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IVF - Treatments

Obesity

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems.Body mass index (BMI), a measurement which compares weight and height, defines people as overweight (pre-obese) when their BMI is between 25 kg/m2 and 30 kg/m2, and obese when it is greater than 30 kg/m2.

Obesity increases the likelihood of various diseases, particularly heart disease, type 2 diabetes, breathing difficulties during sleep, certain types of cancer, and osteoarthritis.Obesity is most commonly caused by a combination of excessive dietary calories, lack of physical activity, and genetic susceptibility, although a few cases are caused primarily by genes, endocrine disorders, medications or psychiatric illness. Evidence to support the view that some obese people eat little yet gain weight due to a slow metabolism is limited; on average obese people have a greater energy expenditure than their thin counterparts due to the energy required to maintain an increased body mass.

The primary treatment for obesity is dieting and physical exercise. To supplement this, or in case of failure, anti-obesity drugs may be taken to reduce appetite or inhibit fat absorption. In severe cases, surgery is performed or an intragastric balloon is placed to reduce stomach volume and/or bowel length, leading to earlier satiation and reduced ability to absorb nutrients from food.

Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults and children, and authorities view it as one of the most serious public health problems of the 21st century.Obesity is stigmatized in the modern Western world, though it has been perceived as a symbol of wealth and fertility at other times in history, and still is in many parts of Africa.

Environment, Lifestyle & Infertility

Reduced fertility is often determined by factors over which you have no control, such as a disease or an illness that you were born with. However, it is important for you and your partner to also be aware that you can influence some of the factors that impact on fertility. For example, smoking can cause abnormalities in menstruation in women, and high alcohol consumption can influence sperm production in men. The combination of several risk factors together can further reduce fertility. While overcoming a fertility problem is seldom as simple as drinking less or stopping smoking, changing certain elements of your lifestyle can nonetheless improve your chances of a pregnancy. In this section, smoking, alcohol and drugs, all of which can make it more difficult to have a child, along with other important lifestyle factors are reviewed. A recent English study investigated the effect of various factors on the fertility of 2112 pregnant women. Both men and women were asked about their age, smoking and alcohol consumption. The survey also collected information on tea and coffee consumption, weight, standard of living, drug use and the frequency of sexual relations. The results showed that lifestyle has a significant effect on fertility. The influence of smoking, alcohol and tea/coffee consumption seemed to depend on the level of intake. Besides the individual effect of these various factors on fertility, it was also demonstrated that fertility decreases further if several risk factors were present simultaneously.

 

Drugs & Alcohol:
High use of alcohol and marijuana or other illegal drugs can sometimes significantly reduce the quality and quantity of sperm. For example:

  • Marijuana is associated with many problems of sperm production.
  • The use of anabolic steroids can cause sterility.
  • LSD can cause damage to chromosomes.
  • Excessive drinking can affect sexual performance.

Alcohol, in particular, can reduce testosterone - the male hormone that plays a part in sperm production. This effect is reversed in the months after drug and alcohol misuse is stopped. In the case of women, drinking can lead to irregular menstrual cycles and non-ovulatory periods (menstruation that occurs without ovulation). Alcohol can also increase the chances of a miscarriage after a woman has become pregnant and can cause a number of serious birth defects, which are known as Foetal Alcohol Syndrome or FAS. In general, it is best to avoid the use of alcohol while you are trying to get pregnant and during pregnancy.

 

Smoking:
Smoking can affect the fertility of both men and women. In the case of women, smoking can lead to menstrual problems, ectopic pregnancy and disorders of the cervix and fallopian tubes. A relationship has also been found between smoking in women and a poor outcome for assisted reproduction: the ovaries are often less responsive to drugs reducing success rates. It is also strongly established that smoking during pregnancy can harm the health of the baby. Children of mothers who smoke have, in general, a lower birth weight and a more difficult birth. In the case of men, smoking can lead to problems of semen composition. Clearly, stopping smoking must be a serious consideration for couples trying to get pregnant, especially couples with unexplained infertility and men whose sperm counts are borderline. This is important for both partners because of the risks of passive smoking during pregnancy or after a child is born. Studies have shown that children who are exposed to passive smoking have an increased chance of health problems.

