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It is important to consider what type of azoospermia is involved in order to establish the most appropriate treatment.
In cases of obstructive azoospermia, a testicular biopsy could be a solution for obtaining sperm. In addition, other alternatives would be microsurgery, eliminating the obstruction, and joining the ducts, epididymovasostomy or vasovasostomy.
On the other hand, secretory azoospermia can be solved with hormonal treatment, but this should always be personalized.
Time-lapse incubators have an image capture technology that allows us to generate a film of the entire development of the embryos so that we can analyze the embryonic kinetics.
This allows us to observe the embryo division without removing the embryos from the incubator at any time so that they are not subjected to the temperature changes that occur during this process. This improvement in culture conditions helps more embryos to reach the blastocyst stage.
Time-lapse technology allows us to improve embryo selection, since we will not only rely on specific observation on days 1, 2, 3 and 5 of development, but we will also have information about everything that has happened during the development of the embryo, the times and the way in which these processes have taken place. This makes it easier for us to choose the embryo to be transferred to the uterus.
The FERTILE® chip is a sperm selection device that uses the microfluidic technique to select sperm. This technique imitates the conditions of the vaginal tract, facilitating the selection of spermatozoa with better motility, morphology, and low rates of DNA fragmentation.
The seminal sample is used without any preparation, it is not centrifuged, which eliminates the damage that occurs during it and the generation of reactive oxygen species (ROS).
The FERTILE® chip is recommended primarily in patients who have been diagnosed with high fragmentation of double-stranded sperm DNA, although it could also be used in couples who in previous cycles have shown slower than normal embryonic kinetics, implantation failure or repeated miscarriages
Oligoastenothermalospermia may be cured depending on its cause. For example, varicocele can be treated with surgery or hypogonadotropic hypogonadism with hormonal drugs.
In cases where the exact cause of oligoastenatozoospermia is not known, empirical treatment with antioxidants or antiestrogens may be used. These treatments must last at least three months and their effectiveness has not been proven.
Therefore, there are only a few patients with oligoastenothermia who can benefit from a specific treatment, the rest of patients could use empirical treatments and try to lead a healthy lifestyle. In most cases, assisted reproduction is the only treatment for them.
A number of scientific studies suggest that sperm quality has decreased substantially in the past 50-80 years. For instance, a recent study indicates that, on average, the sperm count per ml is 52%, and the total amount of ejaculate is 59%.
These studies suggest that the decreased is more noticeable in industrialized countries.
Although the causes of this phenomenon are varied, it seems that the main reason can be found in the environment, and are endocrine disruptors. I am talking about chemical substances that simulate the effect of hormones by sending confusing signals to the organism, causing different dysfunctions, including a reduction in the sperm production process.
Endocrine disruptors are commonly found in consumer products, such as plastic, personal hygiene products, cleaning products, air fresheners... Also, many are present in foods.
Some examples of endocrine disruptors are dichlorodiphenyltrichloroethane (DDT), which was prohibited long time ago, bisphenol A, phthalate, styrene, certain solvents, resorcinol, etc.
The term necrospermia refers to a sperm disorder where 85 percent of sperm present in the ejaculate are dead.
The factors leading to necrospermia are unclear yet, but the most common include:
- Alcohol or street drug consumption
- Unbalanced diet
- Radiotherapy or chemotherapy
- Genitourinary infections
- Hormonal disorders
In these cases, curing necrospermia is complicated, as well as increasing sperm vitality. In short, it is likely that the affected man has to turn to assisted procreating to have children.
We talk about implantation failure when pregnancy has not been achieved after three failed cycles of IVF/ICSI using her oocytes, or after two donor-egg cycles, as long as high-quality embryos were selected, no technical issues have occurred during the transfer procedure, and the woman doesn't have evident uterine anomalies.
Often, couples with implantation failure are referred to PGD (Preimplantation Genetic Diagnosis) to determine whether the cause are chromosomal abnormalities.
