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CASE STUDY

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had to find an answer. With a Google search, he stumbled upon Malpani Infertility Clinic (www.drmalpani.com), an infertility treatment clinic in Mumbai, which is often ranked in the top five infertility clinics in India. For the first time, Hameed came across the treatment option of testicular sperm extraction with intracytoplasmic sperm injection (TESEICSI). The collection of testicular sperm directly from the testes allows doctors to help men with azoospermia to procreate with their own sperm. But India was far away. When Hameed enquired with IVF clinics in Pakistan, he was told that this particular advanced procedure required a lot of technical expertise and was not available in Pakistan. For the love of his unborn child, Hameed decided to become a reproductive tourist and emailed Malpani Infertility Clinic. The couple flew into Mumbai and the moment they stepped into Malpani Infertility Clinic, Hameed was informed that a single testis biopsy is not necessarily representative of spermatogenic activity in all parts of the testis. One choice was TESE-ICSI, with a 20 per cent chance of finding testicular sperm on multiple testicular biopsies. In order to treat patients with obstructive azoospermia, using sperm from the epididymis and testis for ICSI is logical. Soon after, Dr Aniruddha and Anjali Malpani proceeded with Hameeds TESE-ICSI treatment cycle. Shama was superovulated with 3 ampoule of HMG (225 IU daily) from day three, after downregulation with Inj Buserelin, 0.5 mL sc daily from day one (short protocol). When the follicles were mature, 10,000 IU of HCG was given, and 20 eggs

IVF TREATMENT LAWS

In Italy and France, single women and lesbians are forbidden from using artificial insemination and IVF to conceive Austria and Italy ban sperm and egg donation for IVF Germany and Norway allow sperm donation, however, egg donation is prohibited In Sweden, couples need to be in a steady relationship for at least a year before qualifying for fertility treatment Except Ukraine, in all almost European nations, couples are banned from hiring a woman for carrying a pregnancy for them In Pakistan, donor egg IVF is banned In all sunni Islamic countries, prohibitions against gamete donation are enacted in law or professional medical code of ethics FACT FILE
Dr Aniruddha Malpani, MD Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba Mumbai-400 005 Phone: 91-22-22151065, 22151066, 2218 3270, 65527073 Website: www.drmalpani.com Email: info@drmalpani.com

Counting the
blessings at Malpani

infertility Clinic
BY PREETI VERMA LAL

Dr Aniruddha Malpani and Dr Anjali Malpani

baby is Gods opinion that the world should go on, wrote American poet Carl Sandburg. However, not for every couple is the arrival of a child as simple as Gods expression of keeping the world going. Though infertility is no longer a dead-end for childless couples, archaic or strict laws in several countries (see box) add to the woes of infertile couples who want a family. As a conse-

quence, childless couples are stepping out of their boundaries to seek infertility treatments in other countries and reproductive tourism is catching up in India. This story is about a young couple from Pakistan, Hameed and Shama (name changed to protect identity). Donor egg IVF is prohibited in Pakistan, but for this couple, law was not the hurdle; it was religious tradition that prohibited the use of donor gametes for childbearing. Hameed, 25, and Shama, 23, got married in 2009 and were keen to start a family right-away. When Shama failed to conceive, she made that mandatory trip to her gynaecologist. But her medical reports came out to be normal. Did the fault lie with Hameed? After much persuasion, when Hameed agreed to undergo a semen analysis, the results were disheartening. His sperm count was zero. The diagnosis was nonobstructive azoospermia. His testes were small (volume of 6 mL), FSH level was high (18.2 mIU/mL) and his testis biopsy confirmed maturation arrest. Hameed was distressed but he

were recovered by ultrasound guided vaginal egg collection. Of these, 18 eggs were mature (metaphase II). Thereafter, Hameed was taken into the OT, where andrologist Dr Vijay Kulkarni took six microbiopsies from each testes under local anaesthesia, using the closed needle biopsy approach. A testicular biopsy may sometimes result in some bleeding, and often the testicular tissue handed to the lab by the surgeon is blood stained. When these samples are processed to recover testicular sperm, it is extremely difficult to identify viable sperms, as RBCs obscure the field completely. Hence, the doctors used a modified protocol for processing this testicular tissue for TESA. Dr Aniruddha Malapani further explains the procedure, After pro-

Dramatic advances have been made in treating infertility.

While IVF was primarily used to treat female infertility, using ICSI
and surgical sperm retrieval now allows treatment of nearly all infertile men with high success rates
cessing, I placed microdrops of the washed testicular tissue content on the ICSI dish, which is layered with culture oil. I then scanned the drop using a micromanipulator and looked for testicular sperm. Much to my elation, I could identify a few testicular sperm. An injec-

tion pipette was used to pick up the testicular sperm from the prep and move it to a PVP drop until injection. It took almost two hours. All 18 eggs were injected, each with a single testicular spermatozoon immobilised by stroking the tail. After overnight culture, 10 oocytes showed two pronuclei and three eight-cell Grade A embryos were transferred into the uterus on day three. Shama conceived in this very cycle and nine months later, the couple were blessed with a healthy baby boy. This successful pregnancy proves that dramatic advances have been made in treating infertility. While IVF was primarily used to treat female infertility in the past, using ICSI and surgical sperm retrieval now allows treatment of nearly all infertile men with high success rates.

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