Fertility NEWS LETTER

Fetus day celebrated on 31st OctoberFetus day celebrated on 31st October

1. HEALTHY FETUS HEALTHY NATION

Genetic diseases, Its diagnosis and prevention may reduce the burden of lots of preventable genetic disorders, like thalassemias and sickle cell disorders. Down syndrome screening is now a routine. Prenatal diagnosis ,a term once considered synonymous with invasive fetal testing and karyotype evaluation, now encompasses pedigree analysis, fetal risk assessment, genetic counseling and fetal diagnostic testing.

Defining fetal status clarifies many perinatal decisions. If fetal conditions is reassuring and the situation is stable, management is confidently conservative, seeking further intrauterine time for maturation. If fetal status is uncertain, management will depend on gestational age : near term ,delivery may be the best option; before then, enhanced surveillance and preparation for delivery is indicated; remote from term, intrauterine therapy might be in order. When fetal compromise is certain, our primary responses are delivery and neonatal management – down to the frontiers of  viability. So what we do is determined by what we think of the fetal status.

The availability of high-resolution ultrasound imaging and screening programs has made the : Unborn child a true patient. In some cases , intervention before birth may be desirable, which oftern does not require direct access to fetus-for example ,transplacental administration of pharmacological agents for cardiac arrhythmias or antibiotics in case of fetal infection. Other conditions can be treated only by invasive access to fetus. In utero transfusion of hydropic fetus to treat the anemia of Rh isoimmunisation, first described  in1961, was probably the first successful invasive therapeutic procedure. Today blood transfusion through umbilical cord, intrahepatic vein, or (exceptionally) directly into the fetal heart is widely offered, with good fetal and long term outcome when procedures are done by experienced operators. Some conditions are amenable t surgical correction, and in majority of cases this is best done after birth.

To summarize , fetus should be taken as an separate individual ,not an transient appendage to the “would be mother”. A healthy fetus becomes a healthy child and a healthy offspring is a great asset to the society, and a healthy pool of strong child makes the nation strong. In other way we can even go the extent that “ Fetus should be assumed as father of an adult”.

2 .  IVM ( invitro maturation ) of oocytes from women with PCOS

PCOS is very hertogenous  syndrome, often first diagnosed when the patient presents complaining of infertility; approximately 75 % of these patients suffer infertility due to anovulation. The majority of women with anovulation or oligo ovulation due to PCOS have menstrual irregularities,  usually oligo or amenorrhea, associated with clinical and / or biochemical evidence of hyper androgenism.  In almost all these patients, ultrasonic scan of the ovaries typically reveals numerous antral follicles. Fertility tre atments for women with PCOS include lifestyle management, administration of insuli sensitizing agents, laparoscopic ovarian drilling, ovulation induction, and IVF. This group of patients has an icreased risk of severe ovarian hyperstimulation syndrome ( OHSS) from gonadotropin stimulation compared with women who have normal ovaries. The risk of multiple follicle ovulation and subsequent multiple pregnancies is also of crucial importance. However , the high number of antral follicles in patients with PCO makes them prime candidates for IVM treatment,even if the appearance of PCO in the scan is mnot associated with an vularion disorder. Indeed , the main determinant cinically of success rates of IVM treatment is antral follicle count.when hCG priming is used before oocytes tretival, it has bben found that immature oocytes retrieved form normal ovaries , PCO , or women with OCOS have a similarly high maturation  , fertilization, and cleavage potential. However , although the implantation rate was lower, the live birth rate was singnificanatly lower in IVM group. These results suggested that IVM is a promising alternative to conventional IVF treatment for women with PCO or a high antral follicle count  who require assisted conception.

3. Coventional IVF in natural cycle

A women aged 34 yrs undergone ovarian stimulation for IVF with flare protocol. She developed only 3 good follicle and only 3 eggs retrieved. They were put in conventional IVF and only one embryo formed and day 3 transfer of a fragmented embryo done, resulted in no pregnancy.

As there were only 3 follicle, we did the AMH and it was 1.2 ( lesser than normal lower limit).

We discussed about egg donation but the couple refused and accepted another attempt with higher amount of gonadotropins after 2 -3 months.

In between, she had her periods and came to us on day 8 of cycle for further discussion. I did an ultrasound to see the ovaries and the endometrial lining.

There were two follicle on of 12 mm and other was 11 mm. and endometrial thickness was 6 mm.

I convinced her for natural cycle IVF with a very lesser cost (US $ 300). I tracked the follicle and put one HMG150 on day 9 and Gn Rh antagonist on day 10. On day 11 there was only one follicle and it was 16 mm. Inj hCG 10,000 IU given in midnight. Egg collection was done after 36 hours.

We retrieved one single egg with good quality. After 3 hours of maturation, it was inseminated with conventional IVF.

It fertilized and on day 1 there was a good quality PN. On day 3 single good quality 8 cell embryo with confluent margins transferred atramatically. Luteal support was given as usual with vaginal progesterone. After 14 days of embryo transfer, a urine pregnancy test was done and it came positive.

There is literature that when ovarian stimulation fails then a natural cycle some time gives better egg and embryo