 

Environmental Hazards:
Sometimes the enviroment around you can actually interfere with your ability to become pregnant. Toxic fumes, lead, and other poisons can cause serious fertility problems, especially if you are exposed to them on a daily basis. Try to avoid:

  • pesticides
  • herbicides
  • fungicides
  • paint fumes
  • radiation
  • chemical cleaners or solvents

If you work in an industry that requires you to come into daily contact with any of these chemicals, speak with your health care provider about how your job may be affecting your future fertility.

How to Improve Semen Quality

It has been well researched that for a man to be fertile there has to be a generous supply of anti-oxidants in the body in general and in the genital tract in particular. Men with problems of low sperm counts and low semen volume distinctly lack in three essential anti-oxidants namely: Lycopene, Retinol and Beta-Carotene.
Beta Carotenes are the precursors of Vitamin A. If the body is deficient in Beta carotene the liver converts the existing Beta carotene into Vitamin A and the anti-oxidant activity is lost during the conversion. It is thus better to get more Lycopene. Lycopene is the agent that gives tomatoes the red color. What is interesting is that the Lycopene becomes more readily available when the tomatoes are processed like in tomato pasta sauce or tomato ketchups. Scientists in Israel have been able to engineer tomatoes with 4 times the Lycopene content than the ordinary tomato giving rise to the term Lyc-O-mato.
Consider this statistic. The average time taken to make a sperm is about 120 days. After this long wait only around 300-400 of the 400 million odd sperms are able to reach the egg in the female genital tract where the best 'man' fertilizes the egg. It has been shown that 600 mg of Vitamin E taken daily for 3 months improves the sperm counts and quality by over 20%. Imagine what having 20% over and above the normal 400 million sperms can mean to your fertility! Another essential ingredient for sperm count and semen volume improvement is Selenium which is a potent anti-oxidant.
There are few other important ingredients necessary for good sperm counts and quality. The amino acids L-Arginine and L-Taurine are essential for the formation of healthy sperms. One of the biggest micronutrients essential for fertility in both men and women is Zinc. Zinc plays an important role in reproductive functions and is crucial in determining the length of time that the sperms spend in the female genital tract. 50 mg of Zinc taken daily by both partners can improve sexual health.
So in order to improve your sperm counts and semen volume make sure you get your daily supply of Lycopene, Beta Carotenes, Zinc, Vitamin E, Selenium and amino acids like L-Arginine and L-Taurine.

Interpretation of Semen Analysis Report

Introduction:
Pregnancy occurs of course as the result of a sperm making the massive journey up to the Fallopian tube, making contact with and penetrating the wall of the egg (ovum). So, conception bears some resemblance to winning on the lottery. The more pounds you invest the better are the chances of winning a fortune and the greater the number of sperms that can be produced with the biggest proportion of vigorously swimmers the more likely you are to get pregnant.

 

Sperm count reports:
These vary in complexity but usually show the following headings.
Number of days abstinence (from sex!): 3 days is the standard, fewer than 3 reduces the count
(sometimes dramatically).
Volume of ejaculate: Normal is 2-7 mls but usually we see around 2-4 mls. Volume is important because a large volume increases the total number of sperms being delivered but small reported volumes are sometimes misleading as spillage during collection is common!
Time of production and examination under the microscope: Standard is no more than 60 minutes between production and examination although some labs say 120 minutes. The longer the interval the less vigorous the sperms are at swimming. Watch out for long delays with the sample sitting around in the lab. before analysis.
Appearance, viscosity pH and agglutination can be ignored. These results give an indication of the contribution to the ejaculate from the prostate and seminal vesicles and very rarely are abnormal.
Motility: It is normal to have up to 50% of sperms dead. 25% of the total count of sperms or more should be showing signs of making rapid forward progression and the remaining 25% may show signs of less vigorous swimming or twitching.
Motility is sometimes expressed as
Grade A (making rapid forward progress); B (Slow progess); C (Twitching) ; D (Dead)
Sperm concentration: The number of sperms per ml. Normal is given as 20-150 million per ml or 10 to
the power of 6.
Antisperm antibodies: Sometimes referred to as the MAR test, often as just antisperm antibodies. It is recommended that you ignore this test result. See later under post reversal interpretation.
Morphology / % abnormal forms: This refers to the shape of the sperms and the variation from what is regarded as normal configuration. Up to 85% abnormal forms is regarded as normal.

