be told to stop your injections. No hCG injection will be given and no egg retrieval will occur. You will be asked to schedule an appointment with your physician to make decisions regarding future treatment cycles.

When ovulation induction medications are used in fertility therapy, the ovaries are coaxed to produce more than one egg to the point of maturity. Consequently, hormone levels of estrogen and progesterone reach much higher than normal values. When the estrogen level becomes mildly to moderately elevated, side effects that may be experienced include, but are not limited to, fluid retention with slight transient weight gain, nausea, diarrhea, pelvic discomfort due to enlarged cystic ovaries, breast tenderness, mood swings, headache and fatigue.

If the estrogen level rises excessively and hCG is administered to trigger final maturation of the eggs, the following more serious complications may result:

Excessive fluid retention with fluid in the abdomen and/or chest cavity;
Thrombosis of arteries and/or veins (formation of blood clots) which may lead to stroke, embolus, or potentially fatal complications;
Abnormally enlarged ovaries, which have the possibility of rupturing or twisting (a surgical emergency)
Any of the three problems listed above may require prolonged hospitalization.

Given the potential for such severe complications, it is important that we carefully monitor the response to these medications. This monitoring also allows your physician to determine when the eggs are ready for the next stage, oocyte (egg) retrieval. Monitoring includes frequent blood drawing for estradiol (estrogen) and possibly progesterone, LH and FSH levels. These blood tests will take place over approximately a twelve-day period. Risks associated with blood drawing may include, but are not limited to:

Pain at the site of needle stick
Tenderness or infection of the skin
Bruising or scarring of the site of blood draw
Development of a blood clot in the vein (thrombosis, thrombophlebitis)

The second portion of the monitoring phase in IVF involves the use of intravaginal ultrasound to track follicular growth. The eggs develop inside fluid-filled cysts of the ovaries called follicles, which enlarge as the eggs mature. Ultrasound studies usually begin after an estrogen response has been measured and continue on a frequent basis until oocyte (egg) retrieval. The ultrasound studies are performed using a vaginal probe. Vaginal sonograms carry no appreciable risk but may cause slight discomfort, particularly as you near the point of ovulation.

Intracytoplasmic Sperm Injection (ICSI)

Through the controlled application of ovarian hyperstimulation, it is current practice to time the retrieval of mature oocytes (eggs) from a woman's ovary. The yield may vary anywhere from one to 30 or more eggs that may be retrieved depending on the responsiveness of the ovaries to the gonadotropins used to stimulate them. These eggs are gathered by the embryologist into an appropriately balanced salt solution and maintained at body temperature (37°C) until such time as they are ready to be inseminated. Meanwhile, a sample of semen containing the sperm destined to be used for each specific set of eggs is collected and processed by cell separation techniques to provide as clean and active a sample of sperm as possible. A major emphasis of the IVF laboratory is directed toward guaranteeing that the correct sperm go with the right eggs through good labeling and check systems. Ultimately, following several hours in culture, eggs and sperm can be mixed and allowed to bind and fertilize in a relatively natural fashion. Depending on the quality and maturity of both eggs and sperm, it is common for fertilization rates to vary considerably relative to the original number of eggs collected. Twenty eggs retrieved in no way guarantees 20 embryos. Likewise, 20 fertilized eggs in no way guarantees that there will be 20 embryos of sufficient quality for both cryopreservation and fresh transfer to the woman's body.

Central to the question of how many embryos are actually utilized in any IVF treatment cycle is the period during which the embryos are cultured in vitro. This can be as little as one day, or up to five in the case of blastocyst growth and transfer. Assuming that culture conditions are relatively optimal, there is less and less reason not to culture embryos throughout their pre-implantation stages to allow the embryos to "select" themselves for transfer or cryopreservation. The blastocyst is the term given to the very last stage of an embryo prior to it implanting into the endometrial lining of the uterus. The poorer the rates of blastocyst growth are, the more restricted the choice of embryo is at this stage of development. In any event, growth of any embryos to the blastocyst stage improves the level of discrimination of embryo viability available to the embryologist, and is key to reducing the numbers of embryos used for uterine transfer. The more confidence a clinic has in the viability of the embryos it transfers, the less need there is for multiple transfers of three or more embryos. Thus with the transfer of three or less embryos, the risk of multiple pregnancies is significantly reduced, in turn minimizing risks of pregnancy loss or fetal abnormalities common in multi-fetal pregnancies.

Micromanipulation is the technique whereby sperm, eggs and embryos can be handled on an inverted microscope stage, performing minute procedures at the microscopic level via joysticks that hydraulically operate glass microtools. Micro-manipulation first saw clinical use in IVF for purposes of assisted fertilization in the treatment of male factor infertility, where fertilization potential was low in cases of poor sperm quality. The ultimate evolution of this approach has been the development of the single sperm injection procedure referred to as Intracytoplasmic Sperm Injection, or ICSI. Sperm of virtually any quality and from any level of the male reproductive tract may be used with the only criterion for use being that the sperm is alive even if it is not moving (motile). Dead sperm may be able to achieve fertilization; however, the DNA or genetic material from such sperm is too degenerate to form a viable embryo. Immature sperm from the testicle or the epididymis can be retrieved for use with ICSI for men who possess no sperm in their ejaculated semen (azoospermia). This azoospermia is either due to an obstruction in the tract (obstructive), or to extremely low production of sperm in the testicle itself (non-obstructive). In certain cases, men may produce sufficient sperm, but they do not survive to the point of ejaculation (necrozoospermia). Consequently, instead of using non-viable sperm from the ejaculate, testicular biopsy will provide a ready source of freshly produced viable sperm.

