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In an age when a small quantity of sperm can lead to pregnancy through IVF / ICSI, selecting healthy sperm(s) is of paramount importance. Although semen analysis is the most important test for evaluating male infertility, it does not provide information regarding all functions of sperm or for predicting male fertility potential and the likelihood of success of assisted reproductive technology. Common surgical procedures and conditions:
Sperm DNA fragmentation (SDF) is a term used to denote abnormal genetic material within the sperm, which in turn may lead to male subfertility, IVF failure and miscarriage . SDF is known to be higher in infertile men.
Aeitology is usually multifactorial but the major contributing factor for sperm DNA fragmentation is oxidative stress, which can be associated with one or more of the following:
➥ Infection
➥ Pyrexia
➥ Elevated testicular temperature
➥ Recreational drugs
➥ Smoking
➥ Alcohol
➥ Stress
➥ Diet
➥ Environmental and occupational pollutants
➥ Advanced chronological age
➥ Varicocoele
Treatment of high SDF depends essentially on the cause. Treatment options include:
➥ Antibiotics in the co-existence of an infection.
➥ Life style changes – drugs, smoking and occupation.
➥ Diet – fresh foods, particularly those containing antioxidants and multivitamins.
➥ Varicocoele surgery
➥ Testicular aspiration of sperm (DNA damage occurs at the post-testicular level, hence testicular sperm may have a better DNA integrity than ejaculated sperm).
➥ ICSI.
During IVF, fertilized eggs are kept in the lab for 2 to 5 days, allowing them to divide and develop into an embryo. Healthy embryo(s) are then transferred to the woman’s uterus to achieve pregnancy. During this process of development, the embryo gets surrounded by a protective shell called zona pellucida. For implantation to occur, this protective shell breaks out naturally. But in some cases, the outer layer of the embryo hardens, making it difficult for the embryo to hatch and implant. In laser-assisted hatching, a precision laser beam is focused over the zona pellucida making a small opening, between 10-20 microns to facilitate embryo hatching. LAH is done just before the embryo transfer.
This improves implantation and hence the pregnancy rates.
Patients who might benefit from LAH :
➥ Patients with day 3 embryos having a thick Zona pellucid
➥ Patients with previously Failed IVF / ICSI cycles
➥ Women older than 37 years of age, might have a tendency to produce eggs with a harder zona pellucida than younger women
➥ Women with high Follicle Stimulating Hormone (FSH) levels.
Using the LAH technique with IVF yields significant success in older couples and IVF failure cases and also in cryopreserved embryos
Preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) are the most advanced and revolutionary methods of treating infertility by using highly specialized molecular genetic techniques in examining the genetic state of the embryo prior to embryo transfer. Difference between PGS & PGD ? PGS is used for testing chromosomal abnormalities only, testing of a specific gene or mutation is performed by PGD. PGS is comprehensive chromosome screening that examines embryos for chromosomal abnormalities. All 24 chromosomes (22 autosomes plus X and Y) are examined to evaluate any gains or losses of chromosomes viz.
➥ Chromosomal Duplications: An extra copy of chromosome 21 also known as Downs Syndrome and other such conditions
➥ Chromosomal Deletions: Missing copies of chromosomes
➥ Sex-chromosome abnormalities: Duplications and deletions of X & Y chromosomes
PGS identifies embryos that display chromosomal abnormalities that may result in IVF failure, miscarriage, or babies born with Down’s Syndrome or Edward’s Syndrome. It aims at improving pregnancy and lives birth rates by screening your embryos for chromosomal abnormalities and only implanting chromosomally normal embryos.
On the other hand, PGD provides information on whether or not a specific genetic disease affects an embryo. Families affected by any genetic disease should use this test to reduce the risk of their progeny carrying the genetic disease.
Some single gene disorders identified using the PGD technique are:
➥ Cystic Fibrosis
➥ Haemophilia
➥ Sickle Cell Disease
➥ Spinal Muscular Atrophy
➥ Thalassemia
➥ Huntington’s Disease
General steps followed in an IVF lab to proceed with PGS / PGD:
➥ Embryos are formed via In Vitro fertilization (IVF), supplemented by ICSI so as to avoid interference with paternal genes during screening
➥ Embryos are grown till Day 3 or Day 5
➥ Embryo biopsy is performed to remove cells from the embryo
➥ The biopsied cells are processed for PGS or PGD
➥ Based on the diagnosis, genetically healthy embryos are transferred into the patient.
Biopsy could be Either:(Day 3 / Blastomere Biopsy) : On day 3, the embryo comprises 6- 8 cells which are compactly arranged. The Blastomere biopsy removes 1-2 of the 8 cells for analysis. As cell size is comparatively large in comparison to day 5 blastocyst cells, it requires a large hole/laser hatching in the embryo shell to remove tightly attached cells. This may at times be traumatic for an embryo.
Day 5 / Trophoectoderm biopsy :
On day 5, embryos reach to blastocyst stage & comprise more than 100 cells. A biopsy can be done to remove 5-6 cells at this stage which gives much more accurate results of DNA analysis.
Also, a comparatively smaller portion of the embryo is removed from the outer layer of the embryo destined to form the placenta, called the trophectoderm (TE). The cells that form the baby are undisturbed, preserving the embryo’s true potential & thus is less traumatic for an embryo.
PGS and PGD are both advanced technologies in assisted reproduction and help to improve success rates in IVF procedures.
For years women with Poor Ovarian Reserve or those with Ovarian Failure have had only one option to conceive that is IVF with Egg Donation. Recently published clinical studies investigating effects of autologous platelet-rich plasma have shown to improve outcomes in IVF. PRP has already been successfully used in various medical fields like orthopedics, sports medicine, dermatology and plastic surgery.
PRP is a concentrated blood product that contains a high percentage of platelets (biomolecules with natural healing and regenerative properties).
Through activating platelets in PRP, cytokines in addition to growth factors (GFs) turn out to be bioactive and are released within 10 min right after clotting. These factors consist of vascular endothelial growth factor (VEGF), transforming growth factor, platelet-derived growth aspect, and epidermal growth factor. They can regulate cellular migration, attachment, proliferation plus differentiation, and promote extracellular matrix accumulation.
PRP injected directly into the ovary releases cytokines and growth factors to heal and revive the local tissues in the ovaries to produce eggs again. In the case of women with premature ovarian insufficiency and menopause, it allows them to have a baby with their eggs.
The procedure is done in two steps:
➥Around 20 ml of blood is withdrawn by vein puncture by ACP double syringe and it is processed for separation of PRP by the standard procedure of double centrifugation.
➥ The next step is the injection of the PRP into the ovaries in a procedure similar to egg pickup done during IVF. It is done under sedation / local anesthesia. The patient can go home in 1-2 hours.
As it is prepared from the patient’s own blood (autologous), hence it has no side effects.
Endometrium thickness less than 7 mm is called thin endometrium and may be responsible for cycle failure. Currently, there are reports in the literature that infusion of PRP (Platelet Rich Plasma) in the uterus, helps in improving the thickness of the endometrium.
It has been quite successfully used in patients of RIF (recurrent implantation failure), where the PRP was done 48 hours before the embryo transfer.
The infertility workup starts with a detailed history of both partners followed by laboratory & imaging tests. For the female partner, these mainly focus on ovarian reserve, ovulatory function & evaluation of the uterus. For the male partner, the cornerstone of the infertility workup is the semen analysis. Any abnormalities in either of the partners are then evaluated accordingly.
