Dr Tejas Gundewar:

He has completed “M.Ch. Reproductive Medicine & Surgery” from prestigious Sri Ramachandra Medical College, Chennai; the first institute in entire country to start such a programme. It’s a matter of great pride for Ruby Hall Clinic as he is the 1st M.Ch. in this field from the State of Maharashtra & one of the first few in the entire country. This branch deals with all aspects of Male – Female Sub-Fertility, Male – Female Sexual Dysfunction, Male – Female fertility enhancing surgeries, IVF/ICSI & Recurrent Pregnancy Loss.

Having trained with Dr Ranjit Ramaswamy, a world renowned andrologist, he has an unique skill set of managing patients with Male Infertility & Sexual Dysfunction. He is well groomed for performing Micro-TESE, Vaso-Vasostomy, Vaso-Epididymostomy to name a few. He is also proficient in using Neuro-Stimulatory methods for sperm retrieval. His special interest lies in managing patients with Diminished Ovarian Reserve, Thin Endometrium, Recurrent IVF failures & azoospermia patients. He is also keen in using regenerative medicine techniques like Autologous P-PRP & Mesenchymal Stem Cells.

Male Sub-Fertility

I.  Basic & Advanced Semen Analysis:

Semen analysis is a laboratory test for male fertility evaluation, providing an initial screening test for assessing male reproductive health. Basic semen analysis focuses on the amount, shape and movement of the sperm while advanced analysis helps in prognosticating the case and deciding on appropriate management for Sub-Fertile couples.

II. Sperm Function Test

A sperm function test is a procedure used to discover or determine if the sperm quality is good enough to fertilize an egg.

  • Sperm DNA Fragmentation Test -The integrity of genetic material in the sperm is crucial for successful fertilization and normal embryo development. Sperm DNA fragmentation is a term used to denote abnormal genetic material within the sperm, which in turn may lead to male sub fertility, IVF failure and miscarriage. A conventional semen analysis cannot assess these molecular level sperm abnormalities, which is done DFI test.
  • Reactive Oxygen Species Test - ROSare fundamental mediators of physiological sperm function, such as signal transduction mechanisms which have an effect on fertility. Abnormal levels of ROS have a detrimental effect on sperm function interfering with natural fertility.

III. Sperm Culture and Sensitivity test

Semen Culture aims at detecting potential pathogenic microorganisms that may cause infection of the male genitourinary tract. It checks for the presence of common aerobic and anaerobic pathogenic microorganisms. Sensitivity test helps us to determine the appropriate antibiotic to treat the infection.

IV. Post Coital Test

The PCT/Sims Hunher Test examines interaction between sperm and cervical mucus, its survival in cervical mucus & assess its migration through the same. It is advised if female is ovulating regularly, tubal function is normal & male partners semen analyses is optimal. A positive test indicates cervical abnormality in the female partner.

V. Ultrasound Services

Ruby Hall Clinic offers one of the most advanced 3D/4D Ultra Sound facilities in & around Pune.

A. USG Testis - A testicular ultrasound is a diagnostic test that obtains images of the testicles and the surrounding tissues in your scrotum. It’s required in patients where clinical examination is difficult or exam results are not clear.

     

B. Scrotal Doppler - Doppler ultrasound helps identify blood flow inside the scrotum. In patients with Varicocele i.e dilated testicular veins; this test will help confirm the diagnosis as well as aid identification of sub-clinical varix.

   

C. Penile Doppler Test – This test allows to identify the vascular cause of erectile dysfunction. It also allows the andrologist to determine and document if you have an inflow or outflow type of erectile dysfunction.

D. Transrectal ultrasound (TRUS) - This technique is used most commonly in cases of Azoospermia (absent sperms in semen), to identify the site of obstruction.

VI. Hormonal Testing

We focus on bringing the best-in-class testing facilities via best equipped labs and a team of experienced doctors and nurses.

  • Serum Testosterone test: Testosteroneis the main sex hormone in males that controls sex drive, maintains muscle mass, and helps make sperm. the testosterone test can help find the reason for sexual problems, like reduced sex drive or erectile dysfunction. If you're having a hard time getting your partner pregnant, the test can tell if your blood testosterone level is low.
  • Serum Bioavailable Testosterone test: In men, a part of blood testosteroneis inactive and the remaining part is either free or weakly bound to albumin. The total free and albumin-bound forms constitute bioavailable testosterone which is responsible for the hormonal effects.
  • SHGB Test: The sex hormone binding globulin(SHBG) test may be used to help evaluate men for low testosterone and women for excess testosterone production. It may be ordered in conjunction with other tests to evaluate the status of a person's sex hormones.
  • Serum Prolactin Test - This hormone is made in your pituitary gland, which is located just below your brain. Raised levels of this hormone interfere with sexual activity & may be responsible for erectile dysfunction.
  • Thyroid Profile - A thyroid profile test refers to a set of blood tests which measures the levels of the thyroid hormones secreted from thyroid gland. It is also known as thyroid function test. Thyroid hormones are responsible for maintaining certain processes in the body including metabolism, energy generation, mood & have a role in sexual function as well. Thyroid profile test includes the test of TSH, Free T3 and Free T4. The tests are designed to differentiate hyperthyroidism and hypothyroidism from the euthyroid state.
  • Serum Estradiol Test: Estradiol, also known as E2, is one of the four types of estrogen that the ovaries chiefly produce. Though estradiol is primarily a female hormone, optimum levels are essential for reproductive health in males. Having too much or too little estrogen can interfere with sexual function & spermatogenesis that is process of sperm production.
  • Serum FSH Test: Follicle-stimulating hormone (FSH) is an important part of the reproductive system. It’s responsible for the growth of ovarian follicles & sperms in females & males respectively. The test helps to determine the cause of decreased sperm count & whether medical management can help improve the sperm count.
  • Serum LH Test : Luteinizing hormone (LH) is an important hormone that affects the sex organs in both men and women. In men, LH acts on the Leydig cells in the testis to produce testosterone. LH levels are critical for spermatogenesis.

