Producing semen sample for Semen Analysis or any Fertility treatment can be worrisome for a male partner. Usually in a Fertility Clinic or a lab, a private room or, in many places, a restroom is set aside for semen collection. A new environment and the anxiety of the results may make a person uncomfortable.

In such situations, semen collection at home could be a better option. But transporting the collected semen from home to the fertility clinic or a lab might pose a challenge, as the sample needs to be transported at an optimum temperature. Variation in temperature, both high or low, could result in abnormal test results. Accurate reporting is very essential as the course of treatment is very much dependent on semen parameters. Due to these reasons, patients are often advised to carry the collected semen container close to the body during transport causing discomfort.

For the first time in India, we introduce ‘Transperm’, a temperature-controlled semen transporting device, that can maintain the semen sample at body temperature. In addition, at Crea we have andrology technicians who are involved in evaluation and treatment of infertile couples for many years. So, getting a world class report from the comfort of your home is a possibility today.

Reproduction is a fundamental feature of all life known. It is a basic drive in all animals including humans. Each individual organism exists because of reproduction. This basic drive which was once thought to be so very easy to be fulfilled has become a dream for many a couple. It is surprising and contradictory that in a nation like ours where there are continuous and tremendous measures taken by the government to control our population, there are couples who would like to do anything to have a child.

Majority of developing countries are experiencing a marked decline in Fertility rates for the past 40 years from 1960. Fertility declines were rare earlier and fertility rates actually rose in some countries between 1945 and 1960. Yet, many parts of the world with different cultural, political, economic and social backgrounds are experiencing low fertility rates from 1960.India is no exception to this trend.

Pattern of fertility decline

The total fertility rate has declined from 6 in 1947 to 3.3 in 2000. It is expected to decline further to the level of replacement by 2020. A major contributor has been the increase in the average age at marriage. In 1961, the average age at marriage for men was 22 years and 16 for women. By 1993, this had increased to 26.5 and 24.5, respectively. There is a significant increase in the number of couples seeking medical treatment for infertility now more than ever before.

Infertility is defined as failure of conception after 12 months of uninterrupted sexual intercourse. One of the major factors determining this trend is that more and more women are delaying childbirth until their late 30's and into their 40's for various reasons, one of them being to develop their professional careers. This voluntary delay in childbearing not only poses a problem in terms of the 30-50% reduced pregnancy potential of older women, but also other risks like: the effect of pregnancy on other maternal illnesses, an increased risk of pre-eclampsia, hypertension and diabetes, and an increased risk of chromosomal abnormalities, abortions, and stillbirth.

The fact that decrease of female fecundity (ability to bear a child) begins in the early 30's, increases by mid thirties and becomes more pronounced after 40 is well documented. The most rapid decline in fertility potential in any single year has been found to occur at 35 years. Beyond this fertility is irreversibly lowered.

There is an approximately 70% decrease in the fertility rate of women attempting pregnancy at the age of 40 or older compared with younger women, and a twofold to threefold increase in the rate of spontaneous abortions. The biological basis of this reduced fecundity with increasing maternal age is due to various factors of which the effect of aging on every organ of the reproductive system is an all important factor.

Fertility decreases with women's age

Aging has an effect on every organ in the body and the ovary in the female is no exception. It is of general acceptance that most women are fertile through their early twenties. By mid thirties infertility rate increases by almost 30%. There is something known as the biological clock which is a direct result of the limited egg supply with which each woman is born.

Women are born with a finite number of germ cells and they are not replenished during their lifetime. Though this dogma has been challenged of late, there is no clear cut evidence so far to think otherwise. Before birth the female fetus has about 7 million follicles. Each follicle contains the oocyte or the egg, surrounded by granulosa cells or support cells for the oocyte. Of this initial number 2 million remain at birth. By puberty the follicular supply comes down to 300000. Of this pool, only 400 follicles are utilized during the women's lifetime for ovulation.

