(PROF.) DR. SRIMANTA KUMAR PAL (SENIOR GYNECOLOGIST)

Monday, 1 June 2020

Genes & stress can lead to formation of PCO

Genes and Stress can cause PCO; How metformin will make a solution?? How does polymorphisms in both subunits of the IL-6 receptor affects the woman?? How does Argo polymorphism in the gp130 gene is more frequent in control health women as c compared with hyperandrogenic patients: . Such control women had lower 11-deoxycortisol and 17-hydroxyprogesterone concentrations and a significant decrease in free testosterone levels, suggesting that this polymorphism might have a protective effect against androgen excess.
Arg148 allele of the Glee 148 Argo polymorphism in the gp130 gene ILr6::- This cytokine seems to be implicated in insulin resistance mechanism, and increased levels were found in peritoneal fluid of anovulatory PCOS patients, suggesting a role in the pathogenesis of hyperandrogenic disorders . Common polymorphisms in both subunits of the IL-6 receptor have been studied, and the Arg148 allele of the Glee 148
What explanation we have to account for more AFC in PCO women? Any Genetic explanation?? Ans: Let us quickly recapitulate the physiology of folliculogenesis in healthy women?? In a normal cycle, only the dominant follicle responds to LH action when it reaches 10 mm in diameter. In PCOS patients, the response to LH occurs inappropriately in smaller follicles; a large number of antral follicles reach a terminal differentiation before the appropriate time, producing a larger amount of steroids and inhibin B that have a negative feedback on the production of FSH: the result is the arrest of follicular growth.
In PCOS patients, the response to LH occurs inappropriately in smaller follicles; a large number of antral follicles reach a terminal differentiation before the appropriate time, producing a larger amount of steroids and inhibin B that have a negative feedback on the production of FSH: the result is the arrest of follicular growth.
It has been shown that polycystic ovary presents a greater number of small antral follicles (2-9 mm in diameter) than the normal ovary. This morphological scenario could be the consequence of a potential dysregulation of the recruitment mechanism of primordial follicles that, on the contrary, are present in physiological number. But we have to remember that the final pathway of follicular growth, which is gonadotropin dependent, is blocked in the majority of PCOS patients, and it is the basis of anovu-lation and oligo-/amenorrhea.
Can the clinical, features of P CO be so silent that we even the senior physicians may miss the very early symptoms of PCO? As discussed in details about 5 genes that are involved in PCO, it may be possible that many more genes may be responsible for PCO . Such mutation are just possible. Admittedly, the etiology of this syndrome is still partly unknown, but it is likely to be multifactorial. The most significant theories are explained below:
* Exaggerated Adrenarche: the primary stimulus. & , which provides, in response to a stress condition, a transient adrenal androgen hypersecretion, triggering an abnormal pattern of the pituitary gonadotropins’ pulsatility. It is possible that PCOS might be established and maintained in response to an abnormal adrenal hypersecretion of androgens due to congenital adrenal enzyme deficiency. Researchers have suggested that an important etiopathogenetic model involving stress as the primary stimulus. & , which provides, in response to a stress condition, a transient adrenal androgen hypersecretion, triggering an abnormal pattern of the pituitary gonadotropins’ pulsatility. As puberty progresses, the adrenal cortex is replaced by ovaries in maintaining the hypersecretion of androgens.
Finally, the increase in ovarian androgen level changes adrenal specific enzyme activities involved in the process of steroidogenesis .
• Abnormal Secretion of Gonadotropins: The sequence of events are like this. Initially there is stress induced elevated endogenous Opioid tone- might cause an exceeding GnRH release - followed by abnormal LH pulsatility The high levels of LH in women with PCOS are due to greater amplitude of the peaks of this hormone and its increased frequency of pulsatility; on the contrary, the average concentration of FSH is mostly decreased. The high levels of LH are not caused by an inability of the hypothalamic-pituitary axis to respond to the negative feedback exerted by estrogen, but it might be caused by the high pituitary sensitivity to LH-RH. The chronically elevated and acyclic levels of estrogens in PCOS patients may, in turn, increase both the basal levels of LH and LH response to GnRH.
Moreover, an elevated endogenous Opioid tone might cause an exceeding GnRH release with a following abnormal LH pulsatility, causing increased level of LH- dependent ovarian androgens .

