Infertility- A Global Problem | Dr R G Patel | TEDxNHLMMC

Introduction

• Infertility is a global problem affecting around 17.5% of young adult couples, with approximately 1 in 6 couples suffering from infertility, requiring immediate help and urgent, affordable, high-quality care (19s).
• For fertility, several factors are necessary, including good eggs, sperm, embryo, functioning patent tubes, a good uterine cavity, receptive endometrium, and timely intercourse (43s).
• Both males and females can be responsible for infertility, with 40% of cases involving both partners, and causes can include blocked tubes, septum, endometriosis, PCOD, polyfibroid, infection, genetic problems, and hormonal issues like thyroid hyperemia (1m3s).
• The global fertility rate is declining due to factors such as aging, late marriage, late planning, addiction, pollution, fast food, obesity, lack of exercise, and infection (2m7s).

Investigation of Female Infertility

• To investigate female infertility, clinical examination, blood tests, hormone tests (e.g., FSH, LH, AMH, prolactin), and transvaginal sonography are used to assess the uterus, endometrium, and ovary (2m31s).
• Advanced technologies like 3D and 4D sonography can assess the uterine cavity and detect pathologies such as unicorn uterus, septate uterus, and intrauterine adhesions (2m58s).
• Laparoscopy can be used for diagnostic and operative purposes to diagnose and treat problems related to the fallopian tube and uterus, such as fibroids, PCOD, and blocked tubes (3m40s).
• Robotic surgery is also available for more precise surgery on the uterus, and hysteroscopy can be used to diagnose and treat problems inside the uterine cavity, such as septum, polyp, or infection (4m19s).

Counseling and Lifestyle Management

• Counseling is essential for the management of infertility, including discussing the exact problem, treatment methods, success rates, costs, number of visits, and potential side effects (4m41s).
• Lifestyle management, including diet, exercise, yoga, and meditation, is also crucial for treating infertility, and patients should be counseled to drop unhealthy addictions and adopt a healthy lifestyle (5m11s).
• Improving wealth and health can lead to better egg quality, sperm quality, and ultimately, increased IVF success and a healthy baby (5m27s).

Initial Treatments for Infertility

• Counseling is crucial, and simple treatments like ovulation induction using oral medicine can be effective, with a success rate in indicated cases (5m39s).
• Intrauterine insemination (IUI) is a cost-effective treatment with a success rate of around 10-20%, and patients can be advised to undergo 3-6 cycles before considering IVF (5m57s).

In Vitro Fertilization (IVF)

• IVF has come a long way since the first test-tube baby, Louise Brown, was born in 1978 in the UK, thanks to the efforts of Edward and Steptoe, who won the Nobel Prize (6m36s).
• Indications for IVF include damaged fallopian tubes, endometriosis, PCOS, IUI failure, male infertility, and unexplained infertility (7m4s).
• Advanced technology, better understanding of physiology, and improved ultrasound and endoscopy techniques have increased the acceptance of IVF (7m22s).
• Modern labs with triple gas incubators and advanced culture media have improved embryo quality and implantation rates (7m48s).
• Artificial intelligence is used to select the best embryos, increasing the success rate of IVF (8m1s).
• Factors contributing to IVF success include patient selection, ovarian stimulation, clinic experience, drug purity, and embryo transfer technique (8m11s).
• Protocols for IVF include long protocol, antagonist protocol, and recombinant technology, which offers advantages such as consistency, increased viability, and better egg quality (9m0s).
• Recombinant technology has evolved from the first generation, derived from urine, to the third generation, which is recombinant, offering benefits such as reduced disease transmission and increased pregnancy rates (9m19s).
• Triggering with analog instead of HCG reduces the risk of OHSS, making it a safer option for patients (9m52s).
• The use of antagonist protocol and analog triggering has made IVF clinics safer for women, reducing the risk of OHSS (10m12s).
• Modern IVF allows for increased pregnancy rates without the need for rest or work cessation, enabling the management of embryo transfer timing (10m31s).
• The IVF process involves stimulating the ovaries, using transvaginal sonography to pick up oocytes, fertilizing the eggs, and transferring the embryo into the uterine cavity (10m48s).
• A modern IVF lab requires a class 10,000 HEPA filter, air handling unit, triple gas laminar flow, micro manipulator, laser-assisted hatching, embryoscope, vitrification, and strict quality control for better culture systems (11m3s).

Advanced Techniques in IVF

• Intracytoplasmic sperm injection (ICSI) is used in cases of male factor infertility, such as low-quality or low-number oligospermia or azoospermia (11m37s).
• A good incubator, such as a triple gas incubator, is necessary for better culture systems and higher-quality embryos (12m1s).
• A witness system is used to avoid mismatching embryos between couples (12m15s).
• Advanced technology is used to improve culture systems, embryo formation, and pregnancy rates (12m32s).
• To improve pregnancy rates, it is essential to select the best-quality embryo, which can be achieved through pre-implantation genetic testing (PGT) (12m47s).
• PGT can assess the number of chromosomes and detect structural rearrangements, such as translocations, deletions, and inversions (12m56s).
• Single-gene disorders, such as thalassemia or muscular dystrophy, can be detected through PGT, and genetic diseases like breast cancer or colonic cancer can be avoided through PGT (13m2s).

Embryo Freezing and Transfer

• Embryos can be frozen using liquid nitrogen at -196°C for future use, and frozen embryo transfer cycles are now more comfortable and result-oriented (13m49s).
• The goal is to achieve a good outcome in IVF results by selecting the best-quality embryo, transferring a single embryo, and avoiding twin pregnancy (14m39s).

Improving IVF Outcomes

• To achieve this goal, it is essential to assess egg function, sperm function, and uterine function and provide better stimulation, handling of eggs and sperm, embryo formation, and PGT if needed (14m54s).
• In cases of thin endometrium, platelet-rich plasma (PRP) or growth factors can be used to treat the endometrium, and stem cells from the iliac bone marrow can be isolated and injected into the uterine cavity (15m20s).
• Ovarian regeneration can be achieved through stem cell treatment for poor responders, which involves laparoscopy or catheterization of ovarian vessels to stimulate the ovary (15m45s).

Egg Freezing and Donation

• Egg freezing is an option for individuals who are not planning for pregnancy immediately, are career-oriented, or have a family history of premature menopause, allowing them to preserve their eggs for later use (16m2s).
• Egg freezing can be done through stimulation of the ovary, retrieval of the egg, and cryopreservation, which can be used later in a unco patient or in a special donor recipient program (16m9s).
• If there is a problem with egg number or quality, or a genetic issue, egg donation may be necessary, which has a high success rate and fewer visits and abortions (16m47s).

Surrogacy

• If there is a problem with the uterus, surrogacy may be necessary, which can be traditional or gestational, and may involve a surrogate mother or a relative/friend (17m6s).
• Gestational surrogacy involves stimulating the female, taking the husband's sperm, making an embryo, and transferring it to a surrogate mother (17m27s).
• Altruistic surrogacy is an option where a relative or friend can act as a surrogate without payment, and is allowed in many countries (17m42s).
• Indications for surrogacy include absent uterus, thin endometrium, hypoplastic uterus, recurrent implantation failure, recurrent pregnancy loss, or if the mother is not medically fit for pregnancy (18m4s).

Male Infertility

• Male infertility can be diagnosed through sperm analysis, and treatment options are available, including hormone tests and sonography to rule out any issues (18m18s).
• The WHO criteria for normal sperm include 15 million sperm per milliliter and 4% morphologically normal sperm, as per the 2021 guidelines (19m2s).
• Male factor infertility can be treated, and it is essential to investigate and treat the male partner, rather than just the female partner (19m15s).
• If the male partner has azoospermia, treatment options include hormone tests, sonography, and genetic studies to determine the chances of retrieving sperm (19m32s).
• Surgical sperm retrieval is possible if the test results are normal, but the chances of success are lower if the FSH is high and the testes are small (19m56s).
• Micro-TESE is a technique used to retrieve sperm from the testes, which involves making a small incision and sending the tissue to the laboratory for examination (20m27s).
• The process involves investigating tubules in a lab setting by an embryologist to find sperm, which can then be used for procedures like IIE and forming embryos with the individual's own sperm, leading to pregnancy. (20m38s)
• The advantages of using a micro technique include minimal fibrosis and scarring, faster recovery for the male partner, the ability to retrieve more sperm, and reduced damage to testicular blood flow. (20m51s)
• Post-procedure, there is a lower chance of hematoma, infection, and pain for the male partner. (21m5s)
• Patients with azoospermia can be treated using their own sperm with the micro technique. (21m12s)
• The tubules can be examined under a microscope to identify normal sperm production. (21m20s)