EDITORIAL BOARD Dr. Sunil K. Jindal Dr. Anshu Jindal

Editorial

Best wishes to our readers, contributors, friends and well wishers. We would like to express our appreciation to all the valuable contributors

who have helped us to produce this newsletter that is not only of critical substance but also a pleasure to read. We have tried to express our

ideas and experiences and bring together contributions made by you so as to add value to this growing science.The aim of this newsletter

was to start a paper which could be utilised by the general public as well as a little bit of knowledge for every Doctor. We would love to

distribute Joy, peace and knowledge.With your best wishes, in the month of May our center has 8 ICSI (Intra Cytoplasmic Sperm Injection) & 9 IUI pregnancies.

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Monthly subscription : Rs. 1/-onlyAnnual subscription : Rs.10/- onlyJHAL&IC NEWSLETTER1 Vol.18 | Issue No. 5

28 May 2019

RNI Registration No. UPBIL/2002/8455Postal Registration No. Meerut-131-2018-2020

EVES CROSSING, HAPUR ROAD, MEERUT (U.P.) 250001

Phone:91-121- 2642599, 2644599, 4000444, Fax: 91-121-4000444

E-mail: drsunilkjindal@gmail.com, jindalhospital@gmail.com |

jindalart@gmail.comWeb: www.jindalhospital.org

Laboratory Services Offered

•Semen Analysis culture & survival/ Kruger strict

criteria

• Hormonal assay & tabulation

• Sperm function test

• Sperm DNA studies

• Antisperm Antibody Testing

• Retrograde Ejaculation Evaluation

• Testicular biopsy evaluation

• Sperm Processing for A.R.T. Preparation Method

• Semen and/or Testicular Tissue Cryopreservation

and Thawing

• Sperm banking

• Male genetic analysis

Facilities Available

ANDROLOGY FACILITIES - CENTER OF EXCELLENCE

Surgical Management

• Male infertility evaluation

• Microsurgical varicocele ligation

• Microsurgical vaso-vasal anastomosis

• Microsurgical vaso-epididymal anastomosis

• Vasectomy

• Endoscopic ejaculatory duct obstruction release

• Surgical sperm retrieval

o PESA-Percuteneous epididymal sperm aspiration

o TESA- Testicular sperm aspiration

o TESE- Testicular sperm extraction

o Micro TESE- Micro dissection testicular sperm

extraction

o Multiple FNA mapping

• Andrology Laboratory management

Assisted Reproductive Technology in

Andrology

• Sperm preparation for –

o IUI

o IVF

o ICSI

o Surgically retrieved sperm processing

technique for

PESA, TESA, TESE, Micro TESE

Medical Management of semen

parameters

• Hormonal management

• Gonadrotrophins treatment

• Reactive oxygen damage management

Male sexual dysfunction

•Fracture penis evaluation and treatment

• Erectile dysfunction assessment and treatment –

o Investigation Hormonal & flow studies

o Penile Doppler

o Medical & surgical therapy

• Premature ejaculation assessment and treatment

• Ejaculatory dysfunction assessment and treatment

Male sexual dysfunction

• Delayed puberty evaluation and treatment

• Andropause assessment and treatment

• Penile curvature surgery

• Penile prosthetic surgery

o Rigid

o Malleable

o Inflatable

Male sexual dysfunction

• Gynecomastia evaluation and management

• Pre and post marriage counseling

• Treatment of nonconsumated marriage

• Comprehensive Men’s health assessment

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N E W S L E T T E RJHAL&IC NEWSLETTER2