PCOs and genes

Not one particular shoe will fit all women!!!!! Any woman with PCO are usually are treated with variety of drugs . Unfortunately in fair no of cases such primary agent don’t work.  Can we select the most appropriate agent after UNLOCKING the defective genes and then select the right drug for right women; Which are the culprit genes  in development of PCO in embryonic life ??  

The first   genetic mutation for PCO genesis:        LH gene mutation is the most common (major ) cause of genetic diseases of  PCO and that mutation occurs in either in gametogensis(male / female)  or post immediate  fertilization growth  disorders : To remind all of you that  LH hypersecretion is present in almost 50 % of PCOS women, and  two mutations, Trp8Arg and IleI5Thr, could be the cause of an abnormal LH p molecule LH : LH hypersecretion is present in almost 50 % of PCOS women, and  two mutations, Trp8Arg and IleI5Thr, could be the cause of an abnormal LH p molecule  The first PCOS GWAS (genome-wide association studies) identified LH/choriogonadotropin receptor (LHCGR) as a susceptibility gene for PCOS: the interaction of LHCGR and its ligand, LH, plays a fundamental role in the folliculogenesis of mammals. 

Can HHcyst itself de novo initiate PCO if the female foetus is in uero an=d mother is having high Homocysteine?  Daig & remedy to avert HHcys in pregnancy period ?? How relevant to   maintain H.Hcy ( avoiding excess  homocyeine)  in normal levels while planning pregancy or in pregancy period?? Can HHcyst itself de novo initiate PCO?? A study suggested that LHCGR might participate in the physiopathology of PCOS by deviations in the methylation statuses of its promoter CpG sites, a hypomethylation in particular.

Unlock Phase 1:-The question we can we unlock those genes of PCO?? : The unlock phase -1: Can we unlock the candidate genes resulting in to PCO and killing hundreds of women in India a daily due to DM, CVS (MI in particular), hemorrhagic stroke , Thrombotic stroke , endometrial Ca ?? PCOS is a multifactorial polygenic disease (interaction between several genetic and environmental factors), with a heritability of ~70 %. It is intrinsically difficult to study by a genetic point of view, and most of the current literature (>70 studies based on the candidate gene approach) is inconclusive, with many studies resulting inconsistent, controversial, and without a clear consensus. Recently, the inheritance was confirmed by some authors who found that PCOS was present in 35 % of the mothers and 40% of the sisters of PCOS patients. Moreover, increased incidence of insulin resistance in the fathers and brothers of PCOS women has been considered as the “male phenotype” in PCOS families. Ethnic variations of genetic expression for hyperandrogenism: à phenotypic variability of hyperandrogenic disorders. -The genes involved in the pathogenesis of hyperandrogenism are expressed in a variable way depending on the factors predominating in every different ethnic population. This explains the phenotypic variability of hyperandrogenic disorders. What is nongenetic inheritance?? Environmental cause of PCO?? .Some insults during pregnancy may induce to intrauterine growth retardation, which probably induces a “thrifty phenotype” in small for gestational age babies potentiated by in adult life by environmental factors such as a sedentary lifestyle and a diet rich in saturated fat. . To summarize there is one nongenetic theory of PCO which is of no less importance than genetic cause of PCO.:-theory is that the features of PCOS families result from nongenetic inheritance,and they are related to environmental factors that are present only in the affected families. Researchers have hypothesized that some insults during pregnancy may induce to intrauterine growth retardation, which probably induces a “thrifty phenotype” in small for gestational age babies.These have a high risk of suffering from insulin resistance, which may result in hypertension, glucose intolerance, adrenal axis hyperactivity with relative cortisol excess, functional hyperandrogenism, and PCOS later in life, especially if they are exposed to environmental factors such as a sedentary lifestyle and a diet rich in saturated fat. These environmental factors may cluster in certain families because exercising and dieting are greatly influenced by parental lifestyle. The metabolic abnormalities of the “thrifty phenotype” can induce additional insult to the pregnancies of these SGA (small for gestational age) and PCOS women, and these defects might be transmitted to another generation without the participation of any genetic abnormality. Q. Can we prevent nongenetic inheritance of PCO?? If small for gestational age babies , after birth and during upbringing have healthy habits, insulin resistance and its consequences might be improved, and theoretically, the third generation -à their fetuses will not be exposed to a hostile metabolic environment during pregnancy(as mother has god lifestyle during her childhood and puberty, adolescent and such good health habits continue to be practiced in childbearing age too then her siblings will not have PCO. This dedication of adhering to strict good eating and exercising habit will , prevent nongenetic inheritance of these conditions, PCO, DM, MI in particular . However, intrauterine growth restriction might be influenced by genetic variants as well, and the most likely scenario is represented by an interaction between predisposing genetic abnormalities and unfavorable environmental conditions. Thus, even if several studies conducted in families of women with PCOS have demonstrated the genetic basis of the syndrome, nowadays a genetic pattern certainly involved in PCOS predisposition has not been identified. Most studies have included different kinds of genes: those related to androgen biosynthesis and action and their regulation, genes involved in insulin resistance and associated disorders, and also genes involved in chronic inflammation and atherosclerosis UNLOCK Phase 1 : Genetic cause of PCO & Environmental cause of PCOS( a) unhealthy environment while foetus was inside the uterus and after child birth such intrauterine insult are aggravated by ( b )environmental factors such as a sedentary lifestyle and a diet rich in saturated fat.

