Male evaluation
Male factor problems may be related to:
»	Inadequate or abnormal sperm production and delivery
»	Anatomical problems
»	Previous testicular injuries, or hormonal imbalances
»	Sexual dysfunction and impotence

Our laboratory is fully equipped to perform detailed semen analysis. Non invasive Doppler examination is done to assess the presence of varicocele.

Female infertility is primarily due to ovulatory dysfunction, fallopian tube dysfunction, uterine or pelvic pathologies.

Ovulation and connected phenomenon can be detected by Ultrasound Examination including colour doppler study ( this is a clinical tool for imaging the dynamic changes in the ovary and uterine endometrium). Follicular sonography is best performed with vaginal transducer and the follicular details are clearly imaged.

Hysterosalpingogram (HSG)- an x-ray of the uterine cavity and fallopian tubes using a radiographic dye to detect structural abnormalities of the uterine cavity and fallopian tubes. Also Sonosalpingography is done to rule out tubular blocks.

Hysteroscopy- often done in conjunction with laparoscopy or separately visualize the interior of the uterine cavity for scar tissue, adhesions, polyps, tumors, and other abnormalities and to eliminate endometriosis.

Diagnostic laparoscopy- a minimally invasive surgical procedure typically performed as an outpatient day surgery. It permits direct visual assessment of the uterus, fallopian tubes, ovaries, and lower pelvic\s. It is particularly useful in diagnosing endometriosis, tubular disorders, or pelvic adhesions and generally is performed at the end of a work-up, but may be performed earlier if deemed appropriate by the patients history and referral diagnosis.

Hormonal evaluation

Serum hormone testing- measures the levels of luteinizing hormone, follicle stimulating hormone (FSH), prolactin, progesterone,and thyroid stimulating hormone (TSH). Follicle stimulating hormone is produced by the anterior pituitary gland and stimulates the ovary to develop a follicle for ovulation. Progesterone hormone is produced after ovulation has occurred and prepares the uterus for pregnancy.

Luteinizing hormone and follicle stimulating hormone levels are checked for hypothalamic pituitary dysfunction. It should be done on the 2nd day of a naturally occurring periods. Prolactin ( a hormone that stimulates breast milk production) levels are checked to see for it’s excess (hyoperprolactinemia) a condition that interferes with ovulation. Progesterone levels are performed to determine, if inadequate, or levels are interfering with the development of the endometrium, the lining of the uterus that prepares itself for embryo implantation. FSH, T3, T4 is checked to measure thyroid function.

For a pregnancy to occur, ovary has to release an egg and it has to unite with a sperm. Normally this union, called fertilization, occurs within the fallopian tube which joins the uterus (womb) to the ovary. Howevery, in IVF the union occurs in a laboratory after eggs and sperm are collected and under congenial conditions, allowed to unite. Embryos are then transferred to the uterus to continue growth.

Monitor the development of ripening of egg(s) in the ovaries.

Collect eggs - the woman is given hormones to produce multiple follicles

Obtain sperm

Put eggs and sperm together in a petridish in the laboratory, and provide correct conditions for fertilization and early embryo growth.

Transfer embryos into the uterus

To check that egg development is satisfactory, we utilize ultrasound exminations of the ovaries (a painless method of seeing the image of the enlarging follicles containing the eggs); hormone levels are also checked by taking a series of blood and/or urine samples. Using the above information we determine when to administer an injection to cause final ripening of the eggs and when to schedule egg retrieval.

The retrieval procedure to obtain the eggs is performed under anaesthesia transvaginally using a hollow needle guided by the ultrasound image(this is comfortable under adequate sedation and local anesthesia. Eggs are gently removed from the ovaries using the needle. This is called “follicular aspiration”.

The eggs are immediately identified by our embryologists in the adjacent IVF laboratory. They are placed with sperm. The sperm and eggs are then placed in incubators to allow fertilization to take place. The eggs are examined carefully at intervals to ensure that fertilization and cell division have taken place; the fertilized eggs are now called embryos.

Embryos are usually placed in the wife’s uterus 2 or 3 days after egg retrieval. A speculum is inserted into the vagina to expose the neck of the womb (cervix). The embryos are suspended in a tiny drop of fluid and then very gently introduced through a catheter into the womb, often under ultrasound guidance. The transfer is followed by some rest, and then blood tests and possibly ultrasound examinations are carried out to see if pregnancy has been established.

VF is of demonstrated value for patients with absence of both falopian tubes or irreversible tubal blockage (where corrective surgery has either failed or is inadvisable).

Intra cytoplasmic sperm injection (ICSI)

A tiny pipette is used to inject a single sperm into the awaiting egg in a revolutionary new procedure, Intracytoplasmic Sperm Injection.

A series of functional capabilities is required for a sperm cell to reach, and ultimately penetrate into the egg and initiate fertilisation. Recent estimates suggest that only about 10% of male infertility is attributed to underproduction of sperm due to maturation arrest or germinal aplasia, and that only 10% more can be attributed to pure motility disorders. This means that approximately 80% of infertile men have disorders ranging from profound oligospermia to failure of the sperm to acrosome reaction.

The acrosome reaction allows the sperm to penetrate through the sona pellucida, to enter into the perivitelline space, and ultimately bind to the egg membrane or oolemma and penetrate into the egg.

IN 1992, a “seminal” paper in a July issue of Lancet (15) described a powerful new method that has revolutionized the treatment of male infertility. Thatb method is intracytoplasmic sperm injection(ICSI). ICSI allows fertility experts and embryologists to effectively treat the large number of couples where the sperm cannot penetreate into the egg to initiate fertilization.

ICSI involves microinjection of a single sperm cell into each egg. This means that if as few as one viable sperm per available egg can be obtained from the semen, epididymis, or testes, then otherwise infertile men can now father children. ICSI is also performed on failed IVF patients.

ICSI can also benefit the additional group of post-vasectomy males for whom after vasectomy reversal often have diminished sperm quality, or who can avoid vasectomy reversal entirely through NSA ( non-surgical sperm aspiration) and ICSI. ICSI can be utilised for unexplained infertile couple.

PESA is indicated for men with irreparable obstruction resulting in azoospermia (lack of or no sperm), congenital absence of the vas deferens or failed vasectomy reversal. The procedure takes approximately 10 to 20 Minutes and does not require a surgical incision-a small needle is passed dirctly into the head of the spididymis and fluid is aspirated. Subsequently, the IVF labortory team retrieves the sperm cells from the fluid and prepares them for ICSI because of the limited amount secured. The Fertility Centre team in New England was the first to offer PESA.

Surgical removal of a portion of the testical tissue for patients who are not good candidates for PESA. In the andrology laboratory, tissue is homogenized (minced) and individual sperm is collected for ICSI.

In VIMS it is done in batches, to help overseas patients and employed female patients. This helps the couple to take leave from thier office and plan theprocedure, It is to some extent economical.

There are various steps in this programme

a.	Hormone injection to produce more number of eggs(controlled ovarian stimulation).
b.	Collecting/retrieving the eggs under anaesthesia.
c.	Seperating the eggs from the follicular fluid and inseminating/injecting with sperm.
d.	Final embryo transfer