Section 1: PhySiology 1 1. Anatomy of the Male and Female Reproductive System 3 Mir Jaffar, BV Srinivas

Male Reproductive System 3; Female Reproductive System 9

2. Oogenesis and Folliculogenesis 15 Mandeep Kaur, PM Gopinath

Primordial Germ Cells 15; Oocyte Formation 16; Postnatal Oogenesis 16; Primordial Follicle Formation 16; Formation of Primary and Secondary Follicles 17; Initial Recruitment 17; Preantral Follicle Development 17; Formation and Role of Gap Junctions 18; Antral Follicle Development 18; Rescue from Atresia or Cyclic Recruitment 19; Role of 2-Cell 2-Gonadotropin Concept in Follicle Selection 19; Selection of a Dominant Follicle 20; Preovulatory Follicle and LH Surge 20; Role of Inhibin and Activin in Folliculogenesis 20; Other Growth Factors 20; Prevention of Premature Luteinization 21; Ovulation 21; Follicular Stimulating Hormone Surge 21; Fall in Estradiol Levels and Shutdown of LH Surge 22; Luteal Phase 22; Luteal Follicular Transition 22

3. Regulation of Menstrual Cycle 26 Arveen Vohra, Nameeta Mokashi Bhalerao, Kamini A Rao

Reproductive Neuroendocrinology 26 The Hypothalamo-Hypophyseal Portal Circulation 27; Hormones in Female Reproduction 28;

Hypothalamic-Pituitary-Ovarian Axis 32; Ovarian Feedback on the Hypothalamus and Pituitary 32

Physiology of Menstrual Cycle 34 Ovarian Cycle 34; Follicular Phase 34; Ovulation 39; Luteal Phase 41; The Luteal-Follicular

Transition 41; Uterine Endometrial Cycle 42; Proliferative or Follicular Phase 43; Secretory or Luteal Phase 43; Implantation Phase 44; Menstrual Phase or Phase of Endometrial Breakdown 44

4. Sperm Production and Migration 50 Manishi Mittal, Kamini A Rao

Primordial Germ Cells 50; Gonadogenesis 50; The Seminiferous Tubules 50; Spermatogenesis 50; Spermiation 53; Epididymal Maturation 53; Endocrine Control 54; Genetic Control 55; Nitric Oxide 55; Blood-testis Barrier 56; Effect of Temperature 57; Seminal Plasma 57; Ejaculation 57; Sperm Migration through the Female Genital Tract 57

5. Ultrastructure of Human Gametes, Fertilization and Embryos in Assisted Reproduction: A Personal Survey 60

A Henry Sathananthan

Review of Early Literature 61; Methodology 61; The Male Gamete 61; The Female Gamete 64; Fertilization 69; Preimplantation Development 74; Abnormal Gametes and Embryos 74

6. Endometrial Receptivity 82 Deepika K

Window of Implantation 82; The Endometrial Cycle—Towards Uterine Receptivity 83; Assessment of Endometrial Receptivity 84; Impact of Ovarian Stimulation on Endometrial Receptivity 92; Endometriomics 94

Contents

Volume 1 Infertility

xx Volume—2 IVF and Laboratory Aspects of Andrology

7. Implantation 106 Deepika K

Preimplantation Embryo Devel opment and Genomic Activation 106; Hatching of the Blastocyst 107; Morphological Steps of Implantation 107; Endocrine Control of Implantation 113; Embryo Maternal Signaling: How the Embryo Dialogues with the Mother to Accomplish Implantation? 114; Immune Acceptance of Pregnancy 116; Summary of Embryo Implantation 119

Section 2: RePRoductive endocRinology 125 8. Hyperprolactinemia and Thyroid Disorders 127 Arati R Rao

Hyperprolactinemia 127 Prolactin: The Hormone 127; Hyperprolactinemia 128

Thyroid Disorders in Infertility 132 Hyperthyroidism 132; Hypothyroidism 134

9. Hirsutism 138 Pramila Kalra

Pathophysiology of Hirsutism 139; Etiology of Hirsutism 140; Investigations 143; Treatment 144

10. Fertility Management in Primary and Secondary Amenorrhea 148 Sathya Balasubramanyam

Primary Amenorrhea 149; Secondary Amenorrhea 152

11. Luteal Phase Defect 155 Sankalp Singh, Swati Singh, CM Ashraf

Pathophysiological Basis of Luteal Phase Abnormality 155; Etiological Factors Linked to Presence of Luteal Phase Defect 156; Assessment of Luteal Phase Defect 159; Treatment of Luteal Phase Defect 160

12. Anovulatory Infertility 165 Abha Majumdar, Mangal Nisha Sharma

World Health Organization Classification of Anovulation 165; WHO Class 1 165; WHO Class 2 167; WHO Class 3 176

Section 3: Male infeRtility 183 13. Etiology and Pathophysiology of Male Infertility 185 PA Baiju

Primary Testicular Disease 185; Scrotal Hyperpyrexia 188; Obesity 188; Gonadotoxic Drugs and Radiation 188; Genetics of Primary Testicular Disease 188; Aging 190; Obstructive Lesions of Male Genital Tract 192; Systemic Diseases 193

14. Clinical and Endocrinological Evaluation of the Infertile Male 196 Usha Sriram

Evaluation of the Infertile Male 196; Main Etiologies of Male Infertility 196; Clinical Evaluation 196; Medications 197; Physical Examination 197; Endocrine Assessment 198; A Stepwise Approach to Male Infertility 199

15. Microbiology of Semen and Male Genital Tract Infections 200 Sachin Narvekar

Diagnosis of Male Genital Tract Infections 200; Specific Bacterial Infections 201; Viruses 204; Leukocytospermia 206

Contents xxi

16. Sexual Dysfunctions in Male Infertility 212 SS Vassan

Biological Basis of Male Sexual Response 212; Pelvic Floor Muscles and Sphincters during Erection and Ejaculation 213; Nonconsummation of Marriage 213; Protocol for Urinary Alkalization 216; Vibratory Stimulation 217; Erectile dysfunction 220

