FAQs

• Infertility:A couple is usually considered to be infertile when pregnancy has not occurred after one year of unprotected intercourse.
• Primary infertility: Inability to conceive within one year of marriage by regular unprotected intercourse.
• Secondary infertility:Inability to conceive within one year of regular unprotected intercourse, after having first pregnancy.

When it comes to various issues of assisted reproduction, it is very normal that person has lots of queries. These queries are related to various facets like causes of infertility, when couple should consult doctor, success rate of treatment, safety of the mother, legal issues etc. We try our best to provide maximum guidance with regards to these questions and have selected some most often asked questions and have tried to answer them for your ready reference. Should you have any further queries, please feel free to discuss with us or email us, we will try to respond as best as possible.

When should the couple start their investigation and treatment after marriage? 
It is estimated that about 90% of couples will achieve pregnancy in the first year & 95% in two years. Therefore, a couple should start investigation and treatment if there is no pregnancy within one year of unprotected intercourse.

Causes of male infertility: Male infertility is caused by

1. Abnormal sperm production and function

1. Oligozoospermia:count less than normal is called oligozoospermia.
2. Asthenozoospermia:decreased motility of sperms is called asthenozoospermia.
3. Teratozoospermia: abnormal structure of sperms is called teratozoospermia
4. Azoospermia: absence of sperms in semen is called azoospermia.Usually the above abnormalities are present in various combinations. These abnormalities are caused by following defects in male reproductive system.

Undescended testis: occurs when the testis fails to descend from the abdomen into the scrotum during fetal life. This leads to total absence of sperm production.

Varicocele:This consists of dilated and tortuous testicular veins that contain stagnated blood. This leads to impaired sperm production in testes.

Hydrocele: This consists of collection of fluid in coverings around the testis. This may lead to impaired sperm production.

Infection of testis (orchitis): This can be caused by sexually transmitted diseases, prostatitis, urethritis, etc.

Genetic diseases:Chromosomal disorder like Klinefelter’s syndrome having 47xxy karyotype can cause low sperm count or azoospermia.

Sperm antibodies: Sperm antibodies can form in individual’s blood that can lead to infertility.

Investigations:
History & examination:Male partner is interviewed and examined by the infertility specialist. Examination of genital system is done and necessary investigations are advised.

Semen analysis: Semen analysis is the most important and easy investigation for male partner. You should have abstinence of at least three days before giving semen for examination. Semen is usually given by self manipulation (masturbation) in a sterile semen collection container in laboratory. Laboratory usually has well maintained semen collection room with adequate privacy.

Analysis of semen usually includes the following components: Sperm volume is the total amount of semen in a single ejaculation. Sperm concentration is the number of sperms present in one ml of semen. Sperm motility is the ability of sperm to move. Morphology indicates the structure of sperms.

Evaluation of male hormones: Testosterone, Follicle stimulating hormone (FSH), Luteinising hormone (LH), Prolactin (PRL), Dehydroepiandrosterone sulphate (DHEAS)

Other hormones: Thyroid hormones (T3, T4, TSH), Prolactin

Scrotal sonography & Color Doppler: this can diagnose hydrocele, hernia or varicocele.

Testicular biopsy: when semen analysis shows absent sperms in repeated semen samples and testicular size is normal, then testicular biopsy is usually indicated to know the cause of azoospermia. In this procedure a small piece of one or both testis is taken for histopathological examination under local or general anesthesia.

Genetic karyotyping: This test is done when some genetic disorder is suspected in male partner or in patients with severe sperm defects. This is also requires before proceeding for IVF or ICSI.

What are the minimal semen requirements for male fertility?

Minimal requirements for male fertility:

Semen volume: more than half ml
Sperm concentration: more than 20 millions/ml
Total sperm count: more than 40 millions/ml per ejaculate
Motility:more than 50% sperms having grade 3 to 4 motility (forward progression)
Morphology: more than 30% normal sperms

Changing the life style:

1. Reduction of mental & physical stress by stress relaxation exercises like yoga, meditation, swimming, outdoor games, etc.
2. Stop using tobacco, alcohol, recreational drugs and anabolic steroids.

Treatment of abnormal sperm production or function:

Fertility drugs: These are given to increase sperm production and motility
Hormone replacement therapy: to correct hormonal problems.
Antibiotics: to treat infections
Surgical treatment: varicocele is corrected by venous ligation and embolisation.
Treatment of hormonal problems: Hormone replacement therapy

Treatment for erectile dysfunction:

• Oral medications like sidenafil, vardenafil, tadalafil
• Urethral suppositories
• Vacuum devices
• Penile implants involve surgical insertion of malleable or inflatable rods or tubes into the penis under anesthesia
• Vascular reconstructive surgery
• Venous ligation

Treatment of azoospermia due to vassal or epididymal blocks 
When semen analysis shows absent sperms but testicular biopsy shows production of sperms in testes then various surgical sperm retrieval techniques are used to retrieve the sperms from testes or the collection system. ICSI treatment is done with these surgically retrieved sperms to achieve the pregnancy. These techniques are:

• Testicular sperm aspiration (TESA)
• Testicular sperm extraction (TESE)
• Percutaneous epididymal sperm aspiration (PESA)
• Microepididymal sperm aspiration (MESA)
• Vas deferens aspiration
• Spermatocele aspiration

Females are termed infertile when they are unable to ovulate or when they have obstructed or damaged fallopian tube or uterus. Pelvic inflammatory diseases like tuberculosis or sexually transmitted diseases (STD), endometriosis, fibroids or tumors, surgeries like appendiectomy, birth defects or abnormally shaped uterus like bicornuate or septate uterus can cause infertility in females.