Vol.18 | Issue No. 528 May 2019

This is a true story that had happened in 1892 at Stanford University. It's moral is still relevant today.A young, 18 year old student was struggling to pay his fees. He was an orphan, and not knowing where to turn for money, he came up with a bright idea. A friend and he decided to host a musical concert on campus to raise money for their education.They reached out to the great pianist Ignacy J. Paderewski. His manager demanded a guaranteed fee of $2,000 for the piano recital. A deal was struck. And the boys began to work to make the concert a success. The big day arrived. Paderewski performed at Stanford. But unfortunately, they had not managed to sell enough tickets. The total collection was only $1,600. Disappointed, they went to Paderewski and explained their plight. They gave him the entire $1,600, plus a cheque for the balance of $400. They promised to honour the cheque soonest possible. "No" said Paderewski. "This is not acceptable" He tore up the cheque,returned the $1,600 and told the boys "Here's the $1,600. Please deduct whatever expenses you have incurred. Keep the money you need for your fees. And just give me whatever is left" The boys were surprised, and thanked him profusely.It was a small act of kindness. But it clearly marked out Paderewski as a great human being. Why should he help two people he did not even know? We all come across situations like these in our lives. And most of us only think "If I help them, what would happen to me?"The truly great people think, "If I don't help them, what will happen to them?" They don't do it expecting something in return.They do it because they feel it's the right thing to do.Paderewski later went on to become the Prime Minister of Poland. He was a great leader, but unfortunately when the World War began, Poland was ravaged. There were over 1.5 million people starving in his country, and no money to feed them. Paderewski did not know where to turn for help. He reached out to the US Food and Relief Administration for help.The head was a man called Herbert Hoover - who later went on to become the US President. Hoover agreed to help and quickly shipped tons of food grains to fee the starving Polish people. A calamity was averted.Paderewski was relieved. He decided to go across to meet Hoover and personally thank him. When Paderewski began to thank Hoover for his noble gesture, Hoover quickly interjected and said, "You shouldn't be thanking me, Mr. Prime Minister. You may not remember this, but several years ago, you helped two young students go through college in the US. I was one of them."The world is a wonderful place. What goes around usually comes around.

What goes around usually comes around

45 Life Lessons This is something we should all read at least once a week!!!!! Make sure you read to the end!!!!!!Written by Regina Brett, 90 years old, of the Plain Dealer, Cleveland , Ohio ."To celebrate growing older, I once wrote the 45 lessons life taught me. It is the most requested column I've ever written.My odometer rolled over to 90 in August, so here is the column once more:1. Life isn't fair, but it's still good.2. When in doubt, just take the next small step.3. Life is too short – enjoy it.4. Your job won't take care of you when you are sick. Your friends and family will.5. Pay off your credit cards every month.6. You don't have to win every argument. Stay true to yourself.7. Cry with someone. It's more healing than crying alone.8. It's OK to get angry with God. He can take it.9. Save for retirement starting with your first paycheck.10. When it comes to chocolate, resistance is futile.11. Make peace with your past so it won't screw up the present.12. It's OK to let your children see you cry.13. Don't compare your life to others. You have no idea what their journey is all about.14. If a relationship has to be a secret, you shouldn't be in it.15. Everything can change in the blink of an eye, but don't worry, God never blinks.16.. Take a deep breath. It calms the mind.17. Get rid of anything that isn't useful. Clutter weighs you down in many ways.18. Whatever doesn't kill you really does make you stronger.19.. It's never too late to be happy. But it's all up to you and no one else.

20. When it comes to going after what you love in life, don't take no for an answer.21. Burn the candles, use the nice sheets, wear the fancy clothes. Don't save it for a special occasion. Today is special.22. Over prepare, then go with the flow.23. Be eccentric now. Don't wait for old age to wear purple.24. The most important sex organ is the brain.25. No one is in charge of your happiness but you.26. Frame every so-called disaster with these words 'In five years, will this matter?'27. Always choose life.28. Forgive29. What other people think of you is none of your business.30. Time heals almost everything. Give time time.31. However good or bad a situation is, it will change.32. Don't take yourself so seriously. No one else does.33. Believe in miracles.34. God loves you because of who God is, not because of anything you did or didn't do.35. Don't audit life. Show up and make the most of it now.36. Growing old beats the alternative of dying young.37. Your children get only one childhood.38. All that truly matters in the end is that you loved.39. Get outside every day. Miracles are waiting everywhere.40. If we all threw our problems in a pile and saw everyone else's, we'd grab ours back.41. Envy is a waste of time. Accept what you already have, not what you need42. The best is yet to come...43. No matter how you feel, get up, dress up and show up.44. Yield.45. Life isn't tied with a bow, but it's still a gift."