17. Cytogenetics and Molecular Genetics of Male Infertility 227 Jayarama S Kadandale, Swathi Shetty, Pooja S Kulshreshtha

Cytogenetic Abnormalities 227; Genetics of Y Chromosome-Derived Infertility 232; Genetic Testing 236; Genetic Counseling 237

18. Role of Ultrasound in Male Infertility 239 Kuldeep Jain, Bharti Jain

Etiological Distribution 239; Scrotal Ultrasonography 240; Transrectal Ultrasonography and Male Infertility 244

19. Varicocelectomy in Infertile Male 247 Saad Alshahrani, Alaa Hamada, Ashok Agarwal

Diagnosis of Varicocele 247; Grades of Varicocele 248; Origin of Varicocele 248; Varicocele and Male Infertility 248; Pathophysiology of Varicocele 249; Is It Progressive Disease? 250; Management of Varicocele 250; Treatment Modalities 251; Complications 255; Varicocele Repair Outcomes 256

20. Medical Management of Male Infertility 262 N Pandiyan, D Ramesh Raja

Physiology of Spermatogenesis 262; Principles of Medical Management of Male Infertility 263; Empirical Therapy 265

21. Evaluation and Treatment of Azoospermia 266 Rajashekaran, R Jayaganesh, Pankaj Kalotia

Initial Diagnosis of Azoospermia 266; Classification of Azoospermia 266; Initial Evaluation of the Azoospermic Patient 267; Genetic Testing in Patients with Azoospermia 269; Treatment Options for Obstructive Azoospermia 270; Role of Varicocele Repair in Patients with Nonobstructive Azoospermia 272; Recommendation for the Evaluation of Azoospermia 272

22. Sperm Retrieval Techniques for Assisted Reproductive Technologies 275 Srinivas BV, Mir Jaffar

Indications for Surgical Sperm Retrieval 275; Sources of Sperm Retrieval 276; Epididymal Sperm Retrieval Techniques 276; Testicular Sperm Retrieval Techniques 278; Future Trends 281

Section 4: geneRal oveRview 283 23. Patient Selection and Management 285 BN Chakravarty

Identification of Cause (s) and Categorization of Infertile Couples 285; Counseling 289; Management Protocols 290; Overview of Assisted Reproductive Technology—Current Scenario and Future Thoughts 299

24. Immunology in Infertility 310 Kamala Selvaraj, Priya Selvaraj

Etiology 310; Immune System of Our Body 312; ASAB and IVF Outcome 312; Diagnosis 312; Clinical Effects of Antisperm Antibodies 313; Treatment for Antisperm Antibody 316

xxii Volume—2 IVF and Laboratory Aspects of Andrology

25. Environment and Infertility 320 Abha Majumdar, Neeti Tiwari

Mechanism of Action 320; Environment and Infertility 320

26. Declining Fertility 330 Arati R Rao

Section 5: feMale factoR infeRtility 333 27. Evaluation of Infertile Female Patients 335 Sandhya Krishnan, Kamini A Rao

Indications for Initial Evaluation 335; Steps for Evaluation 336; Diagnostic Evaluation 336; Ovulatory Function 336; Ovarian Reserve 337; Uterine Abnormality 338; Tubal Patency 339; Peritoneal Factors 340

28. Uterine and Cervical Factors in Infertility 342 Arati R Rao

The Role of the Cervix in Reproduction 342; Etiology of the Cervical Factor 343; Investigation of the Cervical Factor 343; Cervical Mucus Scoring 343; Postcoital Test 344; Treatment of Cervical Factor 347

The Role of the Uterus in Reproduction 348 Intrauterine Adhesions 348; Leiomyoma 348; Endometrial Polyps 348; Adenomyosis 349;

Congenital Uterine Anomalies 349; Tuberculosis 351; New Biomarkers 351; Investigation of the Uterine Factor 351

29. Tubal Factor of Infertility and Assisted Reproduction 358 Sadhana Desai, Partha Guha Roy

Evaluation of Tubal Factor 358; Assisted Reproductive Technologies versus Tubal Surgery 359; Tubal Infertility and Factors Affecting the ART Result 360; Conventional IVF versus ICSI for Couples with Tubal Factor of Infertility and Normozoospermia 362

30. Evaluation of Fallopian Tube Infertility 365 Sarita Suresh, Pankaj Kalotia, Kamini A Rao

Embryologic Development 365; Anatomy 365; Physiology 366; Pathology and Causes of Tubal Obstruction 367; Fallopian Tube and Infertility 367; Investigations of Tubal Infertility 367; Tubal Tuberculosis: Features on Hysterosalpingography 369

31. Infections and Infertility 386 Pankaj Desai

General Aspects of Infections and Infertility 386; Specific Infections: Pelvic Tuberculosis and Infertility 387; Specific Infections: Chlamydia 392; Specific Infections: Gonorrhea 394; Specific Infections: Mycoplasma 395; Nonspecific Pelvic Infection 396

32. Genital Tuberculosis and Infertility 399 Sonia Malik, Vandana Bhatia

Incidence of Genital Tuberculosis 399; Pathophysiology 399; Genital Tuberculosis and Infertility 399; Active Tuberculosis 400; Latent Tuberculosis 400; Restoring Fertility in Tuberculosis 401; Dilemmas in Management 402

33. Transvaginal Ultrasound and Doppler in Infertility 404 Sonal Panchal, CB Nagori

Diagnosis of Abnormalities Causing Subfertility 404; Cycle Assessment 422

Contents xxiii

34. Endoscopy in Infertility 435 Nutan Jain, Tania G Singh, Vandana Jain, Anubha Arora

Laparoscopy in Infertility 435 Laparoscopic Surgery on Uterus 435; Laparoscopic Tubal Surgery 437; Endometriosis 443;