With the almost unlimited potential to achieve some level of fertilization with ICSI regardless of sperm quality, it would seem that male factor infertility would no longer be of concern. It must be noted, however, that sub-fertility in men can be related to certain numerical and structural defects of the chromosomes and, therefore, there is a strong recommendation for all couples that achieve pregnancies from ICSI to undergo prenatal screening. In certain cases of obstructive azoospermia, there is a higher incidence of cystic fibrosis in the male. Hence, before embarking upon treatment of the more extreme forms of male factor infertility, it is advisable to have some cytogenetic screening performed. Incidentally, very subtle compromise in sperm quality may well be responsible for a marginally lower embryonic viability rate and a slightly higher early miscarriage rate even if such embryos implant. Such observations have led to the suggestion that the technique ICSI itself is at fault; but this misses the point that ICSI per se is not causing the problem, merely facilitating the use of sperm, which under other circumstances would never have even achieved fertilization.

The use of ICSI is now routinely applied to a range of clinical situations wherever there is a possibility that conventional in vitro fertilization may be suppressed or not occur. Such situations include the following: idiopathic or unexplained fertility; hyper-responsive ovarian stimulation cases where egg quality may be reduced; post-thaw sperm samples that survive poorly; post-thaw egg insemination; generation of embryos for pre-implantation genetic screening where embryos "clean" from any extraneous contaminating sperm is needed; or, indeed, any case where there is an extreme need to maximize normal fertilization, for example, when a woman has only a few eggs retrieved. It is possible to "rescue" cases following complete failed conventional fertilization with ICSI. The viability potential of these "late-fertilized" embryos is approximately half of timely fertilized embryos; nevertheless, they do generate successful live births. ICSI has become such a common feature of IVF therapy that it is fast becoming the insemination technique of choice.

Two Lawyers

Two lawyers had been life long friends: they were partners and shared everything , including their hot-blooded secretary . 

One day the secretary announced she was pregnant. They told her not to worry and assured her that they would pay all medical costs and would act as co-fathers when the child was born and provide all expenses thereafter. 

The day of delivery arrived. Both the lawyers were at the hospital pacing the floor in the waiting room. Finally one of them said, "I can't take this, I'm going down to sit in my car and wait there. Please come down and tell me as soon as the child is born!" 

The partner agreed to do that. About an hour later the partner approached the car with a very grave look on his face. 

"What happened ?" asked the waiting car occupant. 

The other partner announced, "They were twins and mine died!"


The Italian Don

An old Italian Mafia Don is dying and he calls his grandson to his bed!"
Lissin-a me. I wanna for you to taka my chrome plated 38 revolver so you will always remember me."
"But grandpa, I really don't lika guns. Howzabout you leava me your Rolex watch instead?"

"Looka here sonnie. Somma day you gonna runna da business.....you gonna have a beautifula wife, lotsa money, a biga home and maybe a couple a bambinos."

"Somma day you gonna comma home and maybe find you wife inna bed with another man.

Whadda you gonna do then....... pointa to you watch and say "Times up"?"

Blastocyst Embryo Transfer

Blastocyst transfer achieved the first IVF human pregnancy. Blastocyst transfer is claimed to be more physiological than pronucleate or cleaved-embryo transfer is as it mimics nature more closely. As the embryo advances in the development, after 5-6 days it becomes a blastocyst(see picture). This has an outer thin layer of cells, which will later form the placenta, and an inner cell mass, which will develop into the fetus. A blastocyst has about 120 cells. A blastocyst gives a better idea of the competence of an embryo and has a higher chance of implantation than a cleaved embryo. In conventional culture medium, about 20% of embryos will develop into blastocysts. Recently, the use of sequential culture medium (the embryos are cultured in different media according to their stage of growth) has enabled a larger number of embryos to develop into blastocysts. However, up to 40% of patients will not grow blastocysts and will not have blastocyst embryo transfer. The rationale behind a blastocyst transfer is that an embryo, which has failed to reach the blastocyst stage, would be unlikely to have resulted in a pregnancy. However, if it reaches the blastocyst stage it has about 50% chance of implanting. So the improved implantation rates following blastocyst transfer is due to selection of the best embryos.
Why then do 50% of the blastocysts fail to implant? A defective blastocyst (e.g. chromosomal abnormalities) is a possible cause; a non-receptive endometrium is another cause. Blastocyst embryo transfer into the uterine cavity is performed about 5-6 days after egg collection. Transfer of one or two blastocysts is recommended to avoid high-order multiple pregnancies. Supernumerary blastocysts can be frozen for future use.
Blastocyst transfer is recommended for patients who had repeatedly failed to achieve a pregnancy following the transfer of good quality cleaved embryos (If the embryo arrests and did not develop to blastocyst, this may indicate a potential egg problem). Patients who wish to achieve a pregnancy without the risk of multiple pregnancies will benefit from a single blastocyst transfer. Patients who do not wish to have their spare embryos frozen for whatever reasons may be advised to have blastocyst transfer. About 10% of the embryos that fail to develop to blastocyst in vitro may have done so if replaced inside the womb on day 2 or 3. Up to 40% of patients will not have blastocysts available for transfer. Freezing spare blastocysts is not as good as freezing cleaved embryos. But, with the advent of Vitrification, high pregnancy rates have been reported from countries such as Spain & Japan. We, at Rotunda have just embarked upon our Vitrification Program, which is as yet in a nascent stage

The Guinness Moms?

