What is meant by less number of eggs?
A woman is born with finite number of eggs in her ovaries. This is called “Ovarian Reserve�. In every month, number of eggs are destroyed and this is unavoidable. However, in some women, this process of destruction is accelerated and this is called “Poor ovarian reserve (POR)� or “Less number of eggs�.

How can I know that I have less number of eggs?
Blood results can show low AMH and high FSH. The most definitive test is checking for the eggs (AFC- Antral Follicular Count). It must be kept in mind that a single result is not confirmatory. In short, we have to look into age, AMH and AFC together.

What are the treatment options?
Only a low AMH or low AFC cannot decide what treatment you should have.

We also have to consider your age, duration of infertility, previous pregnancy (if any), condition of your tubes and partner’s sperms. If all other factors are favourable and you have only low AMH and AFC, a short period of Ovulation Induction (OI) and IUI (Intra-uterine insemination) can be tried. If these fail, you may need to consider IVF.

Is IVF done as the last resort?
Low AMH does not always mean that you need IVF. However, if your age is on the higher side or duration of infertility of long, IVF may be the better option for you.

We always encourage the women to try IVF with your own eggs first. If that fails, then ONLY consider donor eggs.

What is the chance of success?
It depends on your age, duration of infertility and your response. In general, the chance of pregnancy after each cycle of IUI is 15-20% and after IVF, 30-40%. However, the chance is slightly lower in women with POR.

Is there no chance of natural conception?
In women who have menopause before 40 years, 10% can conceive spontaneously. In women with POR, this chance of natural conception is even higher. So, POR does not always mean that you have do OI, IUI or IVF.

What medicines can be tried?
Some medicines may be tried to improve ovarian response, like DHEA, testosterone gel or antioxidants, vitamin D etc. However, whether the medicines are actually helpful, is a matter of debate and it needs further research.

Semen Report is Abnormal?
If a single semen analysis report is abnormal, that does not mean that there is great problem. You need to repeat it from authentic laboratory.

What are different types of abnormal sperm reports seen?
Sperm count low (Oligospermia)

Abnormal Sperm Motility (Asthenozoospermia)

Azoospermia (Zero Sperm Count)

Abnormal Morphology (Terayozoospermia)

Pus Cell very high

Should you take any medicines?
Medicines work ONLY in mild to moderate cases. Even then if you want to continue medicine WITHOUT active treatment, sperm counts may decrease further.

Can any Injections help?
ONLY if there is hormonal imbalance, gonadotrophin injections can help. But please DO NOT TAKE TESTOSTERONE injection or tablet, because it will further lower down sperm count. Testosterone should NOT be taken even if your blood level of Testosterone hormone is low.

Are any other tests needed?
If the report is severely abnormal, you may need some tests to find out the cause. These include

Physical examination- Doctor may examine your private areas including testicles and penis.
Ultrasound- of scrotum and prostate gland
Hormone tests in blood- Testosterone, FSH, LH, sugar etc.
Chromosomal tests- Karyotype, Y chromosome microdeletion etc.
When to go for IUI, IVF or ICSI?
It depends on severity of the abnormalities in sperms and the condition of your wife's fallopian tubes and ovaries. In mild cases, IUI can be tried. In severe cases, you should NOT delay IVF-ICSI.

Do you need TESA/ TESE?
Even when there is no sperms in semen, sperms can be collected from your body, from your testicles by inserting fine needle and that can be used for ICSI.

When Donor Sperm is required?
In most cases donor sperm is not needed. It is used when no sperms can be obtained or when you cannot afford ICSI.

Sometimes, people who came for IVF, are asking whether the Fallopian tubes need to be removed before IVF.

Normally, what happens inside our body?
The sperms, deposited in the vagina during sexual intercourse, are travelling through the uterus into the Fallopian tubes (attached on the either side of the uterus), where the eggs released from the ovaries ("Ovulation") are also entering. Thus, inside the tube, the egg and the sperm meets ("fertilization") to produce the embryo, which then comes down inside the uterus. The embryo then attaches to the uterus and gives rise to pregnancy.

We need to understand how IVF is done.
By giving some medicines (injections) in the body, the eggs in the ovaries are grown and then they are collected with a fine needle from the ovaries. The sperms are collected from the male partner. In the laboratory, the eggs and sperms are fertilized to produce the embryo. The embryo is then transferred back inside the uterus, where it can give rise to pregnancy. Thus, basically what happens inside the fallopian tubes are done in the laboratory. Therefore, we are bypassing the function of the fallopian tubes during IVF.

So, IVF can be done whether the fallopian tubes remain open (Sperm problems, low egg counts, endometriosis, unexplained infertility, ejaculation problems, azoospermia) or blocked (in HSG, SSG and/or Laparoscopy). So, there is NO NEED OF REMOVAL OF THE TUBES BEFORE IVF.

However, there is one exception.
That is hydrosalpinx, where there is swelling of the fallopian tubes (one or both the tubes) because of accumulation of fluid. That fluid can come down from the tubes into the iterus and can damage the embryo transferred after IVF. In that case, the diseased fallopian tube is doing more harm than good. Therefore, the diseased tube MUST be removed before IVF. So, in most cases, IVF can be done keeping the Fallopian tubes inside the body.

