Genome, The Fertility Centre

When couples start their family, they have many dreams. Subsequently many of them, if not all, plan to extend their family to give a sense of accomplishment. That is a journey from being couples to being parents. But unfortunately, in some couples the journey is not smooth and some of them have to struggle a lot for it. Yes, you are right. We are talking about difficulty to conceive, popularly known as “Infertility”.

To achieve successful pregnancy, there must be production of sperms, transport of them and proper deposition of them into the vagina by the male partner. In female partner, the deposited perms must travel through vagina and uterus to reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The ovum is produced by the ovary and released into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, which then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Perhaps you have heard that infertility may be due to problems in male (defect in production, transport or deposition of sperms) or female (defect in ovaries or ovulation, bock in the tubes and defects in the uterus). But sometimes there may be more than one problems in either of the couples or apparently no reason is found (everything is normal, so pregnancy depends on chance factor). To clarify the latter, in normal healthy couples with regular unprotected timely intercourse, the chance of pregnancy in one menstrual cycle is only 15%, so it may be matter of time for some couples to conceive. But another important reason for infertility in female is endometriosis.

What is endometriosis?

Endometrium is the inner lining of the uterus. It responds to hormones secreted by the ovaries during normal menstrual cycle. It tends to thicken from the time of ovulation (as described above) and if pregnancy occurs, it continues to grow and supports the embryo to help in continuing pregnancy. If pregnancy does not occur, it is shed off outside the body and is seen as “menstrual Bleeding” or “Period”. Unfortunately, in some women, the endometrium may be present outside the normal position. That condition is called endometriosis. It is commonly present around the ovaries, tubes, surrounding the uterus (outside normal lining) but may be present anywhere in the body (even in lungs, urinary system and rectum). As this endometrium (outside the uterus lining) also responds to the hormones in the same way as normal endometrium (that lines the uterus), there will be bleeding around this abnormal endometrium at the time of menstruation. But this bleeding, unlike normal menstrual bleeding cannot come outside the body and so the blood accumulates and forms a chocolate coloured material (old blood is chocolate coloured) and leads to adhesion between organs. Adhesion is a condition where different organs of our body attaches abnormally with each other leading to various problems. Sometimes this chocolate coloured blood may be surrounded by a membrane formed by body tissue and is then called “Chocolate Cyst” that is found around the ovaries.

What is the reason for endometriosis?

Unfortunately, despite extensive research throughout the world, the reason for endometriosis is not known. It is said to be due to some genetic factors or some environmental factors. Sometimes, delaying pregnancy is stated as the reason. In some women, however, it is caused by backward flow of menstrual blood (that enters into the tubes during menstruation). Usually these women have abnormal development of uterus (problems in uterus since birth), so that all the menstrual blood cannot come outside the body)

What is the problem with endometriosis?

Endometriosis usually causes pain. The pain may be long standing and usually occurs at the time of periods (dysmenorrhoea) or sometimes even between periods. The nature and site of pain depends on where it is located. If it is located very deep inside abdomen, it can cause pain during sexual intercourse (dysparaeunia). In some cases there may be pain during passing urine or stool or bleeding during urination or with stool.

In around 50% cases, it can cause infertility. The cause of infertility is not always properly understood. But it has been seen that endometriosis can cause adhesion and thus can makes it difficult for the Fallopian tubes to pick up the ovum from the ovaries. Apart from this pain during intercourse often makes the woman avoid intercourse. In addition, it can interfere with ovulation, sperm transport, meeting between sperms and eggs and also the process of attachment of uterus with the embryo.

However, endometriosis does not always cause pain or infertility. In some women, there may be both pain and infertility, some women only one symptom and in some women no symptom is found but endometriosis is discovered accidentally during treatment for other purpose (like during laparoscopy for appendicitis or during Caesarean Section).

How endometriosis is diagnosed?

Endometriosis is suspected by history of pain or infertility and examination findings. Like some women may have pain during examination of abdomen or vagina by doctors, even sometimes vaginal ultrasound causes pain. In ultrasonography (or sometimes CT scan is done) there may be presence of cysts or adhesion can be detected. But the “Gold standard” of diagnosis is laparoscopy. It is an operation where (“Microsurgery”), making a small opening in the abdomen under anaesthesia, a telescope is introduced and the area is seen through camera in a television monitor. At that time the chocolate cysts, adhesions and condition of the organs can be seen and diagnosed and if there is any doubt, biopsy can be taken. But in all cases, laparoscopy is not needed and treatment is started after the doctors presume the diagnosis by history from the patients, examination and the ultrasonography reports.

Endometriosis is a peculiar condition in the sense that women with severe endometriosis may not have any symptoms, while women with very mild disease may have severe pain or infertility.

How endometriosis is treated, in general?

As mentioned earlier, endometriosis does not always cause symptoms and so, it does not always need treatment. The common reason for treatment is presence of pain and infertility. Endometriosis-related pain is usually treated by medicines or sometimes by surgery. Before surgery, usually medicines are given to reduce the size and to reduce the blood loss during surgery. All these medicines can cause hormonal imbalance and thus deprives the endometriosis tissues of hormonal stimulation and thus reduces pain. As a result, during the treatment, patients usually cannot conceive because of this intentional hormonal deprivation. Unfortunately after stoppage of medicines, often the symptoms of pain come back.

Surgery for endometriosis is usually done under laparoscopy but it needs properly trained and skilled surgeons to do these operations. Operations can range from “minor” (like separating the adhesions, draining the chocolate coloured fluid) and “major” (like removing the cyst or removing major organs). The surgery has the advantage over medicines is that it confirms the diagnosis and removes the diseased tissues. But there are problems with risks related to anaesthesia and surgery. In particular, there is risk of injury to intestine and urinary tracts, even with the best hands, that may increase patient’s sufferings. Apart from this, even after surgery, the disease can come back again after few months or years.

What is the cure for endometriosis?

Only cure for endometriosis is total deprivation of hormones. That is possible if the woman attains menopause (permanent cessation of menses). This is possible by natural way (around 45-50 years of age when menses cease permanently) or by operations to remove the ovaries and uterus. Another simpler way is achieving pregnancy, as usually after pregnancy most endometriosis patients feel better in relation to pain.

What happens if it is not treated?

Endometriosis is not like cancer. It is not life threatening usually. That means it will make you suffer in the worst way by causing severe pain and infertility but cannot endanger your life. So, you can have the options of not treating it, even if you have the symptoms. And of course, if you do not have symptoms, endometriosis may not require any treatment.

What is the treatment for endometriosis with infertility?

First of all, you have to make sure that you have difficulty in conception (that means you have given sufficient time to attempt but failed). Then we have to see whether there is any pain or other problems and what the condition of the disease by examination or ultrasonography is. We also have to look for any additional problems like problems in male partner, problems in uterus or ovaries or the hormones (like FSH, LH, prolactin, thyroid etc).

Then we have to plan the treatment. As there is no hard and fast rule, your doctor will explain you the options for you and you can decide what suits you the most, after judging merits and demerits of every option.

You may choose directly for surgery. In that case, you may be offered medicines for 2-3 months before surgery to make surgery safer for you and easier for the surgeon. The extent of surgery varies, depending on the disease status and your opinion. Remember, your opinion is important. You can choose for extensive operation (that may mean removal of both the tubes, that may be needed in advanced disease, leaving only option for IVF for pregnancy in future) or only diagnosis (just introducing the telescope and see) or minor operations (like separation of adhesions or removal of the cysts), after judging the merits and demerits of each options. But remember, you should not have any medicines for endometriosis after operation as most of the medicines (with some exceptions) interfere with pregnancy. This is, because, after operation is the best time to conceive and that time gives you the highest chance for pregnancy. If natural conception (or 1. ovulation induction- giving medicines to stimulate growth of your eggs, or 2. IUI- inserting your husband’s sperms by special process inside your uterus) does not occur within 12 months after operation, that’s probably the best time to consider IVF (“Test tube baby”). Of course, if you had extensive surgery or have advanced age (more than 35 usually), your doctor may advise you to go for IVF directly after operation without wasting the time.

You can opt for trial of treatment by medicines. You must know why I have used the word “Trial”. This is because, during medicine treatment, you cannot conceive. But you will be seen after 2-3 months to see if the disease has disappeared or decreased in size significantly. If this is the case, you can start infertility treatment (Ovulation Induction or IUI or IVF in some cases) directly. But if the disease did not respond to medicines by this time, you may need surgery, the extent of which has been described above.

You also have the options of not treating endometriosis at all. In that case, you can request your doctor to start infertility treatment directly. But remember, endometriosis (even treated endometriosis- after medicines or surgery) can interfere with any form of infertility treatment. It can lead to decreased response to medicines used for ovulation induction, thus reducing success rate(normal success rate is 20-25% in a menstrual cycle- that is without endometriosis). It can lead to low success rate after IUI (normal success rate is 25-30% in a menstrual cycle). Even with IVF (where normal success rate is 40-50% per cycle of IVF), the effectiveness of IVF may be reduced in presence of endometriosis.

What if I do not go for any treatment at all?

Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Often we find that patients planning for treatment and in the meantime, they conceive naturally. That means even without treatment, there is some chance of pregnancy. But that chance decreases in presence of any disease (like endometriosis) or increased age. And of course, nobody usually relies on chance. But the important message is that do not forget to have regular sexual intercourse eve if you are awaiting any test or endometriosis treatment. Of course, it’s stressful situation for both the partners. Stress affects conjugal relationships and lead to many couples avoiding conjugal life. Indeed, stress can affect the hormone levels in females and affects sexual performances in males. It’s easier for us to advise you to stay stress-free but is difficult to practice. Nevertheless, try relaxation as much as possible. Think that majority of the couples ultimately conceive by some form of treatment. Have faith in yourself and have faith in your doctor.

