AIH & AID

Historically, artificial insemination was the first technique applied to modify human reproduction almost 100 years ago. Here are two types of artificial insemination - Artificial Insemination by Husband (AIH) and Artificial Insemination by Donor (AID). Both are now widely used.

AIH

This technique is used for some couples who cannot otherwise conceive and, if for example, it is felt that the chances of pregnancy would be increased by concentrating the husband's semen or by inserting it directly into the uterus. Other reasons for AIH occur:

• When the husband cannot ejaculate but instead passes his semen into the bladder (retrograde ejaculation).
• For some couples where the husband is severely physically handicapped and AIH offers the only possibility for him to father a child.
• If a man is to undergo surgery or radiotherapy that may result in sterility, his semen may be stored by deep freezing and used at a late date for AIH . More recently semen has been similarly stored by some men before they undergo vasectomy as a means of permanent contraception.
• Less commonly, AIH may be used to overcome a particular type of female infertility where antibodies which kill the sperm are found in the cervical mucus. In such cases AIH may be successful when the semen is injected into the uterus.

AID

Artificial Insemination by Donor is used when investigations have shown the husband to be infertile or to have significantly reduced fertility. For AID, semen is donated by another man. AID has also been used when a fertile husband stiffens from, or may be the carrier of, a serious hereditary condition for example, Huntington's Chorea; and the couple decide that they will not risk passing on the husband's condition to the next generation.

Both AIH and AID may be carried out using fresh or frozen semen. There have been many successful pregnancies using frozen semen , although the proportion of successful inseminations is not as high as if is with fresh semen. For AIH and AID the semen may either be placed in the upper portion of the vagina next to the cervix or injected into the uterus through a fine catheter.

Egg Extraction/Egg Donation

What is Egg Donation?

Egg donation is the process in which a woman gives her eggs to other people so they can have children of their own. Most of the time, egg recipients are infertile couples who cannot have children without medical help. Sometimes egg recipients are single women or men, and sometimes egg recipients combine donated eggs with the use of a gestational surrogate, a woman who agrees to get pregnant and have a baby for the intended parents. Fertility clinics and egg donor programs usually manage the egg donation process from start to finish.

Indication

A need for egg donation may arise for a number of reasons. Infertile couples may resort to acquiring eggs through egg donation when the female partner cannot have genetic children because she may not have eggs that can generate a viable pregnancy. This situation is often, but not always based on advanced reproductive age. Early onset of menopause which can occur in women as early as their 30’s can require a woman to use donor eggs to grow her family. Some women are born without ovaries or other reproductive organs. Sometimes a woman's reproductive organs have been damaged due to disease or circumstances required her to have them surgically removed. Another indication would be a genetic disorder on part of the woman that can be circumvented by using eggs from another person. Many women have none of these issues, but continue to be unsuccessful using their own eggs.

During the Procedure

Egg donation involves taking several drugs and undergoing a medical procedure to remove the donor's eggs.

The first phase of egg donation usually involves taking drugs to synchronize the donor's menstrual cycle with the intended mother's cycle.

Once synchronized, the egg donor begins taking drugs to stimulate her ovaries to make extra eggs.

The final phase, called egg harvesting, involves surgically removing the eggs from the donor's ovaries.

During the egg harvesting phase, the donor is put under light anaesthesia called twilight so she feels no pain, and doctors place a small needle into her vagina to remove the eggs in a process called egg harvesting.

The entire process, from synchronizing her cycle to egg harvesting is called an egg donation cycle.

Results

Nationwide, egg donor cycles have a success rate of upwards of 60%. When a "fresh cycle" is followed by a "frozen cycle", the success rate with donor eggs goes up to approximately 80%. With egg donation, women who are past their reproductive years or menopause can become pregnant.

The oldest woman thus to give birth is Adriana Iliescu, age 66. Babies born after egg donation are not genetically related to the recipient.

Risks

Egg donation carries risks for both donor and recipient, although it must be made clear that the procedure for the donor, and the medication given, is basically the same as the medication given for any IVF procedure (with or without a donor).

The egg donor may suffer complications from the procedure, such as bleeding from the oocyte recovery procedure and reaction to the hormones used to induce hyperovulation (producing more than one egg), including ovarian hyperstimulation syndrome (OHSS) and, rarely, liver failure.The recipient has the risk of contracting a transmittable disease.

Generally legal documents are signed renounce rights of ownership and custody on part of the donor, so that there will be no claims on part of the donor concerning the offspring. Most IVF doctors will not proceed with administering medication to any donor until these documents are in place and a legal "clearance letter" -- confirming this understanding—is provided to the doctor.

Frozen Embryo Treatment & Replacement(FET)

About Frozen Embryo Transfer

FET is a treatment that involves implanting embryos that were retrieved from the patient during a previous IVF cycle and held safely in a frozen state.

When frozen embryos are available from a previous IVF treatment, subsequent implantations can be accomplished at a savings. The savings reflects the fact that IVF cycles with cryopreserved and thawed embryos are less involved and thus less costly than generating fresh embryos with a new IVF cycle.

