fertility focus issue ix life pro ads

7/29/2019 Fertility Focus Issue Ix Life Pro Ads

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In The Era Of ICSISperm Tests

N ew er D ia gn os ti c

D R . A M I T S H A HMD, DNB , MNAMS

C h i e f C o n s ul t a n t ,

IVF C enter Ina mda r Multis pecia lty

Hos pita l, Pune

R ou ti ne s em en a na ly si s u se d f or m or e t ha n 5 0 y ea rs m ig htn o t d e li ver b e tt e r c l in i ca l i n fo r ma t io n o n f e rt i li t y p o te n ti a l. . .

h e c o m pl e x i ty o f i n v ol u n ta r y c h i l dl e s s n es s

c an be u nd er st oo d i n t he c on te xt o f

fe ma le a nd m al e fa ct ors a nd a v ar ie dTc o m b in a t i on o f b o t h . I n 2 0 % o f c as e s ,m a l e -r e l at e d fa c t o rs a r e r e s po n s i b le w h i l e i n 3 0 %,

1b o t h t h e p a r t n e rs c o n t r i b u t e t o i n fe r t i l i t y .

T ra d i ti o n a ll y, a n a l y s i s o f s p e r m c o n c e n t ra t i on ,

m o t i l i t y a n d m o r p h o l o g y a r e p e r f o r m e d t o

d ete rmi ne t he e ti olo gy o f m al e i nfe rti lit y o r

s u b fe r t i li t y. H o w e ve r, ro u t i ne u s e o f li g h t m i c ro s -

c o py o f 1 00 - 20 0 s p er m at oz o a i s a s so c ia te d a h i gh

m a r g in o f i n t r al a b o r at o r y a n d i n t er l a b o ra t o r y2-3

v a ri a ti o ns . I n a m e ta - an a ly s is o f s e me n q u al i ty

f r o m 9 6 1 2 p r e s um a b ly f e rt i l e m e n , 9 8 m i l li o n / mL1

w a s c o n s id e r e d a s a n o r ma l s p e rm c o n c en t ra t i on

w h il e s p er m m ot i li t y, a s s um e d to b e t h e b es t 4

indicator of fer tility, r anged from 53% to 62% .

F u r th e r m or e , s e m e n a n a l ys i s i s w i d e ly i n f l ue n c e d

b y a n a r ra y o f s e a s on a l a n d g eo g r ap h i c v a r ia t i on s ,

w hi ch m ak es i ts r el ia bi li ty a nd q ua li ty c on tr ol

pr ofoundlychallenging.

N ew er D ia gn os ti c

In The Era Of ICSI

T a b l e 1 . L o w e r r e f e r e n c e s l i m i t s ( 5 t h c e n t i l e ) f o r

s e m e n c h a r a c t e r i s t i c s ( W H O 2 0 1 0 )

Nat al i A, TurekP J etal Urol ogy. 2011.

W H O p a ra m e te r s o f s e m en c h a r ac t e r is t i cs a d d re s s o n l y f e w

a s pe c ts o f s p er m q ua l it y a n d f u nc t io n. D ur i ng t he l a st

d ecad es, sev eral sp erm f u n cti on tests h av e sh own p romi si n g

p oten ti al .T h ese i n cl u d ev i tal stai n i n g, b i och em i cal anal ysi s of

sem en , h yp o-osm oti c swel l i n g test, sp erm p en etrati on assay,h e m iz o na a s s a y, a n t i s p e rm a n t i b od y t e s t, r e a c t i ve o x yg e n

s p e c i e s t e s t s a n d c o m p u t e r - a s s i s t e d s p e r m a n a l y s i s .

Howev er, m an yof th ese tests aren ot rou ti n el yu sed .

F i g 1 . S c h em a t i c i l l u st r a ti o n o f t h e s t e ps o f t h e e g g f e r t il i z a ti o n

p ro ce s s t ha t t he o l d er s pe r m f un ct io n t es ts a ss e ss . 1 . S pe rm

morphologycorrelates with stages of egg cumulus and egg binding,

and egg penetration and fertilization at IVF. 2. S perm penetration

a s s a y a s s e s se s t h e a b i l it y o f s p e r m t o b i n d a n d p e n e tr a t e t h e e g g a n d

d e c on d e ns e w i t h in i t . 3 . H e m i zo n a a s s a y e x a mi n e s s p e r m b i n d i n g t o

t h e z o n a p e l l u c i da . 4 . A c r os o m e r e a c t i o n a nd t h e p r o ge s t er o n e t e s t

a s se s s t h e a b il i ty o f s pe r m t o pe n et ra t e c u mu l us a n d bi n d an d

p e n et r a te t h e z o n a p e l l uc i d a . 5 . H y p o- o s mo t i c s w e l li n g c o r re l a t e s

with cumulus and egg binding and egg penetration and fertilization

a t I V F. 6 . R e a ct i v e o x y ge n s p e ci e s e v a l ua t i o n c or r e l at e s w i t h s p er m

membrane, motility, and DN A integrity.

Nat ali A, Ture kPJ e t al Urology .2011.