It would appear that the quest for motherhood is for some, a desire that fails to subside with age. Empowered by new technologies such as IVF treatments, women are increasingly seeking the assistance of fertility clinics to fulfil their aim of bearing a child when their biological clock has ground to a halt. For single women in Japan, however, this type of assistance is not so easy to come by. Strict laws in the field of surrogacy and artificial insemination are imposed due to the country's traditional approach to human reproduction. As a result, fertility treatment is provided almost exclusively to married couples.
Undeterred, a single 60-year old Japanese woman has taken such restrictions into her own hands. The Times newspaper has reported this week that the woman, who wished to remain anonymous, is now in her fifteenth week of pregnancy after travelling to the United States for fertility treatment. She is believed to be the first and oldest single woman to conceive from a donated egg. The use of donated eggs is strictly limited to married couples under a Japanese medical guideline.
After a series of unsuccessful attempts to find a doctor in Japan willing to handle the pregnancy, Yahiro Netsu, a gynaecologist at The Suwa Maternity Clinic in Nagano, central Japan, has stepped in to help. Speaking to the Associated Press, Mr Netsu confessed that the decision had been a tough one, especially as her age and single status meant that the pregnancy was a high risk and an uncertain future for the child. The gynaecologist, however, was won over by the woman's desire to bear a child in spite of her age. He said:'But she wanted a child, and I decided to do all I can to help her through
expected difficulties'.
Although the pregnancy has yet to reach a happy conclusion, Mr Netsu and his patient should take heart from the birth of a healthy baby boy born last summer to a British woman, aged 62. Dr Patricia Rashbrook, a psychiatrist from Lewes, East Sussex, conceived using a donor egg after her fifth attempt at IVF. Her son, nicknamed JJ, weighed a healthy 6 pounds and 10 ounces. But with the trend for older mothers continuing, it would appear that even Dr Rashbrook has been usurped in the trophy for 'The world's oldest mum'. This accolade is believed to go to a 67-year old Spanish woman who gave birth to
twin boys following IVF treatment last year. She is closely followed by Adriana Iliescu, from Romania, who had a daughter called Eliza Maria in January in 2005 at the age of 66.

Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women, affecting an estimated five to ten percent women of reproductive age in India. For women trying to conceive a child, PCOS is a serious, common cause of infertility - nearly half of all female factor infertility cases can be traced to PCOS. New medical insight into the disease has led to treatment options, including insulin-reducing ovulation medication (Clomiphene, Letrozole, Metformin), dietary changes (low glycemic diet) and surgery (ovarian drilling), which have proven successful and allow many women to overcome PCOS and conceive a child naturally, while reducing the risk of miscarriage. Women who undergo treatment for PCOS but are still unable to conceive naturally often turn to assisted reproductive technologies, including IVF, and experience high pregnancy success rates. At Rotunda, our physicians specialize in this common, yet often misunderstood cause of infertility. We work closely with each patient to understand her specific medical case and personal goals, including weight loss, pregnancy or improving general health, and develop a holistic approach to reach those goals. Oftentimes, the road to overcoming PCOS is not an easy one and it takes a strong commitment from both the patient and the physician. The team at Rotunda is committed to supporting our patients every step of the way. I have just published a monograph on "PCOS" which was released by Anshan Publications (www.anshan.co.uk).
Polycystic ovary syndrome is characterized by anovulation (irregular or absent menstrual periods) and hyperandrogenism (elevated serum testosterone and androstenedione). Patients with this syndrome may complain of abnormal bleeding, infertility, obesity, excess hair growth, hair loss and acne. In addition to the clinical and hormonal changes associated with this condition, vaginal ultrasound shows enlarged ovaries with an increased number of small (6-10mm) follicles around the periphery (PCO like ovaries). While ultrasound reveals that polycystic appearing ovaries are commonly seen in up to 20% of women in the reproductive age range, Polycystic Ovary Syndrome (PCOS) is a estimated to affect about half as many or approximately 6-10% of women. The condition appears to have a genetic component and those effected often have both male and female relatives with adult-onset diabetes, obesity, elevated blood triglycerides, high blood pressure and female relatives with infertility, hirsutism and menstrual problems.
Presently, we do not understand why one woman who demonstrates polycystic appearing ovaries on ultrasound has regular menstrual cycles and no signs of excess androgens while another develops PCOS. One of the major biochemical features of polycystic ovary syndrome is insulin resistance accompanied by compensatory hyperinsulinemia (elevated fasting blood insulin levels). There is increasing data that hyperinsulinemia produces the hyperandrogenism of polycystic ovary syndrome by increasing ovarian androgen production, particularly testosterone and by decreasing the serum sex hormone binding globulin concentration. The high levels of androgenic hormones interfere with the pituitary ovarian axis, leading to increased LH levels, anovulation, amenorrhea, recurrent pregnancy loss, and infertility. Hyperinsulinemia has also been associated high blood pressure and increased clot formation and appears to be a major risk factor for the development of heart disease, stroke and type II diabetes.
There is little agreement when it comes to how PCOS is diagnosed. Most physicians will consider this diagnosis after making sure you do not have other conditions such as Cushing's disease (overactive adrenal gland), thyroid problems, congenital adrenal hyperplasia or increased prolactin production by the pituitary gland. TSH, 17-hydroxyprogesterone, prolactin and a dexamethasone suppression test may be advisable. After reviewing your medical history, your physicians will determine which tests are necessary. If you have irregular or absent menstrual periods, clues from the physical exam will be considered next. Your height and weight will be noted along with any increase facial or body hair or loss of scalp hair, acne and acanthosis nigricans (a discoloration of the skin under the arms, breasts and in the groin). Elevated androgen levels (male hormones), DHEAS or testosterone help make the diagnosis. A two hour insulin and glucose tolerance test will be obtained. Many physicians tell their patients that insulin values are normal, when in fact the value indicates that insulin may be playing a role in stimulating the development of PCOS. Most labs report levels less than 25-30 miu/ml as normal, while in fact, levels over 10miu/ml on a fasting blood sample suggests that PCOS may be related to hyperinsulinism. As women with polycystic ovary syndrome may be a greater risk for other medical conditions, testing for cardiovascular risk factors such as blood lipids should also be carried out.
Traditional treatments have been difficult, expensive and have limited success when used alone. Infertility treatments include weight loss diets, ovulation medications (Clomiphene,Letrozole, Menopur, Gonal-F), ovarian drilling surgery and IVF. Other symptoms have been managed by anti-androgen medication (birth control pills, spironolactone, flutamide or finasteride).
Ovarian drilling can be performed at the time of laparoscopy. A laser fibre or electrosurgical needle is used to puncture the ovary 6-8 times(see picture). This treatment results in a dramatic lowering of male hormones within days. Studies have shown that up to 80% will benefit from such treatment. Many who failed to ovulate with letrozole or metformin therapy will respond when rechallenged with these medications after ovarian drilling. Interestingly, women in these studies who are smokers, rarely responded to the drilling procedure. Side effects are rare, but may result in adhesion formation or ovarian failure if the procedure is performed by an inexperienced surgeon.
For women in the reproductive age range, polycystic ovary syndrome is a serious, common cause of infertility, because of the endocrine abnormalities which accompany elevated insulin levels. There is increasing evidence that this endocrine abnormality can be reversed by treatment with widely available standard medications which are leading medicines used in this country for the treatment of adult onset diabetes, metformin 850 mg two times per day or 1000mg twice daily with meals), Hyponiid (Charak Pharma) (Which is a D-Chiro Inositol containing Indian Ayurvedic Medication) or a combination of these medications. These medications have been shown to reverse the endocrine abnormalities seen with polycystic ovary syndrome within 10-12 months. They can result in decreased hair loss, diminished facial and body hair growth, normalization of elevated blood pressure, regulation or menses, weight loss, reduction in cardiovascular risk factors, normal fertility, and a reduced risk of miscarriage. We have seen pregnancies result in less than 18 months in women who conceived spontaneously at home. By twenty-four months over 90% of women treated with insulin-lowering agents, diet and exercise will resume regular menses.
The medical literature suggests that the endocrinopathy in most patients with polycystic ovary syndrome can be resolved with insulin lowering therapy. This is clinically very important because the therapy reduces hirsutism, obesity, blood pressure, triglyceride levels, elevated blood clotting factors and facilitates re-establishment of the normal pituitary ovarian cycle, thus often allowing resumption of normal ovulatory cycles and pregnancy. We know the polycystic ovary syndrome is associated with increased risk of heart attack and stroke because of the associated heart attack and stroke risk factors, hypertension, obesity, hyperandrogenism, hypertriglyceridemia, and these are to a large degree resolved by therapy with these medications. Side effects are rare. Although metformin, rosiglitazone and pioglitazone lower elevated blood sugar levels in diabetics, when given to nondiabetic patients, they only lower insulin levels. Blood sugar levels will not change. In fact, episodes of "hypoglycemic attacks" appear to be reduced.
When first starting Metformin, people will often experience upset stomach or diarrhea (usually loosely formed stools) which usually resolves after the first couple of weeks. This side effect can be minimized by taking metformin with the heaviest meal of the day and starting with a low dose. I recommend that our patients start with one 850 mg pill daily the first week and increase to twice a day during the second week. Patients with reduced renal function (creatinine >1.5 or creatinine clearance <60%) are at a higher risk for a rare side effect of metformin therapy called lactic acidosis, and the drug should be given cautiously, if at all, to such patients. Patients taking metformin should notify their physician and discontinue the medication. Pioglitazone or Rosiglitazone belong to a class of medications called PPAR gamma agonists. They enhance the ability of smooth muscle to metabolize sugar, thereby reducing insulin resistance. The FDA has recently reviewed the safety of troglitazone (and reports that 35 patients out of approximately 1.5 million have either died or required liver transplant.) Therefore Troglitazone has been removed from the market. As the new alternatives to Troglitazone, Rosiglitazone and Pioglitazone are metabolized by different liver enzymes, experience has shown that these medications appear to pose minimal risk of hepatotoxicity.
Transvaginal follicular studies are done to determine if you are ovulating.You will be asked to return three months after initiating therapy. If you have ovulated, therapy may be continued another three months to see if you will conceive. Re-evaluation will include measurements of lab tests that were abnormal at the initial evaluation. If the laboratory studies are still abnormal, metformin may be increased up to 1000 mg three times daily or rosiglitazone may be substituted alongwith addition of higher doses of Hyponiid. If the laboratory studies are normal but ovulation has not occured, a trial of letrozole may be considered. We have seen that women who were unable to ovulate on up to 250 mg of clomiphene ovulate when very low doses of clomiphene or letrozole are used in conjunction with metformin or PPARgamma therapy. Laparoscopic ovarian drilling may be considered for those women where other indications for laparoscopy are present.
While safety during pregnancy has not yet been established, reports have been published of patients who continued on metformin during their entire pregnancy and one who remained on a glitazone have delivered normal babies. There are no reports of abnormal babies in women who conceived using metformin and all resulting babies were normal. Metformin is a category B medication. This means that insufficient human data is available but no credible animal data suggesting a teratogenic (could produce birth defects) risk. Although to the best of our present knowledge the risk of birth defects would be small, it must also be noted that maternal diabetes has been associated with an increased risk of birth defects and the underlying elevated insulin levels may lead to birth defects if not corrected.
While the most prudent policy may be to avoid the use of these medications during pregnancy until more data on pregnancy outcome is available, the risk of miscarriage may be reduced by continuing metformin during the pregnancy. Women with PCOS who conceive either spontaneously or after ovulation induction have a much higher risk of miscarriage. Hypersecretion of LH was thought to cause chromosomally abnormal eggs leading to an increased risk of miscarriage. But a Japanese study found that PCOS was more common in women whose prior loss was associated with normal chromosomes. Others have suggested that high androgen levels may be a contributory factor. Homburg has shown that miscarriage rates after ovulation induction or IVF is decreased when women are pretreated with a GnRH-agonist such as Synarel, Lupron or Zoladex.
Hyperinsulinemia may be a contributing factor in the higher rate of miscarriage. Elevated levels of insulin interfere with the normal balance between factors promoting blood clotting and those promoting breakdown of the clots. Increases in plasminogen activator inhibitor activity (PAI) associated with high insulin levels may result in increased blood clotting at the interface between the uterine lining (endometrium) and the placenta. This could lead to placental insufficiency and miscarriage.
There are no placebo-controlled clinical trials to indicate whether pregnancy outcomes are improved in pregnancies that result from the use of insulin-lowering medications or whether pregnancy outcomes are better in those who continue metformin throughout the pregnancy or those who discontinue. At present there is insufficient data to routinely advise continuation of metformin during pregnancy. As an alternative to continuing metformin therapy, those women with increased risk of abnormal blood clotting may benefit from baby aspirin, folate supplementation and low molecular weight heparin therapy.

