Aging and Fertility Issues

 Advanced age and Fertility !! Age is not just a number game but when we think about fertility its the main factor.More so the age of the female partner.Definitely we cannot reverese the things but we can think about the ways which can help to give us the best outcome. Various criteria are correlated with age when a couple visits doctor while planing baby-Like FSH,LH,E2,AMH,AFC if we talk in medical terms. As we are aware the number and quality of eggs decline with the adavncing age irrespective whether one had any pregnancy or undertook any fertility treatment prior and so far no ways to reverse or improve that. If we talk about ART (Assisted Reprodcutive techniques), the success rate declines with age While it is true that the ideal age to opt for IVF is late 20s and early 30s because the quality of eggs is robust at that time, even women in their late 30s and early 40s can savour the joy of motherhood through IVF. .But it is a lot better and wiser to give IVF a go in your late 30s and early 40s than regret not taking the plunge for the rest of your lives. The chances of success might be lesser, or even minuscule in some cases, but they certainly are not non-existent. There have been plenty of cases when women over 40s have become mothers by dint of IVF. Moreover, the rigours of undergoing the IVF treatment are completely worth for fulfilling the dream of motherhood. For a woman, nothing can match the happiness of being a mother of a child. They can also look at a brighter side of being mothers at 40 or above. Women in their 40s are more prudent, mature and sensitive than they are in their younger days. Hence the older mothers are more likely to give a well-rounded and holistic upbringing to their children. Another fact of being a mother in 40s is that one is well-settled and established in her professional life and hence more financially secured. So be it emotionally or financially, women in late 30s and 40s are more secured and mature. Hence chances of them providing wonderful upbringing to their children are quite salutary.

Intrauterine Insemination- All You Need To Knkw

 Intrauterine Insemination- All You Need To Know !!

Intrauterine insemination (IUI) — a type of artificial insemination — is a procedure for treating infertility. Sperm that have been washed and concentrated are placed directly in your uterus around the time your ovary releases one or more eggs to be fertilized. Older types of artificial insemination placed the sperm in the vagina. While this was easier, it was not as successful as the current procedure.

The hoped-for outcome of intrauterine insemination is for the sperm to swim into the fallopian tube and fertilize a waiting egg, resulting in a normal pregnancy. Depending on the reasons for infertility, IUI can be coordinated with your normal cycle or with fertility medications.

Indications-

A couple's ability to become pregnant depends on many different factors. Intrauterine insemination is used most often in couples who have:

1) Donor sperm- Frozen donor sperm specimens are obtained from certified labs(as per ICMR) and thawed before the IUI procedure.

2) Unexplained infertility- IUI is often performed as a first treatment for unexplained infertility along with ovulation-inducing medications.

3) Endometriosis-related infertility. Like unexplained infertility, the combination of medications to obtain the best egg and IUI is the first treatment.

4) Mild male factor infertility (subfertility)-Your partner's semen analysis, one of the first steps in the medical assessment of infertility, may show below-average sperm concentration, weak movement (motility) of sperm, or abnormalities in sperm size and shape (morphology). IUI can overcome some of these problems because preparing sperm for the procedure helps separate the highly motile, normal sperm from those of lower quality. This works best if the sperm have only one abnormality, such as only a motility problem.

5) Cervical factor infertility- Your cervix is at the lower end of the uterus and provides the opening between your vagina and uterus. The mucus produced by the cervix around the time of ovulation is supposed to provide an ideal environment for sperm to travel from your vagina to the fallopian tubes. However, if the cervical mucus is too thick, it may impede the sperm's journey. IUI bypasses the cervix, depositing sperm directly into your uterus and increasing the number of sperm available to meet the awaiting egg.

6) Semen allergy-Rarely, women have an allergy to proteins in their partner's semen, so ejaculation into the vagina causes redness, burning and swelling where the semen has contacted the skin. A condom can protect you from the symptoms, but it also prevents pregnancy. If your sensitivity is severe, IUI can be effective, since many of the semen proteins are removed before the sperm is inserted.

 Risks Of IUI-

Intrauterine insemination is a relatively simple and safe procedure, and the risk of serious complications is low. Risks include:

1) Infection-t fewer than 1 percent of women experience infection 

2)Spotting-Sometimes the process of placing the catheter in the uterus can cause a small amount of vaginal bleeding. This does not usually have an effect on the chance of pregnancy.

3)Multiple pregnancy 

 Steps Followed in IUI procedure-

Once the Eggs are ready with medicines and ovulation trigger given and IUI timed then the semen sample is prepared and patient shifted to IUI room

Its generally done in full consciousness with exceptions as per Clinical situation !

While lying on an exam table, you'll put your legs into stirrups and a speculum will be inserted into your vagina — similar to what you experience during a Pap test. During the procedure, the doctor or nurse:

Attaches a vial containing the small sample of healthy sperm to the end of a long, thin, flexible tube (catheter)

Inserts the catheter into your vagina, through your cervical opening and into your uterus

Pushes the sperm sample through the tube into your uterus

Removes the catheter, followed by the speculum

Post IUI-

After insemination you'll be asked to lie on your back for a brief period. Once the procedure is over, you can get dressed and go about your normal daily activities. You may experience some light spotting for a day or two after the procedure.