He

ad

Ne

ck

Tail

Midpiece

Ac

rosome

6

4

5

1

Vol u me ( m L) 1 .56

Con cen trati on ( 1 0 sp erm /m L) 1 56

Total sp erm n u m b er ( 1 0 /ejacu l ate) 3 9

Moti l i ty ( % m oti l e) 4 0

Forward progression 32

Morp h ology ( % n orm al ) 4

Vi ab i l i ty/Vi tal i ty ( % al i v e) 5 8 %6

W h it e b l o od c e l ls ( 1 0 s p e r m/ m L ) < 1 . 0

Cu m u l u s cel l s

Cumulus

matrix

M-II spindle

Oolema

Z on a p el l u ci d a

Sp ermOoplasm

Decondensation

Embryo formation

2

2

6

63

4 4

55

5

PR

1

11

Peri v i tell i n e sp ace

Issue IX February 2011 E v id e n c e -b a s e d A d v an c e me n t s & C l i n i ca l U p d at e s o n R e p ro d u c ti o n , F e r ti l i t y & D e v e lo p m e nt

Fertility

F CUSF CUSSperm Tests

Del aying I C SI Up T o 12Hours Does Not HarmOutcome InRefrigerated Oocytes

Women Have HigherPsychological Distress

Than Men When PreparingFor IVF

Fertility Myths AndIllusory Benefits OfHealthy Habit s In YoungPeople


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Determining Sperm Chromatin Structure

ACRID IN E ORANGE:

A N I LI N E B LU E :

CHROMOMYCIN A:

TOL U IDINE B L U E:

SPERM CHROMATIN STRUCTURAL ASSAY (SCSA):

C h r o ma t i n s t ru c t u ra l p r o b es u t i l iz e h i g h ly s e n s i ti v e n u c l e ar d y e s t o e x a mi n e D N A i n t e gr i t y.

H o w e ve r, t h e i r c y t o c h e m ic a l p e r fo r m a nc e i s f a i rl y c o m pl e x s i n c e s e v e ra l f a c t o rs i n f l ue n c e t h e

p r o c es s o f D NA s ta i n i ng o f c h r om a t in b y n u c l ea r d ye s . T h e s e a r e : ( a ) th e s e c o nd a r y s t r uc t u re o f

D N A , ( b ) t h e r e g u l ar i t y a n d d e n s it y o f c h r o ma t i n p a c ka g i n g , a n d ( c ) t h e b i n d in g o f D N A t o

c h r o ma t i n p ro t e in s . A s s a ys p e r fo r m ed i n t h i s c a t eg o r y a r e :

T h i s t o o l i s i n e x pe n s i ve , a n d s i m p le t o pe r f or m . I t m e a s ur e s in situ DNA6

susceptibility to acid-induced confor mational helixcoiltransition ( Fig. 3) .

T h i s t o o l st a i n s p r o te i n s i n l o o s el y c o n d en s e d c h ro m a ti n .

This tool competes with protamines for association with DNA and staining7

r e la te s t o t h e d e gr e e o f p r ot am i na t io n i n m a tu re s p er m. I t i s s i mp l e t o p e rf or m .

T h i s t o o l s ta i n s p h o s p ha t e r e s i du e s o f l o o s el y p a c ke d a n d f r ag m e n te d s p e r m8

n u c l e ar D N A .

T h is t o ol me a s u re s i n s i t u D N A

susceptibility to acid induced confor mational helix-coil changes with acr idine or ange

f l u o re s c e n ce u s i n g a u t om a t ed c e ll s o rt i n g 20 ( F i g . 3 ) . S C S A i s t h e m o s t w i d e ly u s e d a s s ay , b e c a us e

of pr oven associations with clinical outcomes after natural conception and assisted

r e p ro d u c ti v e . A l t h ou g h t h e p r o c ed u r e i s e x p en s i v e t o p e rf o r m, i t o f fe r s s m a l l in t ra - a n dinter assay var iation.

F ig 2.F low chart for apossible use of sperm chromatin structureassay in diagnosisand treatmentof infertility.S CS A, sperm chromatin structure

assay.*if DF I25%, DF I, DN A fragmentation index.

B ungum M e t al Asian Journal of Andrology 2011; 13: 69 75.

F ig 3. A common method of assessing sperm DN A fragmentation isto

o b s e rv e a c r i di n e o r a n g e ( A O )- s t a in e d s p e r m t h a t i s e x p os e d t o 4 8 8 -

nm laser light. AO intercalated into double-stranded DN A fluoresces

green and AO bound to single-stranded DN A fluorescesred.

N e w e r A d ju nc t iv e S p e rm T e s t s

Sperm D NA Frag m ent at ion

R ec e nt r e se a rc h ha s l i nk ed bi o lo g ic a l c o rr e la te o f fe r ti l it y t o t h e i n te g ri t y o f D N A w i th i n s p er m5

c h r om o s o me s . D N A d a m a ge o r p r e s en c e o f a l t er e d s p e r m c h r o ma t i n s t r uc t u re i s a t t ri b u te d t o f o u r

s o u rc e s : ( 1 ) r e c om b i n at i o n d e f ic i e n c ie s d u r i ng t h e p r o ce s s o f s p e r ma t o ge n e s i s, ( 2 ) d y s f un c t i o na l5pr otamination leading to abnor mal sper matid maturation, ( 3) abor tive apoptosis, and ( 4) oxidative str ess .

Sever al assays examining sper m DNA integr ity can be divided into ( a) assays deter mining sperm chr omatin5

str uctur e, ( b) assays for sper m DNA fr agmentation, and ( c) testsassessing sper m nuclear matr ix .

T es ts O f S pe rm D NAFragmentation

M os t f re qu en t t es t t o d et ec t s pe rm D NA

f r a g m e n t a t i o n i n c l u d e t h e S i n g l e - c e l l g e l

e l ec t ro p ho re s is ( C om e t a s sa y ), t h e Te r mi n al

deoxynucleotidyl tr ansfer ase-mediated dUDP

nick end-labeling ( TUNE L) assay, and the SCSA.

A l l t h re e l a be l s i ng l e o r d o ub l e- s tr an d ed

DNA br eaks.

In situ Nick translation

T h is i s a q u an t if i ca ti o n a s sa y t h at m e as u re s

incor por ation of biotinylated deoxyur idine

tr iphosphate ( dUTP) at single-str anded DNA

b r e ak s ( S S B s) wi t h i n s p e r m D N A . T h i s t e s t i s7

n ot w id el y u se d .

