Dr. Richa Singh

The available eggs in the ovaries at a time are collectively called an ovarian reserve. Low reserve happens when the production of eggs reduces. This affects the chances of pregnancy. The general cause of low reserves can be aging ovaries. In such cases, the ovary may be healthy and functioning even if the reserve is low. Production of eggs lower as a woman ages.

A woman starts with 25,000 to 5,00,000 eggs at puberty and ends up with 1000 eggs at menopause.

Causes:
Low reserves are caused by

1. Production of eggs decreases: Chromosomal abnormalities like Turner syndrome (lack of two X chromosomes) and genetic anomalies like Fragile X can decrease egg production.
2. Ovarian tissue damage: Rough torsion, endometriosis triggered ovarian cysts, malignant or benign tumours, surgical removal of ovary or any other part of it, chemotherapy or radiation, pelvic adhesions, immunological problems or high BMI (Body Mass Index) can destroy the ovarian tissues.

IVF Protocols:
If a woman has low ovarian reserves, then she will be put on the either of the following protocols:

1. Short GnRHa Flare: Gonadotrophin releasing-hormone-agonist (GnRHa) like Lupron, Nafarelin, Synarel or Buserelin is administered. This therapy is initiated at the onset of menstruation. The goal of the treatment is to stimulate the release of the follicular stimulating hormone (FSH) which augments the ovarian follicular growth.
2. Combined Clomiphene or Gonadotrophin/Letrozole Stimulation: Older women are mostly administered this protocol. But it is strongly advised not to, as this protocol can potentially harm the egg or the embryo.
3. Mid-follicular GnRH-antagonist protocol: Once the GnRHa-agonist protocol is commenced, the GnRH-antagonist is given several days later. Once the follicles reach the size of 12mm, GnRHa antagonists like Ganirelix, Orgalutran, Cetrotide and Cetrorelix are added. These drugs stop the pituitary from secreting the luteinizing hormone (FSH leads to secretion of this hormone).
4. Long GnRHa Pituitary Down Regulation Protocol: This is the usual approach to deal with low ovarian reserves.
5. Agonist/Antagonist Conversion Protocol: This protocol inhibits FSH production. This protocol generally yields good results.

One must always check the qualification of doctor. Apart from this, check about technology used by doctor currently in treatments. Additional services offered by doctor are again important for the patient.

Fertility naturally declines with age, and having a baby later in life can increase the risk for pregnancy complications.

The process of sperm production is a complex one as it involves not only the perfect functioning of the testicles or testes but also the pituitary glands and the hypothalamus which is located in the brain that triggers the sperm production by producing necessary hormones. Any damage or malfunctioning of any of these organs can significantly reduce the amount of sperm produced by a male body. In India, it is a taboo to talk about male infertility, but in reality, male infertility is on the rise in India due to low sperm production.

Causes of Low Sperm Production
Several causes can be cited for low sperm production. A few prevalent ones are indicated below:

1. Varicocele which is a condition in which the veins through which the sperm is drained from the testicles get swollen, and thus the quantity and the quality of the sperm get affected.
2. Any infection in the epididymis or the testicles can affect the production of the sperm. There can be some permanent damage to the testicles which causes the sperm production to decrease.
3. Due to an Auto immune disease where anti bodies mistakenly destroy the sperms in your own body thereby reducing sperm quantity.
4. Hormonal imbalance is a common factor in male as well though it is neglected in India. The pituitary gland might not produce the hormone in the required quantity which is needed for the right amount of sperm production.
5. Medication that you are using can interfere with the production of the sperm in your body as certain chemicals can alter the hormonal balance in your body thus affecting the sperm quantity.
6. Rarely, a defect in chromosomes can reduce male sperm production. Known as Klinefelter’s syndrome, the male body has 2 X chromosomes instead of 1 X and 1 Y chromosome which causes abnormality in reproductive men and the organs.

Common Symptoms-
The primary symptom of low sperm count is the inability to have an offspring, but there are many other symptoms as well. It has been observed that a male with low sperm count has a little or diminishing sex drive. They might not hold an erection for long or have erectile dysfunction. There can be swelling or pain in the testicles, and you may even have a lump which is a severe case. Due to hormonal disorder, there can be a decrease in the body or facial hairs.

If you have been observing a few of the symptoms mentioned above, it is better to see a doctor on the quick note. Doctors can ask for a semen test to understand the underlying problem. There are surgical as well as medical procedures to increase the sperm count and have a better sexual life.

IVF is a procedure undergone by couples to increase chances of pregnancy. Its mostly recommended to look for IVF option in case of 3 failures of IUI.

In vitro fertilisation, commonly known as IVF, is the process of fertilising single or multiple eggs outside the body. This treatment can be performed by either using your own egg and sperm or using donated egg or sperm or sometimes both. The resulting sperms and eggs are evaluated for quality and then one or more of them are positioned properly in the uterus through the cervix. IVF is regarded as one of the most commonly opted treatment plans, and it accounts for more than 99% of assisted reproductive technology processes.

Who are suitable for IVF?
IVF can be helpful for you in case you have some issues with the egg quality or ovulation, fallopian tubes that are blocked in some way or endometriosis. It can also help you to get pregnant if your partner has problems with mortality and sperm count and when you have opted for donor eggs. About 1.5% of babies in the United States are conceived through the IVF process.

How does IVF work?
There are several steps through which IVF process works and the timeline follows the following steps:

1. Stimulation for ovary: You will have to take hormonal injections near the start of your menstruation cycle. These injections aid in the stimulation of your ovaries for developing multiple mature eggs to fertilise instead of a single one. You may also need to take an artificial hormone-like cetrofelix and leuprolide for keeping your body from releasing eggs very early.
2. Development of follicle: When you are under all these medications, you will have to visit your doctor’s office often for checking the hormone levels as well as ultrasound measurements for the ovaries.
3. Getting the trigger shot: Once the follicles are ready, you are likely to receive a trigger shot, which is an injection causing the eggs for maturing fully and becoming capable of being fertilised. Your eggs are ready for being retrieved after about 36 hours of receiving this shot.
4. Gathering the eggs: It is the procedure under anaesthesia where a needle is inserted through vagina to collect the eggs formed as a result of stimulation and number varies depending upon the ovarian reserve. 
5. Fertlisation: This is the most vital step, where an embryologist is going to examine the eggs before they are combined with the sperm and incubated overnight. Fertilisation happens at this particular time, but abnormal eggs are not fertilised.

Then the embryos slowly develop and are planted on the basis of your age and clinical condition. When the treatment is working, an embryo is implanted in the uterine walls and starts developing.