Article

Successful pregnancy in men suffering from Azoospermia (zero sperm count)

Dr. Kaberi Banerjee
MBBS (AIIMS), MD (AIIMS), DNB
MRCOG (UK)
Commonwealth Fellow in Reproductive Medicine and IVF
Senior Consultant, Max IVF Centre

About 10% of all couples trying to conceive face difficulty. This could be because of many reasons like infrequent inter course, stressful lifestyle or medical factors. About 50% of these causes are because of male factor and half due to female factor. Male factor includes absent or poor sperm. Female factor includes tubal uterine or ovarian problems. We describe two cases of successful pregnancy in a couple where a problem was identified in a man. Both these men had nil sperm count.

Absence of sperm in the ejaculate can be because of pre testicular, testicular or post testicular issues. Pre testicular cause involves defective hormonal signals to the testis to create the sperm. Testicular cause involves absence or defective progenital cells which synthesis the sperm cells. Post-testicular causes include those cases where the sperm is produced; however it is unable to come out in the ejaculate because of blockage in the ducts. The cause can be identified by measuring the hormonal levels, assessing testicular volume and doing certain radiological tests like ultrasound and Doppler.

Both of the above cases had problems in the post testicular stage. Amira (name changed) was a patient from Iraq being directed by another patient who had successfully conceived after IVF treatment under Dr. Banerjee. A biopsy of the testis done at Iraq failed to show any mature sperms. We performed multiple testicular biopsy at the Max IVF centre. This was done by a small nick in the scrotal skin and was done under complete anesthesia. Multiple tissue biopsy was taken in order to ensure that no normal focus of sperm synthesis was excluded. Testicular sperm was retrieved after finally dissecting the tissue and was kept in special media under specific laboratory conditions. The eggs of the lady were harvested on the same day. This was done by subjecting the lady to multiple Gonadotropin injections which cause the woman to produce many eggs. These eggs were then collected by using ultrasound guided needle aspiration. This was done under general anesthesia. The testicular sperm was then injected into the egg using a micro manipulator. This is highly specialized equipment and the procedure is called intra cytoplasmic sperm injection (ICSI). The fertilized eggs were kept under special laboratory conditions for two days where they divide and grow. The best embryos were transferred two days after fertilization. This was done without anesthesia under ultrasound guidance. The lady was then prescribed certain medications for two weeks and a pregnancy test performed. The pregnancy test was positive with a beta HCG of 205 miu/ ml.

Another couple had a similar problem. The first IVF cycle had failed and we went ahead with second cycle using frozen testicular tissue which was collected in the first IVF attempt. The same procedure described above was carried out. This time it led to a positive pregnancy test.

Being able to father your own genetic child with nil sperm count is a miracle. Says Amira (name changed) “This is nothing but a dream come true for me”. My friend in Iraq who had a successful treatment under Dr. Banerjee referred me to her at the Max IVF centre. My husband and I are so happy that we finally have conceived our own child.

For men with nil sperm count donor sperm insemination is also an option. However, this may not be acceptable to all. Testicular sperm extraction with Intra-cytoplasmic sperm injection is an advanced method to help our patients realize their dreams.

Dr. Kaberi Banerjee
MD, MRCOG.
Commonwealth Fellow in Reproductive Medicine, UK
Senior Consultant, Centre of Reproductive Medicine and IVF
Max Healthcare

IVF CME highlights 12th of August, 2010

A CME was organized by the Max IVF unit on the 9th of August, 2010. This was named ‘Multidisciplinary Scope of IVF’. The Max IVF center has been running for over 1 year and since November 2009 we have done about 150 cases so far with the consistent pregnancy rate with the 40% per attempt. IVF is offered for couples who have difficulty in conceiving for mainly tubal or male factor. It is also recommended when there is unexplained infertility or failure of treatment .This CME intended to cover various other accepts of assisted conception treatment like fertility preservation in cancer patient and the psychological accepts of the infertility treatment. It was a well attended CME where doctors of various specialties of Max Saket and Delhi Medical Association attended. This CME was organized by Dr. Kaberi Banerjee who is the Senior Consultant at the Max IVF Centre. She has trained in IVF from the prestigious Guys hospital London and has done more than 400 IVF Cycles with a very good pregnancy rate.