Te r m i n a l d e o xy n u c l e ot i d y l t r a ns f er a s em e d i at e d d U T P N i c k e n d l a b e l i n g

(TUNEL)

T h i s a s s a y c a n a c c u ra t e ly d e t ec t s d o u b le -

str anded br eaks ( DSBs) in DNA thr ough the

incor por ation of dUTP at DNA br eaks

( catalyzed by ter minal deoxynucleotidyl

tr ansfer ase) . Although TUNEL can efficiently

detect DNA fragmentation in lar ge population

o f s p e r ms , th e t e s t m a y u n d e re s t im a t e a c t u al9

D N A f r a gm e n ta t i o n r a te s . A l s o , t h e t e s t i s

r e l at i v e ly l a b o r- i n te n s i ve a n d s h o w s n o c l e a r10

c l in i ca l p re g na n cy o u tc o me d a ta .

S i n gl e c e ll g el e l ec t ro p h or es i s a s sa y(COMET)

S i ng l e c e ll g e l e l e ct ro p ho re s is a s sa y i s a n e w,

s i m p le a n d s e n si t i ve m e t ho d t o e va l u a te D N A

d a m ag e a n d r e p a ir a t i n d i v id u a l c e l l l e v e l.

T h i s a s s a y c a n b e p e r fo r m e d o n e x tr e m e ly

s m a l l n um b e r o f c e l ls a n d r e su l t s c a n b e

o b t ai n e d w i t h in a r e l at i v e ly s h o r t t i m e. T h i s

a s s ay q u a nt i f i es D N A S S B s a n d D S B s i n s i n g l e

sper m after electrophor esis of fluor ochr ome-11

s ta i ne d D NA . A l th o ug h , C OM E T i s h i gh l y

s e n s it i v e t e s t, i t c a n b e d i f fi c u l t t o s ta n d a rd i z e

t h e c o m e t t a i l le n g t h. I n a d d it i o n , as s a y

cor r elation to clinical infer tility outcomes is

l e s s a p p a re n t t h a n w i th S C S A o r T U N EL12

m e th o ds . C O ME T i s l a bo r i nt e ns i ve .

DFI:10-20%

DFI:20-30%

Fem al e f ecu n di ty

Un treatabl e m od erate

or sev ere d i stu rb ance

Repeated

SCSA

Concentration,

motility,

morphology

SCSA

DFl


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F CUSFertility

Issue IX January 2011

F i g 4. I n di v id u al c e ll s a r e e m be d de d i n a t h in a g ar o se g e l on a

m i c ro s c op e s l i d e. A l l c e l l ul a r p r o t ei n s a r e t h e n r e mo v e d f ro m t h e

cells by lysing. The DN A is allowed to unwind under alkaline/neutral

c o n d i t i o n s . F o l l o w i n g t h e u n w i n d i n g , t h e D N A u n d e r g o e s

electrophoresis, allowing the broken DN A fragments or damaged

D N A t o m i gr a t e a w a y f r o m t h e n u c le u s . A f t e r s ta i n i ng w i t h a D N A -

s p e c if i c f l u o re s c e nt d y e s u c h a s e t h i di u m b r o mi d e o r p r o pi d i u m

i o d i de , t h e g e l i s r e a d f or a m o u nt o f f l u o re s c e nc e i n h e a d a n d t a i land length of tail. The extent of DN A liberated from thehead of the

cometis directlyproportional to the amountof DN A damage.

S p e rm n u c l ea r ma t r i xassays

T h is a s sa y m ay b e u s ed to d et er m in e D N A

o r ga n i z at i o n i n a s e m e n s a mp l e b y

d e t er m i ni n g t h e d e g r ee o f l o o p i n t ac t D N A

depr ived of chromatin pr oteins make

a r o un d s p e r m n u c l e u s m a t ri x . D e f in i n g

sper m DNA or ganization is impor tant

c l i n ic a l l y s i n c e n o r ma l D N A o r g an i z at i o n i s13n e c e s sa r y f o r n o r m al c e l lu l a r f u n c ti o n .

S p e r m n u c l e a r m a t r ix s t a b il i t y

T h i s a s s a y a s s e s se s h i g h -l e v e l D N A

or ganization within the sper m nuclear

m a t ri x . I t c a n d e t ec t a b e r ra t i on s i n t h e

ability of matrix to or ganize DNA into loop-

d o ma i ns . C l in i ca l d a t a o n t h e a s sa y i s l i mi te d

s i n c e t h e p r o ce d u re i s s t i l l b e i n g t e s te d i n i t s

developmental stages.

S p e r m c h r o m at i n d i s p e rs i o n

U n i q ue n e s s o f t h i s a s s a y i s i n f r a gm e n te d

D N A t h a t d o n o t p r o du c e t h e c h a ra c t e ri s t i c

h a l o w h e n m i xe d w i t h a q u e o u s a g a ro s e

after tr eatment to remove nuclear proteins.

F u r th e r ut i l i ty o f t hi s a s s a y i n m a le i n fe r t i li t y

is being investigated.

F ig 5. S c he m at i c i l lu s tr a ti o n o f t h e s t ep s o f t h e e g g f e rt i li z at i on p r oc e s s t h at t h e n e we r s p er m f u n ct i on t e st s a s se s s. 1 . S pe rm D NA

fragmentation correlateswith sperm decondensation and form embryos.2. S perm H A binding examinesthe ability of sperm to bind to the zona

p e l l uc i d a . 3 . U l t r af i n e m o r ph o l og y c o r re l a t e s w i t h t h e a b i l i ty o f s p e r m t o d e c o nd e n se w i t h in t h e e g g a n d f o r m e m b ry o s . 4 . C h r om a t i n

decondensation assesses the ability to sperm to decondensewithin the oocyte.