Every month, during the 28 day cycle, numerous follicles begin to develop out of which one dominant follicle matures and is ovulated or released. This utilization and attrition of the existing follicles from birth to menopause results in their reduced number with advancing age. In the 10-15 years before menopause there is a gradual acceleration in the follicular loss which is related to an increase in follicular stimulating hormone. More important than the reduction in the follicle number is the quality of oocytes which is a striking manifestation of ovarian aging.

In the human, 6 billion DNA molecules are located on 46 chromosomes which are coiled up inside the nucleus of each cell in our body and are divided into 23 pairs, 22 autosomal pairs and 1 sex chromosomal pair, the X and the Y. The child who has 2 X chromosomes will be a girl and one which has one X and one Y will become a boy.

For conception to occur, twenty-three chromosomes from the husband's set of forty-six, and twenty-three chromosomes from the wife's set of forty-six, must meet at the moment of fertilization and become an embryo with a new normal set of forty-six chromosomes. The process whereby primitive sperm cells and primitive eggs lose half of their chromosome number as they become sperm and mature eggs ready for fertilization is called "meiosis." The aging process of eggs makes it harder for them to undergo the meiosis process than sperm. That is why the eggs from older women are less likely to result in a viable embryo, and that is also why older women are more infertile than younger women, and why older women have higher rates of miscarriage and of babies with abnormalities such as Down's syndrome.

Oocyte quality in the female is an important determinant of successful fertilization. Some of the key contributing elements are oocyte maturation, spindle formation, energy supply, syngamy which is fusion of male and female pronuclei during the process of fertilization and early embryonic development. It has been proven scientifically that errors in some of these factors are more likely to happen with advancing age.

Other age related factors include irregular ovulation which occurs with increasing age as the hormone levels change, and luteal phase deficiencies which occur because too little progesterone - which is a hormone that maintains pregnancy in the uterus by making the uterine bed more receptive for the embryo to implant, is secreted. Increased miscarriages with aging as a consequence of altered chromosome numbers, called aneuploidy is also common in older women. This again is an important cause of decline in oocyte quality

Though there is no strong evidence that men suffer the same age related degeneration that women suffer, older sperm do cause genetic problems in the offspring like older eggs do. Unlike women, men are not born with spermatozoa in their testes. They start producing sperm at puberty and this process continues persistently throughout their life. Due to such high sperm production where the DNA is copied again and again, small variations or mutation occur in older men. These mutations cause a long list of genetic diseases in the offspring among which diseases like Lesch Nyhan Syndrome, Polycystic kidney disease and Hemophilia A are the most well known.

Age related changes also occur in the male both in the endocrine (hormonal) and sperm cell parameters. In the testis, the leydig cells which produce testosterone reduce in number and the aging pigment lipofuchin accumulates. There are changes also in the epidydimis, basal membranes and seminiferous tubules. There are localized changes in the spermatogenesis like degeneration leading to reduction in some types of spermatozoa, arrest of spermatogenesis at spermatocyte 1 stage and numerous malformations of spermatids. These changes are seen in relatively small areas and are diffusely distributed in the testis.

Along with genetic mutations, the semen volume, the percentage of motile sperm cells and the percentage of sperm cells with normal morphology also decline with age. Sperm motility and morphology are vital factors which determine the chances of conception. During normal intercourse the semen is deposited in the vagina and from here the spermatozoa in the semen have to swim up to the fallopian tubes of the female where a ripe egg is waiting (following ovulation) for fertilization to occur. Although these endocrine and sperm cell changes do not necessarily mean decline in fertility the incidence of sub fertility and time to achieve pregnancy increases when the male is aged more than 50. Also, for fathers over age 40, the risk of having a child with a disease-causing mutation is similar to the risk the mother has for a child with Down syndrome

Pattern of testosterone secretion in men relating to age

The advent of assisted reproduction technologies has been able to overcome these problems and reduce the sufferings of infertile couples to some extent. During the past 20 years assisted reproduction has made great strides and we have advanced techniques to treat male and female infertility. Now older couples are also able to fulfill their desire to be parents through these techniques and even complicated issues like alarmingly low sperm counts in the male, ovarian and tubal defects in the female have been addressed by this evolving branch of medicine. But research has clearly shown that, success even with this most sophisticated technology is dependent on age. due to factors like decreased oocyte quality, spontaneous abortions and implantation failure as mentioned above. Embryo implanting ability and survival decline gradually after 30 years of age, but by more than two thirds after 40 years

