Cancer is not equal to Infertility

     Cancer and certain cancer treatments, can disturb your reproductive health. It could be worth it to consider ways of preserving your fertility before you begin your treatment. When you are told that you have cancer, your ability to have children may be the outermost thing of your mind. Whether you already have children or haven’t yet thought about becoming a parent, it is worth thinking about your fertility before starting some forms of cancer treatment.

Cancer treatments that can affect your fertility include chemotherapy, radiotherapy, and surgery on your reproductive organs, including the ovaries or testicles. Hormone therapies and other treatments may also have an impact on fertility, but less is known about the effects of these treatments. It can be difficult to know what the effects of the cancer treatment will be until much later. Many people who are treated for cancer, especially those treated for cancer as children, remain fertile and go on to have a family of their own in later life. Some find that their fertility is affected for a short time and then recovers when treatment has finished, but others find that their fertility is affected for longer. It often depends on your individual circumstances, such as your age, the treatment you receive, where in your body the cancer is and whether you are male or female.

Women and fertility

If you’re a woman of childbearing age, cancer treatments can affect your fertility by:
•             stopping you from producing certain hormones
•             stopping your ovaries from working and therefore causing an early menopause
•             damaging the lining of your womb
•             involving surgery to remove your womb

Men and fertility

Cancer treatments can affect your fertility by:
•             stopping, or interfering with, the production of sperm
•             affecting the production of testosterone or other hormones involved with sexual function
•             damaging nerves and blood vessels in your pelvic area, which can make it difficult to get an erection or ejaculate

Fertility treatment

If either your fertility or your ability to have sex has been affected by your cancer or a cancer treatment, you may want to try a fertility treatment to help you conceive.

If you are considering having fertility treatment, speak to your GP first. If you have private fertility treatment, the cost will vary from clinic to clinic.

Your GP will be able to arrange some tests and refer you to a specialist fertility doctor. The specialist will be able to give you information and advice about the most appropriate fertility treatments for you.

Types of fertility treatment include the use of:
•             In vitro fertilisation (IVF)
•             Your frozen sperm, embryos, eggs or ovarian tissue
•             donated sperm, eggs or embryos

Getting support

Trying for a family and finding out whether or not you’re fertile can be stressful. If you’re finding any of these issues difficult, you may find that it helps to talk to someone. Consider discussing your feelings with your family, your partner, a friend or your cancer specialist. Some people find that fertility treatments do not suit them or don’t work. If this is the case, there are other options for having a family, such as adoption or surrogacy.

There is a lot to think about if you’re considering any of these options, so talk them through with someone close to you or your doctor, or contact one of the organisations below for specific information and advice.

CASA - Computer Assisted Semen

CASA- COMPUTER ASSISTED SEMEN ANALYSIS- a state of the art facility available at Ankur

High end Microoptics machine with florescence microscopy “Computer Assisted Semen Analysis”. A Microscope images of moving sperms is translated into a series of measurements and quantified numbers. Compared to conventional methods, it provides:

A revolution in precision and accuracy – especially for sperm morphology, a critical factor of fertilization. A Video Images are depicted live on the computer monitor. Images are shown in negative contrast ie. sperm is seen in white against a black background.

Eliminates operator bias and provides additional parameters of fertilizing ability (see 3 below) and also images to recheck the validity.

Mostly used for assessment of sperm concentration and specific patterns of sperm motility (velocity, linearity etc). Imaging systems in CASA are high end since the sperm movements are upto 80 beats per second and ordinary video systems capture images at 25 to 30 frames per second. The latter will give a hazy image of the tail as well as low reliability of sperm motility. CASA has facility to reconstruct input video images at higher frame rates and is therefore a reliable instrument to analyse fast moving sperms.

It generates kinematic values based on velocity of movement, width of the sperm head trajectory and frequency of the change in the direction of sperm head. Hence it is able to analyse variations in sperm motility patterns in a quantifiable way.

The available clinical data show that the measurement obtained by CASA are correlated with conception in vivo and fertilization in vitro, but comprehensive quality control and quality assurance programs are necessary to ensure accuracy. CASA can be a guide to predict if the sperm can penetrate through the cervical mucous in the female, that the spermatozoa prepared for an in vitro fertilization attempt will succeed / fail to penetrate the coverings of the oocyte.

Breaking 7 Fertility Myths

While infertility is getting increasingly common today, we still tend to take issues around it for granted. A common misconception is that infertility gets cured on its own. This is generally why we refrain from breaking inertia and opting for enhanced life-style choices. Listed below are 7 such myths that need to be over-ridden in order to better combat the problem of infertility.

1. Male fertility is independent of age
Fueled by the fact that couples tend to give lesser importance to male infertility, it often goes unnoticed when an age-related issue arises. In addition to deterioration in semen volume itself, post 40 there is progressive decrease in both sperm quality and its ability pass on healthy genes.

2. You are fertile as long as you are getting pregnant.
Secondary infertility is often experienced by couples seeking to have a second child or ppl having infertility after one conception. A history of good fertility rates in one’s family or previous records of one’s own fertility need not necessarily mean that infertility is alien. Progressive degeneration of both eggs and sperm need to be checked for.