Laparoscopic Ovarian Surgery 445

Hysteroscopy in Infertility 448 Role in In Vitro Fertilization 448; Submucous Fibroids 449; Hysteroscopic Tubal Cannulation for

Proximal Tubal Block 451; Hysteroscopy for Metroplasty 453; Intrauterine Adhesions (Asherman’s Syndrome) 456

35. Assessment of Ovarian Reserve 459 Nameeta Mokashi Bhalerao, Kamini A Rao

Variability of Reproductive Aging 459; Ovarian Reserve 459; Diagnostic or Screening Test 460; Clinical Markers 460; Endocrine Markers 461; Endocrine Dynamic Tests 463; Ultrasonographic Markers 464; Clinical Implications of Ovarian Reserve Tests in ART Practice 464

36. Endometriosis in Infertility 469 Rakesh Sinha, Shweta Raje, Gayatri Rao

Localization and Appearance of Endometriosis 469; Diagnosis and Staging 471; Treatment 472; Management of Ovarian Endometrioma before IVF 476; Stage of Endometriosis and Surgery Outcome 477; Endometriosis and Infertility: Guidelines by the Practice Committee of American Society of Reproductive Medicine 2012 477

37. Interventional and Surgical Management of Fibroids with Infertility 480 Ritika Arora, Mala Arora

How Fibroids Cause Infertility 480; Should All Myomas be Treated in Women Seeking Fertility?; 480 Nonmedical Management of Uterine Fibroids 480; Steps of Laparoscopic Myomectomy 483

38. Reconstructive Surgeries Enhancing Fertility 494 Amr H Wahba, Ahmed Hussein, Osama Shawki

Reconstruction of Distorted Pelvic Anatomy 494; Reconstruction of Blocked Fallopian Tubes 496; Reconstruction of Distorted Uterine Cavity 497

39. Obesity in Infertility Practice 505 Nivedita Shetty

Defining Obesity 505; Obesity and Reproductive Health 506

40. Unexplained Infertility 514 Pratap Kumar

Chances of Conception and Age 514; Testing for Unexplained Infertility 514; Embryo Development and Genetics Control 515; Uterine Receptivity and Unexplained Infertility 515; Molecular Control of the Implantation Window 515; Treatment 516

41. Fertility Preservation in Female Patients 519 Bina Vasan

Balancing Cancer and Fertility 519; Assisted Reproduction and Fertility Preservation 519; Breast Cancer 520; Cancer of the Cervix 520; Endometrial Cancer 520; Childhood Cancers 521; Lymphomas 521; Autoimmune Diseases 521; Benign Ovarian Diseases 521; Effect of Cancer Treatment on Female Fertility 522; Established Methods for Fertility Preservation 522; Obstacles to Fertility Preservation 524; Ethical Dilemmas 524

xxiv Volume—2 IVF and Laboratory Aspects of Andrology

Section 6: ovulation induction 527 42. Drugs for Controlled Ovarian Stimulation 529 Rishma Dhillon Pai, Hrishikesh Pai, Nandan Roongta

The Drugs 529; Adjuncts for Ovarian Stimulation 535

43. Superovulation Strategies in Assisted Conception 538 Duru Shah, Shefali Bansal

Gonadotropin Preparations 538; Recombinant Gonadotropins 539; Long-acting Gonadotropins 539; Protocols for Stimulation with Gonadotropins 539; Premature Luteinizing Hormone Surge 540; Gonadotropin-releasing Hormone Agonists 540; Gonadotropin-Releasing Hormone Antagonists 543; Comparison of Gonadotropin-Releasing Hormone Agonist versus Antagonist Protocols 545; Clinical Applications of Ovarian Stimulation Protocols 545; World Health Organization Classification for Anovulation 547; Luteal Phase Support in Controlled Ovarian Stimulation 549; Assessment of Ovarian Reserve 549

44. Agonists in Reproductive Medicine 552 CV Kannaki Uthraraj

Gonadotropin-releasing Hormone: The Molecule and Mechanism of Action 552; Preparations 553; Dosage 553; Side Effects 553; Agonist in Controlled Ovarian Hyperstimulation: Suppression of Luteinizing Hormone 554; Comparative Studies of Agonist and Antagonist Protocols 556; Choice of Agonist Protocols According to the Response Profile 556; Results of the IVF Survey of the Use of Agonist Protocols 558; Agonist as a Trigger 558; Agonist in the Treatment of Endometriosis 558; Agonist and Fibroid Management 559; Agonists in Precocious Puberty 559; Agonists for Gonadal Protection During Chemotherapy 559

45. GnRH Antagonists 562 Divya Sardana, Kamini A Rao

Structure 562; Mechanism of Action 562; Dosage 563; Antagonist Protocols 563; Pharmacodynamics and Pharmacokinetics 564; Evidence-Based Practice 565; Oral Contraceptive Pill Preprogramming 566; Increasing the Dose of Gonadotropins with Antagonist 566; Special Subgroups 566; Alternative GnRH-Antagonist Protocols 567; Other uses of Antagonists 568

46. Monitoring of Ovulation Induction 573 Nandita Palshetkar, Hrishikesh Pai, Nandan Roongta, Rohan Palshetkar

Monitoring the Ovulation Induction Cycle 573; Extent of Monitoring 573; Home Monitoring 574; Clinical Monitoring 575; Minimal Monitoring 579; Prevention of Ovarian Hyperstimulation Syndrome 580

47. Ovulation Triggers and the Role of Gonadotropin-releasing Hormone Agonist Trigger in Assisted Reproduction 582 Korula George, Mohan Kamath

48. Individualized Ovarian Stimulation 586 Priya Bhave Chittawar

Why Individualization of Ovarian Stimulation is Required in In Vitro Fertilization Cycles? 586; How to Individualize Ovarian Stimulation? 587; Using the Ovarian Reserve Tests in Combination to Form Predictive Models 588