It is evident from demographic studies that the mean age at motherhood has been increasing since 1980 with women delaying childbirth due to various reasons. The risk of childlessness increases with increasing age both in women and men. In women ovarian aging results in reduced number of eggs and impaired oocyte quality which is an important factor for good quality embryos to develop. The implantation potential of embryos decreases with increasing age as evidenced by increased spontaneous abortions in older women. In men advanced age causes reduced motility and morphology in sperms which affects normal conception. Both in men and women increased age causes genetic abnormalities in the quality of egg and sperm leading to the birth of children with genetic defects. Though much research needs to be done into the various factors affecting oocyte and sperm quality in older men and women, we are at a juncture to reevaluate our strategies and priorities in life for us to avoid the burden and displeasure of childlessness which cannot be helped beyond a certain extent even with the latest technical advances in science.

One of the difficult questions while deciding an embryo transfer is when to do the transfer. While some clinics only do Day 2 or Day 3 transfers, others prefer Day 5 or Blastocyst transfers. What is the difference and why the preference?

Blastocyst culture and transfer is usually preferred due to the following advantages:

• Reduced risk of high order multiples, as fewer embryos are transferred
• The ability to select those embryos that have shown to be of superior developmental quality for transfer, as a result of reaching the blastocyst stage

So should transfer at the blastocyst stage be the norm as some infertility specialists insist? What happens if a patient has only three quality embryos available on day 3? What is gained by delaying the transfer in this case? Blastocyst stage embryos have higher implantation potential when compared with cleavage stage embryos, since only those embryos with activated genome reach the blastocyst stage. This is reported to benefit IVF in (i) Improving pregnancy rates and (ii) reducing high incidence of multiple gestations, since only few embryos need to be transferred.

Blastocyst culture (day 5) has many advantages over early stage embryo transfer (day 2, day 3). In the female reproductive system, fertilisation of the egg and cleavage of embryos occur in the fallopian tube and the embryo implants in the uterine cavity at the blastocyst stage. Thus, there is a physiological synchronization of the blastocyst stage embryo with the endometrium. It is physiologically pre-mature to expose early stage embryos to the uterine environment. Also, studies have revealed that uterine contractions decreased significantly over time following HCG administration leading to a significant reduction in uterine pulsatility at the time when blastocysts are transferred and therefore chances that embryos can be expelled are less.

One important factor favouring blastocyst transfer is that a disturbingly large proportion of morphologically normal day 3 embryos are chromosomally abnormal, thus contributing to the 80-90% rate of implantation failure post transfer. While it is a point of debate that extended culture of embryos to day 5 cannot be used as a reliable tool to select against chromosome abnormalities, studies have clearly demonstrated that the incidence of abnormalities can be reduced from 59% to 35% for older women.

A major concern in blastocyst culture is that - less number of embryos on day 3, might lead to embryo loss during extended culture and cancellation of the cycle. The fear that difference between the in vitro and in vivo culture conditions might result in developmental arrest of otherwise viable embryos during extended culture, prevents many labs to go ahead with day 5 culture. Improvement in the culture media together with the optimization of laboratory conditions has enabled prolonged in vitro culture of embryos without compromising their viability. In our lab the overall blastocyst formation rate is 85.3% which has been achieved irrespective of the number of embryos on day 3.

In our experience, we have seen that the number of embryos available on day 3 may not necessarily act as the deciding factor for extended culture of embryos and good blastocyst formation and good pregnancy rates can be achieved with good laboratory conditions and technical expertise even in the presence of a single embryo, provided it is a good quality embryo.