 

How to make your menstrual cycles regular- 8 simple ways

How to make your menstrual cycles regular?

In our clinics everyday some patients at different ages will come with complaint of irregular menstrual cycles. But there are other patients who feel embarrassed to seek doctor's help for this problem. While it seems to be a simple problem related to reproduction only, often it is associated with diseases that are matter s of concern.

First, you should know what is meant by the word "irregular"? In most women period occurs at interval of 28 to 30 days. But it is said to be normal if it happens every 21-35 days. That means you should have periods not more frequently than every 3 weeks or not less frequently than every 5 weeks. But if you had previous cycles at interval of every 4 weeks but now you are having periods every 5 weeks, that is ABNORMAL, although it is occurring every 35 days. In other words change in interval up to 7 days is normal, nit beyond that. For example, if you had periods every 30 days previously and for last 2 months it is happening every 33 days or every 25 days, then it's normal. But if it happens at interval of more than 37 days (30 + 7) or less than 23 days (30- 7) then it's of course abnormal.

So what are the things you can do for regular periods.

1. Normal weight
Ideal weight varies according to the height. We express it in terms of BMI (Body Mass Index) that is the weight in Kg divided by square of the height in centimeters. Ideal BMI should be between 19 to 25. If it's more than 25, reduce weight by diet and exercise. IT can resume normal menstruation without any drugs. IF despite your sincere efforts, you are unable to lose weight or even after normalization of weight menstruation remains irregular, you must consult your gynaecologist for treatment.
On the other hand very low BMI can also cause irregular menses. Treatment is weight gain. This is often seen in athletes and they are even at risk of losing bone calcium because if excessive exercise and strict diet control. If gaining weight does not help, you must consult your doctor for having regular periods.

2. Stress, Anxiety, Tension, Depression
These are inevitable part of modern lifestyle. These may not only cause mental problems but will also cause physical problems by altering the hormone levels. The result is abnormal menstrual cycle. Try to avoid them by relaxation, counseling and if necessary by taking help of doctors.

3. Thyroid disorders

Problem of thyroid gland is common in females and causes abnormal weight and changes action of many hormone s. The result is irregular menstruation. So if you feel lethargy, extreme cold, weakness increased weight, do not forget to check thyroid status after consulting doctor.

4. Pituitary disorders
Pituitary gland is a gland situated inside the brain that controls hormone of other gland s of the body. If there is some tumour or some abnormalities in its function, there will be high lebel of prolactin hormone secretion or there will be deficiency of hormones like FSH and LH. As a result ovaries cannot produce enough hormones and you will have irregular menstruation. So in case of abnormal menstruation, please Check your prolactin level.

5. PCOS
Polycystic Ovarian Syndrome is common nowadays. Apart from causing abnormal menstruation, it increases risk of infertility, high blood pressure, diabetes, heart disease and even cancer. It is diagnosed by clinical features, hormonal tests and ultrasonography. It may also cause weight gain, male like growth of hairs in body and oily skin. The treatment is weight control and drugs to regularize menses. This is particularly important in young women an teenagers, in whom timely treatment can prevent many serious consequences.

6. Premature Ovarian Failure
In some women menopause can come earlier and irregular menstruation may be the early indication of this. This may be followed by permanent cessation if periods. So if you are planning for family expansion but have irregular menses, do not delay pregnancy.

7. Problems in uterus
Excessive trauma to uterus by repeated surgical abortion or infections like STD r tuberculosis can damage the lining of uterus. The result is irregular menses followed by total cessation of menses. But this problem can be easily treated if you consult your gynecologist in time.

8. Systemic diseases and drugs
Irregular menses should never be ignored. Sometimes it may be because if so e undiagnosed diseases like diabetes, diseases if heart, liver, kidney, chest etc. Often it may be the side effect if the drugs you are taking- like antacids containing domperidone, psychiatric drugs, Steroid s or chemotherapy.

In conclusion, irregular menstruation may sometimes warn you about serious disease s and may be associated with infertility and early menopause. Stay health y, have health y diet and lifestyle, maintain normal weight, get rid of tension and attend your doctor's clinics in time.

 

Introduction

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

 In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires

1. Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes
2. Transport of these sperms through the sperm conducting ducts from testes to penis
3. Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina
4. Transport of these sperms from vagina through cervix to the uterus and the tubes
5. Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
6. Pick up of the eggs by the tubes
7. Approximation of eggs and the sperms to form the embryo
8. Transport of embryo from the tubes into the uterus
9. Acceptance of the embryo by the uterus and its growth

What is Infertility?

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.

Thus the common causes may be

1. Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
2. Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examples include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
3. Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out. 

In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress.

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

How Sexual Disorders are related to Infertility?

Sex and fertility are not the same thing. Couples with normal sex life may have difficulty in conception (for example couples with PCOS or low sperm count). On the contrary, couples with normal fertility may have sexual disorders. Sexual Disorders and infertility may be related in two ways.

Firstly, the stress of infertility starts to exert its adverse effects in conjugal relationships. Most of the couples, who had very satisfactory sex life, start to lose interest in sex. They feel sex as a “mechanical” tool whose sole aim is only to achieve pregnancy, in contrast to their life just after marriage, when sex was perceived as an expression of love-making process. The continuous advice from doctors, “you should have regular intercourse” makes the scenario worse. Some of them can feel other problems like erectile dysfunction, ejaculatory problems, painful sex, vaginal dryness etc. Remember, this group of couple never faced sexual dysfunction in earlier part of their life.

But, here we concentrate on second group of couples, who had sexual dysfunction from the very beginning. They did not have penetrative intercourse long time after marriage. Initially they ignore the problems because of pressure from professional field and some of them feel too shy to consult doctor for this problem. But when they themselves want to plan for a baby, or due to pressure from the family, they start to realize the importance of having a good sex life. At this point, most of them consult doctor to find the solution. But the problem seems more complicated than the couples in the first group (above paragraph). This is because, the doctors have to treat two problems together- sex and fertility. Apart from the problems in sex life, the stress factors also come into play.

Again, there are some couples, who come to our clinics earlier. They find problems in sexual intercourse but are not planning for pregnancy right now. In these cases, the treatment is relatively simpler, as we get ample time to correct the problems, to help them conceiving naturally.

What are the common types of sexual disorders that can prevent conception?

In simple words, absence of penetrative intercourse will prevent pregnancy. It may be problems due to lack of desire or problems in physical performance.

Few men and women do not feel any urge (libido) to have intercourse. Others may have the libido but find problems because of erectile dysfunction (lack of hardness) during intercourse. Uncommonly, some men may be able to insert the penis inside the vagina but cannot ejaculate (discharge) the sperms during intercourse. Some women may feel severe pain during attempted intercourse, that prevents them to participate in it.

What are the reasons behind sexual disorders?

It’s a common misconception that all the sexual dysfunctions are due to psychological factors. Indeed, most of such problems may be related to some physical factors.

Life-style factorscontribute a lot. Stress due to various reasons (financial, professional, family related) affect sexual performance and libido. People working in stressful life, particularly marketing, banking and IT sectorsare badly affected. Previous “bad” experience with sex (like previous history of erectile problems, pain, bleeding) often come into play and this performance anxiety makes the situation worse. Relationship conflict also plays important role. Excessive use of alcohol can affect the orgasm and erection. Smoking, apart from its harmful effect on fertility, can affect libido, erection and orgasm. Excessive use of caffeine can also be responsible. Some medicines, particularly medicines used to control blood pressure and abusive drugs like cannabis can create such problems. Excessive weight can affect libido, erection, ejaculation, vaginal dryness and orgasm; in addition to delay in conception.

Sexual dysfunction can be the first sign of serious diseases like diabetes. Other hormonal problems like imbalance in sex hormones (low testosterone in male and female, low estrogen in female, high estrogen in male), high prolactin, thyroid diseases can be responsible for sexual problems and are easily treatable.

Diseases of heart (high blood pressure, heart failure), liver (cirrhosis), kidney (renal failure), nerves (diseases in brain, spinal cord) and blood (sickle cell disease, anaemia) can be responsible for sexual problems. This is another reason, why people with sexual disorders should not think that it’s a disease of reproductive system only.

Some operations (in spine, abdomen, pelvis, hernia, vagina, scrotum) and injuries (spine, pelvis) can have long-lasting serious side-effects on sexual function.

Infections, tumours, endometriosis can be responsible for pain and bleeding during intercourse.

Finally, lack of proper technique, improper knowledge and unrealistic expectations are also responsible.

In general, what are the treatment options for sexual disorders?

The first and foremost action is to find out the underlying cause responsible for sexual dysfunction. That’s why its important to have thorough check up by doctor to find out the cause. The check up includes asking question by the doctor (history taking), physical examination and then if needed, some tests (like blood, ultrasoundetc). It’s important for you to be honest and to disclose all your problems and raise any concerns to the treating doctors.

If the cause is found, the treatment is simply, the correction of the cause, if possible (like correction of blood sugar in diabetic patient).

Even if no cause is found or when the cause cannot be corrected, the couple can have satisfactory sexual life. It involves proper counseling and sometimes “sensate focusing” (initial focusing on perception of the touch, rather than intercourse). Stress reduction and life-style modification (controlling weight, stopping smoking, reducing alcohol) cannot be overemphasized.

Pelvic floor exercise (“Kegel’s exercise”) can help both men and women to improve blood flow to pelvic organs and optimize the pelvic muscle functions, thus in turn, improving sexual function.

