Dr. Khandeparkar's Infertility and IVF Centre

Hello,

This is Dr. Shubhada Khandeparkar from Mumbai. Today I will carry forward my previous discussions on the management of infertile of an infertile couple. Now, when the for the treatment of an infertile couple there are two people involved: the male and the female partner. Today I'll be concentrating more on the female partner and I will come to the male partner in the further next videos. Now, when we consider the female the first important few things are the age of the female and the weight of the female. Now, many times the female though she may be just 35 but her BMI that is a basal metabolic index or the weight is more than 25 in that case it becomes very difficult for this female to have a good ovarian reserve. Even otherwise, if the female is more than 40 and she may have a low BMI in that case also the ovarian reserve is poor. Now, how do we know the ovarian reserve? We have to again as I have already mentioned in my previous videos we look at the antral follicle count on day 2 of mensus and the AMH that is anti mullerian hormone.

If these two are relatively good I mean the AMH is more than 2.5 and the AFC is about 3-5 follicles in each ovary on day 2 yes that means the female has a very good chance of having a baby. Once we have established these two things, then we go further and then we have to see what is the next step is the tubal patency; are her tubes open or closed. I have already discussed this with you that how we test the tubes and any one of the test can be done for the patient and once we know that the tubes are open then we go further up the ladder and we say ok now let us evaluate the ovarian function. Now what do we do in this? We have to see how the oocyte or the egg is growing in the ovary.

In each cycle we see that the female develops one oocyte either on the right or the left ovary and as the oocyte matures, as it reaches a particular size, then it ruptures and around that time if one has intercourse and the sperm reaches the oocyte around that time, around the time of ovulation, one conceives. So, now our priority is to look at the ovarian oocyte folicular development. How do we do that? The gold standard for this today is to evaluate the follicles by doing the ultrasound. By doing a transvaginal scan from say day 5 or day 6 we come to know how the egg is developing. Now, every second or third or fourth day depending on how the follicle growth is coming up we call the patient and do the ovarian study, the folicular growth aspect and we also see the blood flow to the follicle and once the folicular blood flow and the growth has reached to a point of about say the growth the size has reached to between 18-22 mm or 1.8-2cm and the blood flow is increased to about 75% of what the original blood flow was, we think yes that this is the ripe and a mature follicle.

Now, in that event there are two ways we can treat this patient further. Either we give a drug or an injection not a drug an injection to rupture this follicle so that we can time the follicular rupture and then we can advise them when to have intercourse or the other thing we can do is we can tell them to have a planned intercourse. Now, if the follicle is very turgid and we feel yes patient says No, I don't want an injection we can also observe if the follicle ruptures on its own and if a follicle ruptures on its own then we tell them to have the intercourse around that time so we will tell them once follicle is reached 22 we will tell them that ok have intercourse for these three four days and plan your relation, plan your relationship.

If the patient says No, I want to take an injection then we give the injection and we time the follicular rupture exactly 36 hours after the injection, the follicle ruptures. So, in that case we can tell them to plan the intercourse accordingly. We can also confirm rupture around 40 hours, call the patient and see that it has ruptured and then again decide for the relationship or the intercourse to have. Other thing is if the sperms are compromised, if the semen sample is not being so good, the count is less than 20 million, motility is not so great 30%, 40% maybe even less 20% then we advise them that ok let us do intrauterine insemination. Now what is intrauterine insemination? Around the time of rupture, it can be a few hours before or a few hours after we tell the husband to us his semen sample, we process it, remove all the unhealthy sperms, immotile sperms, add a culture media, make them more motile you can say make them powerful and hyper motile and then make them 100% motile if possible till about at least the concentration of 10 million sperms and final count should be at least 10 million, between 8 to 10 million and we put them right inside the uterine cavity around the time of rupture. So, this also helps in the ova meeting the sperm and forming an embryo.

So, this way we can help the couple to conceive. Now, WHO says that ideally one should not do more than 6 intrauterine insemination procedures in career because more than 6 that means you have some other reason for not conceiving. So, one can try 5-6 times IUI, if IUI doesn't succeed I think one should go further and see what best can be done next after this. The other thing is that to promote egg development or what is there with us and actually if the eggs are not the ova are not coming up well then what we do for the couple the lady is there are certain drugs. Now, there are tablets; the two types of tablets: one is a clomiphene and the other is a letrose. Now both these tablets the only disadvantage, no I wouldn't say disadvantage but they help promote one single egg or one or two eggs and also at the same time when we are doing all these folicular studies, I missed out to mention that we should be also monitoring the lining of the uterine cavity that is the endometrium.

