Fertility NEWS LETTER

Ideal fertility : ICSI / IVF & Genetic Center India

Vol IV Issue 8, August 2007

In This issue

  1. Who needs Genetic counseling?
  2. How to prevent LH surge in stimulated IUI ?
  3. First national training program on IVF and Embryology conducted successfully.
  4. Training in IVF and Embryology

In Previous Issue

  1. Embryo reduction in triplet pregnancy, achieved by IVF from oocytes collected from Pouch of Douglas—Case Report
  2. DNA PCR for Human Papilloma virus from chronic cervical erosion, A way of prevention of Cervical Carcinoma—Protocol followed at Ideal Fertility

Dear Colleges
Hello

In this issue we are discussing two important issues, one is genetic counseling and other is timing of insemination in IUI.

We the obstetricians and the gynecologists, most of the time when we deal with a woman who delivered a malformed or mentally challenged baby in her earlier conceptions and now comes to us for consultations and asks pertinent questions:

  1. What happened to my child and who is responsible ?
  2. Should it happen again if I conceive ?
  3. Or I am pregnant ,will it happen again?
  4. Can you prevent it or identify it ?
  5. Is there any treatment ?

These are the few questions they may ask. But unfortunately most of us ,are not in position to satisfy their queries and at the end advice them to go ahead for another pregnancy leaving the things on Almighty God.

This is because we have not been taught genetics in our graduation and post graduation and we feel Genetics as Greek for us.

My submission is “If can not correct the present problem ,at least we can prevent the next episode to a large extent ,provided we know some basic facts of genetics” Other issue is timing of IUI. Timing of hCG and insemination is very crucial in any ART procedure. It increases the pregnancy rate to a great extent and makes the procedure more precise.

Our first national training of IVF and Embryology was outstandingly successful and participants were very happy at the end of the schedule.

Accept my best wishes

Sincerely yours

With best wishes
Dr. D’Pankar Banerji

(Click Archives for Earlier issues of Reproduction and Genetics)

Who needs Genetic Counseling ?

  1. Woman is 35 yrs. Or older or will be 35 yrs or older at delivery.
  2. There is history of pregnancy losses.
  3. There is ongoing medical conditions ,like diabetes, thrombosis , psychiatric conditions or a seizure disorder.
  4. Woman is exposed to medications ,alcohol abuse , street drugs , chemicals , X- rays or infections during pregnancy.
  5. Woman and his partner from an ethnic origin in which a specific genetic condition is more common ( sickle cell anemia ).
  6. The result of maternal serum screening test indicate that her baby is at increased risk for Down syndrome , trisomy 18 or spinal bifida.
  7. The woman and her partner are blood relative.
  8. An ultrasound evaluation has indicated an abnormal finding in the developing baby.
  9. Woman and her partner have a family history of genetic condition ( eg cystic fibrosis or muscular dystrophy, birth defects like cleft palate/lip or heart defects or mental retardation.
  10. First trimester screening tests shows abnormality.

Steps of Genetic counseling :

  1. History taking with particular emphasis on pedigree construction.
  2. Clinical examination
  3. Diagnosis
  4. Management

Few facts regarding medical genetics:

  1. All genetic diseases are not congenital and vice versa.
  2. All genetic diseases are not familial and vice versa.
  3. Absence of genetic disease in the family does not mean that it can not occur in the family.
  4. Each one of us is a carrier of 6-7 deleterious recessive mutations.
  5. All genetic diseases are not rare ( Cystic fibrosis ,thalassemia etc.)
  6. Consanguinity predisposes to autosomal recessive disorders but overall prevalence of genetic diseases in population with high consanguinity need not be high .
  7. Risk of recurrence may vary from 0-100 % .A genetic diseased for an affected individual need not be transmitted ( eg. Chromosomal disorders , somatic cell genetic disorders ).
  8. All genetic diseases are not non-treatable esp. inborn error of metabolism, few of them are well managed.

How to prevent LH surge in stimulated IUI

IUI is most common ART technique for infertile couples. It is indicated as a first line treatment when there are no problems in fallopian tubes and husband is having a normal or just subnormal count of sperms in his semen. The woman may be regularly ovulating or dysovulatory . In these situations there is a component of ovulatory stimulation or ovulatory induction respectively.