Unless fertilization failure has occurred with IVF, we usually take into account all cycles done with both techniques before deciding to move on to another treatment such as egg donation. Even though each patient is different, the average number of IVF attempts recommended is 3 or 4 at our clinic.
Puregon is a fertility drug used for ovarian stimulation in patients who undergo reproductive cycles. Its active ingredient is follitropin beta, a hormone known as Follicle-Stimulating Hormone or FSH. It is obtained using genetic engineering at the lab (FSHr).
The most common side effects in women (1 out of 10 women) are:
- Reactions around the injection site: redness, bruising, swelling, pain, and itching
- Headache, pelvic pain and/or stomachache
- Ovarian Hyperstimulation Syndrome (OHSS)
These reactions are just transitory and not serious. OHSS, however, could lead to more severe complications if the egg retrieval procedure is not cancelled right after its detection. Thus, the most recommendable action in these cases is to cancel the cycle and wait until the next menstrual cycle starts, as by then OHSS will have fully disappeared.
Rare adverse reactions, those that affect 1 out of 100 women, are:
- Breast discomforts: swelling, pain and/or breast engorgement
- Diarrhea or constipation
- Headache and nausea
- Hypersensitivity reaction: skin rashes, redness, urticaria, and itching
- Increased ovarian size
- Ovarian cysts and/or ovarian torsion
- Increased uterine size
- Vaginal bleeding
One should note that, in case of noticing any of the above mentioned adverse reactions, she should visit her doctor as soon as possible.
Finally, as regards very rare reactions, that is, those that might occur in 1 out of every 1,000 women, we could mention thromboembolism or venous thrombus (PL thrombi) as consequences of severe OHSS. Both translate into the development of blood clots within blood vessels, which can lead to a heart attack in the worst-case scenario.
In males, Puregon can cause some side effects as well, including:
- Injection site reactions: redness, bruising, swelling, pain, itching.
- Acne and skin rashes
- Gynecomastia: breast tissue swells in males
- Testicular or epididymal cysts
Even though these side effects have been considered common, one should keep in mind that only a few studies have been conduced on males in comparison with females.
According to the World Health Organization (WHO), a preterm birth occurs when the child is born before the week 37 of pregnancy. Some of the most common causes of preterm birth are:
- Overdistention of the uterus: loss of tone in the uterine musculature that prevents this organ to recover its normal size.
- Infection or uterine inflammation: certain bacteria can damage fetal membranes by causing its rupture and triggering a preterm birth. An infection that affects the uterus directly may lead to preterm birth as well.
- Decidual bleeding: a type of vaginal bleeding that may occur while a woman is pregnant.
There exist many risk factors that can lead to premature birth, including obesity, high blood pressure, etc. A multiple pregnancy is one of these factors.
Adenomyosis, also known as endometriosis interna, is a uterine condition that causes tissue from the inner layer of the uterus (endometrium) to grow in its muscle layer (myometrium). The causes of this condition are unclear, but we know that it is dependent on the hormone estrogen. Amongst the factors that increase the chances for it to develop, we can find having had at least one pregnancy, and previous surgery to the uterus (C-section, D&C, hysteroscopy, etc.). It is associated with age as well, especially in women over 40. Certain types of adenomyosis can only me detected using special techniques such as 4D ultrasound or MRI. In the mildest cases, there exist few treatments with proven effectiveness, and there is still no proof that it diminishes the pregnancy rates of patients. However, in severe cases like T-shaped uteri, it requires surgery through hysteroscopy.
Spermatogenesis is the process whereby male reproductive cells are formed, from the immature ones, spermatogonia, until the mature ones, spermatozoa. This complicated process occurs within the seminiferous tubule in the testis and takes about 64-72 days.
Once spermatozoa (sperm cells) have been produced, they leave the testis and travel to the epididymis, where they will acquire the necessary motility in a process that lasts 10 days approximately. Spermatozoa will be stored in the epididymis until they are expelled with ejaculation. When ejaculation starts, sperm travel through the vasa deferentia and mingle with the seminal fluid that originates in the secretory glands, creating what we all know as semen. Finally, it is expelled through the urethra.