As the follicle grows, the endometrium also starts getting better and better and thicker and thicker and implantation also is achieved because of the thick proper endometrium. Now with some of these tablets which I told you the drugs like Clomiphene citrate sometimes the endometrium though we need mono follicular growth the endometrium doesn't responds so well and it doesn't improve so well, so we have to add some hormones. The other drug is letrose which also is again giving us some mono follicular growth and that is not affecting the lining or the endometrium, so it is many times considered a better tablet to give for folliculogenesis than clomiphene. Of course, it's a choice of the gynaecologist, the personal experience and the condition of the ovaries of the patient and what she/he perceives is very good for the patient and they will choose the drug.

What are the other drugs we can give? We also have injections. You must have heard about them. The injections are gonadotropins are quite expensive, they need to be given every day and they are you know they have to be monitored closely otherwise you can have multiple follicles coming up so there are certain disadvantages of injections on a routine this to give to the patient. So, we will prefer injection maybe for particular cases, in certain well established centres where proper care can be taken of the patient if multiple eggs are produced.

So, in short I will say that the treatment of infertility for a female today is advanced could extend and yes we can monitor closely the oocyte development, help the woman conceive with certain hormonal support and everything. Now after 12 days of the IUI or the inter course planned relations we can do a card test and then during the leutal phase between these 12 days from the intercourse to the twelve days we do support the lady with hormones again and the card test will tell us if it is positive. If not, we been the mensus and the whole thing starts again. I will thank lybrate for giving me this opportunity to speak to you all.

Thank you.

Hello everybody.

 I am Dr. Shubhada Sanjiv Khandeparkar and I'm here to discuss one more important organ of the female genital tract which contributes to causes for infertility in the uterus.

Now uterus in the female is the main important organ of the female genital tract and it has two parts, the upper part of the uterus is called the body of the uterus and the lower part is called the cervix. Now both contribute to infertility, the upper part of the uterus has from outside to inside three parts. The outermost layer is called the serosa, the middle layer is the myometrium and the inner layer is the endometrium.

Now every month we shed off the endometrium during the menstrual cycle. The endometrium is an extremely important structure of the uterus which helps in implantation of the embryo, so the endometrial pathology contributes to about 20 to 30 percent of infertility.
Now what is the commonest causes for infertility due to endometrial reasons is the infection again. The commonest infection is again tuberculosis, tuberculosis affects the endometrial lining which prevents the implantation and therefore the lady becomes infertile.

Other infections again are the sexually transmitted diseases gonorrhea, chlamydia. other pelvic or inflammatory diseases, infections also can cause infertility like staph and also leukorrhea, the excess white discharge also carries infections and causes infertility. Now because of endometrial infections, even multiple abortions can cause infertility I will come to that later. Now because of endometrial infection the endometrium sometimes after the healing takes place sometimes goes and forms adhesions inside and therefore the embryo cannot implant so that is another important reason.

Now anatomically also sometimes a uterine development is at fault and the uterus can have a septum inside or multiple septae or a small cavity, hypoplastic uterus which again prevents the embryo from implantation. The other common causes of endometrial pathology are fibroids which are occurring from the myometrium of the uterus and protruding into the endometrial cavity. Now these fibroids again project inside the endometrial cavity and the cavity becomes obliterated and the embryo cannot implant or it implants over that fibroid however it cannot.

Now what is a fibroid, a fibroid is Myometrial overgrowth of the muscle which overgrows inside the uterine wall and grows in whirls and forms rounded structures, now fibroids per se cannot cause infertility but if they are at certain situations then only they affect the implantation of the embryo and cause infertility, so fibroids near the internal tubule opening they can cause infertility cornual fibroids. Fibroids near the cervix which is at the mouth of the uterus they can cause infertility so these fibroids also are important and about 40% of the causes for infertility in females, the uterine cause is fibroids.

The other important cause for the uterine infertility is the mouth of the uterus. Now if the mouth of the uterus is unhealthy it is enlarged, hypertrophic then also we see infertility. If the opening is stenosed, it's extremely narrow then also the sperm cannot go up and we see infertility. If the mouth has a huge erosion which is also another physiological problem but still because of an erosion we see sometimes this excessive white discharge. mucus is affected and we see that as infertility. So these are a few of the causes because of the uterine reason, why the patient cannot conceive.

How do we diagnose this? the best way to diagnose the uterine causes, the endometrial causes is a procedure called hysteroscopy. Hysteroscopy can be done as a daycare procedure, it can be done by very small scope which is only 3 mm and it can be done in-office procedure, so one does not even many times require anesthesia but one can do it. It's better done under anesthesia, but one can do it without.