Advantages of FET

For a similar reason, some patients find that preparing for a frozen embryo transfer involves less medication and may be easier than an IVF cycle. However FET treatments still require patients to take medications (hormones) to build the uterine lining to prepare to receive the embryos. (For more about specific treatment details, see CHR’s Patient Education primer for FET treatments that also includes details of recommended medications.)

FET Procedures

The duration of FET treatments vary by patient; in general, most patients fall into the three- to four-week range. The number of embryos transferred depends on several factors: patient age, embryo quality, and the number of embryos available after the thawing process. Again, speaking in general terms, our fertility experts prefer to thaw one more embryo than was transferred in the fresh cycle.

Embryos are thawed individually until there are enough available to complete the transfer process as described above. For example, if a patient needs three embryos transferred, initially three will be thawed, and depending on the survival rate, more will be thawed until three viable embryos are obtained. Embryos will be allowed to grow out one or two days after thaw.

Embryo Cryopreservation

Embryos are grown for several days before they are cryopreserved for later use, however may be frozen at any point after fertilization. Indeed, there is general consensus that cryopreservation (freezing) is possible at any stage of embryo development. However while embryos frozen immediately after fertilization, demonstrate capacity to survive the thawing process, the embryos that prove most successful for achieving implantation are allowed to develop in the lab for a day or two prior to the cryopreservation process.

It is difficult to know how many thawed embryos will reach the stage of development desired by the physician for transfer. Therefore, a higher number of embryos must be thawed. If a large number of embryos does reach that stage of development, then there is a dilemma. Either a larger number of embryos must be transferred (which increases the risk of multiple pregnancy) or the extra embryos must be discarded or refrozen.

Frequently Asked Questions about FET

Often we are asked if embryos can be re-frozen. The answer is yes. However this is not an ideal scenario, as each thawing and freezing cycle includes the risk for damage – albeit a minor one. Though, the more cycles an embryo is subjected to, the more often it is exposed to risk.

Embryos can remain frozen indefinitely. CHR maintains a state-of-the-art storage facility for which there are annual fees. In general, couples use their frozen embryos within a few years, though we have had couples return after as long as ten years. CHR regularly publishes the latest data for success rates related to FET.

Hysterosalpingography(HSG)

Overview

Hysterosalpingography (HSG) is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. It entails the injection of a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification. A normal result shows the filling of the uterine cavity and the bilateral filling of the fallopian tube with the injection material. To demonstrate tubal rupture spillage of the material into the peritoneal cavity needs to be observed.

Procedure

The procedure involves ionizating x-rays. It should be done in the follicular phase of the cycle.[1] It is contraindicated in pregnancy. It is useful to diagnose uterine malformations, Asherman's syndrome, tubal occlusion and used extensively in the work-up of infertilewomen. It has been claimed that pregnancy rates are increased in a cycle when an HSG has been performed. Using catheters, an interventional radiologist can open tubes that are proximally occluded.

The test is usually done with radiographic contrast medium (dye) injected into the uterine cavity through the vagina and cervix. If the fallopian tubes are open the contrast medium will fill the tubes and spill out into the abdominal cavity. It can be determined whether the fallopian tubes are open or blocked and whether the blockage is located at the junction of the tube and the uterus (proximal) or whether it is at the end of the fallopian tube (distal).

Complications

Complications of the procedure include infection, allergic reactions to the materials used, intravasation of the material, and, if oil-based material is used, embolisation. Air can also be accidentally instilled in to the uterine cavity by the operator, thus limiting the exam due to iatrogenically induced filling defects. This can be overcome by administering the Tenzer Tilt which will demonstrate movement of the air bubbles to the non-dependant portion of the uterine cavity.

Hysteroscopic Surgery For Fibroids/Polyps/Septum

Overview

Hysteroscopy is a minimally-invasive surgical procedure that can be used to remove certain types of fibroids, Polyps and Septum without difficulty. The surgery involves placing a small telescope instrument within the uterine cavity and examining the cavity.

Procedures

Hysteroscopy has been done in the hospital, surigal centers and the office. It is best done when the endometrium is relatively thin, that is after a menstruation. Typically hysteroscopic intervention is done under general endotracheal anesthesia or Monitored Anesthesia Care (MAC), but a short diagnostic procedure can be performed with just aparacervical block using the Lidocaine injection in the upper part of the cervix. The patient is in a lithotomy position.

After cervical dilation, the hysteroscope with its sheath is guided into the uterine cavity, the cavity insufflated, and an inspection is performed. If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Hysteroscopy has also been used to apply the Nd:YAG laser treatment to the inside of the uterus.

When fluids are used to distend the cavity, care should be taken to record its use (inflow and outflow) to prevent fluid overload and intoxication of the patient.

