How fibroid can affect fertility ?

Presence of fibroid can reduce fertility due to following effects :

• Direct pressure over uterine cavity & fallopian tubes.

• Change in direction of uterine cavity & fallopian tube.

• Change in receptivity of lining of uterus.

• Change in direction of normal Junctional zone contraction waves.

• Recurrent Implantation Failure.

How is fibroid treated ?

In women planning to conceive options are :

• Myomectomy : Surgery to excise the fibroids

• Medical management : Drugs like GnRH agonist & SPRM( selective progesterone receptor modulator ) to shrink the fibroid away from uterine cavity

• No treatment : It is chosen if fibroid is unlikely to affect fertility & pregnancy.

Who should undergo surgery to remove fibroid (myomectomy ) ?

It’s a very individualised decision as fibroids are very commonly seen in otherwise fertile women also.

The decision to remove fibroid is based on detailed fibroid mapping , using 2d & 3D USG to assess the following :

• Location of fibroid -those towards cavity should be removed

• Size of fibroid – larger than 4 cm should be removed

• Number of fibroids – 2 or more in number are better removed

• Closeness to the lining of uterus – Cavity distorting fibroid should be removed.

What to expect after fibroid removal ?

• Couple can start trying for pregnancy after 2-3 month.

• After myomectomy delivery by caesarean section is recommended.

The possibility of pregnancy with natural methods is less if any of the following issues are there :

• Woman’s age is more than 35yrs : For each year of the female partner’s age after 30, the pregnancy rate is reduced by 9 %.

• Couple has already tried for more than 3 years : Each additional month of infertility beyond the average reduces the chance of pregnancy by 2 % ie about about 25%/year.

• There was no pregnancy earlier.

Management options are focused on identifying the causes without adding much to the cost & pregnancy can be achieved with :

• Expectant management

• Ovulation induction & IUI

• Hystero laparoscopy

• IVF & ICSI

Women with PCOD are at increased the risk of following :

• Type 2 Diabetes

• Risk of cardiovascular diseases

• Risk of endometrial hyperplasia & endometrial cancer

• Risk of anxiety & depression

Routine tests & evaluation in PCOD includes :

• Pelvic ultrasound & assessment of ovaries

• Hormonal assessment : LH, testosterone , AMH, DHEAS

• BMI & waist circumference

• Glucose challenge test

• Blood pressure

• Assessment of depression or anxiety

Treatment of PCOS is aimed at correcting the present concern of the patient :

• Ovulation problems

• Correction of period irregularity

• Weight reduction

• Individualised care during pregnancy

• Lifelong follow up to monitor the risk of diabetes & cardiovascular diseases.

Options for fertility treatment for PCOS women are :

• Ovulation induction

• Intrauterine insemination (IUI) if any male factor is present

• Laparoscopy

• IVF

• Prevention of miscarriage

Some infertile women with PCOS may need laparoscopy for following indication :

• Women who fail to ovulate with oral tablets.

• High levels of LH & AMH.

• High risk for Ovarian hyperstimulation syndrome with hormones injection.

• Women who need assessment of fallopian tubes.

• Cannot come for repeated follicular monitoring.

• Normal male factor with fair chance of natural pregnancy.

There are conditions other than PCOS which can cause similar issues :

• Thyroid disorders

• Prolactin disorders

• Cushing syndrome

• Idiopathic hirsutism

Important things to consider during your PCOS treatment :

• PCOS is a very complex hormonal , metabolic , lifestyle & psychological issues.

• It is a lifelong condition.

• It is a lifelong condition.

• Before labelling a woman as having PCOS it is important to make sure that there are no other hormonal conditions which can cause similar issues.

• It requires individualised evaluation & treatment planning.

There are 3 main types of endometriosis depending upon the location :

• Superficial peritoneal lesions

• Ovarian endometriomas ( penetrating inside ovarian tissue & forming cyst )

• Deep infiltrating endometriosis :Penetrating deep under pelvic organs like urinary bladder & bowel.

Based on the above factor these are the treatment options for women with endometriosis planning to conceive :

• Expectant management – wait for a pre decided time duration for pregnancy to happen naturally

• Ovulation induction& intrauterine insemination (IUI)

• Laparoscopy to confirm the diagnosis , check condition of tubes ,remove adhesions & remove endometriotic cyst.