VII. Genetic Testing

Genetic testing is done to identify quantitative & qualitative abnormalities in sperm production. Your andrologist will prescribe tests like Karyotyping, Y Chromosome microdeletion, AURK C, DPY19L2 etc depending on the Spermiogram report.

Varicocelectomy: It’s a surgery done to correct dilated veins around the testis. It may help improve the sperm count & motility & thus help couples conceive naturally. 

Circumcision: It’s a surgery done to remove the skin on glans penis when the opening for passage of sperm is too small which may be interfering with deposition of sperm in partners vagina.

Vaso-Vasostomy & Vaso-Epididymostomy: These procedures are done to overcome a block in Vas deferens (a tube that carries the sperm from the testis in males) so that patients can conceive naturally. It is done in patients with prior history of vasectomy.

Similar pics depicting the procedure can be made.

Surgical Sperm Retrieval:  These techniques are used to retrieve sperms either from testis or epididymis in patients with azoospermia (absent sperms in semen), complete necrozoospermia (all dead sperms in semen) or in patients with poor quality ejaculated sperms.

Window TESE: A variation of conventional TESE (Testicular sperm extraction) in which less than 1cm incision is given on the testis to retrieve the tubules which house the sperm.

 

 

 

 

 

1st pic is better depiction of the procedure.

TEFNA: Testicular fine needle aspiration also known as TESA (testicular sperm aspiration) is a simple procedure in which sperms are aspirated via a scalp vein or needle.

1st pic is a better depiction of the procedure.

Micro-TESE: A highly advanced procedure done under operative microscope at approximately 25X magnification for retrieving the sperms. It is specially indicated in patients with Non-Obstructive Azoospermia or prior history of failed TESE/TESA.

Micro-ESA: This procedure involves microscope guided extraction of sperms from epididymis.

I. Medical

After fertility assessment if there is a scope then fertility can be enhanced by a variety of tablets & injections allowing couples to conceive naturally or minimal assistance.

II. Medically Assisted Reproduction

Intra Uterine Insemination with Self Gametes or Donor Gametes

- A method of activating & pooling good quality sperms to enhance fertility.

III. Surgical

  • Varicocelectomy: It’s a surgery done to correct dilated veins around the testis. It may help improve the sperm count & motility & thus help couples conceive naturally.
  • Circumcision: It’s a surgery done to remove the skin on glans penis when the opening for passage of sperm is too small which may be interfering with deposition of sperm in partners vagina.
  • Vaso-Vasostomy & Vaso-Epididymostomy: These procedures are done to overcome a block in Vas deferens (a tube that carries the sperm from the testis in males) so that patients can conceive naturally. It is done in patients with prior history of vasectomy.
  • Surgical Sperm Retrieval: These techniques are used to retrieve sperms either from testis or epididymis in patients with azoospermia (absent sperms in semen), complete necrozoospermia (all dead sperms in semen) or in patients with poor quality ejaculated sperms.
    • Window TESE:A variation of conventional TESE (Testicular sperm extraction) in which less than 1cm incision is given on the testis to retrieve the tubules which house the sperm.
    • TEFNA:Testicular fine needle aspiration also known as TESA (testicular sperm aspiration) is a simple procedure in which sperms are aspirated via a scalp vein or needle.
    • Micro – TESE:A highly advanced procedure done under operative microscope at approximately 25X magnification for retrieving the sperms. It is specially indicated in patients with Non-Obstructive Azoospermia or prior history of failed TESE/TESA.
    • Micro – ESA:This procedure involves microscope guided extraction of sperms from epididymis.

IV. ART

    • Conventional IVF: It’s a procedure where oocytes (eggs) & sperms are incubated in controlled conditions for certain period of time for fertilization to occur.

    • ICSI (Intra Cytoplasmic Sperm Injection): It’s a microscope guided procedure done at 400x magnification in which sperm is introduced into the oocyte (egg). It is specifically indicated in patients with severe male factor infertility & those with prior failed IVF.

Sperm Selection techniques:

    • IMSI (Intra cytoplasmic morphologically selected sperm injection): It’s an advanced procedure done at approximately 6600X magnification to select the morphologically normal sperm for injection into the egg.