Dr. Kaberi Banerjee spoke about the indication of IVF in an infertile couple. She spoke on when to refer these patients and how these patients should be prepared for IVF. She also highlighted the strengths of the IVF Centre at Max Panchsheel which included a well trained staff, state of the ART IVF equipment and high end technology.

Dr. Urvashi Jha, Head of the Obs & Gynae department Max Saket spoke on the endoscopic methods that can be used in a patient who is about to undergo IVF to improve outcomes. Dr. Rajeev Kumar Urologist at The All India Institute of Medical Sciences spoke on ‘How to assess a couple with Male Infertility problem’. Dr. Harit Chaturvedi, Head of Onco surgery Max Saket spoke on the indication of sperm and egg cryopreservation in patients undergoing cancer treatment. Many patients after cancer treatment lose their capacity to reproduce. Sperm and egg freezing facility is available at the Max IVF centre at Panchsheel. All patients who have not completed their family should be offered this service as it is a very important aspect of their lives. It gives them moral strength to know that even after treatment they can plan to have their own family when they desire even after cancer treatment. The psychological aspects of infertility treatment and the support that can be offered were discussed in this CME.

Infertility is a major social and psychological trauma to couples who suffer from it. The Max IVF centre provides ethical, transparent and a patient friendly atmosphere to help couples overcome this problem. It aims to go a step ahead in its endeavor to help such patients by offering IMSI and PGD (Pre Implantation Genetic Diagnosis) in the very near future.

A girl dreams of being a mother right from her childhood. It is very difficult when she realizes that it is taking time to do so or perhaps impossible. A woman status in society is still measured by her ability to have children. A man’s worth is measured by his qualifications, job, business achievements and wealth. However an equally capable woman will not be held in such high esteem even if she achieves all this if she has not attained the expected role of motherhood side by side.

Infertility is a huge psychological and social burden on the couple. Not only are they going through months and months of personal agony when they fail to conceive. They are also being indicated by the society. This pressure from the society is wholly targeted towards the woman. The cause of infertility is equally divided amongst the man and the woman. Even if the cause is because of the man the blame goes to the woman. Ironically it is the woman folk themselves who antagonize these women. It is high time we all stand up for their cause and lend a supportive and caring hand rather than vindictive attitude. This can come through education of society, awareness of the masses and empowerment of women.

In India the male child is given preference over the female. The reason for this is probably the petriarcle structure of society. The family name and wealth is transmitted on to the sons and the girl is sent off to another family with some wealth which is called as the dowry system. This was the traditional system of society which is still followed in certain parts of the country. However in the cities where 30% of the population is residing the biased towards the male child is still existing and sometimes stronger. South Delhi has the worst female: male ratio in the country. This is because of rampant use of ultrasound to diagnose the gender of the feotus and terminate the female child. Unfortunately the top most educated class of the country, the doctors themselves are in many ways responsible for allowing this gastly pratice to continue. In modern society the value of a male child in terms of carrying on the name of the family and taking care of old age is only a mith. Who remembers the name of the forefathers beyond three generations. Who is taking care of all the old people who are living alone in their homes or old age homes. Most of them have their married sons staying elsewhere or working abroad. It is not uncommon to see daughters coming forward to give emotional and financial help to their aging parents.

Today’s modern woman in India is completely empowered. She is educated, capable, financially strong and independent in every sense of the world. We should be proud to have daughters in our families. It is high time we led go of this age old meaningless desire to have a son and welcome the girl child wholeheartedly and give her the special place she deserves.

Infertility – Social Issues

Dr. Kaberi Banerjee MD, MRCOG.
Commonwealth Fellow in Reproductive Medicine, UK
Senior Consultant, Centre of Reproductive Medicine and IVF

Max Healthcare
Infertility is defined as being unable to conceive after more than 1 year of unprotected intercourse. It is estimated that 10 % of people in the reproductive age group are suffering from it.