49. Mild Approaches in Assisted Reproduction 594 Mohan Kamath, Korula George

Types of Milder Protocols 594; Embryo Quality/Endometrial Receptivity 597; Future Trends 597

Contents xxv

50. Role of LH in Ovarian Stimulation 599 GAA Ramaraju, Mamata Deendayal, Devika Gunasheela, R Gutgutia, Geeta Haripriya, Mirudubhashini, Nayana Patel, Ameet Patki

Role of Luteinizing Hormone in Physiology: The Physiological Hormonal Interplay 600; Pharmacogenomics and Ovarian Stimulation 601

51. Progesterone in Ovarian Stimulation 607 Harpreet Kaur, Kamini A Rao

Source of Progesterone 608; Profiles During Ovarian Stimulation 608; Clinical Implications of High Progesterone During Ovarian Stimulation 608; Proposals for Prevention of Premature Progesterone Rise 609

52. Understanding the Prognostic Factors and Optimizing In Vitro Fertilization Outcome 611 Nivedita Shetty

Prior to Controlled Ovarian Stimulation 611; During Controlled Ovarian Stimulation 616; During Oocyte Retrieval 616; After Oocyte Retrieval 617

53. Luteal Phase Support 622 Umesh N Jindal, Swati Verma

Luteal Phase Deficiency 623; Luteal Phase Support 624; Onset and Discontinuation of Luteal Phase Support 626

Section 7: aRtificial inSeMination 629 54. Intrauterine Insemination 631 Natachandra Chimote, Nishad Chimote, Bindu Mehta

Utilization of Intrauterine Insemination 631; Indications for Intrauterine Insemination Treatment 631; Intrauterine Insemination Procedures and Insemination Methods 633; Types of Intrauterine Insemination Catheters 634; Timing of Insemination 634; Outcome of Intrauterine Insemination Cycles 634; Intrauterine Insemination in Cycles Stimulated with Clomiphene 635; Ovarian Stimulation with Gonadotropins 635; Intrauterine Insemination in Follicle Stimulating Hormone-Stimulated Cycles 636; Conditions Affecting the Prognosis 637; The Premature Luteinizing Hormone Surge in Intrauterine Insemination Cycles 638; Luteal Phase Support: Is it Necessary in Stimulated Intrauterine Insemination Cycles? 638; Luteal Phase after Ovarian Stimulation 638; Clinical Decisions about Intrauterine Insemination and In Vitro Fertilization 639; The Background Prognosis 639; Treatment Plan 639; Counseling Couples 640; Prevention of Multiple Pregnancy 640; Cost-effectiveness 640

55. Optimizing Success in Intrauterine Insemination 645 Sheila Balakrishnan

Indications 645; Factors Optimizing Success 646

Section 8: aSSiSted RePRoductive technologieS 651 56. Anesthesia and In Vitro Fertilization 653 Divya Sardana, Ravikumar, Kamini A Rao

Types of Anesthesia 653

57. Oocyte Retrieval 658 Rajesh Chaudhary, Kamini A Rao

Historical Review 658; Mode of Oocyte Retrieval 658; Planning Oocyte Retrieval 659; Anesthesia to Conscious Sedation/Analgesia 660; Preparation 660; Transvaginal Oocyte Retrieval

xxvi Volume—2 IVF and Laboratory Aspects of Andrology

Procedure 661; Oocyte Retrieval in Special Situations 665; Complications 667; Troubleshooting 667; Learning Curve 668

58. Embryo Transfer 672 Gautam N Allahbadia, Akanksha Allahbadia, Rubina Merchant, Goral N Gandhi

Clinical Discussion 673; Recent Advances 678

Section 9: dileMMaS in aSSiSted RePRoductive technologieS 683 59. Role of Adjuvant Therapy in In Vitro Fertilization 685 Chandrika Kulkarni, Kamini A Rao

Adjuvants for Ovarian Stimulation in Poor Responders 685; Adjuvants for Hyper-responders 688; Others 689; Adjuvants for Improving Endometrial Receptivity 690

60. Altering Management Strategies in Women with a Poor Response to Ovarian Stimulation 697 Late Mehroo D Hansotia, Jaydeep D Tank

Predicting a Poor Response 698; Altering Strategies for Poor Responders 699; Alternative Strategies 701

61. Recurrent Implantation Failure 704 Madhuri Patil

Etiology 704

62. Empty Follicle Syndrome 724 K Jayakrishnan

Classification 724; Incidence 724; Underlying Mechanism 724; Prognosis 726; Management Options 726

63. Elective Single Embryo Transfer 730 Gautam Khastgir

Risks of Multiple Pregnancies for Children 730; Risks of Multiple Pregnancies for Mother 731; Outcome of Elective Single Embryo Transfer 731; Criteria for Elective Single Embryo Transfer 733; Embryo Quality for Elective Single Embryo Transfer 734; Improved Outcome Even in Singletons with eSET 735; Health Economic Aspects of Single Embryo Transfer 736

64. Role of Aneuploidy Screening in Preimplantation Embryos 741 Howard Carp, B Feldman

Target and Timing of Pregestational Screening 741; Techniques 742; Pitfalls 743; Results of Pregestational Screening 743; Authors’ Recommendations 744

65. Epigenetics, Imprinting Errors and IVF 746 Padma Rekha Jirge

Epigenetics and Genomic Imprinting 746; Imprinting Disorders and ART 747

Section 10: coMPlicationS of aSSiSted RePRoductive techniqueS 751 66. Ovarian Hyperstimulation Syndrome: Clinical Aspects 753 Joseph G Schenker, Yoel Shufaro

Classification of Ovarian Hyperstimulation Syndrome 753; Complications 754; Incidence 755; Risk Factors 755; Pathogenesis of Ovarian Hyperstimulation Syndrome 755; Human Chorionic Gonadotropin 757; Treatment 757; Prevention 758