The purpose of assisted hatching is to create a small opening in the zona of an embryo so that it may easily exit when it has developed sufficiently. This procedure was developed as a result of findings that egg and embryo zonae can physically harden or thicken when cultured in vitro. And despite normal development of the embryo, the in vitro-induced hardening characteristics of the zona might actually prevent the transferred embryo from implanting because of a failure to allow exit of the embryo. Assisted hatching can guarantee that an adequate opening will be available for the embryo to pass through when the time comes. Although some clinics require certain indications before performing AHA, we have found no evidence of any harmful effects associated with its use and therefore perform this procedure on all IVF embryos so that every couple could share in the benefits that we believe AHA provides.

AHA (Assisted hatching) is almost always performed on the day of the embryo transfer. The embryologist performs AHA on all embryos that are expected to be transferred, so if there are more embryos in culture than we wish to transfer, the embryologist selects those having the best quality for AHA. After all, we want our patients to have the best chance at pregnancy which means hatching and transferring the best-looking embryos. In the event that there are numerous high-quality embryos available for transfer on day 3, the embryologist will likely opt to delay transfer until the blastocyst stage which usually falls on day 5 or 6 after the retrieval (see day 3 transfer vs. blastocyst transfer discussion for criteria and reasons why one transfer may be selected over the other).

Before laser came into use for assisted hatching, a substance called acid tyrode was used to thin the outer covering of the embryos. This acid has to be released slowed through a pipette and the quantity released is directly proportional to the skill of the embryologist. With this technique the duration of exposure of the embryos to outside atmosphere was more thereby altering the Ph and this could prove detrimental to the embryo growth. With Laser technique the whole procedure takes only a few seconds and the embryos are put back in the incubator as quickly as 20 - 30 seconds after removing.

According to recent studies, the routine sperm analyses such as sperm count, motility and morphology, are not reliable indicators of sperm function.

Sperm chromatin is tightly packaged to protect DNA during the transit that occurs before fertilization. Any abnormality in chromatin structure and integrity could lead to failure in fertilization.

ICSI allows couples with very low sperm counts or poor quality sperm to achieve fertilization and pregnancy rates equal to traditional IVF. It is also recommended for couples who have not achieved fertilization in prior IVF attempts. Sperm of virtually any quality and from any level of the male reproductive tract may be used with the only criterion for use being that the sperm is alive even if it is not moving (motile).

Infertility is defined as the inability to conceive after one year of sexual intercourse without the use of any contraceptive methods. A systematic and standard evaluation of all couples with infertility usually involves three initial tests:

• Semen Analysis (SA)
• HSG - Hystero salpingogram to assess tubal patency
• Assessment of ovulation

If the results of these three tests are normal, and the couple has been trying to conceive for at least one year, the diagnosis of unexplained infertility is made. Of the patients seeking infertility treatment, nearly 10 to 15 percent are diagnosed with unexplained infertility. This means that though the initial tests to evaluate ovulation, the fallopian tubes and SA are normal, this couple has difficulty conceiving due to some inefficiency in the process of conception.

Eventually most couples with unexplained infertility get pregnant. The problem may be an inefficiency that can be overcome with time and more attempts at conception. Most patients with unexplained infertility conceive within six to seven years. Perhaps a younger patient can afford the wait, but older patients may not have the luxury of time.

What is wrong then if everything is normal?

Unexplained infertility may be a misnomer since it assumes that in most cases we do not know what is the cause of infertility. In fact, there is often something wrong at a more basic level. For example, it is possible that there is something wrong at the level of the gametes (egg & sperm), their interaction with each other, or their interaction with the female reproductive organs.

It is also possible to have sperm that appear normal under a microscope, but do not perform the function of fertilization adequately. Furthermore, one can have normal sperm but poor quality eggs that do not fertilize or fertilize at a lower than expected rate. If normal eggs and sperm meet, one can expect a fertilization rate between 60 to 90 percent. The outer shell of the egg, the Zona Pellucida, usually hardens after one sperm enters the egg. It is possible for the outer shell to not allow a sperm to enter, or allow too many sperm to enter the egg. Both these situations result in abnormalities that lead to infertility.