Next comes the role of medicines. There is a common misbelief that sexual dysfunction can ne corrected by steroids only. This is totally wrong, because steroids can rather worsen the sexual problems. Another misconception is that, once started, you need to take medicines throughout the life. The fact is that majority of the patients need medicines only for the time being. Majority of the couples respond well to these methods of treatment.

In very few cases, some additional measures can be needed like corrective surgery or vacuum device for erection problems.

What are the options for fertility treatment in presence of sexual disorders?

As mentioned before, if a couple with sexual problems want pregnancy, the doctors have to deal with two problems- sexuality and fertility. So, proper investigations are needed for both, to find out the cause. Then the treatment decision is taken, based on age and weight, underlying problems, how severe is the sexual problems, the treatment response, affordability and of course, the wish of the couples.

The first step treatment, is obviously to trying for natural conception, by regular penetrative penile-vaginal intercourse. So, the first line of treatment is to correct the sexual problems, as mentioned in the above section. Majority of the couples can have successful sex life after proper treatment and a large number of them conceive in the course of time, provided there is no major fertility problems (sperm, fallopian tubes, uterus, ovaries). If they fail to conceive, the treatment is just like other couples (those without sexual problems). That is, they can be offered ovulation induction, intrauterine insemination (IUI) and in vitro fertilization (IVF).

However, if the sexual problems cannot be corrected, this is not the end of the world. If the man can collect sperm by masturbation, he or the female partner can perform self-insemination. This can be done at home by the couples and can be coordinated with ovulation time and, even with ovulation drugs. This has success rate of 15% per cycle per couple (if 100 couples are trying it, in one month, 15 can conceive).

If self-insemination fails, or is not possible (for ejaculation problems), or is not acceptable to the couple, the option is IUI. For men with ejaculatory problems, sperms can be collected by Vibro-ejaculation (putting a simple instrument over penis, without pain) or by collecting sperms from the urine which is taken immediately after masturbation (‘post-masturbation urine’- for retrograde ejaculation). IUI has the success rates of 20% per cycle, depending on the age, sperm count and other fertility factors. For women feeling severe pain during intercourse, IUI can be done under anaesthesia.

Self-insemination and IUI can only be successful in couples with normal fallopian tubes (at least one tube must be open), normal perm count or sperm counts mild to moderately abnormal, normal ovulation or ovulation done with medicines (as in PCOS). However, if these are not possible, because of fertility factors (very low sperm count, tubes blocked) or IUI fail, then the option is IVF. In one IVF cycle, 40% of the couples conceive in average. IVF can even be done, in men having no ejaculation but who can produce sperms inside the testes (by putting needle in the scrotum).

In very few cases, when these treatment options are not feasible, donor sperm, donor ovum or surrogacy treatment can be done.

What are the reasons behind low sex desire (Libido) in men or women?

The main reasons are life-style factors, hormonal imbalance and anxiety for poor performance.

How low libido is treated?

Treatment is simple, as stated above. It includes life style changes, sensate focusing and correction of the underlying disease.

How can a person with low libido become a parent?

Majority of the couples can conceive naturally after successful treatment of low libido. If the above-mentioned measures fail to correct the libido, then self-insemination, IUI or IVF can be done, depending on the cause.

What are the reasons behind Erectile Dysfunction (ED) in men?

The main reasons are life-style factors, hormonal problems, disorders in heart/ nerve/ blood, operations or injury; as mentioned earlier.

How ED is treated?

Majority of the men respond well to the correction of underlying cause, stress reduction, life style changes, Kegel’s exercises and medicines.

How can a man with ED become a father?

If the treatment of ED is successful, the couples can conceive naturally. However, if these fail, they can try self-insemination, failing which IUI, and occasionally IVF need to be done.

What are the reasons behind Ejaculatory Problems in men?

Ejaculatory dysfunctions are not common, apart from premature ejaculation (discussed below). It can be due to anxiety, diabetes, problems in nerves or prostate gland, after surgery or operation in spine or pelvic area and sometimes infection.

Majority of such men are able to ejaculate during masturbation or are feeling normal nocturnal emission (“night fall”) but fail to do so during intercourse. In these cases, usually no definite cause is found. This is called “situational anejaculation”. A portion of them can have ejaculation with some particular partner, but not with other(s).

Few men are suffering from “absolute anejaculation”. This means, they cannot have ejaculation during masturbation or intercourse. The cause is usually related to problems in nerve, diabetes, surgery or injury. A portion of them may have “retrograde ejaculation”, that is, during orgasm, the sperms are carried back towards urinary bladder (the sac that stores urine), rather than towards the penis. A post-masturbation urine sample can reveal sperm in such cases and diagnoses this condition.

How ejaculatory problem is treated?

Unfortunately, ejaculation problem is somehow difficult to cure. Some medicines can help few men. Vibroejaculatorcan be helpful in some men.

How can a man with ejaculatory problem father a baby?

Ejaculatory problems may not be cured, but such men can father their own baby. This is possible by collecting sperms by various means. If he can masturbate, self-insemination is possible. Alternatively, with vibroejaculation, sperms can be collected at home and self-insemination can be done. IUI and IVF are also possible in such cases.

However, if there is no ejaculation during masturbation, post-masturbation urine can be tested and if there is adequate number of sperms (Retrograde Ejaculation), IUI can be done. If the sperm counts are not enough, a special form of IVF (ICSI- Intra-cytoplasmic sperm injection) can be done.

Even if post-masturbation urine reveals no sperms, the sperms can be collected from the testes and ICSI can be done successfully.

Thus, although ejaculatory problems are uncommon and are difficult to treat itself, successful conception is quite possible.

Can Premature Ejaculation (PE) be related to Infertility?

Premature ejaculation is usually not a cause for infertility, though it can cause inadequate satisfaction during intercourse.

However, if the PE is severe degree, that means the sperm is discharged before vaginal penetration, it ca cause problems in conception. Sometimes, it can be due to some problems in the penis (opening not in proper place- hypospadias). In such cases, if conventional treatment of PE (exercise and medicines) are not helpful, self-insemination, IUI or IVF can be done successfully.

What are the reasons behind painful intercourse in women?

The reasons are mostly related to anxiety or fear. It can be due to some factors like vaginal dryness (when ovaries are not functioning properly, some medicines or local glands are not working) and infection (including sexually transmitted infections). If the pain occurs at deep penetration, it may be due to some tumours (occasionally cancers) in cervix, uterus or ovaries, infections, endometriosis and enlarged ovaries.

How painful intercourse is treated?

Again, the treatment depends on the cause. Counseling, sensate focusing, life-style changes play important role. Medicines and hormones are helpful in selective cases.

How can a woman with painful intercourse get pregnant?

It’s important NOT to use any vaginal lubricants (including saliva) as any lubricants can potentially kill the sperms.  However, some external moisturizers are there, which are sperm-friendly. If the simple measures fail, IUI can be done under anaesthesia. IVF can be done if IUI fails or is unacceptable.

Will my problem in conjugal life remain confidential?

Yes, except you and your partner and the treating doctors, nobody else (even your parents or friends) have any right to know about your personal life. Self-insemination can be done at home, without going to clinic, thus maintaining your privacy. If you have to go for IUI or IVF, you will be treated just like other couples (who fail to conceive despite normal sexual life)

How such problems are treated in the clinic of Dr Sujoy Dasgupta?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We try to take nominal charges and help couples to collect medicines (particularly injections) at lower prices than MRPs.

We try to find out the root cause of the problems in the couples and try to solve them first. If that is possible we encourage them to try for pregnancy naturally. If these attempts fail, we discuss with the couple, the options, that include self-insemination, IUI, IVF and ICSI. We do not pose any of our decision on the couples, rather we discuss with them and help them to make their own decision.

Conclusion

Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Sexual problems are not uncommon but are easily treatable. Pregnancy is quite possible in couples who are not able to have penetrative intercourse.

Most of us have an idea that the couple should go to gynecologist only after they fall pregnant or when there is difficulty in conceiving. But we all know that prevention is better than cure. Then why should not we take precaution to avoid complications in pregnancy so that we can have healthy mother and healthy baby.

 

• Some of the diseases can manifest during pregnancy, like some diseases of heart, blood pressure, blood sugar etc. But if the couple comes to doctor when they are planning pregnancy, then we can diagnose it and start treatment so that pregnancy can be safe to both the mother and the baby.
• On the other hand, some pre-existing disease may turn serious during pregnancy and endanger life of both mother and baby. This includes thyroid disease, hypertension, epilepsy, renal disease, cardiac disease etc. If taken care of properly, the disease can be controlled before pregnancy so that the risk can be reduced. Again all the drugs are not safe for the baby. So, if treated before pregnancy, the mother can be put on safer but effective drugs before pregnancy.
• Some diseases may run in family and often goes undetected and can affect the baby. Thlassaemia, hemophilia etc are the best examples. So, if the couple comes to us before pregnancy, we can screen them to diagnose whether they are bearer of the disease or not and then we can take care to prevent birth of defective baby. 
• Some diseases indicate that there may be problems in having pregnancy, like problems in periods or abdominal pain in female, sexual problems in male and female etc. If treated properly, it will avoid unnecessary time wastage for trying for pregnancy.
• The woman can be instructed how to remain healthy to have normal baby, before pregnancy. She can be advised some drugs (like folic acid), can be asked to avoid harmful drugs and substances (like drugs, excessive vitamin a, excessive vitamin d, excessive caffeine, smoking etc). Even the husband can be asked how to improve his fertility (by avoiding heat exposure to his scrotum).
• Again some infections can be dangerous for the baby. So, before pregnancy we can treat the women for the infections and in some cases we can vaccinate her to prevent infection.
• "a stitch in time saves nine. So, why don't you consult your gynecologist when you are planning for pregnancy? have smooth journey throughout pregnancy and enjoy parenthood.