    • PICSI (Physiological ICSI): Hyaluronic acid is the main component of the cumulus oophorus that is cells that surround the oocyte; it plays a role in the natural selection of mature spermatozoa during in vivo Therefore, the sperm’s ability to bind to HA can be used as the basis for in vitro sperm selection. Since, HA is a physiological component of the cervix, cumulus cells, and follicular fluid, it should pose no additional safety risks when used for sperm selection .

  • Microfluidics: The term “microfluidic” refers to technology utilizing characteristics of fluid movement in a micro- or nano-environment. This emerging technology is used in many biological applications & has found application in Assisted Reproductive Techniques as well. It is one of the most recent technology used for sperm selection.
Sperm is a fundamental unit of male reproduction. As the age progresses sperm quality & to an extent the sperm number decreases. The result of which is a decline in natural fertility. Cryopreservation of semen aka as Semen freezing at the right time helps you to arrest this natural decline. This process is known as Fertility Preservation. It is also highly advisable in cancer patients planned for chemotherapy or radiotherapy.

Male Sexual Dysfunction

Erectile Dysfunction

Inability to get & maintain an erection for satisfactory sexual intercourse.

1. Diagnosis:

The first step in treatment is understanding the underlying cause of erectile dysfunction. For many people, a physical exam and answering certain questions is all that's needed for a doctor to diagnose erectile dysfunction and recommend a treatment. While in the rest of men further tests will be required.

  • Medical History
  • Physical Exam
  • Psychosexual Counselling & Evaluation
  • Hormonal Tests
  • Penile Doppler

2. Treatment:
I) Medical Management: Different Oral & Non-Oral modalities are available for treating erectile dysfunction & your doctor will advise them as per your need.
II) Penile Pumps
III) Penile Implants

Premature Ejaculation/Rapid Ejaculation

It’s a condition when a man ejaculates sooner during sexual intercourse than he or his partner would like. Premature ejaculation is a common sexual complaint affecting approximately 30% men at some time.

  1. Diagnosis: Simple medical history, physical exam & certain hormonal tests will help diagnose & identify the cause of premature ejaculation.
  2. Treatment: Depending on the results of the tests ordered your andrologist shall offer certain behavioural modifications & medications.

Anejaculation/No ejaculation

It’s a condition where the male partner is not able to ejaculate. After proper assessment ejaculation can be achieved by medications or instruments like Penile Vibrator & Electroejaculator.

Miscellaneous

Andropause

 

Debunking The Andropause Myth:

The term “Andropause” or "Male Menopause" has been used to describe decreasing testosterone levels related to aging. Although aging-related hormonal changes in women and men are not the same.

Hormone changes are a natural part of aging. In women, once the follicles in ovary fall below a critical level, menopause ensues resulting in dramatic reproductive hormone dip. On the other hand, in men, production of testosterone and other hormones declines over a period of many years and the consequences aren't necessarily clear. This gradual decline of testosterone levels is called late-onset hypogonadism or age-related low testosterone.

In men testosterone levels decline by approximately 1% every year beyond 40 years of age. Although majority of older men have testosterone levels within the normal range, with an estimated 10% to 30% having low levels.

Low testosterone levels in older men often go unnoticed & many men with low levels do not experience any symptoms. Testosterone levels aren't routinely done. Although, signs and symptoms associated with low testosterone aren't specific, following symptoms do suggest low levels of this principal male hormone.

  • Reduced sexual desire and activity
  • Decreased spontaneous erections or erectile dysfunction
  • Sub-Fertility
  • Decreased energy, confidence & motivation
  • Depressed mood & concentration
  • Breast discomfort or swelling
  • Reduced Muscle bulk & increased body fat
  • Increased sleepiness, Sleep disturbances
  • Height loss, low trauma fracture or low bone mineral density
  • Hot flushes or sweats

 

Treatment recommendations for low testosterone:

For some men, testosterone therapy relieves bothersome signs and symptoms of testosterone deficiency. For others, the benefits aren't clear and there are possible risks.

After assessing your signs & symptoms, fertility status, history of illnesses like prostate cancer, breast cancer, heart failure, stroke, thrombophilia’s etc, our Men’s Health specialist doctor will advise about testosterone therapy.

If you choose to start testosterone therapy, your doctor will explain the different ways testosterone can be administered, target levels and follow-up testing.

If you think you might have low testosterone, talk to your doctor about your signs and symptoms, testing, and possible treatment options. Your doctor can help you weigh the pros and cons of treatment.

Bent penis

Some men have a penis that curves to the side, upward or downward when erect. This is common, and a bent penis in most men isn't a problem.

Generally, a bent penis is only a cause for concern if your erections are painful or if the curvature of your penis interferes with sex.

Causes: Bent penis can occur because of various reasons like Peyronies disease, Penile trauma, Plaques or can be idiopathic.

Management: After assessment of degree of curvature & the underlying cause you doctor will suggest either certain injections or surgery to correct it.

Surgeries:

Penile Plication
Penile Implants