• Endometriotic cyst aspiration

• IVF & ICSI

Embryo quality issues can be due to :

• Advanced maternal age- high risk of chromosomal abnormality in oocytes

• Poor oocyte(egg) quality

• Parental chromosomal abnormalities

• Poor quality sperm

• High sperm DFI ( DNA Fragmentation Index )

• Hardeningof Zona pellucida (outer covering of the egg )

• Suboptimal embryo culture conditions

• Smoking

Treatment is based on correction of above factors like:

• Improvement in oocyte & sperm quality with life style changes & medications.

• Optimal ovarian stimulation protocol

• Optimal embryo culture conditions

• Blastocyst culture

• Selection of normal embryo having normal chromosomes with Preimplantation genetic test for aneuploidy (PGT-A)

• Surgical correction of uterine defects

• Assessment of endometrial receptivity with Endometrial receptivity array (ERA)

• Improving endometrial receptivity with G-CSF /PRP intrauterine infusion.

• Use of Intralipid to help in implantation.

• Immunotherapy

Embryo quality issues can be due to :

• Advanced maternal age- high risk of chromosomal abnormality in oocytes

• Poor oocyte( egg) quality

• Parental chromosomal abnormalities

• Poor quality sperm

• High sperm DFI ( DNA Fragmentation Index )

• Zona pellucida hardening( its covering of oocyte )

• Suboptimal embryo culture conditions

• Smoking

Endometrial receptivity issues can be due to :

• Defect in anatomy( size & shape) of uterus : Polyp , fibroid, adenomyosis, thin endometrium ( lining of uterus), adhesions, septum .

• Endometritis ( infection of endometrium )

• Defect in function of endometrium

• Immunological factors causing rejection of embryo

• Thrombophilia ( blood clotting disorders )

• Presence of hydrosalpinx ( liquid filled fallopian tubes )

Treatment is based on correction of above factors like:

• Improvement in oocyte & sperm quality with life style changes & mediation

• Optimal stimulation protocol

• Optimal embryo culture conditions

• Blastocyst culture

• Selection of normal embryo having normal chromosomes with PGT-A

• Surgical correction of uterine defects

• Assessment of endometrial receptivity with ERA

• Improving endometrial receptivity with G-CSF /PRP intrauterine infusion .

• Use of Intralipid .

The options after failed IUI are :

• Tubal patency test

• Check timing & technique of IUI

• Check method of semen preparation for IUI & quality of inseminated sperms.

• Correction of thin endometrium lining

• Assessment of DFI

• Ovarian reserve test

• Hyster laparoscopy to correct & treat any defect

• Medications to improve sperm & oocyte quality

• After assessment & correction of above factors couple can be advised to go for few more cycles of IUI or IVF.

Treatment of repeated pregnancy loss is focused around identifying &correcting the problems.

1) Genetic problems –Chromosome analysis of the couple is done.

• When no chromosomal abnormality is found then couple can try for natural conception or opt for PGT-A (earlier called PGS).

• When a chromosomal translocation is detected then couple can opt for IVF &PGT-SR procedure to select unaffected embryos.

2) Abnormalities in uterus can be detected by 2D or 3D USG & Hystero laparoscopy.

Any identified abnormality is then corrected before planning for next pregnancy.

3) Women with Antiphospholipid antibody syndrome are treated with medicines which prevent blood clotting like aspirin & heparin.

4) In cases with cervical incompetence USG is done to monitor cervical length & any early opening ( dilatation ) of cervical canal.

In selected cases stich around cervical canal ( Cervical Cerclage ) can be placed at end of 3rd month of pregnancy.

5) PCOD Women with recurrent miscarriage are treated with supportive hormone medication.

6 ) Cases with unidentified causes treatment is focused on giving supportive medications.

7) Counselling & correction of life style factors.

8) Immunotherapy to correct immunological embryo rejections.

There is 60-80 % ‘take home healthy baby ‘chance even after 3 abortions.