Today 25th May is the World Thyroid Day. Thyroid disorders are one of the most common disorders of hormones in our body. Thyroid is a small gland situated in front of the neck and secretes hormones like thyroxine (T4) and tri-iodo-thyronine (T3). These hormones control various functions of our body like heart, blood pressure, digestion, metabolism, growth, blood formation, brain function etc. But one of the most important function is its association with reproduction.

In both sexes, T3 and T4 are needed for sexual development during puberty so that full maturation from a child to adult occurs. That means development of hair (pubic and axillary hair), beard and moustache in boys, breast in girls, genital organ development in both sexes and menstrual function are dependent on thyroid gland. Finally production of eggs (rather maturation and release) and sperms are also related to it. In adults, thyroid function is needed to maintain the functions of sex glands particularly ovaries and testes. Desire for sex (libido) and performance of sex are also related to thyroid function. 

The thyroid glands in turn is regulated by a hormone secreted from pituitary gland, located inside the brain. That hormone- TSH (thyroid stimulating hormone) controls secretion of T3 and T4., Thyroid gland may be affected by various diseases like autoimmune diseases (body itself destroys its organs), deficinecy of iodine, radiation, tumour, congenital causes (cause present from birth) and certain drugs. The result is that thyroid hormone seceretion may be reduced (hypothyroidism) or increased (hyperthyroidism). As a result, blood tests for TSH, T3 and T4 are commonly done to detect abnormalities of thyroid gland. If abnormalities are detected, further tests may be advised, e.g., ultrasound and scanning of thyroid gland. 

So what can happen to reproduction if thyroid function is affected? Thyroid disorders are particularly common in females. Menstrual cycle may be irregular (comin every 2 or 3 months ) or may be scanty in amount or more commonly very excessive flow. These respond well to correction of thyroid hormone levels by drugs. 

Thyroid diorder is a common cause of anovlation- that is women cannot release eggs in each month. The result is irregular menstruation and infertility- the inability to conceive a child. Often correction of thyroid hormone levels result in pregnancy. Please remember if you are trying for pregnancy, then your TSH value should not be the same like other people. We usually treat such women if TSH is more than 2.5 (this may be normal for labaoratory standrads for other people but not for those who plan for preganncy and who are pregnant). 

It can cause low libido, vaginal dryness, reduced orgasm and painful intercourse.

In case of male, the thyroid disease is not very common but is not rare. It can affect sperm production leading to infertility. Apart from that it can afect sexual performance leading to low libido, easy fatigue and erectile dysfucntion (ED). All these resolve after proper treatment.

Never ignore checking thyroid status for adolescent boys and girls. It may be responsible for delayed puberty (delay in appearance of male like features in boys and female like features in girls) or precocious puberty (early onset of menstruation or breast development in girls; or early development of beard and moustache in boys). These may be associated with serious disorders and need proper attention.

Pregnancy is a condition where there is tremenous pressure on thyroid gland and it is needed to help in proper development of baby inside uterus. Women with thyroid disorders can have miscarriage, premature delivery, death of baby inside uterus or poor growth of the baby. She can experience bleeding in pregnancy, high blood pressure (preeclampsia) and even heart failure. In initial periods babies depend on mother's thyroid gland for its development. If baby does not get proper amount of thyroid hormones, its brain and body deveopment hampers. Particularly the brain development can be affected leading to mentally handicapped baby,as it may not be corrected even after treatment. So proper diagnosis and treatment of thyroid diseases in pregnancy are essential. After birth baby should be tested for thyroid disease and appropriate treatment should be started without any delay.

So, if you feel any of the above problems, please do not hesitate to consult your doctor and request testing of thyroid functions. If drug treatment is started, do not stop the drug without consulting doctor. Uncontrolled thyroid disease can lead to heart attack, stroke and emergency situations like thyrotoxicosis or myxoedema- which can be potentially life threatening if not treated in time.

 

In our modern life, stress is an indispensable part. Career, jobs, studies, incomes, business, money, property- all are associated with some sorts of stress. The problem gets exaggerated when it affects the family life. Because, at the end of the day, we all want to enjoy a happy family life. And a family life has its sense when the husband and the wife are in harmony. Needless to say, that a family is incomplete without a kid.

 

• How stress affects family life? Effect of stress is not limited to mind. It has serious effects in the body. It affects blood circulation and the heart. It puts pressure on nerves. It also alters the blood sugar level. And he end result is diabetes, hypertension (high blood pressure) and heart diseases. Ultimately these diseases affect all the organs of our body. Some people try to get rid of stress by smoking and alcohol. These will simply put burden on already affected heart and blood. 
• Stress also alters important hormone levels in our body. The hormones needed for basic reproductive function (sex, conception and pregnancy) are either increased or decreased. Prolactin hormone is increased. Normally prolactin is needed to secrete milk from breast to fed the baby. But abnormally increased prolactin leads to milk secretion from breast (even without pregnancy) and irregularities in periods. Very high prolactin may even lead to problems with ovulation (at middle of each period, the egg gets released from ovary) and as a result, the woman cannot conceive a baby. Even in male, high prolactin leads to difficulty in erection of penis. In some male, it can lead to gynaecomastia (growth of male breast). Excessive high dose of prolatin leads to loss of sex desire in male and interferes with spermatogenesis (sperm production).
• Apart from increasing prolactin, stress can directly affect the hormones secreted from the pituitary gland of both male and female, the testes in male and the ovaries in female. As a result, all the reproductive functions get disturbed leading to problems in sex (loss of desire in both male and female, problems in erection and ejaculation in male), irregular periods in female and ultimately pregnancy cannot occur. 
• The diseases occurring as a result of stress (diabetes, hypertension etc) also affect the normal functions of ovaries causing irregular periods, even no periods at all. There may be problems in ovulation and thus difficulties in achieving pregnancy. Even if pregnancy occurs, it may be aborted because of these diseases. Similarly in male, diabetes and hypertension will cause sexual dysfunction and will affect sperm production. 
• The lifestyles accompanying stress are also responsible for harmful effects on family life. Smoking and alcohol have been mentioned earlier. Stress may be associated with abnormal weight gain and that will affect the woman’s life in badly manner. There will be disturbances in periods, ovulation problems, infertility and even pregnancy loss. Sitting for long time while driving or keeping laptops on laps, will increase the temperature of scrotum in male and thus will decrease the sperm production. 
• Again there is a vicious cycle- stress leads to family problems like problems in sex and in having pregnancy. That will in turn increase pressures from family (especially in-laws) and the society. This will simple aggravate the stress. 
• So, what can be done to avoid these problems? The answer seems to be simple- that is avoiding stress. But it’s very easy to say and difficult to commit. First thing is try to bring stress at home just keep it at your workplace. Avoid smoking and cut down alcohol consumption. Avoid sitting long time in front of computers and take periodical rests when you are working continuously. The rest does not mean that you have to lie down in bed; just have a short walk. Start exercise that will keep you healthy and reduce your stress. Yoga is an Indian culture that taught the Western world how to reduce stress. Take plenty of water and green vegetables and fruits. Avoid fast food. Always put on comfortable dresses. And if all of these do not work, try if you can do something to avoid the stress- like changing the workplace, talking directly to your co-employees or the employer. If still all these cannot help, consult psychological counselor. A timely counseling will reduce stress significantly. In very few cases, drugs may be needed to reduce stress. But remember, drugs can only be useful if you are trying all the other measures. Simple dependence on drugs won’t help much.
• Now regarding family problems associated with stress follow simple measures. Often we feel embarrassed to discuss these issues. Try to enjoy time of personal intimacy to the fullest. Don’t think of any problems during that time. If still there are problems, don’t hesitate to take medical help. And please remember, the drugs used to solve sexual problems may have side effects. So, these should be taken only after medical consultation. 
• In case of female, maintain optimum weight. Avoid fast food, alcohol and smoking. If periods are irregular, maintain a menstrual diary. Consult a doctor to find out if there are some serious issues associated with these problems (like hormonal problems, thyroid diseases, even some tumours). You doctor will then decide the best treatment for you. If there are low desire for sex, don’t hesitate to take help of doctor. It may be a symptom of hormone deficiency that can affect your different systems (like bone, heart, blood etc). Now a days, there are lots of treatment options available for this.
• For male, if there is low desire, consult your doctor to find out the cause of this problem. At the same time, avoid any anxiety, alcohol and smoking. Sometimes there are problems with erection. Instead of trying drugs shown in media or newspaper, feel free to talk to your doctor; because erection problem may be caused by some serious issues like heart disease, diabetes etc. So, if you have erection problems, consult doctor. He/ she will counsel you and give you the best treatment. Now if the problem is with ejaculation (like early loss of semen or very low semen), that issue can also be solved in the same way.
• What’s about infertility problems? Stress and infertility are inter-related, as described before. Now, if there is problem with fertility, please remember few facts. Even in totally healthy couples, the chance of pregnancy after regular intercourse in fertile period (in the middle of menstrual cycle, usually) is only 20%. Though it appears disappointing, majority of couples conceive in course of time. So, couples are requested to report to doctor only if they tried regularly for one year without any protection. Then your doctor will assess you and try to find out the problem. And again, treatment of infertility is also depending on chance. Hat means we have to increase the chance above the natural chance (which is 20%). So, even one treatment fails, there is enough scope, so no need to lose hope. In other words, there is no need to increase the stress.
• So, stay healthy, keep your mind healthy by avoiding stress and keep your family relationship totally stress-free.