Once an egg is fertilized, there is an 80 percent chance of cell division. The rate of division of the resulting embryo is also of significance. Usually 48 hours after fertilization, the embryo is between two to four cells (blastomeres). At 72 hours, they are usually between six to eight cells. After five days of growth, they are usually over 120 cells with a fluid cavity in the middle (Blastocyst). If a larger than expected percentage of embryos divide slowly or stop dividing at any stage, this can result in infertility.

There can also be problems with normal attachment or implantation of the embryo once it reaches the uterine cavity. This can be due to the presence or absence of certain important factors needed for implantation at the level of the uterus or the embryo. The outer shell of the embryo can be too hard or thick and not allow hatching of the embryo out of its shell (Zona Pellucida). This can result in a lower chance of implantation. A genetic abnormality with the embryo can lead to infertility. The embryos suspected of having a higher chance of a genetic abnormality are embryos with a higher degree of cell fragmentation (abnormal looking cells in the embryo).

Although an evaluation of the fallopian tubes, ovulation, and a SA are good initial screening tests, they do not identify all causes of infertility. Unexplained infertility therefore is not one specific diagnosis, but possibly a combination of one or many inefficiencies in the processes of conception.

Treatment options for unexplained infertility:

• Ovarian stimulation and/ or intrauterine insemination
• Clomid and timed intercourse
• Clomid plus insemination, IUI
• Injectable gonadotropins plus intrauterine insemination
• Assisted reproductive technologies

Unexplained infertility is thus a diagnosis encompassing many possible abnormalities resulting in a less efficient conception process. It defines couples with normal tubes, ovulation and SA who experience infertility. There are many possible causes, and some can be treated with assisted reproductive technology and some abnormalities are beyond the reach of our current knowledge. Usually, empirical treatment with inseminations is the most appropriate plan for three to six months before a more aggressive treatment with IVF is recommended, as many couples do conceive with less invasive and less costly treatments.

Testicular failure affects approximately 1% of the male population and 10% of men who seek fertility evaluation. Azoospermic men with testicular failure (non-obstructive azoospermia) have either Sertoli cell-only pattern, maturation arrest, or hypo spermatogenesis on testis biopsy.

The most severe expression of male factor infertility is azoospermia, where no sperm is present in the ejaculate. Azoospermia is found in 15-20% of men evaluated for infertility. Causes of azoospermia include congenital and acquired reproductive tract obstruction as well as spermatogenic failure. Azoospermia may have different etiologies and can be divided into Obstructive and Non-obstructive categories.

Until recently, it was assumed that men with non-obstructive azoospermia were untreatable. The only options offered to these couples to have children were the use of donor spermatozoa or adoption. Several clinically relevant findings have changed our approach to this condition. First, we have observed that direct evaluation of testis biopsy specimens often demonstrates sperm in men with non-obstructive azoospermia, despite severe defects in spermatogenesis.

In addition, it was previously thought that sperm must traverse the male reproductive tract before acquiring the ability to normally fertilize an egg. Our experience with men who have unreconstructable obstructive azoospermia, including congenital absence of the vas deferens suggests that complete transit through the epididymis is not a prerequisite for fertilization. Retrieval of sperm from the testis or epididymis was associated with good pregnancy rates using in vitro fertilization. Our subsequent experience indicated that micromanipulation of gametes during assisted reproduction could improve these pregnancy rates. Optimized in vitro micromanipulation techniques can further enhance fertilization and pregnancy rates using epididymal or testicular sperm.

This leads us to the second important clinical observation, that sperm can be retrieved from the testes of men with obstructive azoospermia and used with the assisted reproductive procedure of intracytoplasmic sperm injection (ICSI) during in vitro fertilization (IVF) with a high chance of achieving pregnancies and deliveries of normal children. These findings have led investigators from Belgium and elsewhere to perform testicular sperm extraction (TESE) with ICSI for men with non-obstructive azoospermia. Low pregnancy rates of 20 to 21% per attempt have been reported.