Unlock Phase 1:-The question we can we unlock those genes of PCO?? : The unlock phase -1: Can we unlock the candidate genes resulting in to PCO and killing hundreds of women in India a daily due to DM, CVS (MI in particular), hemorrhagic stroke , Thrombotic stroke , endometrial Ca ?? PCOS is a multifactorial polygenic disease (interaction between several genetic and environmental factors), with a heritability of ~70 %. It is intrinsically difficult to study by a genetic point of view, and most of the current literature (>70 studies based on the candidate gene approach) is inconclusive, with many studies resulting inconsistent, controversial, and without a clear consensus. Recently, the inheritance was confirmed by some authors who found that PCOS was present in 35 % of the mothers and 40% of the sisters of PCOS patients. Moreover, increased incidence of insulin resistance in the fathers and brothers of PCOS women has been considered as the “male phenotype” in PCOS families.

Ethnic variations of genetic expression for hyperandrogenism: à phenotypic variability of hyperandrogenic disorders. -The genes involved in the pathogenesis of hyperandrogenism are expressed in a variable way depending on the factors predominating in every different ethnic population. This explains the phenotypic variability of hyperandrogenic disorders.

What is nongenetic inheritance?? Environmental cause of PCO?? .Some insults during pregnancy may induce to intrauterine growth retardation, which probably induces a “thrifty phenotype” in small for gestational age babies potentiated by in adult life by environmental factors such as a sedentary lifestyle and a diet rich in saturated fat. . To summarize there is one nongenetic theory of PCO which is of no less importance than genetic cause of PCO.:-theory is that the features of PCOS families result from nongenetic inheritance,and they are related to environmental factors that are present only in the affected families. Researchers have hypothesized that some insults during pregnancy may induce to intrauterine growth retardation, which probably induces a “thrifty phenotype” in small for gestational age babies.These have a high risk of suffering from insulin resistance, which may result in hypertension, glucose intolerance, adrenal axis hyperactivity with relative cortisol excess, functional hyperandrogenism, and PCOS later in life, especially if they are exposed to environmental factors such as a sedentary lifestyle and a diet rich in saturated fat. These environmental factors may cluster in certain families because exercising and dieting are greatly influenced by parental lifestyle. The metabolic abnormalities of the “thrifty phenotype” can induce additional insult to the pregnancies of these SGA (small for gestational age) and PCOS women, and these defects might be transmitted to another generation without the participation of any genetic abnormality.