Pregnancy gives a woman completeness by turning her into mother from a simple woman. It is the thing which makes the couple parents, the dream which they nurture right time from their marriage. Of course, there are many couples who are not fortunate enough to achieve pregnancy and they are usually termed infertile and we have discussed it in separate post. But there are other couples who may or may not (as this is the usual case) find difficult to conceive but the pregnancy does not continue to the age of viability. Age of viability means the age, when a baby born can survive. Thanks to the improvement in neonatal care by leaps and bounds and availability of NICU which made it possible to survive even a baby born at 22 weeks. For example, last month we delivered a baby at 28 weeks of pregnancy, who is fine now. But if the baby is 'born' before 20 weeks, it is called MISCARRIAGE. This is because these babies who weigh less than 500 grams cannot survive outside the uterus. It is seen that 10-15% couples who conceive successfully may not be able to carry pregnancy beyond 20 weeks. Thus, the miscarriage rate for a single pregnancy is 10-15%. But in most of the time this mishap does not recur in future. We call it 'sporadic miscarriage' and often the cause is not known. But almost 1% of the couples who want to get pregnant may suffer from repeated miscarriage. That means the unfortunate events can repeat. These are called 'RECURRENT MISCARRIAGE' or 'REPEATED PREGNANCY LOSS *RPL)

CAUSES

So, what's the reason for RPL which is equally frustrating for the patients as well as the doctors? First of all let me honestly confess that in most of the cases the cause is not known (50-60%) and this is called 'UNEXPLAINED RPL'. Again, we have to admit that despite tremendous advancement in science, the knowledge behind RPL is limited. Many theories and causes have been proposed but most of them could not withstand the taste of time. That means if a problem is found in husband or wife, we are not certain whether the treatment of that problem will prevent future miscarriage. This should be explained properly to the couples to have realistic expectations and avoid unnecessary frustration s in future. Only factors which are definitely associated with RPL are only two- anti-phospholipid antibody syndrome (APS) and chromosomal problem of either of the couples. Detection and treatment of these problems are often rewarding as after treatment pregnancy continuation rate us very high. The other causes have been proposed but as mentioned above the link between RPL and these causes are not yet very clear and need further scientific research. Please remember according to the timing, RPL may be divided into two categories- the 1st trimester RPL (occurring before 12 weeks in each pregnancy) or second trimester RPL (12-20 weeks in each pregnancy).

4-5% cases may be due to genetic or chromosomal problem of the couples. These problems can affect the egg (ovum) and/or the sperms. Even if the couples are normal, the baby may have abnormal chromosome.It is blessing that a genetically abnormal baby is miscarried by the nature, otherwise if it survives there is high chance that it may be mentally or physically handicapped. The reason may be increased age of the mother (above 35 years especially), exposure of mother to some environmental pollutants or sometimes increased age of the father (the latter is controversial). The diagnosis is done by chromosomal analysis of the couple by Karyotyping or FISH from blood samples. If the baby has been miscarried, it may be rational to send the tissue of the baby for chromosomal analysis to find out the cause. The treatment option in next pregnancy in such cases is genetic counselling by an expert and in most cases unfortunately only one option remains- that us IVF and PGD (pre implantation genetic diagnosis) where only genetically tested normal embryos are transferred by IVF ('test tube baby').

Anatomical factors are responsible for 12-15% if RPL, in most cases the second trimester RPL. The most common cause is 'CERVICAL INCOMPETENCE'. The cervix is the mouth of the uterus which should remain closed in pregnancy to support pregnancy and should only open during delivery. But in some cases, it can open prematurely leading to miscarriage. Usually this causes apparently painless miscarriage. In many women fibroid is found as a tumour of uterus. Whether fibroids cause RPL is again very controversial among the scientists and doctors. In some women who had repeated abortion or surgery to uterus and even tuberculosis (TB) there may be adhesion (binding together) between the walks of uterus. This is called Asherman Syndrome which causes scanty or absent periods and RPL. In few women there may be Congenital Anomaly of the uterus- that is where is some abnormalities inside uterus from birth. Therecan sometimes cause RPL, although controversial. These anatomical problems are diagnosed by proper examination, some tests like HSG (hysterosalpingogram), SSG (sonosalpingogram), 3D ultrasonography (USG), MRI, hysteroscopy and/or laparoscopy, depending on the women and test results. The treatment should be done cautiously as treatment may not always prevent RPL. For cervical incompetence usually, we put stitch in the cervix in pregnancy or sometimes before pregnancy. Operation can be done, before pregnancy for fibroids, Asherman and congenital anomalies.

In many cases (more than 70%) cases hormonal problems may be there and these may cause both 1st and 2nd trimester RPL. However, whether treatment us beneficial or not, is again controversial. The commonest pattern is Luteal Phase Deficiency (LPD) due to deficiency of hormone progesterone. PCOS (Polycystic Ovaries) is also associated with RPL. The other causes are uncontrolled diabetes, thyroid problems, high prolactin and high testosterone, high insulin and low ovarian reserve. As mentioned earlier, it is not clear whether they all need testing and treatment but usually tests advised for these are blood for progesterone, TSH, Prolactin, FSH, LH, AMH, Insulin, Testosterone, sugar, HbA1C etc. Treatment is usually progesterone supplement along with correction of hormonal imbalance. It is to be mentioned that these patients need high dose of thyroid drugs (TSH normal for other people may be considered abnormal for RPL) and more tight control of blood sugar in diabetes.

In 60-70% cases the cause is Thrombolphilia, that is tendency to thrombosis or blood clotting. The most common is anti phospholipidantibody syndrome (APS) which may or may not be associated with thrombosis in other sites but can cause thrombosis if blood supply to the baby and thus causes stoppage of its heart and miscarriage. Although more common in the Western World, some Hereditary Thrombolphilia may be found in other family members and commonly cause miscarriage and thrombosis. Deficiency of folic acid and vitamin B12 rarely can cause thrombosis and RPL. The APS testing is often successful, so as the treatment with aspirin and heparin injection throughout pregnancy. With this 80% women can expect full term pregnancy. Folic acid and B12 vitamin supplement is commonly given to RPL patients. Whether testing for hereditary thrombophilia is needed in our country or not is controversial. But treatment is like APS- that is aspirin and heparin injection.

Diseases of mother like diabetes, epilepsy, liver or kidney diseases, SLE etc can cause miscarriage. Exposure of mother to harmful substances like environmental pollution, radiation, chemotherapy and some toxic drugs, smoking, alcohol, cocaine, cannabis etc are also responsible but the latter usually cause sporadic miscarriage rather than RPL. So, these drugs should be stopped and replaced by safer drugs and the diseases must be treated properly. Even exposure of father to some drugs can cause RPL. Again, some abnormalities of sperms may cause RPL. So, semen analysis of the husband is usually done as a test for RPL.

The most controversial topic for RPL is the infections. But it is the fact proved by scientific studies that only infection in current pregnancy causes miscarriage. So, infection is a cause of sporadic miscarriage, not RPL. In the past TORCH testing was very much popular but nowadays it is obsolete test and there is no scientific ground for tests or treatment of TORCH. Only test we recommend is rubella testing. If rubella IgG is negative that means you may get infection in pregnancy so we advise to take rubella vaccine and avoid pregnancy for one month. On the other hand, rubella IgG positive means you are already immune and thus you can never get rubella. So vaccine is not useful in those cases. If any genital infection is found in husband or wife, both of them should be tested and treated aggressively.

TESTS REQUIRED

First of all, we need to know when we should advise tests. Assuming that most cases of miscarriages are SPORADIC, we usually do not advise investigation after single miscarriage unless the couple insists or there is some reason by the doctor to suspect some abnormalities that might cause future miscarriage. In the past testing was started after 3 miscarriages. But nowadays we do not want to give the couple, especially the woman a third trauma. So, we usually advise tests after 2nd miscarriage. The tests usually start with checking for chromosome of the baby. It is followed by chromosome analysis of both the partners along with proper history taking and physical examination. Semen analysis is done for the husband. The wife is advised ultrasonography, routine blood, thyroid testing, testing for APS and blood group. These are tests usually done everywhere. Further tests are done depending on the results if initial tests and especially if no cause is found after initial tests. It should be mentioned to the couples that the 2nd group if tests often do not have scientific grounds and are done only on benefit of doubt. They may not change the management plan. TORCH test is not done in modern era.

TREATMENT

The basic treatment is support if the couples, reducing stress as stress can be responsible for RPL. When a cause is found this should be treated. While an optimistic approach should be taken with expectations for normal pregnancy in future but this should be based on scientific and realistic approach to avoid future frustration. The treatment may not be 100% effective and most treatment may not have scientific base but are usually not harmful. Treatment may not guarantee a successful future pregnancy but a positive attitude is necessary. This is called TENDER LOVING CARE (TLC) where proper support and discussion can help more than explanation if mere statistics. Treatment should be continued both before and after pregnancy confirmation, as mentioned above. This is to be mentioned that even after 6th miscarriage, the chance that future pregnancy will be normal is more than 50%. So, the message should be not to give up hope.

 

Erectile dysfunction (ed) occurs when the man is unable to achieve or maintain his erection of penis to meet his or his partner's sexual satisfaction.

The problem is often faced by newly married men. Fortunately with experience, most of them are able to overcome this problem. Again it is increasingly common with increased age. 