It is known for a fact that decrease of female fecundity (ability to bear a child) begins in the early 30's, increases by mid-thirties and becomes more pronounced after 40. The most rapid decline in fertility potential in any single year has been found to occur at 35 years. Beyond this, fertility is irreversibly lowered.

There is an approximately 70% decrease in the fertility rate of women attempting pregnancy at the age of 40 or older compared with younger women, and a twofold to threefold increase in the rate of spontaneous abortions. The biological basis of this reduced fecundity with increasing maternal age is due to various factors of which the effect of aging on every organ of the reproductive system is an all important factor.

Women are born with a finite number of germ cells and they are not replenished during their lifetime. Though this dogma has been challenged of late, there is no clear cut evidence so far to think otherwise. Before birth the female fetus has about 7 million follicles. Each follicle contains the oocyte or the egg, surrounded by granulosa cells or support cells for the oocyte. Of this initial number 2 million remain at birth. By puberty the follicular supply comes down to 300000. Of this pool, only 400 follicles are utilized during the women's lifetime for ovulation.

Every month, during the 28 day cycle, numerous follicles begin to develop out of which one dominant follicle matures and is ovulated or released. This utilization and attrition of the existing follicles - from birth to menopause - results in their reduced number with advancing age. In the 10-15 years before menopause there is a gradual acceleration in the follicular loss which is related to an increase in follicular stimulating hormone. More important than the reduction in the follicle number is the quality of oocytes which is a striking manifestation of ovarian aging.

In women ovarian aging results in reduced number of eggs and impaired oocyte quality which is an important factor for good quality embryos to develop. The implantation potential of embryos decreases with increasing age as evidenced by increased spontaneous abortions in older women.

Oocyte quality in the female is an important determinant of successful fertilization. Some of the key contributing elements are oocyte maturation, spindle formation, energy supply, syngamy which is fusion of male and female pronuclei during the process of fertilization and early embryonic development. It has been proven scientifically that errors in some of these factors are more likely to happen with advancing age.

Other age related factors include irregular ovulation which occurs with increasing age as the hormone levels change, and luteal phase deficiencies which occur because of too little progesterone - the hormone that maintains pregnancy in the uterus by making the uterine bed more receptive for the embryo to implant - is secreted. Increased miscarriages with aging as a consequence of altered chromosome numbers, called aneuploidy is also common in older women. This again is an important cause of decline in oocyte quality.

When in vitro fertilisation was first introduced, it was believed that semen quality as judged by light microscope was able to predict the generation of viable embryos and when the sperm quality was below a certain threshold it would affect the the outcome of IVF techniques. In due course increasing evidence suggested that the basic semen parameters where not enough to predict the fertility potential of spermatozoa and advanced sperm function tests were introduced. Though introduction of ICSI reduced the importance of these tests by achieving fertilisation and development of embryos using subnormal spermatozoa, it became evident that in spite of generating embryos with ICSI many of them were not viable and resulted in repeated implantation failures.

Normal Embryo development is dependent on the genetic integrity of the spermatozoa. High level of DNA fragmentation in sperm cells may cause of male infertility which is not detected by a routine semen analysis including - sperm concentration, motility analysis, morphology assessment. Irrespective of the assisted reproductive technology used, high levels of DNA fragmentation above the critical threshold will significantly compromise the possibility of a successful pregnancy, though fertilization or the first and the second embryo cleavage rates are not affected. High DNA fragmentation level, which is significantly higher in sub-fertile men, are closely correlated with IUI, IVF and ICSI miscarriage and pregnancy rates. Men with poor semen parameters are more likely to have high DNA fragmentation. High sperm DNA fragmentation can also be found in men with normal semen parameters.

Sperm DNA Fragmentation Index provides a reliable analysis of sperm DNA integrity which can help us to identify men who are at risk of failing to initiate a healthy on going pregnancy, and also help in the clinical diagnosis, management and treatment of male infertility. It also helps in assessing the outcome of assisted conception treatment.