Q. Can we prevent nongenetic inheritance of PCO?? If small for gestational age babies , after birth and during upbringing have healthy habits, insulin resistance and its consequences might be improved, and theoretically, the third generation -à their fetuses will not be exposed to a hostile metabolic environment during pregnancy(as mother has god lifestyle during her childhood and puberty, adolescent and such good health habits continue to be practiced in childbearing age too then her siblings will not have PCO. This dedication of adhering to strict good eating and exercising habit will , prevent nongenetic inheritance of these conditions, PCO, DM, MI in particular . However, intrauterine growth restriction might be influenced by genetic variants as well, and the most likely scenario is represented by an interaction between predisposing genetic abnormalities and unfavorable environmental conditions.

Thus, even if several studies conducted in families of women with PCOS have demonstrated the genetic basis of the syndrome, nowadays a genetic pattern certainly involved in PCOS predisposition has not been identified.

Most studies have included different kinds of genes: those related to androgen biosynthesis and action and their regulation, genes involved in insulin resistance and associated disorders, and also genes involved in chronic inflammation and atherosclerosis

UNLOCK Phase 1 : Genetic cause of PCO & Environmental cause of PCOS( a) unhealthy environment while foetus was inside the uterus and after child birth such intrauterine insult are aggravated by ( b )environmental factors such as a sedentary lifestyle and a diet rich in saturated fat.

PCOs -its genetics * environental effects in a girl child

ROS i semen and REc IUI failure

Excess ROS may be a cause of your IUI failure: ROS are usually washed away with semen preparation in IUI /ART: Reactive oxygen species are metabolites of oxygen and include A) superoxide anion, B) hydrogen peroxide, C) hydroxyl radical and D) nitric oxide.

ROS is produced by both spermatozoa and leucocytes. Increased number of sperms would produce more ROS. When present in excess they can initiate oxidative damage to cellular lipids, proteins and DNA.

Fortunately most cells are equipped with enzymatic or non enzymatic antioxidant systems. The seminal plasma also has these enzymes. Now coming to sperm preparation , while preparing sperms, seminal plasma is removed and the sperms are rendered vulnerable to oxidative attack affecting sperm function.

Tests can differentiate ROS produced from sperms and those from leucocytes. Chemiluminescent procedures employing probes such as luminal or lucigenin may be used to measure ROS production.

What is peroxidase staining?? Ans: The ejaculate contains cells, other than spermatozoa, referred to as round cells. These include germinal line cells sloughed cells from seminiferous tubules, epithelial cells from genitourinary tract, prostate cells, spermatogenic cells and leukocytes. A normal ejaculate should not contain more than 1 x 10 ⁶round cells/ml. The number of leucocytes should not exceed 1 x 10 ⁶. The concentration of granulocytes in semen can be determined using peroxidase staining and hemocytometer counts.

Round cells that lack polymorphonuclear morphology may be 1) immature germinal cells (spermatocytes, spermatids) 2) exfoliated epithelial cells. These may be degenerating and difficult to identify. To identify them special staining procedures with monoclonal antibodies are used. If round cells are more than 1 million it should be ascertained whether they are leucocytes or spermatids, as leucocytes more than 1 million indicate an infection which may affect fertility. Although CASA system can be used to automatically measure sperm concentration, errors are encountered when there are high and low concentrations, significant agglutinates or large amount of significant debris. The manual count can be obtained with a coefficient of variation of less than 10%.