67. Ectopic Pregnancy 761 PG Paul, Harneet Kaur, Dimple K, Gaurav Chopade

Epidemiology and Risk Factors 761; Diagnosis 761; Management Options 762; Laparoscopic Surgery 763; Salpingostomy 763; Segmental Excision 766; Salpingectomy 766; Old Ectopic 766; Nontubal Ectopic Pregnancy 767; Reproductive Outcome 767

Contents xxvii

68. Iatrogenic Multiple Pregnancy and Assisted Reproductive Technologies 770 Veronica Irene Yuel

Incidence 770; Risks Associated with Multiple Pregnancies 770; Strategies to Reduce the Risk of Multiple Pregnancies During Assisted Reproductive Technologies 772

69. Fetal Reduction 776 Revathi S Rajan, Kamini A Rao

Background 776; Medicolegal Issues and Psychological Impact 776; Procedure 777; Methods 777; Prerequisites 777; Technique 778; Other Methods 779; Potassium Chloride 779; Complications 779; Failed Reduction 779; Selective Reduction 779; Studies on Fetal Reduction 779

70. Oncogenic Risk Related to Assisted Reproductive Technology 782 Manish Banker, Pravin Patel, Varsha Chauhan, Aarti Gupte, Hetal Benani, Dipesh Sorathia

Possible Mechanisms for Oncogenicity 782; Assisted Reproductive Technology and Maternal Oncogenic Risk 782

Section 11: thiRd PaRty RePRoduction 789 71. Oocyte and Embryo Donation 791 Ameet Patki, Alok Sharma

Indications for Donor Oocyte 791; Evaluation of Oocyte Recipients 792; Evaluation of the Partner of the Oocyte Recipient 792; Selection of the Donor 792; Pretreatment Evaluation of Endometrial Receptivity 794; Results of Donor Oocyte Programs 795; Legal Implications of Donor Oocyte Program 795; Embryo Donation 795; Ethical and Social Implications 796; Recent Advances 796

72. Oocyte Sharing Program 798 Devika Gunasheela, Jyothi Patil, Ashwini S

History of Egg Sharing in United Kingdom 798; Indications for Oocyte Donation 799; Sources of Oocyte Donors 800; Egg Sharing 800; Evaluation of the Oocyte Recipient 800; Evaluation of the Partner of the Oocyte Recipient 801; Selection and Screening of the Donor 801; Payment to the Donor 802; Counseling 802; Protocol for the Donor and Recipient 802; Outcomes 804; Ethical and Moral Issues 804

73. Surrogacy 807 Jaideep Malhotra, Narendra Malhotra, Nayna Patel, Parul Arora, Neharika Malhotra Bora

Indications for Treatment by Surrogacy 808; Patient Selection 808; Selection of the Surrogate 808; Screening of the Surrogate 808; Counseling 810; Cycle Management 810; Replacement in a Controlled Cycle 810; Surrogacy and Law 810; Ethical Issues 811; Suggestions 811

74. Challenges Faced in Setting-up of a Surrogate House within the ICMR Guidelines 819 Nayna Patel

Advantages of Having a Surrogate House 819; Assisted Reproductive Technologies 2008 Guidelines 819

75. Adoption 821 Jaideep Malhotra, Narendra Malhotra, Parul Arora, Keshav Malhotra

Adoption Types 822; Who can Adopt? 822; Adoption Issues 823

Section 12: MiScellaneouS 825 76. Batch In Vitro Fertilization: Practical Considerations 827 Ashadeep Chandrareddy, Baiju Ahmed Kutty, Seema Pandey

Batch In Vitro Fertilization 827; Different Types of Settings where Batching is Done 827; Preparation for a Batch 828; Batch 828; Advantages of Batching 830; Disadvantages of Batching 830; Strategies to Optimize Outcome in Batch IVF 831

xxviii Volume—2 IVF and Laboratory Aspects of Andrology

77. Alternatives to Assisted Reproductive Technology 834 Nalini Mahajan

Alternatives to Intrauterine Insemination 834; Alternatives to In Vitro Fertilization 834; Indications 834; Treatment Protocol 834; Alternatives to Intrauterine Insemination 835; Alternatives to In Vitro Fertilization 837

78. Endometrial Preparation in Frozen-thawed Embryo Transfer 841 Shivani Singh, Shalu Gupta, Nalini Mahajan

Advantages of FET 841; Main Indications of Freezing the Embryos in ART Cycle 841; Natural Cycle FET 842; Modified Natural Cycle FET 842; Stimulated FET Cycles 843; Hormone Replacement Cycle FET 843; Ovarian Downregulation with GnRH Analogs with Hormone Replacement Cycle FET 844; Programming of FET Cycles in Terms of Thawing and Transfer 844; Adjuvant Therapy for Improving Endometrial Receptivity in FET 845

Section 13: outcoMe following aSSiSted RePRoductive technologieS 849 79. Obstetric Outcome Following Assisted Reproductive Technology 851 Sunita Tandulwadkar, Bhavana Mittal, Vineeta Kharb, Nirzari Mangeshikar

Comparison of Pregnancy Outcome in Fertile versus Subfertile Women 851; Comparison of the Pregnancy Outcomes of Subfertile Women after Infertility Treatment and in Naturally Conceived Pregnancies 851; Comparison of Pregnancy Outcome in Fertile Women versus ART Pregnancies in Subfertile Women 852; Comparison of Pregnancy Outcome in Natural Conception in Subfertile Women/Use of Ovulation Induction (with or without Intrauterine Insemination), and Use of In Vitro Fertilization 853

80. Outcome of Children Born through Assisted Reproductive Technology 855 Mandeep Kaur, Kamini A Rao

Hurdles before Livebirth 855; Assisted Reproductive Technology Couples 856; Congenital Abnormality 856; Multiple Pregnancies 857; Outcome in Singleton Pregnancies 858; Neonatal and Childhood Development 858; Psychological Concerns 859