Normal, healthy pregnancies do occur in couples where the male partner has a high percentage of sperm with fragmented DNA, although the chances are significantly reduced, as the percentage of sperm bearing low levels of DNA fragmentation is much lower. Embryos derived from sperm whose DNA is highly fragmented have a poor prognosis. Evidence suggests that this could result in initiation of apoptosis and mutations resulting in blastocyst arrest, miscarriage, abnormalities in the offspring and an increased susceptibility to childhood cancer. Protection against high DNA fragmentation may be afforded by younger oocytes which are much more efficient at DNA repair of defective sperm than older oocytes. Couples undergoing fertility treatment where sperm DNA fragmentation is high have a better prognosis if the female partner is young.

A major causative factor for sperm DNA damage is oxidative stress which may be caused by infection, sperm cytoplasmic droplets, fevers, increased testicular temperature, diet, drug use, cigarette smoking, exposure to environmental and occupational pollutants, advanced age and presence of varicocoele

Some causes of DNA fragmentation cannot be treated. But if the damage is caused by free radicals, a change in lifestyle and a diet designed to protect against oxidative stress may help reduce the levels of DNA fragmentation in some of these patients. Treatment of infection with antibiotics would also be expected to reduce DNA fragmentation. Initiatives to reduce the levels of fragmentation can be assessed by undertaking a second test three months after the first. Studies show that ICSI may be a more effective treatment than IVF for sperm with a high DNA fragmentation.

Crea Conceptions is pleased to offer its Minimal Stimulation/ Natural Cycle Programme. This is possible because of its wealth of technical expertise gathered over the years. The scientific team at Crea is highly experienced and respected in the field of Clinical Embryology and brings with it unparalleled skill set in the field which is translated into high fertilization and cleavage rates for its patients.

What happens in a normal ART Cycle?

• First ovaries are stimulated with Gonadotropin Injections to produce multiple eggs.
• The eggs are removed from their follicles under the guidance of Ultrasound Scan.
• The retrieved eggs are fertilized with sperm and are cultured in the Embryology Laboratory up to Day 5 which is the blastocyst stage.
• One to three embryos depending on the age of the patient are transferred into the uterus after 3-5 days of oocyte retrieval.
• Assisted reproductive technologies

The basic difference between conventional ART and minimal stimulation programme is the amount of drugs used to stimulate the ovaries which consequently results in the difference in the number of oocytes retrieved. With a highly experienced embryology team, we are able to produce excellent fertilization rates and good quality embryos even with less number of oocytes, which is the advantage in this approach.

Advantages Include:

• Reduced dosage of gonadotropin injections leading to reduced cost of injections.
• Better tolerance of patients because of reduced number of injections.
• Complete avoidance of OHSS which is a consequence of high dose of gonadotropins.
• More physiological and receptive endometrium at the time of embryo transfer.

Disadvantages include:

• There is a chance that no oocytes will be retrieved in a natural cycle IVF. This can be compensated with repeated attempts since it does not involve frequent visits or hospitalization.
• No extra embryos for cryopreservation.

Candidates for Minimal Stimulation and Natural Cycle IVF are:

• Patients of age < 35 years
• Patients with tubal factor infertility
• Patients with no male factor infertility
• Patients with diminished ovarian reserve
• Patients who are poor responders to gonadotropin injections.
• Patients with normal FSH values.

Over the last couple of decades survival rates for cancer patients have improved dramatically. The population of young cancer survivors has increased today and hence the focus of cancer treatment has shifted from survival alone to quality of life after treatment. One major issue in young cancer survivors is loss of fertility potential after treatment.

Chemotherapy, radiotherapy and sometimes surgical dissection done for treatment of cancer affect spermatogenesis or sperm production. It is difficult to predict the ability of a person post cancer treatment to father a biological child and In such instances it becomes essential to preserve the fertility potential of the individual. In males it is done by collecting semen samples by masturbation and freezing them at -196 degrees Celsius. At this temperature the semen can be stored for an indefinite period until it is required to be utilized. When there are no spermatozoa in the ejaculate in certain conditions, sperms can be recovered by surgical means. Recovery of sperm production post treatment is variable due to

• Effect of treatment
• Pretreatment fertility potential
• Influence of cancer itself on the person's overall health

In cancer patients who are about to undergo treatment it would be a sensible option to freeze semen prior to treatment. Once the treatment is over when the person wishes to have children the frozen semen can be thawed and used.