Causes of repeated IUI failures

Causes of repeated IUI failures?? If repeated failure in IUI cycles : Then Sperm function tets are mandatory. Functional tests for sperms may be done if there is repeated IUI failure for which no cause could be established including genital Koch's /minimal endometriosis: Such tests are A) Hypo osmotic swelling tests: Sperm fertilizing capability—B) nuclear chromatin decondensation test, C) presence of excessive reactive oxygen species.
Test I:-Hypo-osmotic swelling.
These tests determine the sperm membrane structure and function. The presence of large number of vital (living) , but immotile sperms may be indicative of structural defect in flagellum. Hypo-osmotic Swelling Test offers different information about but sperm membrane function is offered by viability test.
When live spermatozoa are exposed to a solution of low osmolarity 33-80% sperms demonstrate tail swelling. The percentage of sperms, with such curled tails in the treated sample, should be subtracted from the percentage of those that reacted from hypo-osmotic solution.
A normal value is taken as more than 55-60% reacted sperms per sample, and an abnormal value is less than 50% reacted sperms (< 50% coiling). However, this test lacks sufficient critical evaluation to determine its role in evaluation of
Basics: This test is based upon the fact that fluid transport occurs across the intact cell membrane under hypo- osmotic conditions until equilibrium is reached between the inside and outside.HOS values may be selectively altered with certain procedures like: Cryopreservation, Presence of sperm antibodies.
Note: Since some spermatozoa may have curled tails before exposure to hypo-osmotic solution, it is essential to examine the ejaculate before the test. Increase in free radicals, which occur when there is increase in number white blood cells in semen.
.
Excess ROS may be a cause of your IUI failure: ROS are usually washed away with semen preparation in IUI/ART: Reactive oxygen species are metabolites of oxygen and include A) superoxide anion, B) hydrogen peroxide, C) hydroxyl radical and D) nitric oxide.
ROS is produced by both spermatozoa and leucocytes. Increased number of sperms would produce more ROS. When present in excess they can initiate oxidative damage to cellular lipids, proteins and DNA.
Fortunately most cells are equipped with enzymatic or non enzymatic antioxidant systems. The seminal plasma also has these enzymes. Now coming to sperm preparation , while preparing sperms, seminal plasma is removed and the sperms are rendered vulnerable to oxidative attack affecting sperm function.

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Polycystic ovarain syndrome associated WITH INFERTILITY

Basically all subfertile women fall into two major groups, be it PCO or non PCO group. I follow that principle and firmly believe that such basic clinical classification is an very useful in day to day clinical practice and formulating investigations in right directions. : You may follow that to minimize the cost of investigations and focus more on earlier definitive pathology. For instance in women with definite Pel lump or uterine fixity/ thick parametrium/ nodules in POD –a detailed endocrine evaluation seems of less importance to me. Those women who didn’t exhibit any mass/ fixity/nodules fall majority of subfertile women (Group A women) and my assumption that such women are major group (about 80% of all cases of subfertility) I personally level them as Group A women.

Part III:-Group A: One note of caution: No hurry in HSG / SIS in Indian context where Genital Kochs is common though I shouldn’t call it as rampant this procedure should be deferred as the procedure can flare up a tubal pathology and aggravate the tubal factors of subfertility which is often difficult to diagnose . However, In absence of any palpable pathology, or visible Cervical lesion uterotubal evaluation should be deferred and only to be done after following interventions like

Intervention 1: To be initiated only after 1 yr of trying and after normalization of BMI, life style modifications as appropriate and correction of any medical disorders, if there be any .

Relevance of basal sacn:-Routine day 3 USG is very important, ovarian morphology in particular. Any hydrosalpinx should be noted. .It often so happens that when the couple comes to you (consultant) then a basal scan has been performed .You have to see plate yourself.. One should add L Methyl folate, correct anemia, complete the immunization if due, should insist on deworming if clinician considers essential .To conclude the first phase if tr , I must summarize by saying 1) To suppress PRL is level is > 35 or clinical evidence of Galactorrhoea (current terminology is “Inappropriate lactation” and Metformin according to your conviction & judgment.

Take care of associated minor endocrine aberrations like raised PRL, high TSH, Raised DHEAO4 & insulin resistance . Meanwhile to keep TSH < 2.5 IU/ml. Vit D suppl (insulin sensitizer like Myoinositol) if indicated. Stress free life, Brisk walking in morning / evening at small lanes of your locality /. Open parks/ Fields/ or at least at your roof.