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N E W S L E T T E RJHAL&IC NEWSLETTER3

Vol.18 | Issue No. 528 May 2019

Dr. Sunil JindalMS, DNB, MNAMSAndrology Facilities Available

Semen Analysis culture & survival/ Kruger strict criteria

Sperm Function Tests

Sperm DNA Studies

Antisperm antibodies (mixed agglutination reaction)

Retrograde ejaculation

Testicular biopsy evaluation

Sperm processing for ART preparation method

Sperm banking

A male factor for infertility is diagnosed when an abnormal semen analysis is found. Male factor infertility is solely responsible in ~20% of cases and contributory in ~30 - 40%. Therefore, in at least 50% of cases a male factor for infertility contributes to failure to conceive. A semen analysis is still a cornerstone laboratory evaluation and contributes to defining the severity of a possible single or contributing male factor to a couple's infertility.The laboratory must comply with international standards and techniques (e.g. WHO semen analysis guidelines) Routine semen analysis should include (a) the physical characteristics of semen, including liquefaction, viscosity, pH, color, and odor; (b) the specimen volume; (c) the sperm concentration; (d) sperm motility and progression; (e) sperm morphology; (f) leukocyte quantification; and (g) fructose detection in cases in which no spermatozoa are found and the ejaculate volume is low.

Sperm function testing is used to determine if the sperm have the biologic capacity to perform the tasks necessary to reach and fertilize ova and ultimately result in live births. These tasks include penetrating the cervical mucus, reaching the ova, undergoing capacitation and the acrosome reaction, zona pellucida penetration, and ooplasm incorporation. Defects in any of these steps may result in infertility.Three functions have been widely investigated as diagnostics for male fertility: sperm–mucus penetration, acrosome reaction, and zona penetration capabilities.

Assessment of the sperm DNA integrity is one of the most investigated sperm parameters during the last decade. Yet, there is little consensus regarding testing methodologies for sperm DNA integrity and cutoff points that are clinically relevant with in vivo and in vitro fecundity. Different methods may be used to evaluate the status of the sperm DNA for the presence of abnormalities or simply immaturity. Most of these assays have many advantages as well as limitations.transferase-mediated fluorescein-deoxyuridine triphosphate-nick end labeling assay (TUNEL) assay have been well standardized and have made their way in routine clinical practice.Testing for sperm DNA integrity is to be considered for the screening of infertile men as well as for the cases of unexplained infertility.

For the mixed agglutination reaction (MAR) test to be considered clinically significant, at least 50% of the motile spermatozoa need to be coated with antibodies. Sperm stimulates an immune response when exposed to the systemic immune defence system, such as testicular trauma, post-vasectomy, or inflammatory reactions in the male or female genital tract. Antisperm antibodies are almost exclusively IgG and IgA, with the latter clinically more important. Depending on the nature and location of the sperm antigen and the levels of antibodies different effects may be seen, as agglutination of sperm with impaired motility and cytotoxicity with low viability are all effects that may adversely affect sperm quality.

Retrograde ejaculation refers to the entry of semen into the bladder instead of going out through the urethra during ejaculation. Retrograde ejaculation may be caused by prior prostate or urethral surgery, diabetes, some medications, including some drugs used to treat hypertension and some mood-altering drugs. A urine analysis performed on a urine specimen that is obtained shortly after ejaculation will reveal a large amount of sperm in the urine.

The combination of testicular biopsy and clinical evaluation for male infertility is becoming progressively more important because new technologies allow men previously considered infertile to father children. Recent guidelines for male infertility have limited the indications for a diagnostic testicular biopsy to the confirmation of obstructive azoospermia in men with normal size testes and normal reproductive hormones. Nowadays, testicular biopsies are mainly performed for sperm harvesting in men with non-obstructive azoospermia, to be used for intracytoplasmic sperm injection. Testicular biopsy is also performed in men with risk factors for testicular malignancy.

Scrotal ultrasound is a valuable tool in the evaluation of the testis and adjacent structures and is often used routinely in male infertility diagnostic work-up. Using ultrasound allows detection of several intratesticular abnormalities, such as microlithiasis and lesions of the gonads.

Potentially fertile spermatozoa are separated from immotile spermatozoa, debris and seminal plasma with several techniques. These techniques can be differentiated in migration, density gradient centrifugation and filtration techniques & swim-up technique.

Sperm freezing is the most successful method of preserving a man's fertility so he can try and have a child at a later date. It's also used to store sperm so it can be used in someone else's treatment.