Today, over 90% of the embryo biopsies that are performed for a PGD procedure are done on day 5, which makes it impossible for embryos to be transferred on day 3. In any case, when the biopsy is carried out on day 3, the result won't be available until day 5, so the embryos will be transferred on day 5 anyway.
Preimplantation Genetic Diagnosis (PGD) is a technique that complements IVF/ICSI and helps us detect the presence of genetic abnormalities in embryos before their transfer to the maternal uterus.
Currently, it is done by performing an biopsy to the trophoblast of a blastocyst embryo, that is, on days 5-6 of embryo culture. The cells removed can be examined to detect the presence of chromosomal abnormalities using PGS (Preimplantation Genetic Diagnosis), or genetic diseases, such as Duchenne muscular dystrophy (DMD).
Intrauterine Insemination (IUI) is the treatment of choice for young patients with mild-to-moderate endometriosis (stages I and II). For this treatment to be possible, no blockage in the Fallopian tubes must exist. However, recent studies suggest that IUI may be ineffective in these cases. The latest European review on the average success rates during years 2016-2017 with AIH (artificial insemination by husband) are below 15% per cycle. So, in conclusion, opting for IUI in cases of mild-to-moderate endometriosis is possible in very particular cases where there is evidence that it might work.
In general, In Vitro Fertilization (IVF) is the first option for patients with a moderate or severe type of endometriosis (stages III and IV), as well as for women with previous failed cycles in spite of having a good prognosis initially.
Adenomyosis, also known as internal endometriosis, is a uterine condition in which there is tissue from the inner layer of the uterus (endometrium) in the muscular layer of the uterus (myometrium). The causes of this condition are not clearly known, although it is known to be estrogen-dependent and, among the factors that predispose it to develop, we find having had at least one pregnancy and previous uterine surgeries (cesarean sections, curettage, hysteroscopies, etc.).
It is also very much related to age, especially after 40 years of age. That is why in some cases it is colloquially called uterine aging.
Certain adenomioses are only detected by special techniques such as a 4D ultrasound or a magnetic resonance imaging. For mild cases, there are very few treatments with apparent effectiveness and it is not fully demonstrated that they have a negative effect on patients' pregnancy rates. However, severe cases such as T-uteruses require corrective surgery through hysteroscopy.
We speak of implantation failure when a patient has not achieved pregnancy after 3 cycles of IVF/ICSI with her eggs, or after 2 egg donation cycles,provided that good quality embryos have been transferred, there have been no technical problems during the embryo transfer and there are no obvious problems in the uterus.
One of the treatments for couples with implantation failure is preimplantation genetic diagnosis (PGD) or preimplantation genetic screening (PGS) to rule out chromosomal abnormalities. In these cases, embryos that do not present any chromosomal anomaly that could be the cause of the implantation failures would be transferred to the uterus, that is, it reduces the number of transfers of altered embryos and the number of transfers making the treatment more bearable without so many negatives, besides reducing abortion rates.
In order to be able to fertilize more than one egg cell in the same IVF cycle, women's ovaries are stimulated using fertility drugs. The number of eggs required depend on the technique used. For IVF, it is enough with 1 or 2; whilst for IVF/ICSI, we should have around 10 eggs ideally. Oftentimes, due to a varied set of causes, the ovarian response of some patients is inadequate and the number of eggs collected is too low (below 5). In such cases, we can turn to the following strategies:
- To cancel the cycle before egg retrieval and start a new stimulation cycle with a different stimulation protocol.
- To freeze using egg vitrification technique the eggs to collect a higher number of eggs in subsequent cycles.
- To freeze using embryo vitrification technique the resulting embryos in order to transfer 2 in the subsequent cycle.
In short, it depends on the history of each couple.