So, what are the causes. In some male, it is psychological, caused by anxiety, depression, stress, marital disharmony etc. Use of alcohol and smoking will aggravate the problem. Psychological causes can happen at any age but more common at younger age. But in some cases, it is associated with serious diseases, especially at old age. It has been seen that in apparently healthy male ed is the first sign of heart disease. So, if you have ed, make sure that i's not caused by your heart problem. Again diabetes is another important cause. Excessive weight gain will also cause hormonal imbalance and thus problems in erection. Some hormone may also cause ed like thyroid, prolactin and even testosterone (male sex hormone). If you have chronic diseases like liver or kidney disease, it may also lead to ed. Diseases of nerves and spines should also be kept in mind. Sometimes, infections or tumour in private parts (prostate, testis etc) will also add to ed. Other diseases of penis like abnormalities in blood vessels can also be responsible, especially in young guys. Apart from these, some surgeries in abdomen and some drugs (like drugs to lower blood pressure, antidepressants, hormonal drugs etc) will also cause ed.

Now, what you can do? if you want to suffer silently, you will land up in other problems like problem in sexual life, problem in family relationships, depression and even inability to make your partner pregnant. But do all men with ed have to go to doctor? initially, the men should try life style modifications like avoiding smoking and alcohol; avoiding stress and anxiety; making good understanding with partner and also reducing weight. The partner should also have sympathetic attitude to the husband who is having ed.

But if still the issue is not resolved you have to consult doctor. It's not a mater of hesitation or embarrassment, as you may think. Rather it is needed to ensure that you are healthy. So, your doctor will talk to you, will check you and try to find out if any cause is there or not (like heart disease, diabetes, hormones etc). He may order some basic tests to ensure that everything is alright. After that he will advise you the treatment. If the cause is found, treatment of the cause (like diabetes) may cure ed. Even if no cause is found, ed can be treated by various ways.

But should you try the drugs shown in television or newspaper? remember, drugs used in ed have important side effects and we advise drugs only when it is absolutely necessary. In most cases simple measures like stress reduction, exercise help. Sex counseling of both the partners helps a lot. And if still ed persists, we advise drugs. There are variety of drugs, all are having own advantages and disadvantages. Particularly sildenafil group of drugs can affect heart and retina. So, we always practice caution before prescribing such drugs. And when patients are advised such drugs we advise to inform us when he feels eye problems, chest pain, fainting or even painful persistent erection of penis (" priapism").

There are other drugs that can be applied directly over penis. Testosterone group of drugs are prescribed only in selective cases as they have serious side effects and even they can reduce the size of your testes. In some cases where drugs cannot be given or drugs fail, we advise penile implants or artificial pump to maintain erection. Finally in very few cases, where blood vessels of penis is blocked, we can cure it by some operations. 

So, if you feel ed, don't get depressed. At the same time don't feel embarrassed to take medical help. Today's embarrassment may harm you in future. So, get cured and enjoy your personal life.

Erectile dysfunction (ed) occurs when the man is unable to achieve or maintain his erection of penis to meet his or his partner's sexual satisfaction.

The problem is often faced by newly married men. Fortunately with experience, most of them are able to overcome this problem. Again it is increasingly common with increased age. 

So, what are the causes. In some male, it is psychological, caused by anxiety, depression, stress, marital disharmony etc. Use of alcohol and smoking will aggravate the problem. Psychological causes can happen at any age but more common at younger age. But in some cases, it is associated with serious diseases, especially at old age. It has been seen that in apparently healthy male ed is the first sign of heart disease. So, if you have ed, make sure that i's not caused by your heart problem. Again diabetes is another important cause. Excessive weight gain will also cause hormonal imbalance and thus problems in erection. Some hormone may also cause ed like thyroid, prolactin and even testosterone (male sex hormone). If you have chronic diseases like liver or kidney disease, it may also lead to ed. Diseases of nerves and spines should also be kept in mind. Sometimes, infections or tumour in private parts (prostate, testis etc) will also add to ed. Other diseases of penis like abnormalities in blood vessels can also be responsible, especially in young guys. Apart from these, some surgeries in abdomen and some drugs (like drugs to lower blood pressure, antidepressants, hormonal drugs etc) will also cause ed.

Now, what you can do? if you want to suffer silently, you will land up in other problems like problem in sexual life, problem in family relationships, depression and even inability to make your partner pregnant. But do all men with ed have to go to doctor? initially, the men should try life style modifications like avoiding smoking and alcohol; avoiding stress and anxiety; making good understanding with partner and also reducing weight. The partner should also have sympathetic attitude to the husband who is having ed.

But if still the issue is not resolved you have to consult doctor. It's not a mater of hesitation or embarrassment, as you may think. Rather it is needed to ensure that you are healthy. So, your doctor will talk to you, will check you and try to find out if any cause is there or not (like heart disease, diabetes, hormones etc). He may order some basic tests to ensure that everything is alright. After that he will advise you the treatment. If the cause is found, treatment of the cause (like diabetes) may cure ed. Even if no cause is found, ed can be treated by various ways.

But should you try the drugs shown in television or newspaper? remember, drugs used in ed have important side effects and we advise drugs only when it is absolutely necessary. In most cases simple measures like stress reduction, exercise help. Sex counseling of both the partners helps a lot. And if still ed persists, we advise drugs. There are variety of drugs, all are having own advantages and disadvantages. Particularly sildenafil group of drugs can affect heart and retina. So, we always practice caution before prescribing such drugs. And when patients are advised such drugs we advise to inform us when he feels eye problems, chest pain, fainting or even painful persistent erection of penis (" priapism").

There are other drugs that can be applied directly over penis. Testosterone group of drugs are prescribed only in selective cases as they have serious side effects and even they can reduce the size of your testes. In some cases where drugs cannot be given or drugs fail, we advise penile implants or artificial pump to maintain erection. Finally in very few cases, where blood vessels of penis is blocked, we can cure it by some operations. 

So, if you feel ed, don't get depressed. At the same time don't feel embarrassed to take medical help. Today's embarrassment may harm you in future. So, get cured and enjoy your personal life.

Erectile dysfunction (ed) occurs when the man is unable to achieve or maintain his erection of penis to meet his or his partner's sexual satisfaction.

The problem is often faced by newly married men. Fortunately with experience, most of them are able to overcome this problem. Again it is increasingly common with increased age. 

So, what are the causes. In some male, it is psychological, caused by anxiety, depression, stress, marital disharmony etc. Use of alcohol and smoking will aggravate the problem. Psychological causes can happen at any age but more common at younger age. But in some cases, it is associated with serious diseases, especially at old age. It has been seen that in apparently healthy male ed is the first sign of heart disease. So, if you have ed, make sure that i's not caused by your heart problem. Again diabetes is another important cause. Excessive weight gain will also cause hormonal imbalance and thus problems in erection. Some hormone may also cause ed like thyroid, prolactin and even testosterone (male sex hormone). If you have chronic diseases like liver or kidney disease, it may also lead to ed. Diseases of nerves and spines should also be kept in mind. Sometimes, infections or tumour in private parts (prostate, testis etc) will also add to ed. Other diseases of penis like abnormalities in blood vessels can also be responsible, especially in young guys. Apart from these, some surgeries in abdomen and some drugs (like drugs to lower blood pressure, antidepressants, hormonal drugs etc) will also cause ed.

Now, what you can do? if you want to suffer silently, you will land up in other problems like problem in sexual life, problem in family relationships, depression and even inability to make your partner pregnant. But do all men with ed have to go to doctor? initially, the men should try life style modifications like avoiding smoking and alcohol; avoiding stress and anxiety; making good understanding with partner and also reducing weight. The partner should also have sympathetic attitude to the husband who is having ed.

But if still the issue is not resolved you have to consult doctor. It's not a mater of hesitation or embarrassment, as you may think. Rather it is needed to ensure that you are healthy. So, your doctor will talk to you, will check you and try to find out if any cause is there or not (like heart disease, diabetes, hormones etc). He may order some basic tests to ensure that everything is alright. After that he will advise you the treatment. If the cause is found, treatment of the cause (like diabetes) may cure ed. Even if no cause is found, ed can be treated by various ways.

But should you try the drugs shown in television or newspaper? remember, drugs used in ed have important side effects and we advise drugs only when it is absolutely necessary. In most cases simple measures like stress reduction, exercise help. Sex counseling of both the partners helps a lot. And if still ed persists, we advise drugs. There are variety of drugs, all are having own advantages and disadvantages. Particularly sildenafil group of drugs can affect heart and retina. So, we always practice caution before prescribing such drugs. And when patients are advised such drugs we advise to inform us when he feels eye problems, chest pain, fainting or even painful persistent erection of penis (" priapism").

There are other drugs that can be applied directly over penis. Testosterone group of drugs are prescribed only in selective cases as they have serious side effects and even they can reduce the size of your testes. In some cases where drugs cannot be given or drugs fail, we advise penile implants or artificial pump to maintain erection. Finally in very few cases, where blood vessels of penis is blocked, we can cure it by some operations. 

So, if you feel ed, don't get depressed. At the same time don't feel embarrassed to take medical help. Today's embarrassment may harm you in future. So, get cured and enjoy your personal life.

Introduction

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

 In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires

1. Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes
2. Transport of these sperms through the sperm conducting ducts from testes to penis
3. Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina
4. Transport of these sperms from vagina through cervix to the uterus and the tubes
5. Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
6. Pick up of the eggs by the tubes
7. Approximation of eggs and the sperms to form the embryo
8. Transport of embryo from the tubes into the uterus
9. Acceptance of the embryo by the uterus and its growth

What is Infertility?

 

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.

Thus the common causes may be

1. Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
2. Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examles include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
3. Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out. 

In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress.

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

What is insemination?