Now through the hysteroscope again we connect it to the camera and project it on the monitor and we see internally all the different areas of the uterus. We can pick up adhesions.

one more thing which I forgot to tell about the endometrial pathologies are polyps, so polyps are thick endometrium only which forms into globular structures and it can affect sometimes implantation of the embryo, so we can treat polyps through the hysteroscope, we can resect, can take them off, we can release the adhesions, cut the adhesions inside, we can expand the cavity, we can do so many things through the hysteroscope itself, once we have diagnosed the problem, so hysteroscopy is a gold standard again to diagnose the endometrial causes of the infertile lady, so this is the uterine part of the causes for infertility.

So I think I have covered most of infertility causes and the next sessions will be the treatment for infertility. So thank you very much and yes thanks to Lybrate and any doubts or questions or if you wish to speak to me or contact me you can please do so through Lybrate.

Thank you very much.

Hi,

I am Dr. Shubhada Sanjiv Khandeparkar, Gynaecologist. Today I am going to take further the topic infertility. The investigations in infertility. Now I am going to discuss the tubal factors in an infertile ladies. Now 30-40% infertility happens because of tubal factors. By the side of the uterus, there are 2 tubes known as fallopian tubes. Generally, tubes get blocked and the eggs which come out from the ovaries and sperm enters to form the embryo. Now embryo slides off and comes into the uterus implants and grows into the uterus. If the tube is blocked, sperm and eggs cannot meet and therefore, infertility happening. Causes are endometriosis and infection. The common infection we are seeing are tuberculosis which is very common in our country, STDs, pelvic inflammatory disease because of repeated white discharge. Another infection can be because of severe abdominal infection. The middle region of the tube can get affected and blocked because of scarring.

The digital end of the tube again has a significant role to play and that gets affected or blocked because of TB. In TB fluids start getting collected inside which we call hydrosalpinx and both the tubes get blocked. So, you see that TB is a very important cause in our country for tubal blockage. How do we diagnose the tubal blockage? One more important cause is an ectopic pregnancy. What is it? The formed embryo sometimes failed to slide into the uterus and gets implanted in the tube. Now the tube is very small and thin and it cannot sustain the growth of the embryo and it ruptures and that is called an ectopic pregnancy. In such cases, we have to diagnose tubal factors. How do we diagnose the tubal factor?

There are 3 ways for diagnosing. The first common way was by x-ray which is called hysterosalpingogram (HSG). In HSG, what we do? We push a small instrument from the mouth of the uterus and it goes inside and come out through the tubes and tells us that the tube is open. This is a quite painful procedure and we have to depend upon the radiologist and x-ray machines. A better modality has also been discovered which is known as sonosalpingography. Now, this can be done without anesthesia. We definitely require a sonography machine and we take the patient in OT and we push the normal instrument in the mouth of the uterus. That is also a very good way to know the tubal patency. The gold standard is a laparoscopy. Now, this is a surgical procedure and you need special training, setup and OT and general anesthesia. At the belly button, we make a small incision which is about 1 cm.

We enter through the scope and a camera is being attached to it. Then we see the picture on the monitor to see entire internal organs. Now laparoscopy helps us to see the uterus, tubes. Its relationship with the tubes and the ovaries whether there are any editions around. We can get the entire genital information about the internal organs. This is a gold standard. Suppose there are editions or endometriosis, we can treat at the same time. through the laparoscope. It helps in diagnosis and the treatment. So, proper training is required to perform laparoscopy. So, today we have covered the common cause of the tubal blockage. This is extremely important for the infertile lady to have the tubes open if they are blocked. The only treatment for her IVF and ICSI where tubes are not required to be patent. And in this case, she has to go for it. So, a determination is extremely important in an infertile couple. So, if you have any query, you can contact me through Lybrate.

Thank You!

Hi,

I am Dr. Shubhada Sanjiv Khandeparkar, Gynaecologist. In the last video, I discussed the causes of infertility. Now, today I am going to discuss the investigation in an infertile couple. I will be tattling the female partner today. Now, in the female, there is a structure in the brain called hypothalamus. This is a very important structure. It releases certain hormones which in turn at another gland in the brain called the pituitary. Now, it is a very important gland which has to function properly. Now the pituitary secrets certain hormones and these are called the FSH, LH, TSH, and prolactin. They stimulate the follicle to mature. The thyroid-stimulating hormone acts on the thyroid gland and produces the hormone thyroxin which also is required for the ovulation.