Section 14: gRief counSeling 863 81. Counseling in Infertility and with Assisted Reproductive Technologies 865 Prathap Tharyan

Infertility is a Global Problem 865; Infertility, and Its Treatment, is Associated with Considerable Distress 865; Counseling in Infertility and ART 866

Section 15: ethical and legal iSSueS 873 82. The Ethical, Legal and Social Issues of Modern Assisted Reproductive Technology Treatment 875 Jayam Kannan, RK Sharma, Robert Fischer

Reporting Regulations 875; Financial Aspect for ART Treatment 875; Preimplantation Genetic Testing 876; Fertility Preservation 876; Gamete Donation 876; Embryo Donation 877; Surrogacy and Gestational Carriers 877; Possible Deleterious Effects of ART 877; The Ethicolegal Scenario of Infertility Treatment in India 878

Section 16: futuRe clinical aPPlicationS 883 83. Endometrial Stem Cells and Reproduction 885 Satish Patki, Ujjwala Patki

Stem Cells in the Endometrium 885; Components of the Endometrium and their Originating Stem Cell Types 886; Role of the Endometrial Stem Cells in the Establishment of the Pregnancy 886; Local Injury to the Endometrium and the Stem Cell-mediated Improvement in the Implantation Process 887; The Endometrial Stem Cell Culture “In Vitro” 888; Endometrial Reconstruction with the Stem Cells 888; Stem Cells and Pathogenesis of Endometriosis 888

Contents xxix

Volume 2 IVF and Laboratory Aspects of Andrology

Section 17: andRology 893 84. Semen Analysis in 21st Century Medicine: A Paradigm Shift 895 Vasan SS

The American Urological Association (AUA) Best Practice Policy and the American Society for Reproductive Medicine (ASRM) Practice Committee Report 895; The Probabilistic Nature of Human Fertility 895; Semen Analysis 895; WHO Fifth Manual: Was there a Need for a Shift in Approach of Assessment? 896; Differences in Assessment between 4th Edition as Compared to the 5th Edition of WHO Manual 899; Historical Aspects on Attempts to Define Lowest Levels of Semen Parameters Usually not Associated with Infertility 903

85. Sperm Chromatin Assessment 906 Priya Kannan

Clinical Significance 906; Causes of Sperm DNA Damage 907; Assays for Detection of Sperm DNA Integrity 907

86. Ejaculatory Failure 911 Rupin Shah

Pathophysiology 911; Clinical Classification 911; Sperm Retrieval Techniques 912

87. Sperm Preparation in Assisted Conception: Laboratory Techniques 915 Natachandra Chimote, Nishad Chimote, Bindu Mehta

Semen Collection 916; Semen Analysis 916; Medium for Sperm Preparation 916; Selecting Sperm Preparation Techniques 917; Alternative Methods 921

88. Semen Banking 924 Natachandra Chimote, Nishad Chimote, Bindu Mehta

Techniques for Cryopreservation 925; Effect of Cryopreservation on DNA of Sperm 928; Reproductive Outcome with Cryopreserved Semen 928; ICMR Guidelines for Semen Banks 929

Section 18: eMbRyology 935 89. History of In Vitro Fertilization 937 Neelima Gupta

History of In Vitro Fertilization: The Milestones 938; The Future 953

90. In Vitro Fertilization and Embryo Transfer 959 Haifa Honeneih, Kannamannadiar Jayaprakasan, Alex C Varghese

IVF Laboratory and Culture Systems 959; Oocyte Retrieval 960; Fertilization 962; Embryo Transfer 971

91. Intracytoplasmic Sperm Injection 973 Alex C Varghese, Giles Palmer

Indications for ICSI 973; Location of ICSI Set-up 973; Choice of Microtools 974; Microinjection 974; Intracytoplasmic Sperm Injection: Procedure and Equipment 974; Intracytoplasmic Morphologically Selected Sperm Injection 980; Automation of ICSI 982

92. Analysis of Fertilization 985 Nandita Palshetkar, Hrishikesh Pai, Nandan Roongta

The Physiology of Fertilization 985; Fertilization in Assisted Reproductive Technology 986; Noninvasive Evaluation of the Zygote 987; Abnormal Fertilization 988; Assessment Techniques 990

xxx Volume—2 IVF and Laboratory Aspects of Andrology

93. Morphological Assessment of Oocyte and Embryo 992 Vijay Mangoli, Ranjana Mangoli

Oocyte 992; Zygote 997; Early Cleavage 998; Cleavage Stage Embryos 998

94. Blastocyst Culture and Transfer 1003 Rajvi H Mehta

Why Culture Embryos to the Blastocyst Stage In Vitro? 1003; Morphological Evaluation of Blastocysts 1004; Factors Influencing Blastocyst Development 1005; Advantages and Applications of Blastocyst Culture 1006; Limitations of Blastocyst Transfer 1006; Obstetric and Perinatal Outcomes 1007

95. Advantages and Disadvantages of Embryo Transfer on Day 2, Day 3 and Blastocyst Stage 1010 Vijay Mangoli, Ranjana Mangoli

Embryogenesis 1010; Is Blastocyst Stage Transfer Advantageous? 1012

96. Embryo Transfer Techniques 1016 Hrishikesh Pai, Nandita Palshetkar, Rishma Dhillon Pai, Nandan Roongta

Pre-embryo Transfer 1016; Procedure of Embryo Transfer 1019; Embryo Transfer Procedure 1023; Embryo Transfer: Troubleshooting 1025; Preventing an Ectopic Following Embryo Transfer 1027; Variations of Embryo Transfer Technique 1027