What are the causes of Ejaculation problems?
The problem may be due to some previous surgery (in the prostate gland, hernia, in the abdomen for cancer), diabetes neurological problems, spinal cord injury, diseases of prostate, some obstruction in the sperm conducting ducts etc

What is the next step?
Please do not hesitate to inform your doctor. He/ she will ask some questions and examine you to find out the cause. Some blood tests (like sugar) may be advised. Urine test is commonly advised. In few men, the problem may be retrograde ejaculation (Semen going into bladder instead of moving forward). In that case, sperms can be found in the urine immediately after masturbation. Scrotal ultrasound examines the details of your scrotum (testes and the organs surrounding them). TRUS (Transrectal ultrasound) is advised to see the problems in the prostate gland and around, here the ultrasound probe is inserted inside the anus.

What are the treatment options?
In very few cases, some medicines can help to improve ejaculation. These can help, particularly in retrograde ejaculation. However, in most cases, medicines are not helpful. Nevertheless, pregnancy is possible and you can become the biological father of your kids.

Vibro-ejaculator can sometimes be helpful. It is a small device applied on the front part of the penis ("Glans Penis") to discharge the semen. You can collect the semen in this way and use it at home.

How sperms can be collected?
Non-toxic condom- If you have nocturnal emission (“Night fall�) you can use this condom over penis while sleeping and collect the semen and carry it to the laboratory. The sperms can be frozen for furture use by IUI/ ICSI.
Vibro-ejaculator- can help to collect the sperms, which can be frozen for future IUI/ ICSI.
Testing urine- The sperms can be retrieved from urine and can be used for IUI/ ICSI. However, you need special preparation to reduce the normal acidity of the urine.
Prostatic message- If urine test shows no sperms, inserting lubricated gloved fingers inside your anus to message your prostate gland can sometimes help.
Electroejaculation- If prostatic message fails, your prostate gland can be stimulated using a small probe inserted through the anus under general anaesthesia. However, it is not widely available.
Testicular biopsy- If all of the above method fails, sperms can be collected from the epididymis (small gland above the testis) by small needle (PESA- Percutaneous Epididymal Sperm Aspiration) or and or sometimes, by a small cut (MESE Microsurgical Epididymal Sperm Extraction). All these are done under anaesthesia. If these fail, TESA (Testicular Sperm Aspiration- a small needle is inserted inside the testes) or TESE (Testicular Sperm Extraction- a small cut is made) can be done. Sperms collected by this way, can only be used for ICSI.
In all cases, sperms can be frozen for future use.
What should be the option- IUI or ICSI?
If your wife's results are satisfactory (At least one Fallopian Tube is open, adequate number of eggs in the ovaries), IUI (Intrauterine Insemination) can be a suitable option. In IUI, your sperms can be used, if your sperm count is satisfactory.

In IUI, the sperms are inserted through a small tube, inside the uterus. IUI is cheaper, but the success rate is 10-15% per cycle (out of 100 couples doing IUI, 10-15 can conceive in one month).

However, ICSI is to be done if your sperm count is very low and sperms are collected by TESA/ TESE/ MESA/ PESA. ICSI (Intracytoplasmic Sperm Injection) should also be considered if your wife's reports are not satisfactory (both the Fallopian Tubes blocked, ovaries have less number of eggs) and you have done 4-6 cycles of IUI.

ICSI is a special type of IVF (In Vitro Fertilization). In standard IVF, your wife will be given some injections to mature her eggs, which will be collected through the vagina. These eggs are then mixed with the sperms in the laboratory to produce the embryos.

In ICSI, the sperms collected from your body are directly injected, under the microscope, inside the eggs. The success rate of ICSI is 40% per cycle but it's expensive.

When Donor sperms should be used?
If a couple cannot afford ICSI but IUI using husband's sperm is not possible, Donor-Sperm-IUI is the option, if the wife's reports are satisfactory. Again if TESE sample fails to retrieve adequate amount of good quality sperms, IUI/ICSI should be done with donor sperms.

In some cases, we find one Fallopian tube is Open in HSG and another tube is blocked in HSG. What to do in that case?
Please remember, one Fallopian tube can be sufficient for pregnancy. So, you DO NOT need any Laparoscopy or IVF if all other factors are normal.

If one tube is blocked and other is open, do I need Laparoscopy?
In this case, laparoscopy is needed ONLY in the following circumstances-

1) If any tube is swollen (Hydrosalpinx), because the fluid inside the Hydrosalpinx can damage the embryo. In that case, even if you need IVF, the hydrosalpinx MUST be removed by laparoscopy.

2) If you need laparoscopy for other reasons like Severe pain during periods, Ovarian Cyst, Endometriosis, Fibroid. In these cases, laparoscopy is needed to remove these diseases and improve your chance of pregnancy.

If only oneFallopian tube is open and other is closed, can I try naturally?
Of course, you can try. Even you can have Ovulation Induction (OI), by which medicine is given to improve your chance of pregnancy. However, for how long you will continue this type of treatment, depends on your age, duration of trying for pregnancy, condition of your husband's sperms and your ovaries. If any of these are not satisfactory, you should not rely on trying "naturally" for long periods.

If one tube is blocked and another tube is open, can I try IUI?
In most of cases, if your ovaries and your husband's sperms are good and your age is relatively young, you can try IUI. In most cases, the results of IUI is good. However, in some specific tube block, IUI result is not satisfactory.

Do I need IVF if one Fallopian tube is open?
You need IVF only if your husband's sperm condition is not good, your ovaries are not functioning well, you have been trying for pregnancy for long time or your age is on the higher side. If IUI fails, in that case, also you need to think about IVF.

Conclusion
In majority of the cases of one Fallopian tube block (and other tube remaining open), you don't need to worry. There is no need for laparoscopy or IVF if all other factors remain satisfactory.