Extra steps for Lifestyle modifications:-Listening to sings and game of your choice and weekly once/ monthly once visiting to religious places of your locality temples will go a long way to make HPO axis ,Hypo- Pit-Adrenal axis normalization, . All these steps helps “Pineal body amygdaloidal nuclei” -- and their subordinate staff i.e. hypothalamus in an ordeal way (harmony) . All these procedures relaxation by 1) playing game of your choice, 2) listening to music of your choice/ reading story books.3) Other Life style modification, 4) visiting religious places once a week/ month will rectify the Lock Down imposed by hidden stress in your body –Amygdala nucleus becomes irritated and cause abnormal firing-> abnormal GnRH pulses by hypothalamus. These steps are at no cost but more important than ovulation inducing agents. These five steps are like to please Lord Shiva of Hindu mythology (the amygdaloidal nucleus and six common Neurohormonal including serotonin) . I am sure that if one can adopt such steps amygdala nucleus is bound to be in order . As a result then other nuclei in the midbrain will be compelled to control their abnormal firing(neuronal impulses) in the form of excess / idle GnRH pulse frequency and amplitude and Corticotrophin impulses will be over if one can satisfy amygdaloidal nucleus .

.Intervention 2 : This step ideally correction of abnormal life style. However this chiefly comprises of three cycles of ovulation induction which should be by Letrozole (first cycle 2.5 mg) and second cycle 5 mg tab for 5 days initiating from Day 3;. If conception don’t ensue after 2-3 cycles of letrozole(monitoring by Fol monitoring, LH kits are often yield poor prediction as is self Cx mucus tets-Spinnbarkeet tests-long thread of say 6-10 cm followed by thick small thread of Cx mucus between her finger tips.) After lifestyle modifications, and 3 cycles of Letrozole it will be our duty to insist on HSG Vs SIS if she is aged 26 yrs and TT(trying time is > 3 yrs) .By and large the working rule is to insist on HSG(or say SIS) after couple of cycles of ovarian stimulation which are non gonadotrophin. My feeling is that if one proceeds for gonadotrophin cycles then ideally such stimulated cycles should follow tubal evaluation. This may be either by traditional HSG or better by Saline Infusion sonography.(SIS) .

Part IV. Why Saline Infusion sonography is preferred?? In my opinion, SIS should be done by an expert sonologist as day care procedure and this procedure has an edge over HSG because polyps, small myoma, adhesions (Ashermans ) are better diagnosed by SIS . This is my personal opinion, I may be wrong as well. Hysterosalpingography (HSG) has been used to evaluate the uterine cavity and the tubal status since decades. It uses iodinated contrast and X-rays and is painful and inconvenient for patient. Laparoscopy is considered to be the gold standard for tubal evaluation, but is an operative procedure and needs anesthesia. Though conventional ultrasound is a modality of choice for assessment of uterus and ovaries, it does not allow assessment of the fallopian tube unless there is any fluid surrounding it or inside the lumen. This fluid interface can be created artificially by introducing saline in the uterine cavity and fallopian tubes and scanning simultaneously.

The procedure is named Saline infusion HSG. Saline infusion sonohysterosalpingography (SIS) can be done with B mode US and Doppler. SIS can demonstrate a patent tube but if blocked, the site of block cannot be demonstrated.

Part V. What do we mean by “hystero-contrast sonography (HyCoSy) ? Ultrasound contrast agents can be used for tubal assessment using contrast mode on the scanners. This procedure is known as hystero-contrast sonography (HyCoSy). This actually shows the passage of hyperechoic contrast agent through tubal lumen and delineates it and locates the site of block. Using the volume ultrasound may even make the demonstration of tubal status and fimbriae better. Results of HyCoSy have been found to correlate well with laparoscopic findings, which are a gold standard. It is recommended by National Institute for Health and Clinical Excellence as a primary investigation for tubal assessment in patients without any positive history of tubal damage and also can replace a second look laparoscopy.