 

Assessing your result:
Returning to the theme in the introduction, your chances of conception depend on how many active sperms are in the ejaculate ie
Concentration x volume x % motility = total no. of fertile sperms
The lower limit of normal is regarded as 20/ml x 2 ml x 50% = 20 million.
Where the lab report merely overall numbers of sperms with any degree of motility, 50%+ is normal. Where the lab. reports grades of motility, use the grade A motility figure and regard 25% or more as normal
i.e. 20m/ml x 2 ml x 25% = 10 million rapidly progressive sperms
For example 50million sperms per ml x 2.0 ml volume of ejaculate of which 25% actively motile gives a total number of motile sperms per ejaculate of 25 million (where the lower limit of normal is 10 million).

 

Sperm counts after vasectomy reversal:
Vasectomy reversal creates an exit path for sperms that have been trapped for years. There is therefore a massive backlog of sperm fragments and debris to be shifted before fresh sperms (which take 2 months to be generated) can come through.

We use the initial test at 6-8 weeks to confirm that our connection is open and functioning. We would usually see relatively small numbers of sperms, the vast majority of which are dead (eg. 5 million with an overall motility of as little as 3%). With the next test at 4 months we would expect to see a rapid increase both in terms of numbers and motility eg 20 million with 25% overall motility and a final return to normal levels after a further few months.

Regular intercourse, using the Zinc and Selenium supplements, wearing loose underwear and leading a healthy lifestyle ensures you are doing your best towards a rapid return to fertility.

It is possible to reach very high counts very quickly after reversal but this is the exception rather than the rule. If this happens to you, congratulations, you will probably improve then stabilise. Early pregnancy, with the partners next cycle, does occur but is rare.

 

Some DOs & DON'Ts:
· Do remember that you can approach a private laboratory if you have any difficulty on obtaining tests through your GP/
· Do make sure the test is after 3 days abstinence form sex (tell us of the interval)
· Do note on the lab form the date and time of production
· Do not be disappointed if your first test shows a low count (early low is normal)
· Do have sex on a regular basis (4 days a week) rather than focussing on mid cycle
· Do take the Zinc and Selenium supplements recommended
· Do have follow up tests, ideally every 2 months
· Do not be surprised or worried to see positive antibody test results
· Do let us have a copy of the test report for interpretation and our records
· Do remember that there is great variation between one test and another. Follow up tests are
needed to confirm a trend.

Infection & Male Infertility

Most people assume that infections cause only temporary problems with their health. In fact, if an infection is not treated properly or quickly, it can cause serious problems throughout your body. And this includes your fertility.

 

What Type of Infection Will Affect My Fertility?
Almost any type of infection that makes an impact on your immune system can impair your fertility. In particular, those that affect your reproductive tract, including the prostate, epididymis or the testis, can hinder your fertility. It is unlikely that an infection will impair your fertility so much as to make you sterile, though. Most of the time, the effects of an infection are only temporary. While a pesky cold or some other type of infection may lower your sperm count or slow down your sperms motility, more often than not, your sperm will rebound back to normal in a few months.

 

Those That Damage:
There are some infections, however, that can do serious damage if not looked after right away. Sexually transmitted diseases, or STDs, are the most common infection associated with male infertility. If they are left untreated, you are repeatedly infected, or have frequent flare-ups, scarring and blockage in the reproductive tracts can occur. Mycoplasma, an organism often found in sexually active men, can attach itself to sperm cells, thereby impeding motility. Another illness that is often associated with male infertility is the mumps. Men who contract the mumps after puberty are at risk of developing fertility problems. This is because the illness can lead to orchitis, or inflammation of the testicles. While this complication is rare, if it does occur, it can impair sperm production and sometimes lead to permanent sterility.

 

Getting Treatment:
Unfortunately, many times infections do not cause any symptoms. STDs in particular are known for not producing any signs or symptoms. As a result, getting treatment for the infection may be delayed or never occur causing permanent damage to the reproductive organs. If your sperm production or reproductive tracts have been extensively damaged, it may be necessary to use surgical sperm retrieval methods in combination with ICSI and IVF. Alternately, you may decide to use a sperm donor in combination with IUI. In cases where symptoms do emerge or the infection is caught early on, antibiotics may be prescribed which should clear up the problem, thereby minimizing any damage to your fertility. If damage, such as scarring or blockage, has already occurred in your reproductive tract, then surgery may be done that can clear up the block or remove the scar tissue.