Insemination literally means putting semen in a particular place. Various forms of insemination exist in fertility treatment. First one is “Intravaginal Insemination (IVI)”, where the raw semen, collected by the husband can be put inside the vagina, taking precautions (to prevent infection) by the husband himself or by the wife. Rarely, it needs medical assistance from a doctor. It’s usually advised to couples having sexual disorders where full penetrative intercourse is not possible (erectile dysfunction of the husband or very painful intercourse experienced by the wife) or where ejaculation cannot happen during intercourse (a very unusual problem). Thus, the success rate of IVI is no better than natural intercourse (success rate 15% per cycle), for those couples who can manage successful intercourse.

“Intrauterine Insemination (IUI)” is the treatment where “prepared” semen is put inside the cavity of the uterus, near the Fallopian tubes. Thus, IUI bypasses some hurdles that can cause problems during natural intercourse. The vagina, cervix and the whole length of the uterus are bypassed, putting the sperms near the eggs. Thus it increases the success rate compared to natural intercourse or IVI.

However, to achieve pregnancy after IUI, the female partner must have open tubes, adequate number of eggs produced by ovaries, eggs must be released by the ovaries and sperms must meet the eggs. And, thus nature plays important role, as in natural intercourse.

Please note, we used the word “prepared” semen. In natural intercourse, as mentioned earlier, the dead sperms and bacteria cannot enter the uterus, because cervix prevents their entry. If they are put artificially by IUI inside the uterus, severe reaction can happen. So, after collection, the husband’s semen is processed in the laboratory to remove all those impurities and to select only the best number of healthy and movable sperms and it definitely increases success rates of IUI

When IUI is generally advised?

As you can understand, to perform IUI, there must be minimum number of sperms in the semen, the tubes must be opened, the ovaries must be releasing eggs. If these are present, IUI is usually advised

• Less than adequate number of sperm counts, morphology or motility
• Couples who cannot perform full penetrative intercourse but refuse or unable to conceive by IVI
• Unexplained infertility- although IVF is better than IUI, but considering the cost, many couples in our country opt for 2-3 cycles of IUI before IVF
• PCOS and Mild Endometriosis- where natural intercourse or ovulation induction failed
• Couples in whom only one partner is positive for HIV or Hepatitis B or C- where transmission from one partner to another by unprotected sexual intercourse is not preferable.

What are the tests done before IUI?

The basic infertility evaluation is done before IUI include husband’s semen analysis, assessment of ovarian function (blood tests, ultrasound) and uterus (ultrasound). In some cases, laparoscopy (putting camera to see inside the abdomen by operation) or hysteroscopy (putting camera through vagina inside the uterus, by operation) may be required. Now, if the tubes are blocked, IUI is of no use. So, testing the tubes is advisable before IUI. But some women, who are at low risk of tubal disease (no history of pelvic pain, infection or surgery), one or two cycles of IUI can be done, failing which tubes must be checked by tests like HSG or SSG or in some cases by laparoscopy.

What IUI actually involves?

In the cycle, in which IUI is planned, the woman is asked to take some medicines (or injections) in particular days of the periods as a part of “ovulation induction”. She is then advised to have ultrasound monitoring (TVS- transvaginal sonogram- where ultrasound probe is placed inside the vagina for better accuracy) to see if eggs are growing in response to the medicines or not. If eggs are growing, IUI is planned in a particular time when the egg(s) is more likely to rupture, so that the tie interval between sperm entry and egg release can be kept as minimum as possible.

Is ovulation Induction necessary for IUI?

Frankly speaking, IUI can be done without any medicines (as in case of natural intercourse or IVI), which is called “Natural Cycle IUI”, where only TVS monitoring is done to see how the eggs are growing. This may avoid some side effects of ovulation induction (see below) but is associated with low success rate than IUI done along with ovulation induction.

Is TVS necessary before IUI?

TVS is, undoubtedly, uncomfortable for the woman. But it gives better picture than ultrasound done conventionally. Now, the question is, whether ultrasound monitoring is at all needed or not. TVS directs the doctor how eggs are growing and at what number and size and when they are likely to rupture. Moreover, the rupture can also be confirmed by TVS. Again, the uncommon side effect of ovulation induction can be detected by TVS. That is called OHSS (“Ovarian Hyperstimulation Syndrome”) where excessive eggs can grow inside the ovaries and this can lead to collection of fluid inside abdomen and lungs and can turn very serious. Although very rare, it can be detected by TVS and early actions can be taken to prevent the progress of this condition.

In rare cases, where TVS cannot be done or patient declines, only option is to check urine by LH kit to predict the likely timing of ovulation and at that time IUI is planned. However, it is less accurate than TVS monitoring and is associated with less success.

What, if eggs are not growing in the ovaries?

In some women, particularly those who are overweight, aged or some cases of PCOS, eggs may not respond initially to one medicine. There are various forms of ovulation induction medicines (tablets, injection). If one is not working, your doctor can try increasing the dose of that medicine or add or replace it with other medicines. Please remember, it’s difficult to predict what medicine will be best suited for a particular patient. So, it’s basically a trial and error process.

What is done on the day of IUI?

As timing is important, the couples are requested to stick to the timing, advised by the doctor. The husband will be asked to collect the semen by masturbation, using clean technique (to avoid contamination by germs in the semen container). The semen is then prepared by the embryologist and will be checked to see the final number of sperms and their motility and morphology.

The wife is asked to lie down in the IUI table. After cleaning, a sterile speculum (instruments to separate walls of the vagina to see the cervix) is introduced inside the vagina and then 0.4-0.6 ml of the prepared semen is inserted inside the uterus with the help of a small catheter (fine tube). IUI done, under ultrasound guidance, gives better result than IUI done without it. The patient is asked to lie down few minutes after taking out the catheter and the speculum. The medicines are advised and then they can go home. 

Is IUI painful?

Most women feel little discomfort during IUI but it should not be painful. If there is technical difficulty while putting catheter inside the uterus, your doctor will discuss it with you and in the next cycle, will plan management to solve this issue.

What happens if husband cannot collect semen?

Collection of semen in unfamiliar environment is understandably a matter of discomfort and seems awkward. Proper counseling and maintenance of privacy can help. Stress-free approach is needed. If it fails, do not hesitate to inform your doctor. Some medicines can help. But in those, who are unable to masturbate, there are some instruments, like ejaculator, can help to solve this problem.

What happens if sperm count is low?

IUI can be successful if sperm count is minimum more than 5 million per ml and there is reasonably good morphology and motility. If not, IVF or ICSI would be the better option. But IUI can serve as trial also. That means before putting the semen, the prepared sperms can be examined and it can be predicted what is the success rate of IUI in this particular case and whether IVF or ICSI would be needed. In rare occasions, where sperm count is extremely low but the couple do not wish for IVF or ICSI, pooled semen IUI can help- where the semen is collected in number of occasions and is preserved and the final pool is used for insemination, to give a reasonable success rate.

When donor sperm is used and how?

If a man does not have any sperms or too few sperms to do IUI, IVF or ICSI is not affordable, donor IUI is an alternative. But it is not done without consent from both husband and wife. The donor is not known to the couple or the doctor and no identity of the donor is revealed. No relative or friend can serve as donor. Donor semen is frozen semen, collected 6 months ago and the donor is tested for diseases like STD, HIV, Hepatitis B or C. Usual attempt is taken to chose donor having blood group and skin colour similar to those of the husband. But remember, it’s only given after discussion and written consent by the couple.

Can a couple have intercourse in the cycle where IUI is advised?

Intercourse around IUI increases the number of sperms available at the time of ovulation.

When should one check for pregnancy?

Usually if period does not come within 18 days after IUI, pregnancy test is advised. It can be done at home. If negative, then the cause of not having periods is sorted out.

What is the chance of success after IUI?

In one cycle, chance of success is around 20-25%. Most of the couples conceive after 3rd or 4th cycle of IUI. The chance of pregnancy after 6th cycle is low, so, usually IUI beyond 6 cycles is not advised.

The factors where IUI gives better results include unexplained infertility, sexual dysfunction of any of the partner, PCOS and male subfertility (low sperm count or motility)

What happens if IUI fails?

As said earlier, you should think about further treatment, if 3rd or 4th cycle of IUI fails. There is no use of doing IUI beyond 6 cycles, unless natural intercourse is not possible and the age is favourable. IVF gives better result.

Is there any harmful effect of IUI?

Very few harmful effects have been noted, for examples, hazards of ovulation induction (OHSS< twin pregnancy), pain, infection and discomfort. As mentined, if raw semen is given, unusual allergic reaction can happen.

How IUI is being done in your particular centre by Dr Sujoy Dasgupta?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We try to take nominal charges and help couples to collect medicines (particularly injections) at lower prices than MRPs.

After thorough evaluation of both the partners, we plan for ovulation induction drugs, with consent from them and advise them to come for TVS. After each day TVS, we explain the progress and probable timing of IUI.

On the day of IUI, after requesting the couple to maintain punctuality, we advise the husband to collect semen, in comfortable atmosphere, maintaining the privacy. If there is problem in semen collection, we provide support to him and address his issues in sensitive way.

Our expert trained embryologist then prepares the semen. We always encourage the couples to see the condition of raw and prepared semen under microscope to maintain the transparency.

We advise the woman to fill up the bladder (to take water and not to urinate) to facilitate the passage of IUI catheter. Unlike other places, we perform IUI inside OT to prevent unwanted infection.

Again we maintain our uniqueness in the sense that we perform it under ultrasound guidance. The ultrasound guidance has been scientifically proved to increase the success rate of IUI. Moreover, we show the woman in the ultrasound (real time) how the catheter has been put inside the uterus (to make sure that we are not doing IVI or have placed it in wrong position). This also helps to reduce patient’s anxiety and uncertainty. After that, our nurse takes care of the patient and observes her when she takes rest.

Then we advise the post-IUI medicines and advise them what to expect and when they can go home. Again, this time we try to answer all questions the couples can ask.