Grandfather Semen Donor

A 72-year-old grandfather will be allowed to act as a sperm donor for his infertile son and daughter-in-law, effectively making any resulting child his father's biological half brother. Although theoretically not illegal, according to the Human Fertility and Embryology Authority, is thought that this is the only time such a case has arisen the UK. The decision to allow the couple to use the grandfather as a sperm donor follows many months of consultation with independent bodies and ethics
committees, says Kamal Ahuja, co-medical director of the London Women's Clinic where the couple are being cared for.Ahuja believes that the couple's wish to have a child that is similar to their own identity is understandable. 'We have made the decision on the basis that the couple have special requirements in that the donor sperm in not acceptable to them', he told the Guardian, UK newspaper. 'That applies to many, many groups of people - some religions [such as Islam] don't condone the use of donor sperm. In this particular case there was a mixture of reasons'.
A spokeswoman for the Human Fertilisation and Embryology Authority (HFEA), which regulates the fertility sector, said it did not need to approve the decision. Donations from family members - such as sisters giving each other their eggs - are allowed under the law, she said. Once a donor has consented to the use of his sperm for fertility treatment, he has no legal or parental rights over any children born using his sperm. Upon reaching the age of 18, the child has the right to find out the identity of their donor father.
However the national sperm donation programme accepts only men aged under 45, raising concerns over the increased risks of miscarriage and genetic mutation associated with the raised paternal age. Allan Pacey, of the British Fertility Society, told the Times London: 'I am sure the couple will have been apprised of the risks, but in my view this is unwise. There is a very
real possibility that this will not work, and the chances of miscarriage are also raised. The chances of a genetic defect or illness become greater too. You could say that if everybody is happy they should go ahead, but God forbid if there if there's a child born with a problem. It would be delicate to explain to that child that it might be the result of its grandfather's
72-year-old sperm'.
According to the BBC, the couple, who are in their 30's and have chosen to remain anonymous, have not yet decided whether they will tell the child the true identify of his or her biological father, although the clinic is positively encouraging them to do so. Any baby born using the sperm would be the grandfather's genetic child and its father's half brother. Preliminary tests suggest the sperm is viable - it is not uncommon for men to continue to produce healthy sperm into their 70s and 80s.Keeping the identity of the child similar to their own was a huge factor. The husband said"Society has also changed its perceptions of what is and what is not acceptable. In this case, keeping the identity of the child similar to ourown was a huge factor. I do not have a brother, which is why I chose my own father to assist."

Empty Follicle Syndrome

The Empty Follicle Syndrome (EFS) is a frustrating condition in which no oocytes (eggs) are retrieved at IVF, even though ultrasound and estradiol measurements showed the presence of many potential follicles. The mechanism responsible for EFS remains obscure. Many hypotheses have been put forward, but none truly explain this syndrome. The most likely cause of EFS is ovarian ageing, as many patients who suffer from EFS are also poor responders. If an EFS cycle does occur during your treatment, please make sure you discuss it thoroughly with your fertility physician. EFS is an infrequent event and has been estimated to occur in between 2 - 7% of IVF cycles. However, the overall risk of recurrence in later IVF cycles is 20% and the risk of recurrence is higher as the age of the patient increases.

To date, Empty Follicle Syndrome (EFS) has only been reported in GnRH agonist down-regulated IVF cycles. Some cases have been successfully treated by changing the batch, or by repeating the dose of hCG. A case of EFS was reported recently on PubMed in both GnRH antagonist and GnRH agonist down-regulated IVF cycles when final oocyte maturation was triggered using urinary hCG (u-hCG). Failure to retrieve oocytes occurred, despite administration of a further dose of u-hCG from a different batch and a delayed repeated oocyte recovery performed in the second GnRH agonist down-regulated cycle. A successful oocyte recovery cycle was achieved after triggering of an endogenous gonadotrophin surge using GnRH agonist in an antagonist down-regulated cycle. Nine oocytes were readily retrieved from 10 follicles, at 36 h after GnRH agonist administration, and eight of these fertilized normally. Two good quality embryos were used for fresh transfer and four were cryopreserved for future use. The authors concluded that EFS can occur in GnRH antagonist down-regulated IVF cycles, and can be successfully treated by triggering a natural gonadotrophin surge using GnRH agonist in the absence of any response to previous treatment methods. This represents a novel therapeutic modality for this uncommon but frustrating condition.

Another paper reports experience with three IVF cycles in which no oocytes were collected. In all cases, an additional IVF cycle was performed. The ovarian stimulation protocol, ultrasound and hormonal surveillance methods, human chorionic gonadotrophin timing and oocyte retrieval technique were similar in all patients. The assessment of additional cycles demonstrated a poor response in terms of oocyte quality, since the number of mature oocytes was low despite the high number of oocytes collected. Thus, the data suggest that in these patients, EFS should be considered as a borderline form of poor response to ovarian stimulation. If this is confirmed, EFS should be a recurrent event and an empty cycle could be a good predictor that a subsequent stimulated cycle will be an unfavourable.

