Microsurgery in obstructive Azoospermia

Microsurgical Vasovasostomy (Micro VVA) and newer techniques of Microsurgical Vaso Epididymal Anastomosis(Micro VEA) have very good success rates. In cases of obstructive azoospermia, these procedures are preferred instead of Assisted Production with ICSI. If VEA is successful, the couple could expect to achieve pregnancy with natural cycles.

During Surgery small quantity of sperms Cryopreserved. If the surgery fails ICSI can be done using these sperms or by espiretion of fresh sperms.

Intrauterine Insemination in male infertility (IUI):

Many clinics consider Intrauterine Insemination (IUI) routinely as the treatment for male factor infertility. In severe forms of Oligo Astheno Teratospermia (IUI) will not be beneficial, and repeated attempts at IUI may produce scarring of uterine cavity and infections resulting in tubal blockage .
IUI could be considered only in cases of men with normal or near normal semen parameters or idiopathic infertility, cervical hostility or failure of deposition of sperms due to erectile or ejaculatory dysfunction.

Intrauterine Insemination success rates vary considerably and depend on :

• Age of the woman
• Type of ovarian stimulation used
• Duration of infertility
• Cause of infertility
• Number and quality of motile sperm
• Other factors

Success rates for IUI in women over 35 drop off, and for women over 40 they are much lower.

Pregnancy rates are lower when insemination is used:
• In women over 38 years old • In women with low ovarian reserve • With poor quality sperm • In women with moderate ( or severe) endometriosis) • In women with any degree of tubal damage or pelvic scarring • In couples with a long duration of infertility ( over 3 years)

Intra Uterine Insemination not indicated in following conditions:
1. Female age more than 40 Yrs.
2. Younger women with raised FSH indicating reduced ovarian reserve
3. Low Sperm Count . poor motility and increased no of abnormal sperms.

How is Insemination (IUI) performed?
1. Woman is given medication to Stimulate multiple eggs and release of eggs.
2. Semen specimen produced by masturbation in the laboratory
3. The Sperms are processed (Sperm Washing) to eliminate some harmful components and to obtain concentrated small volume.
4. A speculum is placed in the vagina and cervical area is cleaned.
5. Using a sterile flexible catheter, the washed specimen with high concentration of motile sperms deposited high in the uterine cavity.
6. The woman is advised to lie down for a few minutes after the procedure.

How important is timing of IUI:
The Procedure of IUI is properly timed at or little after ovulation. Egg is fertilizable only for 12 – 24 hrs after ovulation wheres the sperms are viable in the reproductive tract for 4 -5 days.

How many times IUI could be done?
Most pregnancies occur with three IUI cycles provided the quality of sperms are normal and the procedure is timed well. If no fertilization occur the physician should look up for detailed workup for any other factors or counsel the couple for IVF or ICSI accordingly.

What are adverse factors affecting Fertility – What couple need to know?
1. Age of the female ( > 35 less chances ) 2. Duration after marriage ( > 5 yrs less ) 3. Male Factor – ‘ No sperms’ or very few sperms (OAT) 4. Gyneac Problems - Endometriosis . Polycystic Ovarian Disease (PCOD) , uterine fibroids 5. Unexplained Infertility.

In spite of production of sperms in men, normal ovulation in women in the absence of tubal or Uterine factors in about 20 percent of married couple no obvious cause could be made out inspite of all the available investigations. Modern science has recognized several molecular and biochemical factors which are also important for pregnancy.

In Vitro Fertilization (IVF & ET) - Test Tube Baby:

IVF has changed the prospects in the female. IVF involves retrieving eggs from the ovaries by Trans Vaginal aspiration and incubating the sperms in a dish resulting in formation of embryos which are then transferred into the Uterine Cavity. IVF has proven to be effective for Tubal factors(PID) and for conditions like polycystic ovarian disease(PCOD), endometriosis etc.
For IVF to be successful we require more than 100,000 actively motile sperms per egg, but infertile male do not fulfill this criteria. IVF cannot be used for severe male factor infertility and for the sperms retrieved from the testis or epididymis.