Interpretation Of IUI results-

Better see you treating doctor with report in clinic than self analysis and e-consults as there may be many grey areas which can be cleared with face to face discussion only.

Wait two weeks before taking an at-home pregnancy test. Testing too soon could produce a result that is:

False-negative. If your hormone levels are not yet at a measurable level, the test result may be negative when, in fact, you really are pregnant.

False-positive. If you're using ovulation-inducing medication such as HCG, the medication that's still circulating in your body could indicate a pregnancy when you really aren't pregnant.

Your doctor may instruct you to return about two weeks after your home kit results for a blood test, which is more sensitive in detecting pregnancy hormones after fertilization.

If you don't become pregnant, you might try IUI again before moving on to other fertility treatments. Often, the same therapy is used for three to six months to maximize chances of pregnancy.

Painful Menstrual Periods and Fertility Potential(In Hindi) on 21/7/202...

Painful Menstrual Periods and Fertility Potential(In Hindi) on 21/7/2020 at 11am (IST)





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​Dear Viewers In Our next Live video session we will speak about the painful menstrual periods- an agony which many women may suffer silently So Dear Ladies Dont Suffer alone, speak to Your Doctor

Age Not Only Number Game- But Game Changer Of Your Fertility !!

Age Not Only Number Game- But Game Changer Of Your Fertility !!
Author- Dr Richa Sharma

The average chance of becoming pregnant each cycle is only 20%.It takes 5 to 6 months for the average fertile couple to conceive. One out of every six couples has trouble conceiving and/or carrying a child to term. Over 1.2 million deliveries worldwide using assisted reproduction.

Women are born with all the eggs they will ever have. Some are ovulated, but several hundred are pre-programmed to die each month. Accelerated egg loss happens due to- smoking, ovarian surgery, pelvic radiation, chemo agents.Irrespective of whether the patient is undertaking any fertility related treatment or not, there will be a decline in the ovarian reserve with age and its rapid especially after 30 years of age.That’s why the success of an fertility treatment is dependent of the age of the female partner.To determine fertility potential, we as clinicians are dependent upon the clinical,biochemical and sonological parameters that’s called as Ovarian Reserve Assessment(quality and quantity of eggs in a particular age range )

        Trends-
  Many women today are attempting pregnancy at older ages, when they are biologically less fertile.
   Pregnancy rates sharply decline after age 35
   The exact age at which a women can no longer conceive varies widely.   

The trend in delaying fertility may be due to a greater emphasis on establishing a career, later marriages, and remarkable improvements in the area of contraception
Pregnancy rates related to age of female-

       Woman’s Age (y)       % Conceiving in 12 Months                                                                                               

             20-24                           86

             25-29                           78

             30-34                           63

             35-39                           52          

15 - 20% of all couples will experience difficulties with conception, but this increases up to 50% at age 35 – 40.
Reasons Of Decreased Pregnancy chances with age-

v Conception rate of normal fertile couples (~ 20% /month)

Probability of clinical pregnancy following intercourse on most fertile day of cycle:

        19-26 yrs old        50%

        27-34 yrs              40%

        35-39 yrs              30%

v Poor quality of aging oocytes

v Chromosomal abnl., morphologic abnl.

v Decreased ovarian reserve

v Altered hormonal environment– ovulatory dysfunction

v More conditions in older women– polyps,endometriosis, fibroids…

Sexual factors– decreased coital frequency

Treatment Options-

v Ovarian hyperstimulation with IUI

      -  generates more eggs and sperm to be present at                  the optimal time of conception.

v IVF (in-vitro fertilization)- vital to older when time        is critical , tubal pathology

          (live birth rate drop from 32% in women<35 to      10% in women 41-42 yrs)

v Oocyte donation- option for older women

   Pregnancy rates are determined by age of donor, but  pregnancy complications by age of mother.

v Delaying childbearing may increase infertility and the chance of developing chronic medical conditions.

v If no pregnancy after 6 months of trying, refer to specialist!! Time is vital for these patients.

Risks to the prospective pregnancy-

There are various ways to quantify the risks associated with advancing maternal age-

There are multiple tests today to quantify a women’s risk of chromosomal abnormality:

§ nuchal translucency

§ first trimester serum screening           

§ quad screen in 2nd trimester

§ invasive testing– CVS , amniocentesis

What patients need to know ?

As doctor, we are supposed to give clear picture to the patient about impending risks of adverse outcome of pregnancy in the form of

§ preterm birth

§ growth restriction

§ stillbirths

Besides that we should discuss the risks of Hypertension, Diabetes mellitus, low socioeconomic class….all influence outcome

Conclusion-

v Advanced maternal age is associated with reduced fertility and increased risk of adverse pregnancy outcomes.

v Associations are due to poor oocyte quality, age-related changes in uterine/hormonal function.

v Fortunately, the prospects for couples to conceive are better than ever with advancing age with advancement of science and introduction of ART and especially the Third Party Reproduction

Freezing Future- Lots In Magic Box

                            Author- Dr Richa Sharma(Senior IVF Consultant Mumbai)

Reproductive medicine as subspeciality is not only limited to IUI,IVF besides it has many other lateral and vertical extensions which gives wings to the humans to take planned decisions and control their lives and not just meeting the fate.One such miracle is –Freezing of future fertility at will and on need.