Indications

Hysteroscopy is useful in a number of uterine conditions:

• Asherman's syndrome (i.e. intrauterine adhesions). Hysteroscopic adhesiolysis is the technique of lysing adhesions in the uterus using either microscissors (recommended) or thermal energy modalities. Hysteroscopy can be used in conjunction with laparascopy or other methods to reduce the risk of perforation during the procedure.
• Endometrial polyp Polypectomy
• Gynecologic bleeding
• Endometrial ablation (Some newer systems specifically developed for endometrial ablation such as the Novasure do not require hysteroscopy)
• Myomectomy for uterine fibroids
• Congenital Uterine malformations (also known as Mullerian malformations). Eg.septum
• Evacuation of retained products of conception in selected cases
• Removal of embedded IUDs

The use of hysteroscopy in endometrial cancer is not established as there is concern that cancer cells could be spread into the peritoneal cavity.

Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result inAsherman's syndrome.

Hysteroscopy allows access to the utero-tubal junction for entry into the fallopian tube; this is useful for tubal occlusion procedures for sterilization and for falloposcopy.

Complications

A possible problem is uterine perforation when either the hysteroscope itself or one of its operative instruments breaches the wall of the uterus. This can lead to bleeding and damage to other organs. If other organs such as bowel are injured during a perforation, the resulting peritonitis can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media can be encountered. The use of insufflation media can lead to serious and even fatal complications due to embolism or fluid overload with electrolyte imbalances.

The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less than 1% of cases.

IVF(ICSI)

About In vitro fertilization (IVF)

In vitro fertilization (IVF) involves manually fertilizing a human egg with sperm outside of the womb. The technique is most commonly implemented when other means of fertility treatment have been unsuccessful.

IVF procedures may be undertaken in cases of both female and male infertility. Intracytoplasmic sperm injection (ICSI) to inject the sperm cell into the egg may be required in cases of male infertility where sperm numbers are low or poor sperm quality prevents the sperm from successfully penetrating the egg. In cases of ICSI, donor sperm may be required to fertilize the egg.

IVF Procedure

To facilitate in vitro fertilization, ova are removed from the ovaries of the female patient, and combined with male sperm in a laboratory dish. When an egg (zygote) has been successfully fertilized and cell division has commenced, an embryo transfer is performed to transplant the egg into the uterus of the patient.

Prior to the cultivation of ova, ovulation induction is undertaken a few days after the beginning of the menstrual cycle to increase the chance of multiple eggs being cultivated. As not all retrieved eggs will fertilize, multiple eggs are required. The treatment cycle for ovulation induction involves a course of fertility medication to encourage follicular growth in the ovaries. By injecting human chorionic gonadotropins, the doctor can initiate ovulation when follicular maturation is sufficient, and retrieval of the eggs from the ovary can be undertaken.

Under a local anesthetic, the patient will have her eggs cultivated via follicular aspiration, using ultrasound to direct the harvesting needle into the pelvic cavity, piercing the wall of the vagina to access the ovaries. Between 10 and 30 eggs will usually be retrieved.

Embryo transfer will usually be performed two or three days after the eggs have been retrieved. Guided by ultrasound imaging, a speculum is inserted into the vagina and a number of fertilized eggs are transferred into the womb via a catheter.

IVF Risks

There are some risks involved in undertaking in vitro fertilization as any procedure involving anesthesia carries a degree of risk. The ovaries may also become swollen and sore as a result of stimulation, however this is not common. Patients suffering from ovarian hyper stimulation syndrome can expect to feel nauseous, bloated and lose their appetite. With a number of embryos being transferred into the womb, multiple-birth pregnancies are also common after in vitro fertilization. Multiple births increase the risk of premature delivery, obstetrical complications, loss of pregnancy, and neo-natal morbidity.

Laser Assisted Hatching

Overview of Laser Assisted Hatching

A covering layer, or ‘shell’ surrounds embryos or blastocysts called the Zona Pellucida (ZP). The zona has an important role in fertilisation as it allows only one sperm to penetrate the zona and enter the egg to achieve fertilisation. It also acts to prevent premature implantation in the Fallopian tube and may help prevent the early embryo from being attacked by cells of the immune system.

The embryos have to “hatch” or break out of the zona in order to embed into the endometrium lining the uterine cavity. This occurs about four to five days after embryo transfer when the embryo is at the blastocyst stage. Naturally this takes place by expanding/contracting of the zona until it distorts, allowing the blastocyst to “hatch”.

Methods of Assisted Hatching

Chemical

This involves chemicals (acid tyrodes) used to produce a weakened area of the zona. The chemical is applied through a microtool, manipulated by an embryologist.

Laser

The zona is drilled by the microlaser system called Fertilase. It creates a clean-cut precise incision in the zona.

Who is Suitable for Laser Assisted Hatching ?

Those patients who have IVF or ICSI who are over 37 years Patients having FER Patients who have had a previous failed IVF or ICSI treatment cycle Patients undergoing IVF/ICSI for the first time, who are considered poor esponders because they have required a high dose of gonadotrophins for poor varian response Patients who in an earlier IVF cycle have had a low fertilisation rate, for example, less than one third of the embryos achieving fertilsation Patients with three or fewer embryos Patients who request laser assisted hatching and are fully informed of its use and function.