When ever the ovary is stimulated there is an effort to increase the amount of FSH in circulation ( either by clomiphene citrate or Letrosole or gonadotrophins ) so that the more number of oocyte are selected and chances of fertilization increases.

With this effort the level of estradiol in circulation too increases .
This increased estradiol when reaches above the threshold level ,it releases LH from the pituitary by it positive feed back effect , which is most of the time untimely and creates premature release of immature eggs .

Most of the time we give a surrogate LH surge by an injection of hCG and usually it is timed subjectively. If LH surge is already there it is of no use. If it is given early then again it will create problem.

If we can have a control of this premature LH surge during the stimulation or can identify its occurrence then we may get good quality eggs.

Ways to identify and/or control LH surge:

  1. Use of urinary LH card
  2. Use of Norah antagonist
  3. Inject CG before the lead follicle reaches 18 mm

Urinary LH card are cheaper and easily available. It helps the women to do the test in her home atmosphere and report to the fertility specialist next day of LH surge (regular monograph for ovulation can be avoided ).

It is a simple urine test ,like we do for pregnancy test in urine . LH urine test is usually done in second sample of urine of the day . Woman should avoid plenty of fluid before this test. The day when this test has to be started, is decided according the previous menstrual history ( if she is regularly menstruating ). If the lady is induced for ovulation ( not regularly menstruating and dysovulatory ) or controlled ovarian stimulation, then test should begin when the lead follicle is 14-15 mm .Usually this LH test goes for five days . If even after five days the test is negative and the lead follicle crosses 18 mm, it means that LH surge is still not there and a shot of hCG can be given confidently as a surrogate LH surge.

Use of GnRh antagonist is another method to prevent premature LH surge . Ideally, again it should be given for five days ,starting from the lead follicle reaching 14-15 mm. Inj. Cetrorelix 0.25 mg subcutaneous, immediately stops the LH release from pituitary. When the lead follicle reaches more than 18 mm , Cetrorelix is stopped, and next day , LH surge can be achieved either by hCG injection or by short acting GnRh analogue, like Luprolide or decapeptyl subcutaneous. As Cerorelix is stopped, the pituitary is released from competitive inhibition and injection of GnRh analogue releases LH ,which acts as a LH surge. Here things are little bit expensive than the use of LH cards.

Last is ,when there is no LH cards or no GnRh antagonist, then Inj.hCG can be given before the lead follicle reaches 18 mm. This method is crude and presumptive.

IUI can be done ,after one day of spontaneous LH surge ( identified by urine test ) or surrogate LH surge by hCG injection or GnRh agonist injection.

First national training program on IVF and Embryology conducted successfully

At ideal fertility ,First training program was conducted successfully. It was an intense hands on schedule for the participants for Module I and II and conducted from 17th june to 19th June 2007. We have decide to take only two participants per batch so that the personal one to one communication was at its best.

Two participants were Dr. Nitish Biswas from Kolkata and Dr.Shyamala from Hyderabad. Both were practicing gynecologist. Two IVF cases were planned during the training schedule so that the participant had a live feeling of the actual procedure. The participants were in the operating room and in culture room during the procedure. They were trained to make culture media for IUI . They retrieved the oocytes from mammalian ovaries and learnt ,how to place culture in a culture dish. Fundamentals of embryology and lab procedure were covered by our embryologist ,Dr .Mrs. Rinku Banerji.

There was one to one discussion and presentation in the field of reproductive endocrinology and various induction protocols for IUI and IVF. The induction protocols and oocyte pickup and embryo transfer part was covered by Dr. D’Pankar Banerji.

Feed backs from the participants :

Dr.Biswas –“ many many thanks for the training. The embryology and post training advice is very much needed when we start our own.”

Dr.Shyamalla – “your training was very educative and friendly. we got an idea about IVF. Please try to interact after we leave the training and guide us further”.

Dr.Shyamalla ( left ) and Dr.Biswas (right ) with our embryologist Dr.Mrs.Rinku Banerji

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

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