Ovarian reserve should be tested in following conditions also :

• Planning fertility preservation

• Candidate for IVF

• Planning to delay pregnancy for personal reasons

Ovarian reserve can be determined with Ovarian Reserve Test ( ORT ):

• USG for Antral Follicle Count (AFC scan) – Good for number of eggs.

• Blood test for determination of Anti Mullerian Hormone ( AMH ) – Good for number of eggs & quality to some extent.

• Blood test to assess function of ‘Hypothalamic -Pituitary -Ovarian axis’ – Follicle Stimulating Hormone (FSH,) Luteinising Hormone (LH) &Estradiol.

Caution while interpreting result of ORT :

• None of above test can predict the chance of pregnancy with 100 % accuracy.

• Most important factor determining chance of conception is quality of oocyte which cannot be assessed precisely with any available test.

• A woman with good ovarian reserve may face difficulty in having a healthy baby due to issues in sperm quality or implantation issues.

• Woman with low AMH & AFC also can conceive with individualised treatment protocol.

• Women with low ovarian reserve should consult a fertility specialist to discuss their treatment choices.

Sexual dysfunction is categorised into 4 broad types:

• Desire disorder : Lack of or less interest in sexual activity , also called low libido.

• Arousal disorder : Body is unable or difficult to get aroused – like erectile dysfunction in men , vaginal dryness.

• Orgasm disorder :More common in women.

• Pain disorder :Vaginismus , vaginal dryness, infection , endometriosis ,skin condition , yeast infection etc.

Treatment of sexual dysfunction :

• 1st step is understanding the exact issue the person is facing.

• 2nd step is identifying the cause the sexual dysfunction

• 3rd step is correcting the identified cause with combination of medication, surgery , counselling etc.

What not to miss at doctors clinic :

• Discuss about your issue without any shyness or anxiety.

• Discuss about your complete medical history.

• Disclose all drugs & supplements you are taking.

• Discuss about any other discomforting experience in your past.

• Plan a couple counselling if suggested by your doctor.

Effect of cancer on future fertility

The effect of cancer on future fertility depends upon following :

• Type of cancer

• Stage of cancer

• Type of surgery – aim is to minimise tissue damage ( Fertility sparing surgery )

• Type of chemotherapy

• Dose & area of radiotherapy

• Condition of eggs & sperm before start of cancer treatment

• Age at the time of cancer diagnosis.

Fertility preservation options for women :

• Embryo cryopreservation (freezing)

• Egg cryopreservation

• Fertility sparing surgery

• Shielding of ovaries /testes with lead during radiotherapy

• Ovarian transposition to a different location.

Fertility preservation options for men

• Sperm cryopreservation

• Lead shielding of testis during radiation treatment

Fertility preservation options for children :

• It requires counselling of parents & maximum possible explanation of the process to the kid depending upon their age.

• Treatment options largely depends upon if the child has attained puberty.

Fertility preservation after puberty :

• Oocyte preservation for girls ( in process similar to ovarian stimulation in IVF )

• Sperm cryopreservation for boys.

Fertility preservation before puberty :

• It’s very challenging condition for fertility preservation as the child’s reproductive system is lacks mature eggs & sperms.

• Ovarian tissue & testicular tissue can be cryopreserved , but with limited success.

Other things to consider before fertility preservation :

• Early consultation with fertility specialist if you need to delay child bearing.

• Discussion with cancer specialist & fertility specialist to understand the time line & course of cancer treatment.

• Fertility preservation should not affect success of the cancer treatment when done in timely manner without delaying cancer treatment & appropriate ovarian stimulation protocol.

• Pregnancy outcome will depend on your general health condition after cancer treatment.

• Babies born after cancer treatment are generally healthy like other babies except when exposed to cancer treatment during pregnancy.

(2) Pre Implantation Genetic Testing for Monogenic Diseases (PGT-M):

• It was earlier called Preimplantation Genetic Diagnosis( PGD ).

• It is recommended when there is known risk of passing down a genetic abnormality to future offspring.

• Genetic test report of affected family member is analysed in details to plan treatment for the couple.

Who can benefit from PGT-M ?

• Personal or family history of single-gene defects—such as cystic fibrosis, haemophilia, sickle cell anaemia, muscular dystrophy , citrullinemia , multiple exostosis etc.