Ta b l e 3 . A d va n t ag e s a n d d i s a dv a nt a g es o f v a r i o u s D N A i n te g r i ty a s s a y s

Journal of Andrology 2009; 30(3): 219-29.

J ournal of Andrology 2009;30(3):219-29.

C u m ul u s c e l l s

Cumulus

matrix

M-II spindle

Oolema

Z on a p el l u ci da

S permOoplasm

Decondensation

Embryo formation

2

3

34

PR

Perivitelline space

1

H ead

Neck

Tail

Midpiece

Acrosome

1 4

23

Table 2. B asics of common sperm DNA int egrity assays

D i r e ct a s s ay sTUNEL A dd s l ab el ed nu cl eo ti de s t o fr ee D NA en ds % Ce ll s w i th la be le d D NA

Te m p l at e i n d e pe n d e nt L a b e ls S S a n d D S b r e a k s

CO M ET El ec trop hor esi s o f s in gl e s pe rm ce ll s % S pe rm w it h l ong ta il s ( ta il le ngt h,

DN A fragments form tail % of DN A in tail)

I n t ac t D N A s ta y s i n h e a d

A l k a li n e C O M E T

Alkaline conditions, denatures all DN A

I d e n ti f i e s b o t h D S a n d S S b r e a k s

N eutral COMET

D o es n ot d e na t ur e D N A

I d e n ti f i e s D S b r e ak s , m a y be s o m e S S b r e a ks

In situ n ick tra n sla tio n Incorporates biotinylated dUTP at S S DN A % Cells with incorporated dUTP

B r e ak s w i t h D N A p o l y me r a s e I ( f l u or e s c en t c e l l s) .

Template-dependent

L a b el s S S b r e a ks , n o t D S b r e ak s

Indirec t as s ay sD NA b rea k d etectio n FIS H Denatures nicked DN A Amount of fluorescence proportional

W h ol e g e n o me p r ob e s b i n d t o S S D N A t o n u m be r o f D N A b r e ak s

S CD I ndi vi dua l c el ls i m me rs ed i n a ga ros e % S pe rm w it h s ma ll or a bs ent ha lo s

Denatured with acid then lysed

N ormal sperm produce halo

Acrid in e o ra n g e flo w cyto metric

a ssa ys M il d a ci d t re at me nt d en at ur es D NA wi t h S S D FI -t he p er ce nt ag e o f s pe rm wi th

o r D S b r ea ks A cr id in e o r an ge b in ds t o D NA a r at io of re d t o ( re d + g re en ) f lu or es ce nc e

DS DN A (nondenatured) fluoresces green greater than the main cell population

S S DN A (denatured) fluoresces red

F l o w c y t o me t r y c o u nt s t h o us a n ds o f c e l l s

Acrid in e o ra n g e test S ame as above, hand-counting of green % Cells with red fluorescence

and red cells

Bas is of As s ay Meas ured Parameter

D i r e ct a s s a ys

TUN EL Can perform on few sperm Thresholds not standardized

E x p en s i v e e q u i p m e nt n o t r e q ui r e d V ar i a b l e a s s a y p r o to c o ls

COMET Sensitive Labor i ntensive

Can perform on few sperm R equires imaging software

Al ka li ne : i de nt if ie s a ll bre ak s Va ri ab le a ss ay p rot oco ls

N eu tr al : m ay i de nt if y m or e A lk al in e: m ay i de nt if y c li ni ca ll y u ni mp or ta nt f ra gm en ta ti on

clinically r elevant b reaks May i nduce b reaks a t alkaline-labile sites

N e u tr a l : l e s s s e n s it i v e

In situ nick translat ion S imple Unclea r threshol ds, Less sensi tive

I n d i re c t a s s a ys

D N A b r e a k d e t e c t i on F I S H C a n p e r fo r m o n f e w s p e r m L i m i te d c l i n ic a l d a t a

SCD Easy, can use bright-fiel d microscopy Limited clinical data

A c r i di n e o r a ng e f l o w M a n y c e l l s r a p id l y e x a mi n e d E x p en s i v e e q u i p m e nt r e q ui r e d

c yt om et ri c a s sa ys M os t p ub li sh ed s tu di es r ep ro du ci bl e S ma ll va ri at io ns i n l ab co nd it io ns a ff ec t r es ul ts

C a l c ul a t i o ns i n v ol v e q u a l it a t i ve d e c i si o n sManual acridi ne o range t est S imple Difficulty with indistinct colors, rapid fading, heterogeneous staining

Pros Cons

C o me t A s sa y O v er v ie w

DNA damage

(Che mical, UV

org-irradiat ion

Li vi ng cel l s f rom

cul t ure medi a,

bl ood, or t i ssue

C e l l s w i t h

damaged

(rel axed) DNA

havi ng si ngl e-

st and/ doubl e-

st and breaks

S i n g le c e l l s a r e

embedded on

agarose coat ed

sl i de and l ysed

Af t er el ect rophoresi s

and f l uorescent

st ai ni ng t he damaged

DNA i sseparat ed

f r o m t h e i n t a c t D N A

( t h e " h e a d " ) a n d

g e n er a t es a c o m e t

"t ai l "

3

DNA-f ragment t ed sperm

N o r m al s p e rm


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5/8


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R e s ea r c h s h o ws t h a t pe o ple c a n n ot r e c og n iz e f a c to r st ha t h av e no e ff ec t o n f er ti li ty. M os t b el ie ve i n m yt hsa n d h ea l th y b e ha v io r ri t ua l s a nd t r us t t h es e t oactually increase a womans fertility potential.