 

Conclusion

Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Often we find that patients planning for treatment and in the mean time, they conceive naturally. That means even without treatment, there is some chance of pregnancy. Of course, it’s stressful situation for both the partners. Stress affects conjugal relationships and lead to many couples avoiding conjugal life. Indeed stress can affect the hormone levels in females and affects sexual performances in males. It’s easier for us to advise you to stay stress-free but is difficult to practice. Nevertheless, try relaxation as much as possible. Think that majority of the couples ultimately conceive by some form of treatment. Have faith in yourself and have faith in your doctor.

 

Introduction

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus,sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires

1. Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes
2. Transport of these sperms through the sperm conducting ducts from testes to penis
3. Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina
4. Transport of these sperms from vagina through cervix to the uterus and the tubes
5. Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
6. Pick up of the eggs by the tubes
7. Approximation of eggs and the sperms to form the embryo
8. Transport of embryo from the tubes into the uterus
9. Acceptance of the embryo by the uterus and its growth

What is Infertility?

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.

Thus the common causes may be

1. Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
2. Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examples include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
3. Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out. 

In general, what are the treatment options for infertility?

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress.

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

What is Fallopian Tube(s)?

Fallopian tubes (commonly called “the tubes”) are the structures that are connected to the both sides of the uterus, as mentioned above. Each tube is of 10 cm length. The part attached to the uterus is called the “cornu” and the part remaining free is called the “fimbria”. It’s the fimbria, that is present near the ovary and picks up the ovum and transports it inside the tube. The cornu received the sperms from the uterus and passes it inside. Inside the tube, the sperms and the egg meet to form the embryo, which then travels down the tubes into the uterus and then the pregnancy starts.

 

What happens if tubes are blocked?

If both the tubes are blocked completely, anywhere along the length (cornu, fimbria or the middle), pregnancy is not possible. This is quite obvious, because either the sperm cannot enter or the egg is not picked up or they cannot meet.

However, if any of the tubes are partially blocked, then the sperms and egg can pass and meet but the embryo cannot come down into the uterus. As a result, the pregnancy continues inside the tube, which is called “Ectopic pregnancy” that is life-threatening for the mother. It’s important to remember that ectopic pregnancy can happen even if both the tubes are open.

What are the reasons for tubal blockage?

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

What are the types of tubal blockage?

Tubal block may be one sided or both sided. It may involve only a particular part of a tube or multiple parts of a tube. The site of the block may be the cornu, the fimbria or the middle portion.

Hydrosalpinx, is a thing that you must know. In this condition, the tube is blocked but the mid-portion is dilated and contains some fluid (often infected). This tube is not functional. And the problem is even if there is pregnancy by IVF inside the uterus, this fluid from the tube may trickle down, coming in contact with the embryo and can potentially kill the embryo!

How can I understand that the tubes are blocked?

Unfortunately, very few women have signs or symptoms indicating tubal block. However, if you had previous infections in pelvis, tuberculosis in any part of the body, appendicectomy or other gynaecological surgery, there is chance of tubal block. Patients with fibroid and endometriosis are also at risk of tubal block. If you feel severe pain during periods or during intercourse, there is a chance that the tubes may be blocked.

When the tubes should be tested?

As mentioned earlier, the routine investigation of infertility includes testing for the ‘open-ness’ of the tubes- “Tubal patency tests”. That means if pregnancy does not come within 12 months of regular intercourse, then we usually advise the tests. Sometimes, tests are needed, after 6 months of trying (see above). However, in some women, with low risk of tubal block (no risk factors as mentioned above), it may be appropriate to start treatment and continue it for few cycles and if no response, then tubes should be tested.

How the tubes are tested?

The method of tubal patency test depends on your risk of having blocked tubes and also your wishes, availability of resources, other fertility factors and of course the affordability.

Routine ultrasound (like TVS) cannot detect tubal patency. However, it can detect the hydrosalpinx in most of the cases.

If you do not have any risk factors (like pain during periods, endometriosis, previous infections or surgery), you can choose either HSG or SIS. These are done in out-door basis, without any need of anesthesia.

HSG (Hystero-salingogram) is a method by which, your tubes will be seen under Xray. After visualizing your cervix (mouth of the uterus) by a speculum (instrument inserted in the vagina) a small screw will be inserted inside the cervix and a contrast material (which can be seen by the X ray) will be given through it. If tubes are open, the Xray will show that the contrast material will be going through the tubes into the abdomen.

The advantage of HSG is that, a test showing open tube has good correlation with tubal patency (if HSG shows the tubes are open, it’s likely that tubes are open). It is widely available and also cheaper.

However, the problem is that most of the women feel it painful, although they are given pain-killers for it. In addition, there is small risk of infection, for which antibiotics are prescribed. The contrast material can rarely give rise to allergy in some sensitive women and it may be life-threatening in very rare cases. Another problem is the false positive result. That means if tubes are found to be blocked in HSG, in 50% cases, they will be found to be open subsequently in laparoscopy. This is mainly because of some spasm of the muscles of the tube during the test.

SIS (Saline infusion sonography) or HyCoSy (Hystero-Contrast-Sonography) is the method by which tubal patency is checked by ultrasound (TVS) along with water like material inserted inside the uterus through a small tube. If tubes are open, the passage of water can be seen going into the abdomen through the tubes, in the ultrasound.

The advantage of HyCoSy is that it’s much less painful than HSG, although mild discomfort may be there. Pain-killers and antibiotics are prescribed usually. Additionally, problems inside the uterus can be better visualized, even better than normal TVS. In addition, the false positive result is much lower, only 7%. That means if HyCoSy suggests that the tubes are blocked, in most cases, the tubes will be found to be blocked at laparoscopy.

The problem with HyCoSy is mainly the cost and it’s not available everywhere.

An important merit of doing the tubal test is that, sometimes the water or the contrast material used in these tests can open the “mild” block. That’s why we often find patients who conceive spontaneously with pregnancy inside the uterus, after apparently “blocked” tubes in HSG or HyCoSy.

Now, laparoscopy is reserved for those, who are at high risk of tubal block. This includes women with risk factors (pain, surgery, infection etc) o women having “blocked” tube in HSG or HyCoSy. Clearly, it’s done after hospitalization under general anaesthesia inside the OT. Two or three small opening (key-hole surgery) will be put inside the abdomen and through vagina a coloured material (“dye”) will be given inside the uterus. If the tubes are open, the laparoscopic camera will show that dyes coming out of the tubes inside the abdomen.

The advantage is that it’s a definitive test, can help you to make final decision. It also provides the options of treatment. If there is corneal block in HSG, we can make attempt to open the tubes using laparoscopy (see below). In addition, if there is hydrosalpinx, where the tube serves no function, the tubes can be removed (salpingectomy) or clipped (we put clips to block the tubes) to improve the chance of pregnancy if IVF is the only option left for you. In addition, laparoscopy helps us to see whether there is any other diseases that have been missed by routine tests and that may account for infertility. We can treat the cysts of PCOS (by applying current to destroy some cysts), remove any large cysts, remove any adhesion, treat endometriosis etc.

The disadvantage of laparoscopy is of course, the need of anaesthesia and associated surgical and anaesthetic risks, although in modern era, the serious complications are uncommon.

What are my options if tubes are found to be blocked in HSG?

There are simply two options. It depends on your age, fertility factors and affordability. Number one is directly, you can go for IVF. In that case, you can save time and cost. It may be a preferred option, if you are aged or have some other fertility factors (low sperm count, endometriosis etc). The chance of pregnancy per cycle of IVF is usually 40%.

Another option is that you can confirm the block by other tests, keeping in mind that you may need IVF if the tubes are found blocked ultimately. We usually advise to have laparoscopy. However, some women want to give a trial with HyCoSy, because if HyCoSy shows the tubes are open, then you can avoid laparoscopy and you can try different fertility treatment options.

In laparoscopy, first we see if tubes are open or not. If open, there is no need of further treatment in laparoscopy. However, if tubes are found blocked, especially if the block is in cornu, we can try “hysteroscopic tubal cannulation”, where we put a small catheter through hysteroscope (a telescope, like endoscope, put inside the uterus through vagina so that we can see inside the uterus using a camera) to open the tubes. If tubes can be opened, you have all options for fertility treatment open.  However, if we fail to open the tubes, the only option left is IVF. In addition, if there is fimbrial block, it can be released and new opening in the fimbria can be made. The treatment of hydrosalpinx by laparoscopy has already been discussed (see above).

Having said that, there are some group of women, who conceive while waiting for IVF or laparoscopy after a blocked tube found in HSG.

What can I do if tubes are blocked in HyCoSy?

In this case also, there is choice between the two- laparoscopy first and IVF directly.

What can I do if laparoscopy suggests tubal block?

Unfortunately, in that case, the only option left is IVF. As mentioned before, if hydrosalpinx is found it must be treated before IVF. However, sometimes we find hydrosalpinx in laparoscopy but cannot cut the tube of clip it, simply because you did not give consent to us for doing so. In that case, we can suck out (“aspirate”) the fluid from the hydrosalpinx under ultrasound guidance (no need of further laparoscopy) using the needle.

How tubal block is dealt in your particular centre by Dr Sujoy Dasgupta?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We prefer to have SIS or HyCoSy, rather than HSG, to reduce the pain to the women. We discuss all the options if tubes are found blocked.

Conclusion

Tubal factor can account for 20-25% cases of female infertility. It’s more common in secondary infertility (women who conceived earlier- whatever be the fate of the pregnancy). Tubal test is a part of infertility investigation. The choice between HSG and HyCoCy is open to you. If tubes are found blocked, the options are IVF directly or confirming the block by laparoscopy.