A group from UK recently reported five cases in which no oocytes were retrieved after standard ovarian stimulation for in-vitro fertilization (IVF), and in which it was found that mistakes had been made at the time of human chorionic gonadotrophin (HCG) administration. In all five cases, oocyte retrieval was achieved after injecting HCG, when necessary, and reprogramming aspiration 24–36 h later. A mean of 7 ± 3.2 MII oocytes were recovered per patient and 3.2 ± 0.8 embryos were transferred. Three clinical pregnancies were obtained, and four healthy infants were born. In their program, these were the only cases of empty follicle syndrome (EFS) that appeared over a total of 1118 cycles, and were all explained by human error in the administration of HCG. Our experience too shows that human error could be considered a significant factor in the aetiology of empty follicle syndrome, and that EFS may be in part avoided by taking simple preventive measures.

A novel method of rescuing empty follicle syndrome (EFS) was recently published and provides evidence that it is a drug-related problem rather than a clinical dysfunction. In a preliminary study the authors from UK established that in EFS the serum beta-human chorionic gonadotrophin (beta-HCG) concentrations 36 h after HCG administration never exceeded 10 mIU/ ml. beta-HCG concentrations were thus used to confirm EFS when oocytes were not retrieved from one ovary after controlled ovarian hyperstimulation. The procedure was suspended leaving intact all follicles in the second, ovary. After confirmation of EFS, a second HCG from a different batch was administered and 36 h later mature oocytes were retrieved from the intact ovary, suggesting a fault with the HCG previously administered. Three patients have been treated in this way. In the first case, four out of five mature eggs were fertilized after intracytoplasmic sperm injection (ICSI) resulting in the transfer of three top grade (grade 1) embryos. In the second case all seven mature oocytes fertilized after in-vitro fertilization (IVF) and three grade 1 embryos were transferred resulting in a twin pregnancy, now delivered. In the third case, five out of nine oocytes were fertilized after ICSI and one out of the three treated with high insemination concentration IVF fertilized, resulting in the transfer of three ICSI embryos.

We suspected hCG batch-to-batch consistency a couple of times with our own cases, but could never confirm the above. Would love other clinics to post their experiences here.

Weekend Punjabi Puttar Joke

Bill Gates was looking for a new Chairman for Microsoft Europe and
organized an enormous session to interview a suitable candidate.

5000 hopeful candidates assemble in a large room. One candidate is Santa
Singh.

Bill Gates thanks all the candidates for coming and then asks all those who
do not know JAVA to leave.

2000 people leave the room.

Santa says to himself, "I do not know JAVA, but I have nothing to lose if I
stay. I'll give it a try".


Bill Gates asks the candidates who have never had experience of managing
more than 100 people to leave.

Another 2000 people leave the room.

Santa says to himself "I have never managed anybody by myself, but I have
nothing to lose if I stay. What can happen to me?" So he stays.


Then Bill Gates asks candidates who do not have management diplomas to
leave.

500 people leave the room.

Santa says to himself, "I left school at 15, but what have I got to lose?"
So he stays in the room.


Lastly, Bill Gates asks the candidates who do not speak Serbo - Croat to
leave.

498 people leave the room.

Santa says to himself, "I do not speak a singlr word of Serbo - Croat, but
what do I have to lose?"
So he stays and finds himself with one other candidate.


Everyone else has gone. Bill Gates now joins them and says
"Apparently you are the only two candidates who speak Serbo - Croat, so I'd
now like to hear you have a conversation together in that language."

Calmly, Santa turns to the other candidate and says "Hor Paape, ki haal
chaal?"

The other candidate answers "O vadiya veere, tu sunaa". Bolo Ta Ra Ra Ra:)

Tubal Transfer Procedures

The Tubal Embryo Transfer (TET) procedure involves the transfer of embryos that are more advanced in development than those in ZIFT i.e. cleaved embryos. The aim is to achieve fertilization in-vitro (in the laboratory) and then replace the cleaved embryos in the Fallopian tube, the normal site for fertilization. It is suitable only for women who have at least one healthy Fallopian tube. TET is carried out as a day-case procedure under a general anesthetic, using laparoscopy(see picture). You may experience some abdominal discomfort and pain for a few days after the procedure, but painkillers can relieve this. The main groups of patients selected for TET procedure are women who are keen to have gamete intra-Fallopian transfer (GIFT) but where there is doubt about the chance of fertilization, and women who encountered difficulties in previous embryo transfers through the cervix. The success rate for TET is in the region of 25-40% per embryo transfer, but varies depending on many factors such as the woman's age and the number of embryos transferred, etc.

The ZIFT procedure involves the transfer of embryos (zygotes) into the Fallopian tube 24 hours after fertilization. The aim is to achieve fertilization in-vitro (in the laboratory) and then replace the early embryos in the Fallopian tube, the normal site for fertilization. ZIFT offers the best of both IVF and GIFT procedures. It is suitable only for women who have at least one healthy Fallopian tube. ZIFT is carried out as a day-case procedure under a general anesthetic, using laparoscopy. You may experience some abdominal discomfort and pain for a few days after the procedure, but painkillers can relieve this. The main groups of patients selected for ZIFT procedure are women who are keen to have gamete intra-Fallopian transfer (GIFT) but where there is doubt about the chance of fertilization, and women who encountered difficulties in previous embryo transfers through the cervix. If the quality of the embryo's in a preceding IVF cycle was poor, some fertility specialists will advise the patient to have ZIFT rather than IVF.

Gamete Intra-Fallopian Transfer (GIFT) is a procedure in which the eggs are mixed with sperm and the mixture is then injected into the Fallopian tube. It is suitable for women who have at least one healthy Fallopian tube. The aim of GIFT is to allow fertilization to occur in the right place and implantation at the right time. There are selected groups of patients to whom gamete intra-Fallopian transfer (GIFT) is recommended:
a)Couples with unexplained infertility.
b)Women with minimal endometriosis.
c)Men with infertility problem (not severe).
d)Couples who have had failed donor insemination.
e)Where transcervical embryo transfer is impossible and the patient has one healthy tube.