97. Cryopreservation of Oocytes and Embryos by Slow Freezing Method 1031 Varsha Samson Roy

Historical Aspects 1031; Need for Oocyte Cryopreservation 1032; Advantages of Embryo Freezing 1032; Cryobiological Principles of Slow Freezing 1032; Selection of Embryos for Freezing 1033; Role of Assisted Hatching in Frozen Embryos 1033; General Rules for Freezing and Thawing 1034; Slow Cooling of Human Oocytes 1034; Safety of Oocyte and Embryo Freezing 1037

98. Oocyte Vitrification 1039 Varsha Samson Roy

Medical Indications of Oocyte Freezing 1039; Cryobiology—Vitrification 1040; Cryoprotectants 1040; Cryotools 1040; With or Without Cumulus Cells 1041; Temperature at Vitrification 1041; Oocyte Cryopreservation-induced Stress 1041; Disease Transmission Issues 1042; Protocols for Oocyte Vitrification 1042; Protocol for Oocyte Warming 1043

99. Vitrification 1046 Gaurav Majumdar

Principle of Vitrification 1046; Various Factors Determine Ultimate Survival 1047; Vitrification: Closed Systems 1049

Section 19: advanceS in aSSiSted RePRoductive technologieS 1053 100. Assisted Hatching 1055 Gaurav Majumdar

Causes for Impaired Hatching 1055; Plausible Mechanisms 1056; Pitfalls of Assisted Hatching 1056; Selection for Embryo Hatching 1056; Overview of Techniques 1057; Medical Management 1059

101. Embryo Biopsy for Preimplantation Genetic Diagnosis 1061 Shailaja Gada Saxena, Prabhat Ranjan

Evolution of Embryo Biopsy 1061; Steps Involved in Embryo Biopsy 1061; Timing of Embryo Biopsy 1063; Postbiopsy Embryo Development 1065; Role of Cryopreservation 1065

Contents xxxi

102. In Vitro Maturation of Oocytes: A Practical Approach 1068 Varsha Samson Roy

Oocyte Maturation In Vivo 1068; Advantages and Indications for IVM 1069; Clinical Aspects of IVM 1069; Role of hCG in IVM 1070; IVM Aspiration 1070; Oocyte Identification 1070; IVM Culture 1071; Assessment of Oocyte Maturity 1071; Fertilization of IVM Oocytes 1072; Embryo Development 1072; Protein Synthesis 1072; Pregnancy Rates with IVM 1072; Safety of IVM 1073

103. Ovarian Tissue Cryopreservation 1076 Balaji Prasath, Amr Kader, Sujatha R, Alex C Varghese

Cryobiology of Ovarian Tissue 1076; Ovarian Tissue Cryopreservation in Humans 1077; How to Obtain Ovarian Tissue? 1078; Vitrification 1080; Modified Slow Freezing 1085; Sites of Transplantation 1086; Additional Approaches with Ovarian Tissue Cryopreservation 1087; Ethical Concerns in Ovarian Tissue Cryopreservation 1087

104. Time-lapse Video for Assessing the Embryos 1092 Vineet Mishra

How Time-lapse Monitoring Helps? 1092; Time-lapse Technologies in IVF Laboratories 1092; Features of Time-lapse Monitoring 1093; Embryo Selection Parameters 1093; Documented Morphological Selection Criteria 1093; Safety Studies Conducted with the Time-lapse Video 1094; Limitations of Time-lapse Systems and Early Morphokinetic Markers 1094; Images of Embryos Cultured in Embryoscope 1094

105. Polarization Microscopy and Its Clinical Applications 1097 Deepika K, Dileep Kumar R

Principle 1097; Device 1097; Spindle Imaging 1098; Zona Imaging 1102; Sperm Selection 1104

106. OMICS 1108 Jyoti Bali, Hrishikesh Pai

Metabolomics 1109; Analytical Technologies 1110; The Embryonic Proteome 1113; The Embryonic Secretome 1114; Genomics 1114

107. IMSI and Its Clinical Significance 1118 VM Thomas, R Ramya

IMSI Procedure 1118; Microscope Equipment 1119; MSOME Criteria for IMSI 1120; Clinical Significance of IMSI 1120; IMSI for All 1121; IMSI and Severe Male Factor Infertility 1121; IMSI and Sperm DNA Fragmentation 1121; IMSI and Routine Semen Analysis 1122; IMSI and Prolonged Sperm Manipulation 1122

108. Microfluidics in Assisted Reproductive Technology 1124 Viloria Tamara, Ana Cobo, Josep Lluís Romero, Marcos Meseguer, María José de los Santos

Manufacturing Microfluidic Devices 1125; Sperm Isolation 1125; Oocytes Denudation 1126; In Vitro Fertilization 1126; Embryo Culture 1128; Integrated Platforms 1130; Microfluidics for Automated Vitrification 1132

Section 20: ethical and legal iSSueS 1135 109. Certification and Accreditation: Relevance to an IVF Center 1137 Achala Mohan

Certification 1137; Accreditation 1138

110. Accreditation of an Assisted Reproductive Technology Laboratory 1142 Rajvi H Mehta

Introduction and Background 1142; Need for Accreditation 1142; National and International Guidelines on Assisted Reproductive Technology 1142; Validation of whether the Guidelines are

xxxii Volume—2 IVF and Laboratory Aspects of Andrology

Followed or Not 1143; Accreditation as an Indicator of Quality Assurance 1143; International Principles of Accreditation 1143; International Standards Organization 1144; Quality Assurance in Assisted Reproductive Technology 1144; Documentation for Quality Assurance and Certification 1144

Section 21: laboRatoRy ManageMent 1147 111. Setting-up an ART Laboratory 1149 Madhuri Patil

Layout and Components of an ART Laboratory 1149; Construction and Selection of Building Material 1150; “Burning in” of the Completed ART Laboratory before Use 1151; Essential Equipment for the ART Laboratory 1151; Newer Equipment 1156; Consumables Required for the ART Laboratory 1160; Important Facts 1163; Equipment Required for Clinical Procedures 1164; Personnel and Experience 1164; Maintenance and Discipline in ART Laboratory 1165; Quality Control and Assurance 1167; Quality Control Procedures 1167