For a natural conception the sperms, uterus, tube and ovaries need to be healthy. The chance of natural conception in a healthy couple is about 15 % per cycle. Many anxious young couple comes to the infertility specialists, after 3-4 months of marriage, if they fail to conceive. These couples need counseling and reassurance that they will conceive in the near future. However, there are certain patients with tubal block, low sperm count and conditions like polycystic ovarian syndrome and endometriosis. These couples would need medical intervention to help them have a child.

In India, social pressure on the woman to conceive soon after marriage is very high. Even if the problem lies with the man, the burden of infertility is mainly on the woman. She undergoes severe psychological pressure, depression and social ostracisation while facing the problem of infertility. There are two main issues that need to be dealt with. The first one is proper medical awareness among patients as well as the medical fraternity so that these patients get the right treatment at the right time. The second is social awareness to allow the couples face this problem with dignity and privacy.

Many infertile couples end up going to quacks and astrologers who waste enormous amount of precious time and money. If these couples are referred for right medical intervention early on then the chance of successful pregnancy is higher. A woman is born with a fixed number of eggs and by the time she is 35, her ovarian reserve is low. It is better that she receives infertility treatment much before in order to have a successful outcome. Unfortunately many medical practitioners continue treating these patients for years together with ineffective treatment when they should be referred for assisted conception. It is well known that the only treatment successful for the patients with tubal block and low sperm count, is in-vitro fertilization. There is yet another group of couples in the cities now a days that first delay marriage and then delay child bearing. It is important to convey the message that the best chance of child bearing in a woman is before the age of 32.

For most couples with infertility, cure is usually achieved after the right diagnosis is made. For woman with problems like polycystic ovarian disease and endometriosis, there are medical as well as surgical methods to treat these conditions. For this group of patients as well as men with mild male factor problems, inducing multiple egg formation followed by Intra-Uterine Insemination may be the treatment. For patients with tubal blockage and very low sperm count, the treatment usually involves In-Vitro Fertilization with or without Intra-Cytoplasmic Sperm Injection. In this, multiple egg formation is induced through drugs called Gonadotropins. The eggs are retrieved by ultrasound guidance and fertilized by either simply mixing the eggs with the sperms (In-Vitro Fertilization) or injecting each egg with a sperm (Intra-Cytoplasmic Sperm Injection). Once the embryos are formed they are implanted either on the second or the third day into the uterus under ultrasound guidance. If this procedure is done in 10 women who did not get pregnant for more than past 5 years, 4 or 5 patients would get pregnant the first time. The cost of this treatment is between a lakh to 1.5 lakhs of Rupees. This includes the cost of medication. At Max Healthcare there is a fully equipped laboratory with internationally trained staff to perform these procedures. The equipments, which includes the state of the art incubator, ICSI machine and workstation are at par with the best centres in the World. The media that is used for embryo culture is imported and is internationally acclaimed media. The Clinician has worked as a consultant in IVF centres abroad and has established other reputed IVF centres in Delhi. This team of specialists believe in treating patients with dignity and respect and are consistently delivering very good pregnancy rates. The international guidelines of patients dignity, confidentiality, giving the complete and right information and transparency are followed by all the staff members of the Max IVF team.

The issue of social demoralization of these couples especially woman is very high in our country. The value of a woman still lies in her capacity to bear a child rather than any of her academics or career achievements. It is unfortunate that woman themselves are responsible for this situation in many instances. Elderly woman of the family instead of supporting the poor victims of infertility, physically and mentally abuse them. A multi level approach right from the individual level to the government needs to be implemented in a large scale. Empowering the woman of India, when she becomes confident enough to face the world with or without children should be the aim. Banning female infanticide, education and dignity of girl child and employment opportunities to women will come a long way in helping the woman of India. Various infertility fora where patients can interact among themselves and also meet patients who have had successful treatment will help ease the psychological burden of the disease.

I would like to conclude by saying that infertility is mainly a curable disease. The aggrieved couple should get the right treatment at the right time. Society instead of denouncing them should lend forward a helping hand.