The procedure is carried out as a day case surgery under a general anaesthetic, and involves making three small cuts in the abdomen. Fertility drugs are used to stimulate the ovaries, monitoring is also carried out as with IVF treatment. Eggs may be collected either by a vaginal ultrasound scan or laparoscopically using a fine needle and gentle suction.Once the eggs are collected, they are examined under the microscope for quality. The best eggs are then mixed with washed and prepared sperm in a small volume of culture medium. The end of the fallopian tube is grasped gently and a guided fine canula is passed through the fimbrial end of the tube(see picture). The mixture of the eggs and sperm is then deposited into the Fallopian tube. In most cases, three or four eggs are usually transferred per cycle. Any spare eggs that are collected may be fertilized in-vitro and the resulting embryos are frozen (if they are of good quality to freeze) for later embryo replacement. After the GIFT procedure, the patient is usually given hormonal supplements, in the form of tablets, pessaries, gel or injection to help the implantation of embryos.The success rate after GIFT is similar to that of in-vitro fertilization (IVF) treatment. Some specialists claim a higher success rate with GIFT compared to IVF.

More recently, attempts have been made to simplify the procedure by collecting the eggs by vaginal ultrasound and injecting the egg and sperm mixture into the tube via the cervix using a special catheter. The procedure is usually performed under ultrasound guidance. The reported pregnancy rates with this method are less than that with conventional laparoscopy GIFT.

Last week, we did a big Tubal Transfer Procedures Workshop at the Prince Aly Khan Hospital IVF Center (www.testtubebabyclinic.com) where we performed the above procedures on 9 patients. We have made a teaching DVD of the same to teach post-graduates which will be released at the World Congress on Fallopian Tubes to be held at Kolkata from 18-21 October 2007. You can access the meeting homepage on www.sisab.net/tubes2007

Frozen Embryo Transfer

Embryo freezing is a well-established form of assisted conception treatment. An increasing number of IVF clinics worldwide are now able to freeze spare embryos for later transfer. The first frozen embryo baby was born in 1984. Embryo cryopreservation allows multiple embryo transfers from a single egg collection and improves the chances of livebirth. Amongst the advantages of embryo cryopreservation are maximizing the potential for conception for IVF and prevent wastage of viable normal spare embryos. Perhaps this is the most important advantage of cryopreservation. Approximately 50% of women may have spare embryos available for freezing. In some clinics, the pregnancy and live birth rates with frozen-thawed embryo transfer is as high as those achieved with fresh embryo transfer. Freezing all embryos for subsequent transfer may be advised for women who are at a high risk of developing severe ovarian hyperstimulation syndrome following ovarian stimulation for in-vitro fertilization (IVF).

Embryo Freezing is also resorted to when embryo implantation may be compromised in cases such as the presence of endometrial polyps, poor endometrial development, break through bleeding near the time of embryo transfer or illness as also difficulty encountered at fresh embryo transfer e.g. cervical stenosis (inability to pass through the cervical canal because the cervix is narrowed or scarred, etc). Cryopreservation of embryos is very important to be incorporated in the egg donation programs. It is not always possible to synchronize the recipient’s cycle with that of the egg donor. In some countries, it is mandatory to freeze all embryos created from donated eggs, quarantined for a period of six months and until the donor have a repeat negative screening tests. As a result of successful cryopreservation programs, frozen embryos have also become available for donation to infertile couples.

Embryos can be frozen at any stage (pronucleate, early cleaved and blastocyst) if they are of good quality. Embryos are stored in batches of one or more embryos depending on the number of embryos that are likely to be transferred into the uterus at a later date. Embryos are mixed with a cryoprotectant fluid (to protect embryos from damage during freezing process). Then, the mixture is put either in a plastic straw or a glass ampoule and stored in liquid nitrogen at a very low temperature –196°C using a specialized programmable machine. Thawing of embryo involves removing the embryos from the liquid nitrogen, thaw at room temperature, remove the cryoprotectant fluid and mix the embryo in a special culture media. The mixture is then kept in the incubator ready for transfer.

If the embryos were frozen at cleaved stage or blastocyst, they can be thawed and replaced in the same day. However, if they were frozen at the two-pronucleate stage, then they are thawed on the day before and cultured overnight to allow them to divide and are replaced when they become 2-4 cell embryo (s). Different countries have different regulation concerning the length of time that embryos can be frozen. In the United Kingdom, embryos can be stored for a maximum of 10 years. India is yet to define the upper limit of storage.

The first step to transfer embryos from one centre to another is to write to the centre which has the couple's embryos stored in order to release the embryos. Consent from both partners is required. The couple will need to take responsibility of the embryos once they leave the center. The embryos are transferred using a small liquid nitrogen container specially designed.
Not all embryos survive the freezing and thawing process. In a good freezing program, a survival rate of 75-80% should be expected. Therefore, it may be necessary to thaw out several embryos to get two or three good embryos to replace. Damage of embryos does occur as a result of freezing, not during the storage but during the cooling and thawing process. It is important that both the couple and the clinic to keep in contact with regard their frozen embryos. Most IVF clinics will send an annual reminder letter to patients who have frozen embryos stored.

The letter usually offer a couple five choices:

Continue storage for a further period of time.
Arrange for embryo transfer treatment cycle before the expiry date.
Allow embryos to perish by interfering with the thawing process.
Donate embryos to ethically approved research.
Donate embryos to infertile couple.

Frozen/thawed embryos may be transferred into the uterus in a natural cycle, a hormone replacement cycle or a stimulated cycle. In general, the three methods have similar pregnancy and live birth rates. A Natural cycle is usually recommended in young women with regular menstrual cycles and ovulation. It involves serial ultrasound scans to check the development of the follicle and endometrium, blood tests to check the levels of hormone LH, estrogen and progesterone. Embryo transfer is usually performed about 3-4 days after the LH surge (2-3 days after ovulation). The woman is given no drugs until the day of embryo transfer. On the day of embryo transfer, the woman may start a course of progesterone pessaries or tablets to support the luteal phase. Natural cycles have the advantages of a naturally prepared endometrium and reduced cost. The disadvantages of natural cycle frozen embryo transfer is the risk of failure of ovulation. Also, the date of ovulation can not be predicted.

