Fertility NEWS LETTER

Ideal fertility : ICSI / IVF & Genetic Center India

Dear Colleges
Hello

There was a news that world’s first IVF baby ,Luis Brown have delivered a child after a natural conception. There are innumerable births taking place in world but this birth was special. People are still skeptical about the babies born from In vitro fertilization techniques and their further developments. One school even propagates that, babies should not be made by IVF techniques because we may create some defects in them, as these embryos are exposed to extreme lights, atmospheric air and in contact with the substances which are totally synthetic and man made. There are some reports that extreme atmosphere may create epigenetic changes in embryonic genome and there may be faults in imprinting of the genes. But my friends, I feel God is great. He, most of the time, prevents these abnormal births, conceived either naturally or un-naturally, so that who-so-ever arrives in this world should be of good quality and can sustain its independent life.

Hence the research goes on and on and on ……

I wish you all the best
Dr. D’Pankar Banerji

Evolution of the Ovulation Inducing drugs.

Since the college days we are dealing with the ovulation inducing drugs and most commonly is the Clomiphene Citrate. But when we see the literature, we find that there is continuous research for the better inducing drugs. Urinary gonadotropins came, then highly purified products and then the recombinant FSH. So that we can get good quality eggs in more numbers. But one thing was disturbing and that was inappropriate LH at inappropriate time. Further research went on and one of the main target was to deal with the control of premature LH surge.

Now what is premature LH surge?

Whenever we stimulate any ovary by any drug, be it Clomiphene or Letrosol or Gonadotropins, our aim is to raise the FSH level in the circulation. Rise in FSH stimulates the granulosa cells and there is growth of oocyte and simultaneously rise of a hormone called estradiol or E2.

More the amount of FSH increase in circulation more will be number of oocytes selected in the race of survival of the fittest.

But there is a by product also coming from the granulosa cells and that is E2. It also increases in circulation, and it reaches to pituitary in the brain. There is a switch in the pituitary which gets on when E2 reaches above a threshold level. As this gets on, it releases high amount of LH hormone in a fashion of a peak.

The high amount of LH in circulation reaches to growing follicles and it breaks the follicular wall and releases the growing eggs, at whatever stage they may be. This creates a problem. Release of immaure eggs makes them susceptible to injuries and if they get fertilized, a poor and injury prone embryos (injuries are in the form of choromosomal and genetic).

So what we get?

Putting lots of money on inducing drugs and we are getting injury prone poor quality eggs. Here fertilization rate will be less and abortions will be high. Can we control this notorious Premature LH surge while stimuating the ovaries?

Answer is:

Check the pituitary from increasing E2 level to release LH. This is achieved by GnRh analogues and GnRh antagonists. The earlier one does it by making pituitary tired (down regulation) and other is by clamping.

GnRh Analogues are used a whip .It continuously hits the pituitary and makes it tired before we start the gonadotropins for growth of follicles. So even when the rising E2 level goes above the threshold level, LH is not released. Here we inject the LH (as hCG) when we feel the eggs are ripe enough.

Problem with these drugs are, they require more amount of gonadotrpins hence the cycles becomes expensive. They can not be used in combination with clomiphene or letrosol (as these agents require active pituitary). Here come the GnRh antagonists. They clamp the pituitary immediately and whenever withdrawn, release the pituitary immediately. Hence they can be used with other drugs and the total consumption of the gonadotropins will be less. We mean to say that whole exercise was to tide over the premature LH surge and make the cycle more successful.

Fetal defects associated with maternal medical disorders

There are few medical disorders that are associated with the greater risk to the growing fetus, few of them are:

a. Diabetes Mellitus: Infants of insulin dependent diabetic mothers have upto a 22% incidence of cardiac, renal, gastrointestinal, CNS, and skeletal malformations. Most of the malformations occur between the third and sixth week post conception and are increased if there is hyperglycemia during that stage of gestation .

1. The level of risk may be estimated by obtaining glycosylated hemoglobin (Hb A1C) in the first trimester. More than 8% have been associated with a significantly increased risk. Strict glucose control preconceptually has been shown to decrease the frequency of malformations.
2. Malformations common found in the infants of diagetic mother are caudal regression syndrome with hypoplasia of the caudal spine and lower limbs and the other is congenital heart disease ,usually the ventricular septal defects
3. Maternal serum AFP should be done in second trimester to rule out heural tube defects. A detailed ultrasound examination around 20 weeks should be done to identify the major anomalies

b. Hypothyroidism:
This endocrine problem may be associated with a two fold increase in still births and congenital anomalies

1. Cretinism is the result of maternal, fetal and neonatal thyroid hormone deficiency in iodine poor areas. Cretinism is associated with mental retardation. deaf-mutism ,spasticity , strabismus and abnormal sexual maturation .
2. Maternal sub clinical hypothyroidism has recently been observed to possibly decrease several points of IQ scores in their offspring.

c. Phenylketoneuria :
There is deficiency of phenylalanine hydroxylase, a liver enzyme that catalyzes the conversion of phenylalanine t tyrosine. The resulting high level of phenylalanine in maternal serum result in high levels in the fetus. Diet low in phenylalanine before conception can prevent the adverse affects (mental retaedation )of this disorder. Children born to mothers neglected their diets are at risk for the following conditions like Mental retardation ,Microcephaly, Congenital heart disease and low birth weight

d. Epilepsy :
Here the disease process and its treatment both increase the risk. Infants born to epileptic mothers have a 6 to 7 % incidence of major and minor congenital abnormalities Mother who are on antiepileptic drugs; their infants have high chances of cleft lip, cleft palate and congenital heart disease.

e. Virilizing tumors:
This condition may increase the incidence of pseudo hermaphrodite changes in female fetuses.

Training in IVF and Embryology

Module I : Ovulation induction and Intra Uterine Insemination ( One day ),Rs.2000
Module II : Conventional IVF and fundamentals of Embryology( Two days ), Rs.20,000
Module III : Intra cytoplasmic sperm injection, Micro manipulation ( Two days ) Rs.50,000
For details contact ,two participants per batch

Dates :
Throughout the year

Charges :
Module I : Rs.2000.00
Module II : Rs.20,000.00
Module III : Rs. 50,000.00

For Module I and II Rs.20,000
For all the three modules/Module II and III : Rs.55,000.00

Accommodation :
Drafts : should be in favor of Dr. D’Pankar Banerji, payable at Jabalpur.

Stay can be arranged in nearby hotels at an extra cost Rs.250-1000 per day
Lunch will be served during the training session.

Faculty :
Dr. D’Pankar Banerji ,Consulting Gynecologist and Infertility specialist
Dr.Mrs.Rinku Banerji,Embryologist

Maximum candidates will be five for Module II and Module III
Certificate will be issued after the course to participants

Sale and purchase of the used equipments

This column is created for the friends who wish to purchase and sale their medical equipments and provide an interactive space

Letters to the editor:
I welcome your views and comments in this column and will be published in the forthcoming publications.