112. Quality Control of In Vitro Fertilization Laboratory 1169 Ratna Chattopadhyay, BN Chakravarty

Markers of Quality of an IVF Laboratory 1169; Minimum Physical Requirements for an ART Clinic 1170; Essential Equipment and Their Maintenance 1172; Record Keeping and Documentation 1175; Essential Qualifications of the ART Team 1175; Training and Upgrading of Knowledge of the ART Team Members 1176; Maintenance of “Code of Practice” 1176; Future Thoughts regarding Improvement of Outcome or Quality of the Laboratory 1176

113. Embryo Culture Systems 1178 Goral N Gandhi, Gautam N Allahbadia, Sakina Kagalwala, Monali Madne, Ramya Ramani, Varsha Chipkar

Culture Media 1178; Media Systems 1180; Culture Conditions 1181; Media Storage and Equilibration 1182; Incubators 1182; Air Purification Unit 1182; Quality Control 1183

114. Micromanipulators 1186 Mir Jaffar, Theodore Jones, Dileep Kumar R, Kamini A Rao

Micromanipulators 1186; Microinjectors 1191

115. Troubleshooting in Assisted Reproductive Technology 1194 Priya Selvaraj, Kamala Selvaraj

Reporting Success 1194; Contributory Parameters 1195; Clinical Parameters 1195; Laboratory Parameters 1198; Ideal Laboratory Working Conditions 1198; Culture Parameters: Checklist 1201; Ten Tips for Good ART Practices 1202; Optimizing Embryo Transfer Technique 1203; Target for Success 1203

Index 1205

1. Oocyte Cumulus Complex Evaluation 1 Kamini A Rao, Divyashree PS

Mature Oocyte Corona Cumulus 2; Approximately Mature Oocyte Corona Cumulus 2; Immature Oocyte Corona Cumulus 3; Postmature Oocyte Corona Cumulus 3; Atretic Oocyte Corona Cumulus 4

2. Oocyte Nuclear Maturity Evaluation 5 Divyashree PS, Kamini A Rao, Anu Kottur

Metaphase II 6; Metaphase I 6; Germinal Vesicle Oocyte (40x) 7; Germinal Vesicle Oocyte (20x) 7; Oocytes in Different Stages of Maturation 8

3. Oocyte Dysmorphisms 9 Divyashree PS, Bezar Ghan VV, Kamini A Rao

Granular Cytoplasm 10; Vacuoles 11; Smooth Endoplasmic Reticulum Cluster 13; Refractile Bodies 14; Polar Body 15; Perivitelline Space 18; Zona Pellucida 20

4. The Sperm 25 Anitha S Kumari K, Dileep Kumar R, Hemanth Kumar MA

Sperm Count and Motility 26; Sperm Morphology 27; Sperm Viability 28; Sperm Viability by Hypo-osmotic Swelling Test 29; DNA Fragmentation Index 30

5. Normal Embryo Development 31 Bezar Ghan VV, Divyashree PS, Kamini A Rao

Pronuclear Stage 32; Syngamy 32; Two-cell Stage 33; Four-cell Stage 33; Eight-cell Stage 34; Compaction 34; Early Blastocysts 35; Expanded Blastocysts 35; Hatching Blastocysts 36; Hatched Blastocysts 36

6. Embryo Scoring 37 Bezar Ghan VV, Divyashree PS, Anitha S Kumari K

Symmetrical Pronuclei 37; Nonsymmetrical Pronuclei 39; Abnormal Pronuclei 40; Two-cell Grade 1 Embryos 42; Two-cell Grade 2 Embryos 43; Four-cell Grade 1 Embryos 44; Four-cell Grade 2 Embryos 45; Four-cell Grade 3 Embryos 46; Eight-cell Grade 1 Embryos 47; Eight-cell Grade 2 Embryos 48; Eight-cell Grade 3 Embryos 49; Grade 1, Day 4 Embryos 50; Grade 2, Day 4 Embryos 51; Grade 3, Day 4 Embryos 52; Early Blastocyst 54; Blastocyst 57; Expanded Blastocyst 58; Hatching Blastocysts 61; Hatched Blastocysts 62

7. In Vitro Fertilization/Intracytoplasmic Sperm Injection 64 Bezar Ghan VV, Divyashree PS

Oocyte Insemination in IVF 64; Intracytoplasmic Sperm Injection 65

8. Advanced Techniques 74 Anitha S Kumari K, Bezar Ghan VV, Divyashree PS, Dileep Kumar R, Anu Kottur, Kamini A Rao

Physiological Intracytoplasmic Sperm Injection 74 Anitha S Kumari K, Bezar Ghan VV, Divyashree PS

Picsi Dish 74

Contents

Volume 3 Atlas of Human Embryology

xvi Volume—3 Atlas of Human Embryology

Intracytoplasmic Morphologically Selected Sperm Injection 76 Bezar Ghan VV, Dileep Kumar R, Anitha S Kumari K , Divyashree PS

Poloscopy 77 Divyashree PS, Bezar Ghan VV, Anu Kottur

Time-lapse Imaging 80 Divyashree PS, Anitha S Kumari K, Bezar Ghan VV Laser-assisted Hatching 83 Bezar Ghan VV, Divyashree PS, Kamini A Rao

9. Cryopreservation 86 Bezar Ghan VV, Anitha S Kumari K, Divyashree PS

Cryopreservation of Oocytes 86; Cryopreservation of Embryos 94; Blastocyst Cryopreservation 104; Blastocyst Warming 107

10. Assisted Reproductive Technology Lab Setting 112 Divyashree PS, Hemanth Kumar MA, Dileep Kumar R

Essential Equipment of ART Lab 112; Laminar Flow Cabinets 113; Incubators 114; Essential Equipment for Clinical Procedures 121

Index 133