(3) Pre Implantation Genetic tests for Structural Rearrangement ( PGT- SR ):

• Chromosomal structural rearrangements are translocations , inversions ,duplications or deletions of part of chromosome.

• Many time carriers of structural rearrangement are apparently healthy individuals.

• Most of the times structural rearrangements are suspected & detected only when such individual suffer from repeated IVF failure , repeated miscarriage or birth defects in their babies.

Who can benefit from PGT-SR ?

• In known carriers of chromosomal structural rearrangement normal embryos can be selected by PGT SR.

Risk factors for low or nil sperm count include following :

• Cryptorchidism : testes not located in scrotal sac

• Testicular torsion

• Testicular trauma

• Genitourinary infections

• Exposure to environmental toxins.

• Cancer survivors – h/o chemo or radiotherapy

• Use of anabolic steroids

• Varicocele

• Smoking

• Obesity ,life style & environmental factors

• Many time no risk factor is found

Treatment options for men with very low sperm count or nil sperm :

• Men with hypo gonadotrophic hypogonadism can be treated with combined hormone therapy with HCG & FSH.

• Oral antioxidant therapy can be used

• Varicocele correction

• Treatment of MAGI – Male Accessory Gland Infectio

• Correction of life style factors , smoking cessation , weight reduction if obese.

• IUI can be done if sperm count increases above 5 M/ml

• ICSI with sperms in semen ejaculate if count does not improve above 5 M/ml

• ICSI with surgically retrieved sperms if azoospermia persists

The procedure of Assisted Hatching :

• Embryologist can create very tiny hole in zona pellucida with help of Laser shots.

• Assisted hatching can help the embryo to hatch out completely & implant in the uterus.

Assisted hatching can be suggested in following conditions :

• Woman older than 37years

• Previously failed IVF

• It is also done when embryo biopsy for genetic test is planned.

Pitfalls of assisted hatching :

• Natural expansion of blastocyst with breached ZP may be compromised & embryo may hatch out early.

• Loss of cells of embryo (blastomeres) – very rare

• Embryo may become more exposed to immunological reactions & other harmful agents.

• Monozygotic (identical) twinning of the embryo.

Implantation :

• Expanded blastocyst invades inside of lining of uterus ( endometrium) within 24 hours of hatching out.

• Blastocyst embryo starts production of HCG hormone ( Human Chorionic Gonadotrophin ) which gets absorbed in the mother’s blood.

• In a healthy developing embryo, this HCG hormones keeps on increasing & can be detected by blood test of mother.

Blastocyst culture :

• Normally only 30-60 % of day 2-3 human embryo develop till blastocyst stage due to :

1.Internal factors of oocyte , sperm or embryo.

2.Sub optimal embryo culture conditions.

• Earlier usual practice was to transfer 2-4 embryos at cell or cleavage stage (day 2 or 3 after IVF-ICSI) to compensate for less implantation potential of these embryos.

• Blastocyst culture helps to select embryo with higher implantation potential.

• After blastocyst culture, 1-2 embryo of can be transferred based on patient factor and higher success rate can be achieved.

• It reduces risk of triplets & high order multiple pregnancy.

• It is also recommended in cases who need embryo biopsy for genetic tests as blastocyst embryos tolerates embryo biopsy procedure better & have better implantation chance. Also, the biopsy results of a blastocyst are more reliable.

Important considerations before planning blastocyst stage embryo culture :

• Blastocyst culture requires excellent quality embryo culture condition in embryology lab.

• In suboptimal embryo culture condition embryo may show slowing or even arrest of growth , thus may fail to become blastocyst.

• Couple with less number of embryo may not have sufficient number of embryo for transfer after blastocyst culture . In such couple ‘take home baby rate ‘ per started IVF cycle is more when day 2-3 embryo transfer is done.

• Similarly embryo with lesser quality on day 2-3 of growth may become more stressed out during blastocyst culture , resulting in lower pregnancy rate per started IVF cycle when compared to day 2-3 embryo transfer.

Treatment of high sperm DFI is based on correcting identified risk factor :

• Lifestyle modification

• Varicocele surgery

• Treatment of MAGI

• Antioxidant treatment

• Maintain short ejaculatory abstinence

• Sperm selection if couple is going for IVF/ICSI.