What is freezing of fertility ?

It means to preserve fertility for future in the form of freezing of gametes and reproductive tissue.It began with preservation in cancer patients but as per need can be extended in others too.For that IVF lab need to have upto date facilities and embryologist needs to be skilled enough in cryopreservation/vitrification

Who all can opt for ?

·      Improve the efficiency of IVF

·      Alternative to embryo freezing

·      Oocyte preservation for patients with ovarian hyper

·      stimulation syndrome

·      Oocyte donation programme( for quarantine purpose)

·      The treatment of congenital infertility disorders

·      Prevent fertility loss through surgery

·      Treatment of premature ovarian failure (POF)

·      Also in cancer patients prior to exposure to chemotherapy or radiotherapy(fertility Cryopreservation)

·      In career oriented females who want to plan family later due to other commitments

·      In case male partner not available or not able to give semen sample (ED/refuses)

·      In cases of failure to form embryos esp when repeated risk is there- half of the oocytes can be cryopreserved to find out the reason  (as to whether egg or sperm)

Is it limited to any particular gender ?

It can be beneficial in males and females both

How long we can freeze ?

As per ICMR it can be stored upto 5 years and depending upon situation term can be extended

What are pros and cons being in freezing temperature ?

Benefits are clear from indications mentioned above and disadvantage is due to the attrition affect of freezing media and post recovery survival especially when the samples frozen are not that great in quality and quantity

Fluid Collection in Ivf-Myths and Facts

IVF is a finer treatment option for childless couples but it needs a better understanding before opting for it.It has lots of Myths and Facts associated with it.

Patients often have fear of side effects of medicines used to stimulate their ovaries to grow  their eggs.One such side effect is Accumulation of fluid in the body what we call medically as OHSS(Ovarian Hyperstimulation Syndrome) but its not a uniform feature in all IVF patients.OHSS has a tendency to happen in selective group of patients with high risk factors which can be predicted and prevented.So via this write up our focus is on to single out such predisposing factors so that appropriate measures can be taken on time.Its not only duty of a treating doctor but a patient also needs to be aware than landing up with sudden surprises and bitter experiences.

Why is it a concern?

•       Marked increase in patient population in infertility clinics

•       Changing lifestyle

•       Advances in the field of ART – act as a Double edged sword with pros and cons

•       ART technology – is morepatient friendly,with less complication with cost still a limiting factor with no 100% gaurantee

What is OHSS ?

It is a Life Threatening medical(Iatrogenic,drug induced) Complication

and unique to the treatment of infertility with an an acute onset but reversible in nature with enlarged ovaries with cysts and fluid accumulation in body cavities to variable extent depending on gravity and grade

What are types of OHSS ?

Mild,Moderate,Severe and Critical

Who all have risk to develop OHSS ?

•       Young age, Low body mass index

•       Polycystic ovary syndrome (PCOS)

•       Higher doses of exogenous gonadotropins

•        High Estradiol levels with rapid rise

•       Previous episodes of OHSS

•       Multiple developing follicles(20-25)

•       Exogenous hCG for superovulation/ luteal support

•       Multiple Pregnancy

•       Serum factors increasing permeability of blood vessels

How it can be prevented ?

Primary  or Secondary prevention

1. Cycle cancellation
2. Coasting or controlled drift
3. Drugs – GnRH analogs

•       GnRH antagonists

•       Recombinant LH

•       Insulin sensitizers - Metformin

•       IV albumin 20%

•       ACE inhibitors + Angiotensin II receptor blocker

•       Glucocorticoids

4. USG Guided Follicular Aspiration
5. Elective Embryo Cryo Preservation and Transfer in subsequent cycle
6. In vitro maturation of oocytes (IVM)

How will my body behave when I Have OHSS ?

Most frequent symptoms and signs are –

•       Distention of lower abdomen

•       Nausea and vomiting

•       Dyspnea and respiratory distress

•       Diarrhea

•       Quick weight gain

•       Ovaries enlarged up to >12 cm

What to do If I have pregnancy and OHSS Both ?

Course generally unpredictable.That depends on how many pregnancies and response of body and period of onset of OHSS

Can It be 100% Prevented /Eliminated?

No but deterioration can be prevented.There is definitely aim to have OHSS free treatment

How to manage OHSS ?

Principles

•       Monitoring

•       Supportive therapy

•       Maintenance of intravascular volume

•       Prevention/treatment of complication

•       Counselling - Signs and symptoms of OHSS

•       Evaluate the baseline status with

 - complete history

 - complete general and systemic examination

(pelvic examination contraindicated as ovaries are fragile,can rupture or undergo torsion)

Outpatient measures-

•       Limit activity

•       Weigh daily

•       Monitor intake(1liter/day) and output

•       Daily follow up

•       Report if symptoms worsen or

            weight gain > 2lb/day

Admission needed in hospital as per clinical status of the patient