F e r til it y a war e n es s c a mpa ig n s a re n e e d ed t o a d d r es ss u c h f a l se b e l ief s

F CUSFertility


6

Fertility Myths And

Illusory Benefits Of

Healthy Habits In Young

People

e s e a rc h ha s h i g h l ig h t e d t h a t k n o w l ed g e i s a

key factor associated with fer tility self-car e.RA gl o ba l s u rv e y o f a l mo s t 1 7 ,5 0 0 p e op l e( m os t o f c hi l db e ar i ng a g e) f r om 1 0 c o un t ri e s

showed poor level of knowledge r egar ding fer tility

a n d b i o l o g y o f r e p r o d u c t i o n . M a n y p e o p l e

o v e re s t i ma t e t h e c h a n ce s o f p r e g na n c y a t t h e t i m eo f o v ul at i on , h a ve l i tt l e a w ar e ne s s o f t h ei r o w n

f er t il e p e ri o d, a n d a r e n o t a w ar e o f t h e n u an c es

of infertility.

I t i s v ita l t o d is se mi na te k no wl ed ge a bo ut t he

b i o l og i c a l pr o c e ss o f r e pr o d uc t i o n. F o r i n st a n c e,

i n fo r m at i o n o n w h e n a w o m an i s m o s t f e rt i l e , h o w

l on g sp er m su rv iv es , wh en i s t he b es t t im e f or

u n p r o t e c t e d i n t e r c o u r s e a n d t h e d i f f i c u l t i e s

a s s o c ia t e d w i th c o n c e p ti o n . H o w e ve r, e q u a l l y

i m po r ta n t i s f or p e o pl e t o b e a wa re o f f a ct o rs t h at

c o u l d r e d uc e t h e c h a n c es o f c o nc e p t io n , a nd h o w

la ck of kn ow le dg e i n t hi s a re a ma ke s p eo ple

u n i nt e n ti o n a ll y r e d uc e t h e i r o w n f u t u r e p r o s pe c t s

of fertility.

Erroneous belief is ani mp o r ta n t f a c t or a f f e c t in gfertility self-care. Forinstance, people falselyb e l ie ve t h a t t h e y i n cr e a s etheir fertility by nots mo k in g r a t h er t h a n s i mp ly

avoiding decrements inf e r t il i t y d ue t o s mo k in g .

I n a r e ce n t i nv e st i ga t io n , Bu n ti n g an d B io v in

a s se s se d k n ow l ed g e o f f er t il i ty m o re b ro a dl y i n

y o u ng p e o p le . T h e a u t h or s i n ve s t i ga t e d t h r e e a r e as

o f k n o w le d g e , na m e l y r i s k f a c to r s a s s o c ia t e d w it h

female infer tility, beliefs in false fer tility myths, and

b e li e fs i n t h e i l lu s or y b e ne f it s o f h e al t hy h a bi t s o n

fe ma le fe rt il it y. S tu dy e nro ll ed 1 49 s ub je ct s

c o n s is t i ng o f 1 1 0 f e ma l e a n d 3 9 m a l e p o s t gr a d ua t e

a n d u n de r gr ad u at e u n iv e rs i ty s t ud e nt s ( a ve ra g e

a g e 2 4 . 0 1, S D = 7 . 81 ) . K n o wl e d g e s c o r e s w e r e b a s e d

o n a t a s k t h a t r e q ui r e d pa r t i ci p a nt s t o e s t im a t e t h e

e ff ec t a f ac to r w ou ld ha ve o n a g ro up of 10 0

w o m en t r y i ng t o g e t p r e g na n t . I t e m s ( n = 21 ) w e re

gr ouped accor ding to thr ee categor ies: r isk factor s,

m yt hs , an d he al th y h ab it s ( e. g . b ei ng n or ma l

w e i g ht ; 7 i t e ms ) .

R e s u l t s s h o w e d t h a t y o u n g p e o p l e w e r e

s i gn i fi c an t ly b e tt e r a t c o rr ec t ly i d en t if y in g t h e

e ff ec ts o f r is ks c om pa re d w it h n ul l ef fe c ts o f

h e a l t h y h a b i t s ( P < 0 . 0 0 1 ) o r f e r t i l i t y m y t h s

( P


7/8

F CUSFertility


7

Pe rce iv e d decre ase (-) or incre ase (+ ) in fe rt ilit y

cause d by pre se nce of fact or

-35 -25 -15 -5 5 15 25 35

Questiions

HIGH RISK FACTORS

B e in g a g e d b e t w ee n 3 5 a n d 3 9 y e a r s o l d


B e in g a g ed b e tw e en o v er 4 5 y e ar s o l d

Be i ng ove rwe i ght

S m o k i ng 1 0 - 1 9 c i g a r et t e s p e r d a y

S m o k i ng m o r e t h a n 2 0 c i g a r et t e s p e r d a y

D r i n ki n g m or e th a n 1 4 u n i t s o f a l c o h a l p e r d a y

S t r e ss t h a t a p e r s on f i n d s u n a b l e / im p o s s ib l e t o c o p e w i thE v e r h a v i n g C h l a my d i a ( a S e x u al l y T r a n s m it t e d D i s e a s e , ( S T D )

S m o k i ng ma r i j u an a m o r e t h a n 4 t i m es p e r w e e k

E a t i ng f i v e p o r t io n s o f f r u i t a n d v e g e ta b l e a d a y

N o t u r i n a ti n g a f t er s e x

L y in g d o wn f o r 1 0 m i nu t es a f te r s e x

P l a c in g a p i l lo w u n d er t h e wo m e n 's h i p s d u r i ng a n d a f t er s e x