What is unexplained infertility? 
When there are no obvious causes of infertility in the couple even after complete investigation, it is termed as unexplained infertility.

The success of conception depends on causes of infertility in a couple, age of female partner, number and grade of embryos transferred, experience of treating doctors, IVF lab standard and many other factors. In our center, the success rate is 50 to 60% pregnancy having attained with ICSI, practically over-ridding male factor. This success rate is comparable with worldwide success rate of IVF– ICSI.

Success rate of IVF-ICSI depends upon the age, general condition of female partner, cause of infertility in couple, response to fertility drugs, number of eggs retrieved and fertilized, number of embryos transferred, condition of uterus, laboratory standard and experience of center.

a) Maternal age: Success rate of IVF-ICSI decreases with increasing maternal age as number of eggs produced and their fertilization rate decreases with increasing age. Success rate of IVF-ICSI is 60% for women in age group of 25 to 35 years, where as it is 18% for woman in the age group of 40 to 45 years.

b) Cause of infertility: This is another important factor deciding the outcome of IVF-

ICSI cycle. Highest success rates are found in patients having tubal damage with good uterine cavity and lowest among those with male factor infertility. Infection of uterus causes adhesions or scarring in uterine cavity or decreased endometrial thickness that can cause implantation failure. Also general ill health, debility and systemic diseases decrease the chance of conception.

c) Failure of response to drugs: In spite of giving daily injections of fertility drugs some patients respond poorly to produce sufficient number of eggs. This can be due to increasing age of patient or resistance to the drugs.

d) Failure of fertilization: Failure of fertilization may be due to poor quality oocytes, sperms, genetic diseases or improper culture conditions in the laboratory.

e) Number and grade of embryos transferred: Pregnancy rate increases with increasing number of grade 1 embryos transferred. But this also increases the risk of multiple pregnancies. Good quality grade 1 embryos have good potential for implantation and further development than grade 2, 3, 4 embryos.

f) Embryo cryopreservation: Cryopreservation of excess embryos increases the cumulative pregnancy rate in a given IVF-ICSI cycle. It also decreases the cost of treatment and risk of multiple pregnancies. Now day’s embryo freezing is an integral part of IVF-ICSI cycle.

g) Genetic disease: : Genetic diseases in a couple can cause fertilization failure, cessation of growth of embryo or abortion. Karyotyping of couple, at least in high risk cases, is necessary before IVF- ICSI treatment to rule out genetic diseases.

h) Male factor infertility: Extremely low sperm count, impaired motility or poor sperm morphology represent main causes of failed fertilization in conventional IVF. Now days these factors are tackled by ICSI to some extent.

Men with sound medical health and known fertility can donate their semen for IUI, IVF or ICSI procedures after submitting his written consent for the same. They should be between 25 to 45 years of age and should not have had any past history of infectious diseases. They are required to submit their infectious diseases evaluation report, semen analysis and general health analysis report, which should include a complete physical examination done and certified by a registered medical practitioner. For infectious disease evaluation, the donor is required to be tested negative for Hepatitis B, C antibodies, HIV 1 and 2 antibodies, Trichomonas, Candida, Cytomegalovirus and HTLV-I. Three semen samples of the donor is taken at regular intervals of 3-4 weeks and is tested for volume, pH, count, motility, abnormality, pus cells, agglutination and particulate matter. His semen analysis is required to match with the normal semen parameters of WHO. The donor semen tested should maintain the quality standards in his three trial attempts and only then he is recruited on our lists of semen donors. The donor should be willing to undergo the infectious diseases evaluation tests as well as semen analysis tests every three months. If he fails to do so or if the results tend to become substandard, he is eliminated from our list of regular donors. When and for whom is cryopreservation necessary? Firstly, cryopreservation is of utmost advantage to couples whose male partner is not always available during his spouse’s ovulation period i.e., when the husbands work away from their homeland or when the husbands are unable to produce semen sample when it is required. It is also beneficial to those husbands who have to undergo chemotherapy. In such situations freezing of husband’s semen is beneficial so that during his wife’s ovulation time his frozen semen after thawing can be used for IUI, IVF, or ICSI as the case may be. Secondly, after the process of super ovulation, women tend to develop oocytes that are more than sufficient for one cycle. Usually one to three embryos are replaced per IVF cycle. In centers which do not have cryopreservation facilities, the remaining would remain non-utilized and hence wasted. With cryopreservation, excess embryos can be preserved so as to transfer them for future embryo transfer cycles. In this way the female can avoid undergoing frequent ovarian stimulation, avoid the risk of multiple gestation and it would also prove cost beneficial. Frozen specimen is also easy to transfer to other locations if the patients prefer to get embryo transfer done at their new location. What is the survival rate of the specimen after the freezing procedure? Freezing and thawing does reduce the number of viable cells and so, the total count of the spermatozoa tends to become less after thawing. At our center, 70-80% of fertilization has been attained using cryopreserved spermatozoa. Cryopreserved embryos also have the tendency to get degraded; however, we regularly cryo-preserve the embryos and we are getting good pregnancy and take home baby rate. Pregnancy rates of 50% per IVF cycle can be achieved with use of frozen thawed embryos which is comparable with pregnancy rate of fresh embryo transfer cycle.