3. Weight and fertility are not linked
Women who are over-weight do conceive and therefore couples battling infertility under-mine the implication of those extra-pounds. However, lesser known is the fact that being overweight causes hormonal imbalances in both men and women. Every 5-10% weight gained leads to a recorded drop in fertility. For women battling ovarian cysts, weight reduction is often all it takes to conceive that bundle of joy!

4. A woman’s egg reserve does not diminish till 40
Women only have as many as 400-500 ovulating eggs in a lifetime despite having a reserve of thousands at puberty. The ovarian reserve decreases with age. While the reserve undergoes a loss of about 10% in late 20’s, in 30’s women often have about 15% chances of a healthy pregnancy. By the age of 35, a woman’s chances of having a baby is a meek 10% which is further reduced to 5% at 40.

5. Smoking does not affect fertility
Both active and passive smoking are risk factors for infertility. Researchers have proven that smokers experience infertility issues twice as often as non-smokers do. Besides a drop in sperm count, men who smoke tend to pass on mutated genes more often than men who do not smoke. In women, smoking causes a steep drop in egg reserve and leads to pre-mature menopause.

6. Infertility Runs In Family.
Infertility is not hereditary. However, there are medical conditions that are hereditary which may interfere with your ability to get pregnant. Some types of fertility problems can be hereditary. Endometriosis is one female fertility problem that can be hereditary. Generally speaking, fertility problems tend to have more to do with lifestyle factors than with heredity or genetics. The most severe fertility problems cannot, by definition, be passed on, because there are usually no children to which the problem could be passed.

7. How position affects conception
Whilst semen inevitably comes out of the vagina following an ejaculation, sufficient sperm is deposited in the neck of the womb which then heads towards the egg, regardless of the sexual position.

The silver lining is the fact that it is never too late to make wellness a way of life. The key is to accept the facts about one’s body and embracing realistic solutions for the same. Small changes in your day-to-day lifestyle can go a long way in preventing fertility problems.

Microsurgical Epididymal Sperm Aspiration

What is it?
Under direct observation, a special needle is used to aspirate viable sperms from the epididymis instead of the testis. Like TESE this is a useful adjunct to IVF and in particular to ICSE. Alternatively it can be done to extract sperms which can be kept refrigerated and used later. Cryopreservation offers the benefit of repeat procedure, should the IVF fail.

Who requires it?
Men with obstruction of the male reproductive tube – congenital or acquired. congenital absence of the Vaz deferens on both sides is a good indication. Acquired causes may be due to infection, injury, previous failed spermatic duct recanalization or failed duct – epididymis recanalization (called vasoepididymostory). Iatrogenic causes may be traceable bladder neck, pelvic, abdominal or inguino-scrotal surgery.

What is the rationale of using TESE?
It was a general conclusion that in a normal male the sperms undergo a certain amount of maturity, mobility and fertilizing capacity before proceeding to the Vaz deferens. However, recent research has shown that in reproductive tract obstruction, good quality sperms are available in the upper part of the epididymis. Microscopically and functionally y they are as good as the sperms of the testis and can be aspirated and used for IVF. However the same cannot be said for the distal epididymis. Here the sperms undergo destruction and plenty of macrophages can be found in histology. These observations become important while selecting the site of sperms aspiration during MESE.

Why it is preferred to donated sperm? Compared to a donor sperm, it is always preferable to have the husband’s sperm if the morphology is ok.

Are there any problems with this procedure?
This is a minimally invasive procedure done using an operating microscope. Only a tiny segment of the epididymis is sliced (called micropuncture) to extract sperms. In comparison a bit of testis tissue is removed in TESE. In MESE, amount of blood contamination of the epididymal fluid is minimised due to the micropuncture. This improves the fertilizing quality of the sperms.

MESE procedure: A tiny surgical incision is made in the scrotum and the testis is first identified. The epididymis is then identified – this is located above and behind the testis. Using an operating microscope , a micropuncture is made on the tubule in the upper part of the epididymis. Epididymal fluid is gently aspirated. The aspirate is immediately handed over to the embryologist who immediately examines the same under the microscope and confirms adequacy and good quality of sperms (sperm count and motility). It optimal amounts of sperms of the right quality is not found, the efferent ductules can similarly be approached through micropuncture. This is one advantage on the procedure. Similarly only a few microliters of fluid is required to harvest the sperms. Hence the procedure can be considered minimally invasive.

Sexually Transmitted Diseases

Sexually Transmitted Diseases (STD) have an influence on your fertility levels on many levels. While the ability to conceive itself is disturbed, the health of the child is also affected. Here are pointers on how you could reduce risk factors as a pregnant STD patient-

• Seeking the right treatment while pregnant could as much as bring down the chances of your infant developing STD from 25%-2%.

• Pelvic Inflammatory Disease (PID ), a consequence of other sexually transmitted diseases can be avoided when you treat the initial intense discomfort caused.

• Chlamydia, has long term side effects, if left untreated. It not only affects your health, but also that of your baby.

• Neonatal Herpes Infection, a serious illness can be life threatening. While most women with herpes do not transmit neonatal herpes to their children, if you or your partner has genital herpes, it is important to inform your doctor about your risk.

• Symptoms of Gonorrhea include bleeding after sex and yellow or bloody vaginal discharge which can inflame the pelvic area, causing epididymitis. This is known to hamper your conception.
Women tend to be at the risk when it comes to STD. Therefore, most doctors agree that a pre-conception STD test is essential to check for undiagnosed STD from the past and to see if any unknown damage could impede the woman’s chance of getting pregnant.

Menstrual & Uterine Cycles

The menstrual cycle is entirely hormone driven and controlled by the ovaries and it is superior to the pituitary gland. It is not advisable to attempt any procedure for stabilization of uterine cycle unless the cause of the problem is known. The end result of hormonal imbalance is always anovulatory cycles. The patient however will present with history of menstrual irregularities and inability to conceive. A brief approach to such a case in terms of diagnosis and treatment is presented here. Specific strategy will depend on the nature of the problem.

If the bleeding is chronic, the patient may show evidence of anemia. This must be treated.
A urine based pregnancy test is done to rule out possible pregnancy as a routine precaution. This is to ensure that in the event of a pregrancy already in progress, the patient is not subject to any further investigation.

Tests to check the number and quality of platelet is done to confirm if the patient is suffering from any coagulopathies. If confirmed, this can be confirmed.

A PAP smear is a simple test to rule out cervical cancer.

Liver function tests and tests for thyroid hormone status can help eliminate these problems and if necessary correct them.

Progesterone, esterogen and prolactin levels may need to be checked. Prolactin level may be
high in a pituitary adenoma. Similarly DHEAS may be high in polycystic ovarian disease.
An endometrial biopsy may be necessary through a D & C procedure, direct hysteroscopy enabled biopsy to understand the histo-pathological status of the uterus. A transvaginal ultrasound may be needed to understand the state of the uterus and ovaries.

Generally, most cases of menstrual irregularities will have a high estrogen level in the cycle and a low progesterone level. Besides estrogen, optimal levels of progesterone at the right time is needed for ovulation. Hence using prepared hormones, the patient is placed on a regime that almost mimicks the normal menstrual cycle. If all other factors are normal, this itself will be sufficient to induce ovulation during the fertility window period. This in essence is the method of stabilization of uterine cycle. Oral contraceptive pills are prescribed with caution and only when the female does not want pregnancy. For couples desirous of a child , the female is given a series of progestin therapy. Cycles should stabilize in three months failing which hysteroscopy and if necessary, clomiphine induced release of eggs may be considered.

Non steroidal anti-inflammatory agents (naproxen, mefanemic acid) may be used to reduce bleeds and also pain if any.

Stages of Menstruation

Menstruation is a monthly occurrence for almost all sexually mature females. Menstruation occurs when the uterus sheds the endometrium (inner nutrition rich mucous membrane of the uterus) in the absence of pregnancy. It happens in women from puberty (between age 11to 15) to menopause (between age 45-50.)
Here is a brief description of the four stages that the endometrium undergoes during Menstruation. The animation graphically represents this process. (The myometrium is a layer of the uterus that consists of uterine myocytes).
Stage of Menses (Days 1-4)
Also known as the bleeding phase, menses is caused due the withdrawal of the ovarian hormones – oestrogen and progesterone at the end of the ovarian cycle. Normal bleeding consists of dead endometrial cells, blood, vaginal cells, mucous from the cervix and other necrotic tissues. Most women bleed for 3 to 5 days.
Stage of Repair (Days 4-6)
Post the menstrual bleeding, for a short duration of about 48 hours the endometrium rests and repairs itself. The endometrium is disorganized and about 1mm thick during this stage.
Stage of Proliferation (Days 6-16)
As estrogen gets produced in the ovary, the endometrium proliferates. It increases in size and thickness. New blood vessels grow from the stumps of the old vessels. Endometrial glands grow bigger although their number remains the same. At the end of the proliferative stage, the endometrium is about 2-3 mm thick.
Women who are being treated to cure infertility undergo ultrasonography to measure the endometrial thickness.
Stage of Secretion (Days 16-28)
Once ovulation occurs, progesterone produced in the ovary increases and the endometrium continues to grow to reach a thickness of around 5-7 mm. Women undergoing ultrasound treatment for Infertility tend to have thickness up to 10 -15mm.
The endometrial glands begin to secrete in this stage, due to which it’s called the stage of secretion. Initially, the secretions get collected in the cells of the glands but towards the last few days of this stage, the secretions are pushed out of the cells and get collected in the endometrial cavity.
Endometrial growth stops from the 22nd day of the cycle as the corpus luteum (the essential lining that grows waiting to nourish a healthy pregnancy) degenerates. Eventually it begins to shrink, after which shedding of the endometrial lining occurs. Thus starts the next menstrual cycle.