Li vi ng i nthe countrysi de

L i v i n g i n c i t y

A d o p t in g a b a b y

MYTHS

B e i n g a g e d 2 4 o r y o u n g er


Be i ng of normal we i ght

N e v e r s m o k i n g

Ne ve r dri nk i ng al cohol

E x p e ri e n c in g a n e v e n t t h a t o n e c a n c o p e w i t h

L e s s t h a n 7 m i n u te s o f e x er c i s e p e r d a y

7 - 5 9 m i n u t e s o f e x er c i s e p er d a y

Ne ve r smok i ng mari juana

HEALTHY HABITS

S m o k in g 1 - 9 c i g a r et t e s p e r d a y

D r i n k in g l e s s t h a n 1 4 u n i t s o f al c o h ol p e r w e e k

E x p e r ie n c i ng a n e v e n t t h a t o n e f i n d s d i f f i c u lt t o c o p e w i th

S m o ki n g m a ri j ua n a l e s s t h an 4 t i me s p e r w e ek

LO W RIS K FAC TO RS

F i g 8 . P r e gn a n c y g a i n / l o ss s c o re s p e r i t e m , a cc o r di n g t o t h e c a t eg o r y i n a s u r ve y o f k n o wl e d ge a b o ut f e m al e i n f er t i l i ty i n y o u ng p e o p le .

120

100

80

60Count

40

20

030

Outcome

Negative

Posit iv e

v eg et ab le s h ad t he l ar ge st s co re w it h p os it iv e

p r e g n a n c y o u t c o m e w h i l e l i v i n g i n t h e c i t y

decr eased the number of women getting pr egnant.

A t t h e s a me t i me , p a rt i ci p an ts b e li e ve d t h at l i vi n g

i n c o u n tr y s id e a c t u al l y i n c re a s e d t h e l i k el i h o od o f

conception. Inter estingly, other than exer cising

l es s t ha n 7 m in ut es p er day, al l t he h ea lt hy

b e h a vi o rs w e r e r a t e d a s h a v in g a p o s i ti v e i n f l ue n c e

o n t h e p r e g n a n c y r a t e . A g a i n, b e i n g 2 4 y e a rs o f a g e

w a s a s s o c ia t e d w i t h a p o s i ti v e g a i n s c o r e o f 1 9 . 5 6

w hi le t he a bi li ty t o c op e w it h s tr es sf ul ev en ts

showed the smallest gain ( 1.24) .

T he s tu dy a ls o s ho we d t ha t b es id es t he m yt hs ,

p a rt i ci p an t s w r on g ly b e li e ve d t h at o n e c o ul d b em o re f er t il e b y n ot d o in g s om e th i ng u nh e al t hy

( e . g. n o t c o ns u mi n g a l co h ol ) . T h is a s su m pt i on is

f a l se s i n c e f o l lo w i n g h e a l th y l i fe s t y le s h e l p r e d uc e

t h e e x p o su r e t o r i s k r a th e r t h a n p r o m ot i n g h e a l t h.

T he se f in di ng s s ug g es t t ha t w he n fa ce d wi th a

f e r t i l i t y p r o b l e m , p e o p l e o f t e n e n g a g e i n

i n e ff e c ti v e b e h av i o rs t h a t u s u a l l y d e l ay t h e p r o ce s s

of seeking pr ofessional inter vention.

I t i s n ot s ur pr is in g t ha t p eo pl e w ho m ai nt ai n a

h e al t hy l i fe s ty l e a r e o f te n a s to n is h ed t h at t h ey

s ho uld be i nfe rti le g ive n th at t he y we re t he

healthiest in their family. Indeed, fur ther r esear ch

i s r e qu i re d t o es t ab l is h t he i m pa c t o f i nc o rr e ct

i n f or m a t io n o n pe r s o na l r i s k p e r c ep t i o n an d

d e c i s io n - ma k i n g p r o ce s s e s p e c ia l l y w h e n c o u p le s

ar e faced with difficultiesin conception.

I n t h e p r es e nt s t ud y,womans age was associatedw i th t h e l a rg e st p r e gn a nc yloss score (29.43%).P a r t icip a n t s iden t if ied t h a tf e rt i l it y de c li n ed f r om 3 5years of age. However, inW est er n c o un tr ies , t h ere h a sb e en a s t ea d y in c re a se i n t h en um b er o f w om en h a v in gc h il d re n o v er 3 5 y e ar s o f a g e .In d eed , s t ud ies o n gen er alversus personal riskp er ce pt io n s ho w t ha t i n t heprocess of decision-making,p e op l e d o n o t a p pl y ri s k t othemselves. Having access tor i g ht i n fo r ma t io n m a y on l y bet h e fi r st s t ep i n t h e pr o ce s s ofbehavior change.

Eff ect Of Bo dy Mas sIndex On In VitroFertilization Out-

c o me s I n W o me nO b e s it y h a s b e c o me a m a j o r h e al t h p r o bl e m a c r os s

th e wo rld . I n w ome n, it i s k no wn to ca us e

anovulation, subfecundity, incr eased r isk of fetal

a no ma li es a nd m i sc ar ri ag e r at es . H ow ev er, i n

women going for assisted r eproduction the effects

of obesity on egg quality, embr yo quality, clinical

p re g na n cy, l i v e b i rt h r at e s a r e c o nt ro v er si a l. I n a

r ec e nt a n al y si s , S at hy a a n d B al a su b ra m an ya m

a ss es se d t h e e ff ec t o f w o me n' s b od y m as s i nd ex

( B M I ) o n t he r e p ro d u c ti v e o u t co m e o f n o n d o n o r

I V F ) / I C S I . T h e e f f e c t s o f B M I o n t h e i r

g o na d ot ro p hi n l e ve l s ( d ay 2 L H , F SH ) , g o na d o-

tr ophin dose r equir ed for ovar ian stimulation,endometr ial thickness and oocyte/embryo quality

w e re e x am i n e d, a f t e r c o r re c t i n g f or a g e a n d p o o r

ovar ian r eser ve.

R et ro sp ec ti ve m ed ic al re co rd s o f 3 08 w om en

u n d e rg o i n g n o n do n o r I V F c y c l es w e r e e x a mi n e d .