Laser assisted hatching – a photo essay

It’s a sad fact that IVF technology today is still not perfect. Only one of ten embryos we transfer in the uterus implants successfully in the endometrium to become a baby. Why is the embryo implantation rate only 10 ? Some doctors believe this is because the surrounding shell of the embryo (called the zona pellucida) hardens when it is cultured in the laboratory.

Laparoroscopic Surgery For Endometriosis (PCO)

Overview

Laparoscopy is the most common procedure used to diagnose and remove mild to moderate endometriosis. Endometriosis is the growth of endometrial tissue-which normally lines the uterus-in other parts of the body. Instead of using a large abdominal incision, the surgeon inserts a lighted viewing instrument called a laparoscope through a small incision to remove any visible endometriosis implants and scar tissue that may be causing pain or infertility.

Your doctor may recommend a laparoscopy to:

• View the internal organs to look for signs of endometriosis and other possible problems. This is the only way that endometriosis can be diagnosed with certainty.
• Remove any visible endometriosis implants and scar tissue that may be causing pain or infertility. If an endometriosis cyst is found growing on an ovary (endometrioma), it is likely to be removed.

Precaution

You will be advised not to eat or drink for at least 8 hours before a laparoscopy. Laparoscopy is usually done under general anesthesia, although you can stay awake if you have local or spinal anesthesia. A gynecologist or surgeon performs the procedure.

Procedure

For a laparoscopy, the abdomen is inflated with gas (carbon dioxide or nitrous oxide). The gas, which is injected with a needle, pushes the abdominal wall away from the organs so that the surgeon can see them clearly. The surgeon then inserts a laparoscope through a small incision and examines the internal organs. Additional incisions may be used to insert instruments to move internal organs and structures for better viewing. The procedure usually takes 30 to 45 minutes.

If endometriosis or scar tissue needs to be removed, your surgeon may either cut and remove tissue (excision) or destroy it with a laser beam or electric current (electrocautery).

After the procedure, the surgeon closes the abdominal incisions with a few stitches. Usually there is little or no scarring.

Laparoscopy is usually done at an outpatient facility. Sometimes a surgery requires a hospital stay of 1 day. You will likely be able to return to your normal activities in 1 week, or maybe longer.

Ovulation Induction

Introduction

Ovulatory disorders can be identified in the woman in 18 to 25 percent of couples presenting with infertility. Most of these women have oligomenorrhea, arbitrarily defined as menstruation that occurs at intervals of 35 days to six months. While ovulation may occasionally occur, spontaneous conception is unlikely.

Induction of ovulation in these women is aimed at inducing monofollicular development, subsequent ovulation and ultimately pregnancy and birth of a healthy newborn. Induction of ovulation should be differentiated from stimulation of multiple follicle development in ovulatory women, as is done with assisted conception techniques. The method of ovulation induction selected by the clinician should be based upon the underlying cause of anovulation and the efficacy, costs, risks, and potential complications associated with each method as they apply to the individual woman.

Ovulation induction with clomiphene citrate

Clomiphene citrate has been the most widely used treatment for fertility enhancement for the past 40 years. Clomiphene was a revolutionary advance in reproductive medicine and quickly became popular for induction of ovulation because of its ease of administration and minimal side effects. Ironically, it was initially synthesized as a synthetic estrogen for possible use as a contraceptive. The pharmacology, indications, and administration of clomiphene citrate will be reviewed here. Other drugs for induction of ovulation are discussed elsewhere.

Ovulation induction with aromatase inhibitors

Women with anovulatory infertility can be categorized based on their gonadotropin status as defined by the World Health Organization (WHO): WHO I refers to hypogonadotropic hypogonadism, WHO II refers to eugonadotropic, and WHO III refers to hypergonadotropic hypogonadism. Women with WHO II anovulatory infertility typically have normal follicular phase estrogen levels and withdrawal uterine bleeding after a progestin challenge. Clomiphene citrate (CC) is the most commonly used pharmacologic agent to induce ovulation in these women, but some women fail to conceive with this therapy. During the past decade both insulin sensitizers, such as metformin, and aromatase inhibitors have been used for ovulation induction in women who fail to conceive with CC. Aromatase inhibitors are a class of drugs that block estrogen biosynthesis, thereby reducing negative estrogenic feedback at the pituitary.

This topic review discusses studies on the experimental use of aromatase inhibitors for ovulation induction in women with WHO II anovulatory infertility. However, at this time, use of aromatase inhibitors for ovulation induction in premenopausal women is controversial due to the possibility of fetal toxicity and fetal malformations raised by one abstract. However, two subsequent publications have shown no evidence of fetal malformations with the aromatase inhibitor letrozole and no difference in birthweight compared to spontaneous conceptions.