Semen obtained by masturbation is analyzed for quality and is frozen in vials. One day later a small aliquot of the sample is thawed and checked for post thaw quality. Not every sample frozen will thaw the same. There is considerable difference in the thawing capacity of each individual semen sample and depending on this the number of samples to be frozen will be decided. A total of 5-6 samples with an abstinence period of 2-3 days in between is frozen. Whenever the couple decides to have a child, the sample is thawed and utilized for conception either through IUI or ICSI.

Semen freezing can also be a viable option for men prior to vasectomy and for men who are about to undergo treatment for conditions like psychiatric illness, diabetes etc since many of the drugs used for these conditions might affect the quality of sperms which will reflect on the fertility potential.

As a consequence of the increase in the number of patients surviving cancer, greater attention has been focused on the delayed effects of cancer treatments on the quality of future life of the survivor. Increase in the awareness of the effects of cancer treatments on fertility has created a need for fertility preservation among men and women. This demand has led to advancement of various techniques to preserve fertility through assisted reproduction and cryopreservation. The available options range from clinically well-established techniques such as embryo cryopreservation to highly experimental ones such as ovarian tissue cryopreservation.

A woman's reproductive life span is finite and depends on the number of oocytes with which she is born. Ovaries, which are endowed with an irreplaceable number of follicles, are extremely sensitive to cytotoxic drugs that induce an irreversible damage. There is a possibility that the ovaries & oocytes get damaged due to chemotherapy causing premature ovarian failure thereby leading to premature menopause and permanent infertility. Older women are said to have higher risk of developing complete ovarian failure compared to young women with high follicular number.

Patients who are under the risk of developing future ovarian failure and those suffering from benign ovarian diseases and undergoing radical surgery may all benefit from fertility preservation technologies. Fertility preservation is especially challenging in children, as embryo or oocyte cryopreservation is neither ethical nor practical. Currently the only option that could be offered to child patients is ovarian tissue cryopreservation, provided that the families are thoroughly informed about the post thaw status of the technique.

Method of cryopreservation:

In case of oocyte and embryo cryopreservation, ovaries are stimulated with hormonal injections to induce the growth of multiple follicles. When the follicles reach a definite growth stage, final maturation induction is done. The eggs are subsequently removed from the body by transvaginal oocyte retrieval. The procedure is usually conducted under sedation. The retrieved oocytes are either frozen immediately (Oocyte Cryopreservation) or after insemination of sperm and development of embryo (Embryo Cryopreservation) using cryo-protectants at extremely cold temperatures.

Ovarian tissue cryopreservation involves freezing a part of the ovary and storing it in liquid nitrogen whilst therapy is undertaken.

Available techniques for Fertility preservation in women:

• Embryo Cryopreservation: IVF/ICSI can be performed to store embryos for future use, if the patient has a partner and enough time prior to treatment.
• Mature Oocyte Cryopreservation: Embryo cryopreservation may not be an option for single women unless they choose to use sperm donation. In these patients, if they have time to complete ovarian stimulation prior to cancer therapy, freezing mature oocytes can be considered instead.
• Ovarian Tissue Cryopreservation: Ovarian tissue contains follicles with oocytes arrested at first meiotic division. High surface and absence of zona pellucida make the follicles less susceptible to cryo-damage. This tissue can be later be thawed and implanted near the fallopian tube, where it starts to produce eggs, allowing normal conception to take place.

IVF with donor oocytes and donor embryo transfer are other alternatives in patients who suffer from premature menopause or low ovarian reserve due to cancer treatment. The number of options to preserve fertility is growing. These options vary depending on the patient's age, the time available, type of cancer and whether the likelihood of ovarian involvement is high.