EMBRYO TRANSFER ( ET )
Embryo Transfer Technique is critical step in IVF selection of the most viable embryo for transfer is important. Embryo Transfer on Day 3 or Day 5 Blastocyst Stage, Not more than 3 Embryos are transferred. Embryos retained or retransferred affects pregnancy rates. While Embryologists is loading the inner catheter, the clinician keeps the outer sheeth of the catheter in the cervical canal immediately after the transfer the catheter is inspected for retained embryo. Avoid damage to endometrium and unwanted uterine contractions. The so called difficult transfer has clear impact on pregnancy rate. Atrametic gentle transfer characterized by lack of blood in catheter tip.
Embryo transfer may be performed directly or ultrasound guided with full bladder. To prevent unwanted uterine contractions , use soft transfer catheter, avoid touching the uterine fundus and avoid using tenaculum which may stimulate cervix to produce uterine contractions. Trial transfer at time of Oocyte retrieval 2 – 5 days before Embryo Transfer. Site of Embryo deposition fundal touch may cause damage to endometrium and indicate uterine contractions. The time from embryo leaving the incubator until it is deposited in the uterine cavity is of utmost importance. Following Embryo Transfer progesterone luteal phase support is given.

ICSI - A reproductive revolution for male infertility:

With ICSI procedure, men with severe oligo asthenospermia and azoospermia have an opportunity to produce their own biological child, without resorting to Donor Insemination or Adoption. In cases of Congenital Bilateral Vasal Agenesis (absence of VAS), failed vasoepididymal anastomosis(VEA) and non obstructive azoospermia, ICSI has proved to be successful.
In cases of repeated failure with conventional In Vitro fertilization, ICSI could be considered to maximize the chances.

What is ICSI?

ICSI (Intracytoplasmic Sperm Injection), is a procedure where a single sperm is injected into the egg. To achieve fertilization the sperm is withdrawn into a tiny pipette, the egg fixed with a holding pipette and the sperm injected into the cytoplasm of the metaphase II (mature Oocyte). After the ICSI procedure the Oocytes are incubated and the resultant embryos are transferred into Uterine cavity by using a specially designed embryo transfer catheter. After the embryo transfer, Progesterone supplementation is given. The confirmation of Pregnancy done with estimation of HCG and after 6 weeks for the foetal heart on ultrasound.

(ICSI) Micro manipulation of single sperm into each Oocyte (egg)

The sperms for ICSI are obtained from the ejaculate. The sperms obtained during VVA and VEA are cryopreserved.

Sperm Retrieval Methods for ICSI:

In cases of obstructive azoospermia sperms were retrieved by :

Percutaneous Epididymal Sperm Aspiration(PESA):
In case of blocks to sperm pathways epididymis or VAS, the epididymal ducts are dilated which contain plenty of motile sperms. Using a 21 guage butterfly needle attached to a 20ml syringe, fluid is drawn and examined under microscope. This is a simple procedure which does not involve operative surgical expertise.

Micro Epididymal Sperm Aspiration (MESA):
This is a good procedure for retrieving sperms from dilated epididymal tubules using magnification. The individual tubule is entered and fluid aspirated and examined for the presence of sperms.

Under magnification Aspiration of Epididymal fluid and evaluation of sperms suitable for ICSI

Modified Testicular Sperm Extraction (TESE):
In case of Non Obstructive Azoospermia, most of the tubules show atrophic changes. Still there could be some tubules which may contain sperms adequate for purpose of ICSI. A few seminiferous tubules are thus excised and they are teased out for presence of sperms. These cases of Non Obstructive Azoospermia are not suitable for any form of medical or surgical treatment and ICSI with the sperms recovered from the testis is the only option for them to get biologically their own child.

What are the Advantages of ICSI?

	What prevent normal fertilization	What does ICSI do ?
1.	Low sperm count – No sperms ( Testicular / epididymis sperms only)	Adequate
2.	Cervical mucus hostility	Not applicable since sperms need not have to go through cervix
3.	Mild endometriosis	Not a problem
4.	Poor egg pickup / Tubal block	No problem since ooctye aspiration direct from ovary & egg pick up.

With ICSI procedure, men with severe oligo asthenospermia and azoospermia have an opportunity to produce their own biological child, without resorting to Donor Insemination or Adoption. In cases of Congenital Bilateral Vasal Agenesis (Absence of VAS), failed vasoepididymal anastomosis(VEA) and non obstructive azoospermia, ICSI has proved to be successful. In cases of repeated failure with conventional In Vitro fertilization, ICSI could be considered to maximize the chances.