Hormone replacement cycle with or without GnRh agonist is usually recommended for older women, woman without ovaries or non-functioning ovaries, women with irregular infrequent menstrual cycles or ovulation. It involves giving estrogen in the form of tablets or skin batches and later adds progesterone in the form of tablets, pessaries, gel or injection. Different IVF clinics have different protocols for giving these medications and in some women GnRh agonists may be given in addition to hormone replacement to "switch off" any hormone production by the ovaries which may interfere with the treatment. After embryo transfer, both estrogen and progesterone are continued until the pregnancy test. In the test is positive, the woman should continue the medication for a further 8-10 weeks. Hormone replacement cycle allows accurate programng the date of embryo transfer and ensures that the endometrium is adequately prepared to receive the embryos.

Stimulated cycle is where fertility drugs such as clomifene tablets or FSH injection is given aiming to produce one or two follicles. When the follicle is mature and the endometrium developed satisfactorily, hCG injection is given to induce ovulation. Embryo transfer is usually performed 2-3 days after the ovulation. This regimen is usually recommended for women do not ovulate regularly and did not respond to hormone replacement treatment in a previous cycle.

The success rates depend on many factors; mainly the woman’s age and number of embryos transferred. The outcome of pregnancies resulted from frozen embryo transfer is similar to fresh embryo transfer in the incidence of biochemical pregnancy, blighted ovum, early and late miscarriage, ectopic pregnancy, preterm deliveries and term deliveries. To date there is no evidence that babies born after frozen embryo transfer have any increased incidence of congenital abnormality.

There are several ethical and moral issues surrounding the embryo freezing process. These include the following:

Fate of the stored embryos on the death of couple - 'orphaned' embryos.
Ownership of the embryos if the couple divorce.
Safety of embryo freezing.
Concern that the length of time embryos have been kept in storage might have a detrimental effect on the outcome of frozen embryo transfer and possible increase in fetal abnormalities. However, no long-term studies have been carried out since the age of the oldest child born as a result of frozen embryo transfer is only 14 years. In addition, there is no evidence that extended storage is detrimental to the outcome of treatment.

Trans-rectal Electro-ejaculation (TREE)

Trans-rectal electroejaculation (TREE) technique is used to collect semen from men who are unable to ejaculate. The technique has been used in animals since 1930s and in man since 1948 onwards. The aim of trans-rectal electroejaculation (TREE) is to directly stimulate the seminal vesicles. There are selected groups of patients for whom trans-rectal electroejaculation (TREE) is recommended. The majority of spinal cord injuries are among young men. About 5% of these men are likely to achieve pregnancies with their partners without assistance. The loss of fertility in these men is due to a decline of sperm quality, impotence and ejaculatory failure. About 50% of them may able to achieve ejaculation with the use of penile vibrators. Men who are unable to ejaculate by other means, should be offered rectal electroejaculation. Sexual dysfunction is common in insulin dependent diabetics. Trans-rectal electroejaculation (TREE) may be advised for men who are unable to achieve erection and ejaculation. Men with multiple sclerosis who are unable to achieve erection and ejaculation will also benefit from TREE. Men who are impotent and or unable to ejaculate because of psychosexual problems may be offered rectal electroejaculation after failed psychosexual treatment.

The procedure is performed as a day case surgery usually under a short general anesthesia. However, in men with spinal cord injury (SCI) it may be performed without anesthetics (although about 5% of these men may require a general anesthesia. The procedure takes about 15 minutes. The man usually lies on his right side. A metal or plastic tube (proctoscope) is lubricated and inserted into his rectum to inspect the lining of the rectum (see picture). A special probe is inserted into the rectum, the probe is attached to an electric stimulation power unit through which electric stimulation is delivered(see picture). The power is increased gradually until ejaculation occurs. At the same time an assistant will apply massage to the prostate gland and milk the urethra to obtain the ejaculate. At the end of the procedure, another proctoscope is inserted to check for any burn injury in the rectum caused by the hot rectal probe. Like any surgical procedure there are a few potential problems. Autonomic hypereflexia (very high blood pressure) is a potentially severe complication to any spinal cord injured man. Because the normal defenses which protect against a sustained high blood pressure during orgasm are lost. This can have serious consequences such as brain hemorrhage. For this reason, SCI men are usually given pills to lower their blood pressure before they undergo trans-rectal electroejaculation (TREE). Other problems that may occur include burn injury and complications associated with the general anesthesia.

After sperm preparation the fresh sperm is then used for treatment such as insemination, IVF or ICSI depending upon the sperm count and quality. Alternatively the semen sample is frozen for future use. Treatment options will depend upon the sperm count and quality. Other factors such as the fertility of the female partner and the duration of infertility, etc. will also influence the treatment options available. The options include the following:

Intrauterine insemination (IUI)

Intrauterine insemination (IUI) with washed and prepared sperm. This will be advised if the sperm problem is mild and the female partner is young, has regular menstrual cycles and ovulation, and has healthy patent Fallopian tubes. A pregnancy rate of 5-10% per treatment cycle is expected, depending on many factors such as the woman’s age and treatment cycle number, etc.

IVF (In Vitro Fertilization)

In-vitro fertilization (IVF) is usually advised if the female partner is 35 years or older, has blocked or damaged Fallopian tubes or severe endometriosis and the male partners sperm count or quality is not suitable for IUI.

ICSI (Intra-cytoplasmic Sperm Injection)

Intracytoplasmic sperm injection (ICSI) is advised when there is a severe sperm problem, i.e. sperm is not suitable for standard IVF treatment.

Recent advances in assisted conception such as IVF and ICSI have made it possible to achieve pregnancies and live births with ejaculate containing just a few sperm.