This also helps in the ovulation. Once these hormones are all stabilized in the blood and they are normal, then we go to the next phase and that is the genital region of the female. There we have the ovaries. Ovaries are extremely important genital in the female. This is the main functioning organ. Now, we should get a healthy follicle which will rupture and then we transfer the sperm to make the embryo. To get the good follicle, we have to establish how the ovaries are. How do we access the ovaries? The function of the ovaries is accessed by the ultrasound and by the hormone which secret called the anti-mullerian hormone. The test for anti-mullerian hormone is very sensitive and should be done in a standard lab as it can be done ordinarily by any other lab. Once you know that the anti-mullerian hormone test is normal then you need to go for ovarian follicle status. Anti-mullerian hormone tells us how many are healthy and good.

Now, in this modern ear, women do not want to have a child at an early life. They want to settle even if they are married, they want to have their own house, they want to plan pregnancy properly as they say that they are not ready for the baby. Maybe they want to go beyond 30-35. In such cases, we should know are they having enough ovarian reserve to wait that long. If the anti-mullerian hormone tells us that they don't have ovarian reserve then they should rush and at least they should save and preserve their eggs or they should preserve their embryos. What is antral follicle count? Antral follicle count where we do transvaginal scan the 2nd day of menses and we see each ovary that how many follicles we can see. We should have at least 5-6 good follicles with 2-5 mm.

Now we can also monitor the follicular status by transvaginal scan during the cycle till the follicle becomes mature and that also helps us in the case of the infertile couple to find out how the egg is developing and when the egg will mature, it will rupture. So, these are a few tests in the infertile female. Now, the other test which is there is for the uterus, tubes and the cervix. Now, these 3 areas I will tackle in the next episode.

Thank You!

Hi! I am Dr Shubhada Sanjiv Khandeparkar, Gynaecologist. Today I will talk about male infertility. It is seen in 40% of the couples are infertile. 7% in the male population and in the whole world is infertile. How do we come to know about it? The only way is the semen analysis. What are the common causes of male infertility? 1st is ejaculatory dysfunction. 2nd is poor production of the semen. 3rd is low production of the semen. 4th is poor quality and last is blockage of semen. It is commonly seen in stress male. These types of couple need counselling and distressing therapies.

Then the common causes are infections, varicocele, tumours of the testis, excess tobacco chew, smoking, alcohol consumption, obesity. Other conditions like exposure to chemicals like pesticides. Less or no exercise, huge driving can also lead to this problem. If testosterone is low in the body, it can also cause infertility. If a male has the breast then also this problem can arise. So, the examination of the semen is very important. Thank You.

Hi,

I am Dr. Shubhada Khadeparkar here. Today I am going to discuss about infertility. Infertility means a couple who is unable to conceive and after trying for at least one year of uninhabited intercourse now infertility today in India is a major problem. There are about 27.6 million couples who are infertile and if you ask me the incidence it is about 10% on an average. Certain states like Uttar Pradesh has less infertile couples like 3.6% and states like Kashmir is about 15% infertile couples. Now infertility can again be divided into 2 types primary and secondary. Now primary infertility is when the couple just does not conceive at all and secondary infertility is when they have one baby and they do not conceive after again for the 2nd child may be one year after trying for that. Now the infertility couple as we say are male and female partners. So infertility can again further be divided into a female factor a male factor and there is a third factor which is unknown infertility.

The female factor contributes to about 40 to 50%. The male factor in total infertile couples the male factor contributes to about 30 to 40% and the unknown factor which we call idiopathic infertility is about 10 to 20%. What is the causes of female infertile couple? Now when the ovaries are damaged or not healthy as we see in polycystic ovaries when there are multiple small eggs getting formed or when the ovary is infected inflamed or when the ovary again is because of age is not producing adequate oocytes in all these cases we see that the patient can become infertile. In polycystic ovaries commonly we see cycles become very irregular patients become obese gets acne on the face and hormonal imbalance is seen. Certain other causes for ovarian infertility are thyroid hormone insufficiency deficiency prolactin hormone etc. The other second common cause in female infertility is tubal factors.

Now if the tubes are blocked then the female cannot conceive. Which are the common causes of tubal infertility? Again infection which is a pelvic inflammation we see also tuberculosis. In our country tuberculosis is endemic it's all around the year and this is one of the very common causes again. The third common cause for infertility is the uterine factors. Now in the lining of the uterus which we call the endometrium is not healthy. We again see that the baby cannot implant or the embryo cannot implant in the uterine cavity and again the patient becomes infertile. Commonest causes again for uterine factor are infection any procedure done in the uterine cavity in the past specially when adequate antibiotic coverage is not given and that is again pelvic infection and also ageing. Ageing uterus does not have good lining of the endometrium and the patient can become infertile. So today I have discussed basically the main factors in the female the next session I want to discuss the male factors and then of course I will go to the management of the infertile couple.

Thank you!