S u b j ec t s w e r e c l a s s if i e d i n t o t h r ee g r o u ps : n o r m al2

w e ig h t ( B MI < 25 k g / m ) , o v er w ei g ht ( B MI > 25 < 3 02 2

k g /m ) an d o be se ( BM I> 30 k g/ m ) . A ll wo me n

under went contr olled ovar ian hyper stimulation

u s i n g l o n g a g o n is t p r o to c o l . T h e r e w e r e 8 8 ( 2 8 . 6% )

i n t he n o rm a l we i gh t g ro u p, 1 4 7 ( 4 7. 7 %) i n th e

o v er w ei g ht a n d 7 3 ( 2 3. 7 %) i n t h e o b es e g r ou p . A l l

t h r ee g r o u ps w e r e c o m p a r ab l e w i t h re s p e c t t o a g e ,

d u r at i o n of i n fe r t i li t y, f e ma l e a n d ma l e c a u s es o f

i nfe rt il it y. T he t hre e g ro up s w ere s im il ar w it h

re sp ec t to d ay 2 L H/ FS H l eve ls , end ome tri al

t h i c k n e s s a n d g o n a d o t r o p h i n r e q u i r e m e n t s ,

oocyte quality, fer tilization, cleavage r ates, number

o f g oo d qu a l i ty e m b r yo s a n d c l i n i ca l p re g n a n cy

r a te s . A n i n c r e as e d b o d y m a s s i n d ex i n w o m e n w a s

n o t a s s o c i a t e d w i t h a d v e r s e I V F o u t c o m e .

However , pr econceptual counselling for obese

w o me n i s n e ce s sa r y a s w e ig h t r e du c ti o n h e lp s i n

r educing pr egnancy-r elated complications.

F ig 9.Effect of B MI on pregnancy outcome3012+, 14, (total = 26), P-0.95(not

s i g n if i c a nt ) . C o r re l a t i on s t u di e s b e t we e n t h e b o d y m a s s i n d i ce s a n dthe pregnancy rates, implantation rates and fertilization rates failed

to show anysignificant association.

J H u m Re p r od S c i . 2 0 1 0; 3 ( 3 ) : 1 3 5 1 3 8.


8/8

SOLVAY PHARMA INDIALTD.

SOLVAYPHARMACEUTICALS IS NOWABBOTT

Disclaime r : T heopinion or v iews expres s ed in this profes s ional educ ation supplementare thos eof thea u t h o r s a n d d o n o t n e c e ss a r i l y r e f l e ct t h e o p i n i o ns o r re c o m me n d a t i on s o f S olv ay P h ar ma In d ia

Limite d . D o s a g es , i n d i c a ti o n s a n d m e t h o d s o f u s e o f p r o d u ct s r e f er r e d t o i n t h e s u p p le m e n t b y t h e

a u t h o rs m a y r e f l e c t t h e i r c l i ni c a l e x p e r i en c e s o r m a y b e d e r i v ed f r o m t h e p r o fe s s i o na l l i t e r a t ur e o r

other c linic al s ourc es .

F CUSFertility


Comprehensive Algorithm For The Evaluation,D i agno s is A nd T r e atm e nt Of T he I nfe r t ile ManP r e se nt i ng W i t h L o w S e m en Vo lu m e

Fig 10. Eval uati on And Tre atme nt Of Low-vol ume Ejacul ati on S/A = se me n analy sis; OAT = oligoast he not e rat ozoospe rmia; Abdo US = abdominal

u l t ra s o u nd ; C F = c y s ti c f i b ro s i s ; P E U = p o s t- e j a cu l a te u r i na l y si s ; T R U S = t r a ns r e c ta l u l t ra s o un d ; P E S A = p e r cu t a ne o u s e p i d i d ym a l s p e r m a s p i ra t i on ; I C S I =

i n t ra c y to p l a sm i c s p e rm i n j e ct i o n; R E = r e t ro g r a de e j a c ul a t io n ; T U R ED = t r a ns u r et h r al r e s ec t i o n o f t h e e j a c u l a to r y d u c ts ; S V = s e m in a l v e s i c l e; I U I =

i n t ra u t er i n e i n s e m i na t i on ; E D O = e j a c ul a t or y d u c t o b s t r u ct i o n . Zini A etal Journal of Andrology 2009; 30(3): 219-29.

Low- v olume

ejaculate

H i s to r y &

physical exam

RepeatS/A

C ollection/

abstinence

problem

Psychogenic

anorgasmia

Refer tosex therapist

S ym ptom s/signs

of hypogonadism

C o n s id e r c l o m i d

( i f f e r t i l i t y d e s i r e d )

o r T ( i f f e r t i l i ty

n o t d e s i r e d )

C F t e s ti n g+/- abdo US

PESA +

IVF/IC SI

Tlevel

A b s en c e o f

v as def erensAzoospermia

T R U S a n dPEU

MRI if

inconclusiv e

EDO

suspected

PEU+

(RE)

PESA +

IVF/IC SI

T U R E D + / -

SV aspirationP seudoephedr ine/

imipr amine

Sperm retriev a l +

IU I or IVF/IC SI

PEU

Tria l of

ps eudoephedrine/

imipra mine if RE

s us pect ed

T R US i f

PEU normal

Consider T UR E D if

par tial E DO

suspected

Normal S/A

or OAT

Table 5. Etiology Of Low Semen V olume Table 6. The Patient s H istory

E tiology Features

Artifact S h o rt a b s t in e n ce p e r i od I n c om p l et e c o l l ec t i o n

Psychogenic Anorgasmia

Pathologic R etrograde ej aculation

S tructural (damage to bladder neck)

F unctional (nerve and neurotransmitter )

F ailure of emission (nerve)

E j a c ul a t o ry d u c t o b s t r u c ti o n

C o n g en i t al ( s e m i na l v e s i c l e s o r v a s a n o ma l i e s )

Acquired

A g e n es i s o r a p l a s i a o f t h e s e m i na l v e s i c le s ,

prostate

S eminal vesicle disease (infection, cysts, ADPKD)

H ypogonadism

I s T h i s A n A r t i f a c t ?