WHO Criteria for Normal Sperms

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N E W S L E T T E RJHAL&IC NEWSLETTER4

Vol.18 | Issue No. 528 May 2019

Male genetic analysis

Male infertility evaluation

Microsurgical Varicocele ligation

Microsurgical vaso-epididymal anastomosis

Vasectomy

Endoscopic ejaculatory duct obstruction release

Percutaneous sperm retrieval techniques (PESA)

Testicular sperm aspiration (TESA)

Microsurgical sperm retrieval techniques

Microsurgical testicular sperm extraction (micro-TESE)

Men with severe oligospermia (<5 million sperm/mL ejaculate fluid) or azoospermia should receive genetic testing to clarify etiology of male infertility prior to treatment. Categorization by obstructive azoospermia (OA) or non-obstructive azoospermia (NOA) is critical since genetic testing differs for the former with normal testicular function, testicular volume (~20 mL), and follicle-stimulating hormone (FSH) (1-8 IU/mL) when compared to the latter with small, soft testes and increased FSH. History and physician examination along with laboratory testing (following appropriate genetic counseling) is critical to accurate selection of genetic testing appropriate for azoospermia due to primary testicular failure as compared with congenital hypogonadotropic hypogonadism (HH). Genetic testing options include cystic fibrosis transmembrane conductance regulator (CFTR) testing for men with congenital absence of the vas, while karyotype, Y chromosome microdeletions (YCMD), and other specific genetic tests may be warranted depending on the clinical context of severe oligospermia or NOA.

Over the past couple of years the indications for and techniques of surgery for male infertility have been significantly refined, resulting in substantially increased success in the management of male-factor infertility. These advances include (1) refined microsurgical techniques for sperm retrieval combined with in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) for men with nonobstructive azoospermia (2) improved techniques for microsurgical reconstruction for obstruction; (3) the use of varicocelectomy for enhancement of spermatogenesis in azoospermic or severely oligospermic men, for prevention of future infertility and androgen deficiency in young men, and

1for treatment of androgen deficiency in men of all ages ; (4) increasing use of genetic and molecular biologic markers to better select patients for surgical treatment.

Varicocele ligation is the most common operation for male infertility. It is reported that 35–40% of infertile men have clinically palpable varicoceles.

Vasovasostomy (VV) and vasoepididymostomy (VE) are surgical procedures designed to bypass an obstruction in the male genital tract. These procedures are usually performed to restore fertility, although they are occasionally undertaken to relieve pain, such as in postvasectomy pain syndromes.Vasovasostomy involves the anastomosis of segments of the vas deferens above and below an obstruction.

Vasectomy also called male sterilization is a surgical procedure. It is meant to protect against pregnancy permanently. There are two types of vasectomies the incision method, and the no scalpel method. No scalpel methods lower the risk of infection and other complications, and generally takes less time to heal.

Ejaculatory duct obstruction (EDO) remains a rare but surgically correctable cause of male sexual dysfunction and male infertility due to obstructive azoospermia, diagnosed in up to 5% of infertile men. EDO should, therefore, be considered within the list of differential diagnoses for men undergoing infertility investigations, with work up including clinical examination, transurethral ultrasonography, semen analysis, chromotubation, seminal vesiculography and seminal vesicle aspiration. Early endoscopic treatment can reverse symptoms and prevent the progression of partial obstruction to bilateral, complete obstruction, and transurethral resection of the ejaculatory duct remains the main treatment option for EDO.

Nonobstructive azoospermia (NOA) comprises a spectrum of testicular histopathology resulting from various causes, such as environmental toxins, medications, cryptorchidism, genetic and congenital abnormalities, varicocele, trauma, viral orchitis, endocrine disorders, or idiopathic causes.PESA is indicated in obstructive azoospermia cases only. PESA is carried out under local anesthesia only or in association with intravenous sedation. In both cases, a 10 ml solution of 2% lidocaine is injected around the spermatic cord near the external inguinal ring.

TESA may be performed in either OA or NOA cases. In OA, TESA is carried out after a failed PESA, but may be also used as a primary retrieval procedure in cases of absent epididymis or intense epididymal fibrosis. In NOA, TESA may be used as a diagnostic tool to obtain testicular parenchyma for histology analysis and sperm search previous to the ICSI cycle. Also, it is indicated for sperm retrieval in cases of favorable prognosis, such as the ones with a previously successful TESA attempt or those with testicular biopsy result showing hypospermatogenesis.

Microsurgical sperm retrieval may be performed under either local anesthesia in association with intravenous sedation or epidural anesthesia. MESA is indicated in obstructive azoospermia cases only.

Micro-TESE is indicated in NOA cases only.A single, large, mid-portion incision is made in an avascular area of the tunica albuginea under 6–8× magnification, and the testicular parenchyma is widely exposed.Dissection of the testicular parenchyma is carried out at 16–25× magnification searching for enlarged seminiferous tubules (more likely to contain germ cells and eventually normal sperm production).