The use of clomiphene, metformin, and gonadotropins is reviewed separately.

Selective Fetocide

Overview

Surrogacy is an arrangement where a woman agrees to become pregnant and deliver a child for a contracted party. She may be the child's genetic mother (the more traditional form of surrogacy), or she may, as a 'carrier', carry the pregnancy to delivery after having been implanted with an embryo, the latter being an illegal medical procedure in some jurisdictions, for example, Costa Rica, and sometimes highly regulated in other countries.

Procedure

Egg Production

The IVF cycle is performed on the donor (or intended mother) using one or more fertility drugs to increase the number of eggs produced. Multiple follicles (the part of the ovary that contains the eggs) are needed to increase the number of eggs retrieved, thereby increasing the number of embryos developed and hence the chances for conception.

The process begins with the synchronization of both donor and carrier's menstrual cycles and may require using the medication Lupron. The donor will also be taking daily injections of Fertinex, Follistim, or Gonal-f to encourage this multi-follicular development. Follicular maturation is evaluated by daily blood levels and ultrasound. At a time determined by the physician, an injection of human Chorionic Gonadatropin (hCG) is given to bring the eggs to final maturity. Approximately 35 hours after this injection, the donor will undergo the egg retrieval that is done in the clinic on an outpatient basis.

Preparing The Uterus For Implantation

The carrier will be hormonally synchronized to the donor using Estrogen and Progesterone. The carrier's endometrial receptivity will be evaluated similarly using blood tests and ultrasounds. In addition, the angle and depth of the cervix and uterus will be determined using a catheter identical to the one that will be used for the actual embryo transfer.

Egg Retrieval

Aspiration of follicles for eggs is performed through an ultrasound guided approach under IV sedation. The retrieval consists of aspirating the ovarian follicles and identifying the eggs in the follicular fluid under a microscope. The eggs are then held in an incubator until the time of insemination in the laboratory. On this day, the sperm donor (or intended father) will be expected to produce a sperm sample that will be used to inseminate the eggs.

Embryo Transfer

The embryo transfer may be done 3-5 days after the retrieval. The physician performing the transfer will discuss with the carrier and the intended parents the status of the embryos and the number to be replaced. The number of embryos transferred varies according to their quantity and quality. At this point, there may be an opportunity to cryopreserve any remaining embryos that continue to develop normally, for possible transfer in future cycles.

The embryo transfer is done under sterile conditions, in a reclining position with legs up, as if having a pap smear. The transfer is easy and virtually pain free in most cases. Following the transfer the carrier is required to lie flat for a half hour and afterwards may return home to relax for the remainder of the day.

Testing for Pregnancy

Approximately 2 weeks after the transfer, the carrier will take a blood pregnancy test. If it is positive, the clinic will generally monitor you for several more weeks before discharging you to your own obstetrician.

TCM For Fertility

Overview

In reviewing TCM literature, the term "infertility" was seen as early as the 2nd century BC. Chapter 60 of the classic Suwen (The Book of Plain Questions) states, "If the Governor Vessel is damaged, the woman will be infertile." Thereafter, relevant knowledge was shaped and consolidated by accomplished medical practitioners of different medical approaches, and their findings were gathered and published in various medical works. Some notable theories for its causes are listed below:

In a woman:

• Regulating the menstrual cycle.
• Relieving hormonal disturbances.
• Enhancing immune compatibilities between sexual partners.
• Amending tubal obstructions.
• Releasing stress-related dysfunction.

In the man:

• Increasing sperm count and motility.
• Improving ejaculatory and erectile conditions.

While Western medicine targets certain situations specifically, benefits of a TCM approach are in addressing all aspects of infertility causes and focusing on eliminating their ultimate pathological outcomes. TCM remedies have positive effects on general physical health and emotional well-being, which are especially helpful for those who need to turn back the clock of time and rejuvenate their fertility.

TCM Causes of Female Infertility

According to the TCM physiology, normal conception happens as follows:

On a monthly basis, a woman's essence (acquired and congenital) will gradually be enriched to a particular level by the kidneys, the kidneys will then produce a substance called tian-gui. Under the action of this substance, the Conception Vessel and Thoroughfare Vessel become exuberant and flushed with abundant qi and blood. When the excessive qi and blood in the vessels become overflowing, they drift into the uterus and turn into menses. This signals the woman is ready to conceive. When an egg from her ovary is fertilized with a sperm, pregnancy results. From a TCM understanding, this fertilization process involves the combination of congenital essences from both sexes, which are transmitted into the embryo in the uterus. Thereafter, the uterus supplies the nutrients for the growth and development of the fetus until childbirth.

Basically, TCM understands that the location of infertility begins in the uterus, and its development is related to the liver, spleen and especially kidney function. The kidneys control our congenital essence, which is our inherited self; the spleen provides an acquired foundation based on our nutrition, and, the liver stores blood and regulates qi (vital energy) movements. Normal functioning in these organs ensures a proper material basis for conception.