I also have a feeling that these three uterine conditions (synechiae, small polyp/s or small submucous myoma) collectively account for about 7-10% of all cases of F subfertility. All these minor conditions are difficult to palpate clinically and often missed in traditional HSG. Such conditions which chiefly result in implantation failure or result early embryonic demise due to unreceptive endometrium.

Part VI. My answer to her (Ex PGT) : Subfertility with PCO how to investigate & Tr in Indian context?? ::Routine evaluation: I assume that subfertile couple who come to under your treatment has 1) normal seminal parameters with 2) normal sexual relation(availing fertile days at least for 1 yr for women < 30 yrs & trying time should ideally be < 6 months in women above 30 yrs,) . For each type of subfertile women you quoted it will be better to plan the treatment according to her age & months of trying. I also presume you have assessed medical fitness for pregancy, in the sense of Viral screening, STI screening, Hepatitis serology and above all complete haemogram & ruled out Haemoglobinopathies. A Pap smear is appropriate as is Basal Scan on day 3-5 in non-induced cycle, Ovarian volume estimation, its echo structure and AMH History immunization and past medl or surgical history should be elicited , Drug abuse, life style , dietary habits and above all stress can be evaluated with some patients without hurting the couple. Regular intake of drug has to be enquired,. Any past history of miscarriage have to be enquired and cycle regularity and recent weight gain should be enquired. Family h/o Diabetes carries a risk factor for hyperinsulinaemia in fair number of cases. In such women life style modification and 3 yarely lipid profile estimation, LFT profile should be recorded and preserved in her diary.

. But admittedly not all these tests are done in all cases just for financial reason , though all such tets are noninvasive in nature .Such screening procedure is uncommon in most of the rural centers as is uncommon is CBE(Clinical Breast Examination on annual basis after the age of 40yrs).

Part VII: interventions 3: If lifestyle & BMI is controlled and Letrozole have failed then as mentioned earlier SIS/ HSG should be performed. However in cases of adnexal mass / fixity of uterus Lap Hyst procedure should be planned at an earlier date and letrozole induction may be planned after Lap hysteroscopy then after a course of antibiotics for PID (chlamydia related drubs) she should be offered .

PART VIII : The role of Lapraohysteroscopy and in most cases pelvic adhesions of nonspecific nature will be observed or endometriotic spots of varying degrees will be visualized and video recorded. In type B cases HSG or SIS(saline Infusion sonography)/ HSG should better be avoided. Endometriosis is a common cause as is Kochs. A low threshold for pelvic antibiotics, exclusion of Kochs & STI and Tr of Chlamydial infection seems rational and worthy. In fact , though seems illogical often prescribe drugs for chlamydia to both partners on empirical basis( not supported by any academic bodies) .

Part : IX:-Type B cases (say 20% cases) Subfertile women with palpable pelvic mass / Fixity :

Your third type of couple: 3.Pt who tried 3 OI,1 IUI, with irregular cycles. How to work them out? “Ans: As because her cycles are irregular most likely there are some endocrine disorder is there and unless that is diagnosed and rectified it will be difficult for her to conceive. Try to normalize insulin, androgens and PRL, TSH ,etc . Having said that If she is aged > 30 yrs then ART will be better option. The causes of IUI failures are 1) Minimal endometriosis which was unsuspected with resultant poor quality oocytes, and failure to fertilize or poor onward growth potential of fertilized ova to progress beyond blastocyst. 2) Local endometrial pathology 3) abnormal sperm functions, morphology in particular 4) suboptimal training of staff deployed for sperm prepn techniques. 4) Faulty/ poor quality media delayed servicing of incubator or centrifuge machine.

Part X:-- Semen analysis is often done by Hemocytometer method, rarely by Makler's chamber(costly approx Rs 32,000/-) , Micro Cell. Laminar flow is not essential but will add to the result as is change of IUI canula. These have to rectified in consulation with your senior known colleague to whom U personally are acquainted.