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N E W S L E T T E RJHAL&IC NEWSLETTER5

Vol.18 | Issue No. 528 May 2019

Medical management of semen parameters

Reactive oxygen damage management

Male Sexual dysfunctionPenile fractures

Erectile dysfunction (ED)

Premature ejaculation

Modulations in sex hormone levels may improve semen parameters in the appropriately selected patient and agents such as SERMS, AIs and HCG are generally well tolerated. Correction of PRL, thyroid and GH levels may help in those that have abnormalities in semen parameters pertaining to those specific hormones.Human chorionic gonadotropin (HCG) The use of HCG for the treatment of male infertility is most commonly applied to the treatment of patients presenting with hypogonadotropic hypogonadism (HH). The mechanism of action of HCG involves its action as an analogue of LH and its subsequent role in maintaining and/or increasing intratesticular levels of testosterone.

There are numerous exogenous and endogenous factors that are able to induce excessive production of reactive oxygen species (ROS) beyond that of cellular antioxidant capacity, thus causing oxidative stress. In turn, oxidative stress negatively affects male reproductive functions and may induce infertility either directly or indirectly by affecting the hypothalamus-pituitary-gonadal (HPG) axis and/or disrupting its crosstalk with other hormonal axes.

Penile fractures usually require surgery. The stitches is use to close the tear in the tunica albuginea and corpus cavernosum. The primary goals of surgical repair are to expedite the relief of painful symptoms, to prevent erectile dysfunction, to allow normal voiding, and to minimize potential complications due to delay in diagnosis. Indications for immediate surgical intervention include the presence of obvious clinical signs and symptoms of penile fracture. Surgery is also warranted if diagnostic cavernosography or MRI findings are equivocal but clinical findings are consistent with penile fracture.

Erectile dysfunction (ED), also known as impotence, is a type of sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual activity. ED can have psychological consequences as it can be tied to relationship difficulties and self-image. For some men with ED, specialized testing may be needed to guide treatment or re-assess you after a treatment fails. Blood test such as Testosterone and other male hormones, blood sugar (Diabetes), Ultrasonography (penile Doppler) to check blood flow, A shot into the penis with a vascular stimulant to cause an erection, Pelvic x-rays like arteriography, MRI or CT scanning are rarely needed to check ED unless there is history of trauma or cancer.

Premature ejaculation (PE) is when ejaculation happens sooner than a man or his partner would like during sex. Occasional PE is also known as rapid ejaculation, premature climax or early ejaculation. Ejaculation is controlled by the central nervous system.. When men reach a certain level of excitement, signals are then sent from your brain to your reproductive organs. This causes semen to be released through the penis (ejaculation).Psychological therapy, behavioral therapy, and drugs are the main treatments for PE.

ULTRASOUND –

Dr. Anshu JindalDr. V. Nanda

INFERTILITY –

Dr. Anshu JindalDr. Sunil Jindal

M.D., DNB.M.S., DNB.

OPERATIVE ENDOSCOPY –

Dr. Umang Mittal

ONCOLOGIST –

M.S.

DENTISTRY –

M.D.M.D.

Dr. Sunil JindalDr. Anshu Jindal

M.S., DNB.M.D., DNB.

GASTROENTEROLOGIST –

Dr. Anil Kumar D.M.

NEUROLOGIST –Dr. Vinod Arora D.M.

Dr. Rajeev Jindal BDS

N E W S L E T T E R

Dr. Sunil K. Jindal

Dr. Sunil K. JindalDr. Anshu Jindal

M.S., DNB.

GYNAECOLOGIST –

M.S., DNB.M.S.M.B.B.S, DGO

ORTHOPAEDICS –

ANAESTHETIST –

Dr. Nalini MithalDr. Pranav Gupta

Dr. N. GargDr. Praveen Mittal

PAEDIATRICS –

Dr. Rajiv PrakashDr. Sanjiv Goel

M.D.M.D.

Dr. Anshu JindalDr. Savita AgarwalDr. Suneeta

PHYSICIAN –

Dr. Rakesh AranDr. S.P. SondhiDr. Anil ChauhanDr. V.K. Bindra

MDMDMDMD

SURGEON –

CONSULTANTS

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Meerut.Published at: Jindal Hospital & Nursing Home, Eves

Crossing, Hapur Road, Meerut Editor: Dr. Sunil K. Jindal

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