The final pathological development is summarized as follows:

1. Exhaustion of kidney-qi

Congenital deficiency or indulging in excessive sex usually damages kidney-qi. When this happens, there will be inadequate essence to produce tian-gui regularly, which leads to a deficiency in the Conception and Thoroughfare Vessels. The uterus becomes malnourished and cannot collect sperm and promote conception.

2. Insufficiency in blood

Blood is the material basis for conception. When an individual has a constitutional weakness or dysfunction in the spleen and stomach, blood production is affected. As a result, the extra meridians become vacuous (deficient and/or dysfunctional) and the uterus is not nourished making it impossible for a woman to conceive.

3. Stagnation of liver-qi

TCM believes normal emotional health depends on a smooth flow of qi (vital energy) and blood, which are mainly regulated by the liver. In cases of emotional disturbances, especially frustration and anger, the liver's regulating functions are impaired and a condition termed "stagnation of liver-qi" results. When internal qi and blood flow become disharmonious, the extra meridians are affected and the menses will not come regularly resulting in difficulty conceiving.

4. Obstruction by phlegm and dampness

Improper dietary habits or yang deficiency in the kidney and spleen lead to dysfunction in water metabolism and cause excessive phlegm and dampness evils to accumulate. When the body has too many phlegm and dampness evils, qi movement is disturbed and meridians around the uterus are obstructed resulting in irregular menses and conception problems.

5. Retention of stagnated blood in the interior

Damage during a previous delivery, exogenous evils invasion, long term illness and qi deficiency are factors that affect the blood flow and lead to stasis. If stagnated blood remains in the uterus and impairs the Conception and Thoroughfare Vessels, a woman's menstruation can become irregular and conception may be difficult.

6. Accumulation of damp-heat

Improper sanitary habits in the perineum region may allow dampness and heat evils to invade the uterus. When the extra meridians become obstructed, blood and qi supplies are interrupted. There will be difficulty in combining the congenital essences from both sexes to transmit into the embryo in the uterus.

TCM Treatment Methods for Female Infertility

The Chinese place a large emphasis on the family so they take every possible measure to continue their progeny. Fertility management of both men and women has been well developed in TCM. Hundreds of herbs have been identified and used extensively along with acupuncture, massage, diet and lifestyle modification for treating this condition. They have become increasingly popular in Western countries as more and more couples find they work. In fact, TCM fertility techniques are relatively non-invasive and can sometimes offer a better success rate for less cost. They are significant for non-organic incidences of infertility where the problem may be functional and not structural.

Outlined here are some treatment options that can be employed singly or in conjunction with one another.

Chinese Herbal Therapy

Acupuncture and Moxibustion Therapies

Massage Therapy

Chinese Folk Therapies

Testicular Sperm Extraction

Overview

The best treatment choice for the man with azoospermia ( zero sperm count) is testicular sperm extraction ( TESE) with ICSI ( intracytoplasmic sperm injection) in which testicular sperm are injected into the eggs in order to fertilise them. Here is a photo-essay which describes the painless technique we use in our clinic for extracting testicular sperm in azoospermic men when they need TESA-ICSI ( testicular sperm aspiration with intracytoplasmic sperm injection.)

Most men are understandably scared of allowing a surgeon near their testes - and even a testis biopsy can be a very painful experience. This revolutionary technique allows us to extract testicular sperm, even from men with tiny testes, without having to make a skin incision!

Not only is this much easier for the patient, it also much less traumatic, which means it can be repeated if needed. It is usually done under local anesthesia. We can sample multiple areas (needle mcirobiopsies) of the testes with this method.

Procedure

• The testis is stabilised by stretching the skin tightly over it.
• A "butterfly" needle is inserted into the testes through the taut skin. Negative pressure is applied using a 10 ml syringe.
• Multiple passes are made into the testes with the needle, allowing us to apply significant negative pressure to "suck" out the testicular tubules.
• The needle is withdrawn, and a strand of testicular tissue follows the needle on its way out. This is pulled out gradually from the testis.
• The strand of testicular tissue is grasped with a fine forceps.
• This strand is pulled out gradually.
• The tissue is then collected in culture medium. We can get a surprisingly large chunk, with not a drop of blood, in a few seconds.
• This tissue is then examined under the stereozoom microscope in the IVF lab, and the tissue processed and analysed for the presence of testicular sperm.

Tubal Ligation

Overview

Tubal ligation (informally known as getting one's "tubes tied") is a form of female sterilization, in which the fallopian tubes are severed and sealed or "pinched shut", in order to prevent fertilization.

Procedure

There are mainly four occlusion methods for tubal ligation, typically carried out on the isthmic portion of the fallopian tube, that is, the thin portion of the tube closest to the uterus.

