IVF & Genetic Center Jabalpur Madhya Pradesh, India

Dear Colleagues

I wish you happy dussera and forthcoming Diwali

In previous two months 18 babies took birth conceived by IVF and ICSI techniques.

We have achieved 45.2 % success rate in age group below 30 yrs.

In this issue I am putting one case who delivered by embryo donation. The couple came from Nepal for treatment by the reference of their relative in Jabalpur. Both the husband and wife were devoid of gametes. As this was major problem they should either adopt or go for embryo donation. They chose the second one and their Didi-Jijaji helped them by donating their embryos.

Second topic I feel is very important for obstetricians and pediatricians . There is always a love and hate relationship between the two esp. when there is neurological problem in immediate neonatal life. Obstetrician is usually blamed for the affair and some times the matter goes to court of law to fix  the responsibility. I tried to make one thing clear that , intrapartum hypoxia  responsible for cerebral palsy is correct, in very less number of cases and it has to be established by various criteria before the obstetrician is held responsible.

With good wishes

Dr.D’Pankar Banerji

1.Lady delivers a baby girl by donated embryo

Jabalpur.

Premature failure of  the ovaries is a devastating phenomenon for young girls. It creates stoppage of period and release of eggs .The reason is still unknown but most of the time it is disoprder of genetic origin or immunological problems.

These girls as they are devoid of eggs ,hence the pregnancy is impossible on there own. Previously the only way to get a child was through adoption. But there is always a great desire for motherhood for any married girl.

Test tube baby came as a great saviour for these couples.

In our center: Ideal fertility and test tube baby center,Jabalpur one couple came from Nepal ( Mrs. Renu Age 27yrs,wife of Mr. Prakash Thapa--Name changed )for treatment . They were married for 6 yrs and donot have any issue.On examination it was found that wife had no menstrual period since five yrs ,all her eggs are lost and her husband is devoid of any sperms in his semen. Renu has an intact uterus . Only way to get a child was to get an embryo and place in her uterus .But from where to get an embryo and how to make it?

For there help Renu contacted her sister and brother in law. Her sister had one child by natural way . Her sister was then explained about the test tube baby and making an embryo with her husbands sperms and then put it in her sister's ( the patient) uterus.

Both the sisters were then taken for treatment.  After one month treatment Renu's uterus is prepared for recieving an embryo . In the mean time the donor's eggs are created by giving drugs . On appropriate day the eggs are retrieved or taken out from the ovary under general anesthesia( it does not require any operation). Under the watchful eyes of Dr.Rinku Banerji, The Embryologist of the center, the eggs are then fertilized artificially by Renu's brother in-law's sperms in lab environment, mimicking all the ingradients of inside atmosphere. The embryos were formed and grown for five days to stage called blastocyst,the stage exactly when the fertilized egg enters into the uterus in natural fertilization. This blastocyst embryo was then gentlely put into Renu's uterus on 5th January 2008 and drugs started for its support .

A pregnancy was confirmed after 15 days of embryo transfer. The pregnacy continued and on 9th september 2008,Renu delivered a baby girl by cesarean operation, a perfectly healthy child.

It is a miracle of test tube baby technique that Renu borrowed an embryo from her sister and brother in-law and delivered a girl child ,which was beyond expectation few years ago

2. Cerebral Palsy (CP)in neonate : Is obstetrician always responsible

For many years CP has been attributed to the occurrence of intrapartum hypoxia. Epidemiological studies suggest that the incidence of CP secondary to peripartal events is 8-15% ,rest are due to other reasons and even for those reasons ,the onus most of the times goes to the person who conducted the delivery

Essential criteria to define an intrapartum event as possible cause of cerebral palsy

1. Evidence of metabolic acidosis in intrapartum umbilical arterial blood or very early neonatal blood samples ) pH < 7.0 and base deficit _> 12.0 mmol/L
2. Early onset of moderate or severe neonatal encephalopathy in infants > 34 weeks gestation
3. Cerebral palsy of the spastic quadripegic or dyskinetic type .

Criteria that together suggest an intrapartum events that may be responsible for cerebral palsy but by themselves are not specific

1. A sentinel hypoxic event occurring immediately before or during labor
2. A sudden, rapid and sustained deterioration of the fetal heart rate patterm usually following the sentinel event where the pattern was previously normal.
3. Apgar scores of 0-6 for longer than 5 minutes
4. Early evidence of multisystem involovement
5. Early evidence of acute nonfocal cerebral abnormality .

One of the most important and frequent  causes of neonatal encephalopathy and CP is intrauterine infection. Clinical and histological chorioamnionitis are significant risk factors for CP and periventricular leukomalacia. Also it is well known that newborn with proven sepsis or born to infected mothers are at increased risk for the development of CP. Furthermore , the development of fever during labor , a sign usually associated with infection or with epidural anesthesia has a strong correlation with the  development of neonatal seizures.

Fetal inflammatory response syndrome : Intrauterine infection is associated with inflammatory response of the host and was the cause of the brain abnormality in neonate. It was found that newborns that developed CP were born to women with high concentrations of IL-6 and IL –8 ,high white blood cell counts in the amniotic fluid and with neutrophil infiltration into the umbilical vessels or the Wharton’s jelly .

The clinical symptoms and signs of the fetal inflammatory response syndrome are similar to those caused by severe fetal hypoxia. Fetal tachycardia, minimal or absent variability, severe variable or late decelerations, episodes of fetal bradycardia, and meconium in the amniotic fluid are indicators of the nonreassuring fetal situations that may be caused by hypoxia or by inflammation.

At the time of birth the similarities between fetal inflammatory response and intrapartum hypoxia continue.

The fetal inflammatory response syndrome is characterized biochemically by the production of proinflammtory cytokines, particularly IL-1B,IL-6 and TNF-a. These cytokines increase the permeability of the blood brain barrier and have a direct cytotoxic effect on oligodendrocytes that are the cell responsible for the production myelin.. Brain development  in the preterm infant is dependent on the availability of myelin and CP will result from the interference of cytokines with myelin production .

Hence non hypoxic causes of neonatal encephalopathy may be :

1. Fetal inflammatory response syndrome
2. Fetal hypoglycemia
3. Fetal infection
4. Fetal congenital disease
5. Maternal infections
6. Fetal metabolic disorders
7. Toxic effects of drugs
8. Congenital myopathies

Thus a newborn who is not doing well in immediate neonatal life ,the intrapartum hypoxia is not always the cause ,rather it affects only 8-10 % of the babies , and the obstetrician who has conducted the delivery should not be seen as the responsible person for this neonatal abnormal behavior.

The vaginal infection during the later part of the pregnancy should be taken seriously and should be treated by vaginal clindamycin pessaries . The urinary tract infection has to be treated properly ,because it is also found to be one of the responsible fator for preterm delivery and fetal inflammatory response syndrome.

Subacute chorioamnionitis may be one of the important factor caused by regular vaginal flora, which may harm fetal neuronal system ,even though the delivery is managed carefully