IVF & Genetic Center Jabalpur Madhya Pradesh, India

Dear Colleague

Hello

We are discussing one interesting case of obstructive Azoospermia . The husband had been operated for vassal obstruction but unfortunately it was not succeeded. We at our center did Percutaneous Epididymal sperm aspiration and ICSI – IVF and fortunately the lady conceived in first attempt but with a triplet, which is no so welcoming event.

Other topic is with LH therapy. The synergistic relationship of FSH and LH are essential for oocyte development and maturation. The need for exogenous LH administration during controlled ovarian hyper stimulation has ,nevertheless remained controversial. Those in favor of supplementation argue that pituitary sensitization with GnRH agonists or antagonists results in such profound LH suppression that proper oocyte maturation does not take place .Consequently ,the interaction of both gonadotropins is essential for physiological follicular development .Opponents of that view, however, claim the even marginal concentration of endogenous LH are sufficient for appropriate oocyte development .

I put one experience of a genetic counselor in USA . What is the routine practice in prenatal genetic screening.

With best wishes

Dr.D’Pankar Banerji

1.Azoospermia : Couple get triplet by PESA-ICSI-IVF

Azoopsepermia are of three types ,pretesticular,testicular and post testicular. In these variety the testicular is difficult to get any sperms while doing the aspiration. Post testicular Azoospermia is usually due to blockage in the vas deference or total absence of vas ,a congenital defect.

A couple attended  our center ,husband with azoopsermia. The azoopspermia was worked out and found to be post testicular .

Wife ,Vineeta age 28 yrs, the periods were regular. Injection Luprolide acetate 1 mg s/c per day started in the midluteal phase. The injection continued till she gets the next period. After finishing the period, she was examined to assess the downregulation. Downregulation was confirmed by ultrasound alone . The criteria were, endometrium less than 2 mm and there is no follicle more than 2mm in size.

Ovarian stimulation was started along with Inj luprofact with urinary highly purified FSH 300 IU per day for three days. From day4 Injection HMG started 300 IU per day.

Injection HCG 10000 IU injected when lead follicles reached 17 mm diameter.

After 36 hours oocyte retrieval was done under inj.propophol. 9 good quality oocytes retrieved .

After egg pickup, husband(Deepak age 32Yrs.) was taken for sperm aspiration. Local anesthestheic injected in spermatic cord. 17 gauge needle inserted in the epididymis and suction with 10 ml syringe applied . Small amount of fluid came out and examined under inverted microscope . There were 3-4 motile sperms present per high power field.

All the oocytes were denuded with hylase and 6 were in MII stage . ICSI was done after 2 hours of denudation .

On next day all the six oocyte shows 2 PN . Out of this 4 were of ZP1.

On Day 3, good 8-10 cell embryos developed from the 4 ZP1 fertilized oocytes.

Embryo transfer was done under ultrasound guide with Cook ET catheter. Four embryos were transferred.

Luteal support was give as usual .

Urine pregnancy test was done after 14 days of transfer and was positive.

After 15 days ( 27^th May 2008)we did an ultrasound and there was three sacs present with fetal pole

Conclusion : Azoospermia is treatable condition most of the time and especially the obstructive one where the chances are good to retrieve sperms and get a pregnancy too.

2. LH : The threshold value and the Ceiling value

recent evidence points to a central role for LH in both steroid biosynthesis and the follicular selection and dominance process. Two series of clinical experiments have been performed to assess the minimal and maximal doses of LH required to achieve adequate follicular growth. First, the minimal effective dose needed to complete folliculogenesis according to the “ LH threshold theory” has been tested in women with gonadotropic insuffiency ( Hypogonadotropic Hypogonadism, WHO group I ) . Second ,the consequences of high doses of LH to test the “ LH ceiling concept” have been  evaluated in women with WHO group II anovulation( dysovulatory infertility)

LH threshold : according to the two cell- two gonadotropin theory ,it has been postulated that androgens produced by theca cells through LH stimulation act as precursors for estrogen production. Consequently a minimal supply of LH ( the LH threshold ) is required to achieve a complete folliculogenesis. Evidence to support theis theory was provide by studies performed in patients totally deprived fo FSH and LH secretion ( WHO group I )In those patients , a dose dependent study was set up to assess the defects of different doses of r-hLH( from 0-225 IU) in patients treated with a low dose FSH step-up protocol. Results shows that follicular growth could be observed in all treated groups but, as regards estradiol production , a minimal daily effective doe of 75 IU was required . In addition ,pregnancy was observed only in patients treated with 75-225 r-hLH. Therefore this studey fully confirmed the two cell-two gonadotropin theory whereby a threshold of LH exists to ensure complete follicular development and to achieve pregnancy.

LH ceiling: Pre clinical evidence suggests that developing follicles have finite requirements for exposure to LH, beyond which normal maturation ceases. Indeed ,in-vitro studies using human granulose cells from pre ovulatory follicles have shown that LH exerts a dual dose –dependent effect. While LH constantly stimulates steroid production by mature granulosa cells ,the effect of LH on cell proliferation are dose dependent : low LH concentrations stimulate in vitro cell proliferation while high doses exert a suppressive effect. These data have given rise  to the concept of an ‘LH ceiling’ which defines an upper limit of stimulation

3. Prenatal Genetic Counseling:

Every pregnancy has a small risk of having some kind of birth or genetic defect. Depending upon various factors the risk could be higher than this baseline level or lower. A higher risk suggests the disorder to be more likely than just by chance. Prenatal genetic counselors assess risk based on ethnicity, age and family history for the current pregnancy. After assessing risk they provide options for testing or other procedure. They give information on the course of the disorder and outcomes. They explain genetics in simple terms with visual aids. Giving information about the family and stating some long forgotten facts and then coping up with the risk is very hard on the couples. The counselors apart from scientific explanation provide emotional and psychological support.

This spring I was a genetic counseling intern at Cedars Sinai Medical Center in Los Angeles. This rotation was mainly prenatal counseling and occasionally preconception. The standard of prenatal care in the United States requires the gynecologist to offer screening for chromosomal disorders and also to offer carrier testing for a few common genetic disorders in specific populations. Women above age 35 are offered diagnostic testing. At this age the risk for the baby to have chromosomal abnormality is equal or lesser than the risk for miscarriage because of the invasive diagnostic procedure (~1/200). I learnt different ways of communicating risks, understanding people, explaining genetics. It was so rewarding to tell them the results that nothing is wrong chromosomally and even when the results came positive so that the family can be prepared for it. What strikes me the most is that medical genetics has advanced so much that we can do preconception genetic diagnosis (PGD) for a panel of 13 chromosomes, and prenatal diagnosis as early as 10 weeks but with the positive results all we can offer is termination of the pregnancy. Even today there is no cure available for most of the genetic disorder. I hope in future I will be able to provide more pleasant options to the families.

4. Summer course in Biotechnology

From 16^th june to 26^th june 2008 ;

Course includes : Primary tissue culture, molecular genetics and embryo biotechnology.The course in made esp. for university students of BSc.,MSc. Biotechnology and Biosciences students. It will help them to have a hands on experience and will act as an orientation course for various interviews

5. Training in IVF and Embryology