• Partial salpingectomy, being the most common occlusion method. The fallopian tubes are cut and realigned by suture in a way not allowing free passage. The Pomeroy technique, is a widely used version of partial salpingectomy, involving tying a small loop of the tube by suture and cutting off the top segment of the loop. It can easily be applied via laparoscopy. Partial salpingectomy is considered safe, effective and easy to learn. It does not require any special equipment to perform; it can be done with only scissors and suture. Partial salpingectomy is not generally used with laparoscopy.
• Clips: Clips clamp the tubes and inhibits blood flow to the portion, causing a small amount of scarring or fibrosis, in turn, preventing fertilization. The most commonly used clips are the Filshie clip, made of titanium, and the Wolf clip (or "Hulka clip"), made of plastic. Clips are simple to insert, but require a special tool to put in place.
• Silicone rings: Tubal rings, similarly to clips, block the tubes mechanically. It encircles a small loop of the fallopian tube, blocking blood supply to that small loop, resulting in scarring that blocks passage of the sperm or egg. A commonly used type of ring is the Yoon Ring, made of silicone.
• Electrocoagulation or cauterization: Electric current coagulates or burns a small portion of each fallopian tube. It mostly uses bipolar coagulation, where electric current enters and leaves through two ends of a forceps applied to the tubes. Bipolar coagulation is safer, but slightly less effective than unipolar coagulation, which involves the current leaving through an electrode placed under the thigh. It is usually done via laparoscopy.

Effectiveness

A tubal ligation is approximately 99% effective in the first year following the procedure. In the following years the effectiveness may be reduced slightly since the fallopian tubes can, in some cases, reform or reconnect which can cause unwanted pregnancy. Method failure is difficult to detect, except by subsequent pregnancy, unlike with vasectomy or IUD. If pregnancy does occur it carries a 33% chance of being an ectopic pregnancy.

Prevalence

Worldwide, female sterilization is used by 33% of married women using contraception, making it the most common contraceptive method. As of June 2010, there is a recent decline of tubal ligation procedures in the United States after two decades of stable rates, possibly explained by an improved access to a wide range of highly effective reversible contraceptives.

Tubal Ligation Reversal

For many women, having a tubal ligation (also known as female sterilization or getting your "tubes tied") is a permanent way to manage your family size. Usually done once a woman feels that her family is complete, as much as 25% of women who have had the procedure end up changing their minds. If you have had your tubes tied but now regret your decision, you may want to consider having a tubal ligation reversal.

Tubal Reversal Surgery

Just as a tubal ligation is considered to be major surgery, so is a tubal reversal. Normally, this procedure takes two to three hours and is done under general anesthetic. In order to make your fallopian tubes functional again, the doctor will unclamp; reattach; remove any devices that may be blocking your tubes or place an implant into your fallopian tubes. This type of surgery does require a hospital stay of at least one night but you may need to remain in the hospital for as much as five days after the surgery. Once you leave the hospital, you can expect to completely recover from the procedure over the course of the next four to six weeks.

As with any type of major surgery, complications are always a possibility. Although they are rare, side effects of tubal ligation reversal surgery may include:

• Bleeding
• Infections
• Damage to the surrounding organs
• Complications due to anesthetic

Thanks to the advances made in microsurgery, though, it is possible for tubal reversals to be done in less than an hour on an outpatient basis. Additionally, only local anesthesia is necessary for this procedure. While this type of surgery is far less invasive than the traditional tubal ligation reversal surgery, thereby significantly reducing the risk of complications, the technology is still new and not widely practiced.

Are There Other Options?

Understandably, many women may think twice about having a tubal ligation reversal. Some women may consider having in vitro fertilization (IVF) instead of "untying" their tubes. Although this can seem like an easier option, it is important to note that undergoing IVF can also be quite taxing on your system.

IVF requires you to take hormonal medications in order to stimulate your egg follicles and help you produce several mature eggs instead of your usual one. Just before your eggs are naturally released, your fertility specialist will retrieve the mature eggs and combine them with a semen sample from your partner. Any fertilized eggs will then be left to develop for a few days before being transferred back to your uterus. The entire process, from beginning the medications to embryo transfer, can take anywhere from four to six weeks. On average, 35% of women undergoing IVF are able to conceive while 29% of women will have a live birth.

Am I a Candidate for Tubal Reversal?

Not all women who have had a tubal ligation will be able to have the procedure reversed. During your initial assessment for the procedure, your fertility specialist will examine the current health of your fallopian tubes, most likely through laparoscopy. She will also look over the surgery and pathology reports from when you originally had the procedure done. Your specialist will also consider the following factors:

• How your tubal ligation was done (whether your fallopian tubes were cut, tied, cauterized or non-surgically blocked)
• At what point in your fallopian tubes the sterilization took place
• Just how much of your fallopian tube is left
• How healthy your fallopian tubes are
• Your age

Will I Get Pregnant?

Although pregnancy rates after a tubal reversal are significantly better than trying to conceive through IVF, having the procedure done does not guarantee that you will become pregnant.

Women under the age of 40 who have a tubal reversal through the traditional surgical methods have a 70% to 80% pregnancy success rate, with conception usually occurring during the first year after the procedure. Women who have microsurgery done have a slightly higher success rate, with about 90% of women becoming pregnant within one year of the procedure. However, tubal ligation success rates tend to decline with a woman's age although they are still better than IVF pregnancy rates.