Basic Infertility Evaluation for Women

The basic infertility evaluation for women includes a history and a physical examination. Additional testing to further refine the diagnosis is often completed as well. The evaluation typically starts with a careful history of each woman's symptoms and previous experiences. This can include:

  • A review of the pattern of menstrual cycle bleeding to help determine if ovulation is occurring and if other problems such as diminished reserve (aging) of the ovary or uterine defects (fibroids or polyps) are present. 
  • Collection of information which might suggest an anatomic problem with the tubes, such as questions about past history of sexually transmitted disease, painful periods or intercourse, and/or a previous abdominal surgery. 
  • Questions about prior surgery to the cervix or freezing for abnormal pap smears. 
  • A general review of systems to ascertain symptoms suggestive of other endocrine abnormalities which might be contributing to infertility. 
  • A careful social history to evaluate for any environmental exposures or social habits (such as smoking, drinking alcohol, or drug usage) which could contribute to the infertility.

Next a physical examination is performed to evaluate the pelvic organs and assess potential hormonal problems.

Finally, additional hormonal testing or ultrasounds may be required to evaluate ovulation. An x-ray of the uterus and tubes (hysterosalpingogram or HSG test) may be completed to assess uterine or tubal status and surgical procedures such as a laparoscopy or hysteroscopy may be indicated to evaluate the structure of the uterus or fallopian tubes in more detail.

Basic Infertility Evaluation for Men

Approximately 45% of couples will have associated male infertility. It is for this reason that evaluation and treatment of the male is critical to a thorough comprehensive program for the infertile couple. A combined approach is essential to ensure successful evaluation and management.

An initial male fertility work-up includes a history, physical examination, general hormone tests and one or more semen analyses, which measure semen volume as well as sperm number, motility and quality of motion.

The initial evaluation typically begins with a series of questions that may include: 

  • A review of past medical history, prior surgeries and medications used.
  • A discussion of family history of infertility or birth defects.
  • A careful review of social history and occupational hazards to evaluate potential exposure to hazardous substances that could impact fertility.

Next a thorough physical examination is performed to evaluate the pelvic organs - the penis, testes, prostate, and scrotum.

Laboratory tests, such as a urinalysis, semen evaluation, and hormonal assessment are also conducted. The urinalysis will indicate the presence of an infection. The semen evaluation will assess sperm motility or movement, the shape and maturity of the sperm, the volume of the ejaculate, the actual sperm count, and the liquidity of the ejaculate. Hormonal tests evaluate levels of testosterone and FSH to determine the overall balance of the hormonal system and specific state of sperm production. Serum LH and prolactin are other hormonal tests that may be done if initial testing indicates the need for them.

 

When a diagnosis is not obvious after the initial evaluation, further testing may be required. One or more of the following tests may be recommended:

  • Seminal Fructose Test to identify if fructose is being added properly to the semen by the seminal vesicles. 
  • Post-ejaculate Urinalysis to determine if obstruction or retrograde ejaculation exists. 
  • Semen Leukocyte Analysis to identity if there are white blood cells in the semen. 
  • Kruger and WHO Morphology to examine sperm shape and features more closely. 
  • Anti-sperm Antibodies Test to identify the presence of antibodies that may contribute to infertility. 
  • Sperm Penetration Assay (SPA) to confirm the sperm's ability to fertilize. 
  • Ultrasound to detect varicoceles (varicose veins) or duct obstructions in the prostate, scrotum, seminal vesicles and ejaculatory ducts. 
  • Testicular biopsy to determine if sperm production is impaired or a blockage exists 
  • Vasography to check the structure of the duct system and identify any obstructions. 
  • Genetic Testing to rule out underlying mutations in one or more gene regions of the Y chromosome or to test for cystic fibrosis in men missing the vas deferens.

After the diagnostic evaluation is completed, a therapeutic route is chosen, which may involve medical or endocrinologic treatment, surgical correction, or a decision to manipulate or process the sperm which already exists to achieve a pregnancy.

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Dates 2014

25-27
Sept
Annual Meeting of the Middle East Fertility Society

Location: Abu dhabi, UAE
More Information

26-27
Sept
Epigenetics in reproduction (ESHRE Campus Event)

Location: Lisbon, Portugal
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9-12
Oct
11th Congress of the Mediterranean Association for Ultrasound in Obstetrics and Gynecology

Location: Antalya, Turkey
More information: