New Treatments for Infertility 5

The more high-tech way of dealing with male infertility now is intracytoplasmic sperm injection (ICSI). The setup that we actually have boils down to a way of taking a single sperm and injecting it into an egg that is aspirated after ovulation induction. That sperm, interestingly, can be obtained from the ejaculate the old fashioned way, or it can be obtained from a needle in the vas, or it can be obtained from testicular biopsy, which means that you are taking an immature, immotile sperm and we can now mature those sperm in vitro to the point where they are motile, to be able to select which ones you want to inject. We use a bead of oil to slow them down. We use a little pipelle to pick up each single sperm. You push on the membrane of the leg. Then wee have a holding pipette to hold the egg still. First you catch the sperm and then you have to align the pipelle holding the sperm. Usually we put it so that the polar body is at 12 o’clock or 6 o’clock; that is important because you don’t want to destroy the spindle for it to complete myosis. Remember, with a single polar body you are now in myosis 2 – metaphase. The reason that this is important is that if you don’t see that polar body, she didn’t technically ovulate, even though you extracted the egg, so this is not an egg you want to fertilize. So we look for metaphase 2 cells that have a single polar body to inject. We inject it and the membrane of the egg is very strong. Finally, you remove the needle and this gets placed into the incubator.

The second big area that we need to talk about is ovulation. Ovulatory defects in women make up about forty percent of their cause of infertility. The classic example is polycystic ovarian disease. You need to come to a diagnosis as to what is causing them to be an- or oligoovulatory. There are a lot of other reasons for anovulation, including hyperprolactinemia as a cause, any sort of stress and issues around nutrition that will make a patient oligo- or anovulatory, hypothyroidism is clearly the classic example, but hyperthyroidism as well will lead to oligo- or anovulation and then ovarian failure.

What are some of the types of ovarian dysfunction? Hypothalamic, hyperprolactinemia, hyperthyroidism, hypothyroidism, premature ovarian failure. The workup is essentially the same workup for secondary amenorrhea. All you have to remember, besides measuring beta hCG, because presumably she is not pregnant, is a TSH, prolactin, some assessment of endogenous estrogen – an FSH or progestin challenge – and a pregnancy test if she is just amenorrheic.

What are some of the ways of assessing whether or not somebody is ovulatory? There are a whole host of ways to do it. The classic way of doing it, of course, is to measure a luteal phase progesterone. If you measure P4, it should be elevated in the luteal phase and it is this progesterone that leads to elevation in your basal body temperature curve. This is certainly a very valid way of assessing whether or not somebody ovulates. Progesterone is thermogenic and in general raises the body temperature about one degree Celsius. Ovulation predictor kits are essentially an RIA or ELISA that measures LH in the urine. It usually will predict ovulation 12 to 24 hours in advance of ovulation. It tells you whether or not she ovulated, it is cheap and it helps you therapeutically to guide the couple. Endometrial biopsy is the classic unquestioned way of finding out whether or not someone is ovulating. We all know that immediately after ovulation, you should have subnuclear vacuolization – that is the classic thing – and you can time the endometrial lining by whether or not this person has ovulated, right down to the day. It is a little invasive and obviously expensive. It can produce an endometritis. So as a general rule, we don’t do it very often anymore except in the case of recurrent loss.

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