It is important to note, though, that having a tubal reversal does increase your risk of experiencing an ectopic pregnancy. Among the general population, about 1 in 100 women will experience an ectopic pregnancy. However, for women who have had a tubal reversal, this risk increases to about 5 in 100 women.

If you suspect that you are pregnant, make an appointment with your health care provider right away to ensure that you and your baby are healthy.

Vasectomy

What is a vasectomy?

A vasectomy is a form of permanent birth control for men. The tubes that sperm travel through (the vas deferens) are cut and sealed to prevent pregnancy. Please note: a vasectomy will not protect you against STDs.

Who can benefit from having a vasectomy?

Men who have decided that they no longer wish to have any children with their partner or in the future may decide that a vasectomy is the best option for them. However, this decision is not to be taken likely, and you will need to discuss this with your doctor. Men under 30 who are considering a vasectomy can be refused the procedure if their doctor thinks they are not ready, and may be asked to consider other forms of birth control in the mean time.

Procedure

There are two types of vasectomy surgery; both take around 15-30 minutes to complete and are usually performed under a local anesthetic.

• Scalpel vasectomy - In the case of a scalpel vasectomy, the skin of the scrotum is numbed with the anesthetic and one or two incisions made (about 1cm each). Following the incisions your surgeon can then access the vas deferens (the tubes which carry sperm out of your testes), which are cut and a small section removed, before being heat-sealed or tied shut. The incisions are then closed using dissolvable stitches.
• No scalpel vasectomy - The no scalpel vasectomy means that no incisions are made on the scrotum. Instead, your surgeon will feel for the vas deferens and hold them in place using a clamp. A tiny hole is punctured in the skin of the scrotum, and stretched open. Once the vans deferens have been located, they are then heat-sealed or tied shut, as with scalpel surgery. You will not need any stitches following the no scalpel vasectomy.

Recovery period

A vasectomy does not involve a stay in hospital and you will be able to go home following the procedure. You will probably be aware of swelling and some pain, which you can take painkillers for, and it is advised to take a couple of days off work because of this. It is important not do any strenuous activities for one week, and to wear close-fitting underwear to help support the scrotum. A vasectomy will not lower your sex drive or affect your erection, orgasm and ejection abilities, and you will be able to resume having sexual intercourse when ready. However, you will need to use a condom until you have received test results confirming that your semen is clear of any sperm following the vasectomy (these will be done about six weeks after your vasectomy procedure).

Risks

Risks are minimal with vasectomy surgery, but they can occur. These include increasing pain, blood clotting, hematoma (bleeding inside the scrotum) and sperm leaking into the surrounding tissue creating small lumps (harmless, but sometimes painful). There is also a very rare chance that the tubes can grow back together and begin to generate sperm again.

Vasectomy Reversal

What is a vasectomy reversal?

A vasectomy reversal is a surgical procedure to reverse the results of a vasectomy.

Who can benefit from having a vasectomy reversal?

A small percentage of men who have undergone a vasectomy may decide that, due to a change in circumstances, they now wish to have children. This can be possible by restoring the patient’s fertility through performing a vasectomy reversal.

Procedure

There are two ways in which a vasectomy reversal can be carried out:

• Vasovasostomy - This type of vasectomy reversal is the most common. Incisions (sometimes only one) are made into each side of the scrotum - similar to in your vasectomy operation. Any residing scar tissue will be removed and the tubes that were initially cut in the vasectomy – known as the vas deferens – are then sewn back together, restoring the sperm flow. Any incisions are then closed.
• Vasoepididymostomy - A vasoepididymostomy is a more complex vasectomy reversal procedure, which involves attaching the vas deferens tubes directly to the epididymis (where sperm are stored in each testicle). Sometimes the original vasectomy or a previous vasectomy removal may have caused blockages in the vas deferens or epididymis. This procedure can bypass the blockage by connecting the vas deferens to the epididymis - above the point of the blockage. Incisions are then closed as with the vasovasostomy procedure.

Recovery period

Following your vasectomy reversal, you will need to stay in bed for a couple of days. Strenuous activities should be avoided for around a month, but you should be able to return to work in a few days. Any dissolvable stitches should disappear within 7-10 days. Avoid ejaculation and sexual intercourse for 3-4 weeks, and wear close-fitting underwear to help support the scrotum. You will need to undergo some tests at various periods following the vasectomy reversal. This is to check on the progress of the sperm flow and success of the operation, which may not become apparent for up to a year or more. Please be aware that a vasectomy reversal is not always successful, and the shorter the period of time since your original vasectomy, the more likely it is of achieving successful results.

Risks

Risks include hematoma (bleeding inside the scrotum), damage to nerves and/or blood vessels, infection, inflammation, fluid build-up, persistent pain, lowered sperm count, and an unsuccessful outcome.