Que st ion t he pat ie nt about t he abst ine nce pe riod, colle ct ion me t hods

use d (mast urbation, SCD, e t c) and comple t e ne ss of colle ct ion. Asking

whe t he r t he pat ie nt fe e ls t hat t he v olume of e jaculat e produce d during

spe cime n colle ct ion is similar t o t he v olume produce d during normal

se xual act iv it y may he lp t o ide nt ify pat ie nt s whose se me n v olume is low

only during spe cime n colle ct ion.

I s T h e r e A P s y c ho g e n ic C a u s e ?

T h e h i s to r y s h o ul d c a re f u l ly a s s es s o v er a l l s e x ua l f un c t i on ( l i bi d o ,

e r e c ti o n , o r g as m , e j a c u la t i on ) t o i d e n t i f y p o t en t i a l c o nt r i b ut i n g

p s y ch o g en i c c o n d it i o ns . O n e i m p or t a nt f a c to r t o d e t er m i n e i s i f th e

pat ie nt act ually has an orgasm.

I s T h e r e A P a t h o l o g i c C a u s e ?

T he p at ho lo gi c c au se s i nc lu de r et ro gr ad e e ja cu la ti on , f ai lu re o f

e m i s si o n an d a lt e ra t i on s i n t he W o lf f i a n d u c t s t r u ct u r es ( s e mi n a l

v e sicle s,e jaculat ory duct s and v asde fe re ns).

Is The re Evi de nce ForRe trograde Ejacul ati onOr Fai l ure Of Emi ssi on?

A hist ory of cloudy urine following e jaculat ion is oft e n associat e d wit h

R E, and t hisshould be e licit e d. Hist ory of surge ry, t raumaor dise ase t hat

m i gh t a f fe c t t h e s ym p at h et i c n e rv es o r t h e b l ad d er n e c k s h ou l d b e

e l ic i te d . A f i nd i ng o f a bs e nt e j ac u la te m us t p ro m pt q u es t io n in g

re garding spinal or ne urologic dise ase , and pre v ious prost ate surge ry.

O t h e r s y m p t o m s o f n e u r o l o g i c d y s f u n c t i o n ( l e g w e a k n e s s ,

bladde r/bowel dy sfunct ion) should also be sought .

Is The re Evi de nce Of AnEDo OrAbse nce Of The Wol f f i anDucts?

A h i s t o ry o f p r o s ta t i c s u r ge r y o r i n f e ct i o n, a n d s y mp t o ms s u c h a s p a i n

wit h e jaculat ion or he mat ospe rmia,can be associat e d wit h EDO. W hile

m os t p at ie nt s w it h CB AV D d o no t h av e c li ni ca l CF, 24 h is to ry o f

r e sp i ra to r y i l ln e ss /s y mp to m s, a s w e ll a s a f a mi l y h i st or y o f C F a n d

infe rt ilit y, is use ful.

Are The re SymptomsOf Hypogonadi sm?

L o w t e s to s t er o n e l e v el s c a n b e a s s oc i a te d w i t h v a r io u s s y mp t o ms o f

h y p og o n a di s m , a n d th e s e s h o ul d b e e l i c it e d (l o w en e r g y, m o od

change s, we akne ss, ED, de cre ase d libido).

E j a c u la t e v o l u m e i s a n i m p o r t an t

c o m p on e n t o f t h e s e me n a n a l ys i s a n d

e v a l ua t i o n o f t h e i n f er t i l e m a n, b u t i s o f t e n

overlooked if ot her abnormalit ies are also

p r e s en t o n s e m e n a n a l y si s ( e .g . , lo w s p er m

c o u n t) . A c a r e f ul h i s t o r y a nd p h y s i ca l

e x a m i na t i o n c a n h e l p i d e nt i f y m o s t c a u s e s,

a n d c a n h e l p g ui d e s u bs e q u en t

i n v e st i g a t i on s . T r ea t m e n t t o c o r r ec t t h e

p r o b le m m a y b e p o s s ib l e i n s o m e p a t i en t s

a n d , i n o t h e rs , i d e n t i fi c a t i o n o f i m p o r t a nt

medical condit ions may occur.

SCD=s ilas tic s eminal c ollec tion dev ic e; R E =retrogradeej ac ulation; E DO= ej ac ulatory duc t

obs truc tion; CB A VD=Congenital unilateral abs enc e of the v as deferens ; CB A VD=c ongenital

b i l a t e ra l a b s e n ce o f t h e v a s d e f er e n s ; C F = c y st i c f i b r o s i s ; E D = e r e c ti l e d y s f u n c ti o n .

R e fe r e n ce s : 1 . W H O. W H O L a b o ra t or y M a n ua l fo r th e E x a mi n a t io n a n d

P r o c es s i n g of H u m an S e m en . C a m br i d g e: W H O P r e s s; 2 0 1 0 . 2. G o me z E ,

B uckingham DW, B rindle J, Lanzafame F, Irv ine DS, Ait ke n R J: De v e lopme nt of

an image analy sis sy st e m t o monit or t he re t e nt ion of re sidual cy t oplasm by

human spe rmat ozoa: corre lat ion wit h bioche mical marke rs of t he

c y t op l a s mi c s p a c e, o x i da t i ve s t r es s , a n d s p e rm f u n c ti o n . J A n d ro l . 1 9 9 6 ; 1 7 :

276-87. 3. Ait ke n R J, W e st K M: Analy sisof t he re lat ionship be t we e n re act iv e

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