Fertility Square

When you think of becoming a mother it becomes your responsibility to provide the best in terms of baby’s growth. For that to maintain and follow a healthy lifestyle is a prerequisite.

• Balanced diet: Take balanced diet rich in seasonal fruits and vegetables
• No smoking: Smoking is absolutely very dangerous for the baby as carbon monoxide, nicotine adversely affect the growth of baby’s organs. Smoking is also considered to cause premature delivery
• Stay away from alcohol: Say no to alcohol,If you are taking it under peer pressure then you are not doing anything good for your baby. Doctors always advise expecting mothers to stay away from wine, beer or any other kind of alcohol
• Take adequate sleep: Lack of sleep will make you feel tired and may increase the chances of developing high blood pressure in you, during pregnancy. Minimum 7-8 hours sleep should be there.Proper sleep also helps to get rid of stress
• Junk foods: Avoid Junk foods like burgers, pizzas, cold drinks, cake must go out of your life. A successful pregnancy demands lots of necessary nutrients and vitamins which you cannot get from the junk food. For better health of baby in future, get ready to switch to green leafy vegetables, fruits, dry fruits etc.
• Use of mobile and laptops: Excess use can give you neck and back pain, unseen rays from these gadgets may not be good for your baby. Limit yourself with the use of mobile and computers and focus on book reading or walking or yoga
• Negativity: Stay away from negative things
• Avoid Stress: If you take too much of stress, it can affect your chances of conceiving easily. A stressful mother will not be able to offer good, health to her baby. Stay away from all negative feelings and think positive if you want a healthy and happy baby
• Caffeine: Avoid taking too much of coffee, soft drinks and other beverages containing caffeine. Excess of caffeine intake can give rise to infertility
• Prescription: Don’t take any medicines without consulting your doctor

Fluid Collection in IVF-Myths and Facts                 

IVF is a finer treatment option for childless couples but it needs a better understanding before opting for it.It has lots of Myths and Facts associated with it.Patients often have fear of side effects of medicines used to stimulate their ovaries to grow  their eggs.

One such side effect is Accumulation of fluid in the body what we call medically as OHSS (Ovarian Hyper stimulation Syndrome) but its not a uniform feature in all IVF patients.OHSS has a tendency to happen in selective group of patients with high risk factors which can be predicted and prevented.So via this write up our focus is on to single out such predisposing factors so that appropriate measures can be taken on time.Its not only duty of a treating doctor but a patient also needs to be aware than landing up with sudden surprises and bitter experiences. 

Why is it a concern?

•      Marked increase in patient population in infertility clinics

•      Changing lifestyle

•      Advances in the field of ART – act as a Double edged sword with pros and cons

•      ART technology – is more patient friendly, with less complication with cost still a limiting factor with no 100% guarantee     

What is OHSS?

It is a Life Threatening medical (Iatrogenic, drug induced) Complication and unique to the treatment of infertility with an an acute onset but reversible in nature with enlarged ovaries with cysts and fluid accumulation in body cavities to variable extent depending on gravity and grade   

What are types of OHSS ? 

Mild, Moderate, Severe and Critical 

Who all have risk to develop OHSS?

•      Young age, Low body mass index

•      Polycystic ovary syndrome (PCOS) 

•      Higher doses of exogenous gonadotropins 

•       HighEstradiol levels with rapid rise

•      Previous episodes of OHSS

•      Multiple developing follicles(20-25)

•      Exogenous hCG for superovulation/ luteal support

•      Multiple Pregnancy

•      Serum factors increasing permeability of blood vessels    

It’s a general concept even in layman that for pregnancy one needs to have regular and timely menstrual periods.But in certain patients periods may not come regularly ever since menarche.Besides they may have history of weight gain,acne, excessive hairs on skin of face, may need to go for threading more often than required and may have cousins, sisters or evn mother having same issues.Such symptoms and signs point towards –

• PCOS – as the first most diagnosis
• Hormonal imbalance- FSH,LH ratio change with high LH levels
• Insulin resistance
• May have add on Thryoid/prolactin derrangements

These patients generally have high body mass Index(BMI)but some fall into category of lean with periods regular.

What all these lead to is a situation called-Chronic anovulation- a common cause of infertility.

 Most of such PCOS patients have normal FSH but high LH levels.Its a multifactorial condition with life long implications

What we can do about it ?

Yes we can do major part especially if weight is more then Lifestyle modifications alone will help to keep things on track but it needs constant action in a well planned manner.So tips to keep a check on PCOS-

• Weight loss- at rate of 5-10% over a period of 5-6 months.If you have 80 kg then you should loose between 4 to max 8 kg only slowly with crash courses/diets or short cuts
• Daily brisk walking at least for 30 minutes to burn extra calories
• Moderate exercise on regular basis
• Joining a structured programme like Gym
• Take healthy balanced food(if possible with help of dietitician)
• Cut down carbohydrates like banana,rice,rice products with a check on milk and milk products and less of fats
• Keep proper hydration(3-4 LITRES of water daily)
• Avoid junk foods with empty calories

Dear readers all these need to be followed as part of life and not till you have pregnancy as PCOS has more of chronic affects also later on due to tendency to gain weight due to hormonal disturbances

Polycystic ovary syndrome (PCOS) is diagnosed in

approximately 60–70%of  women with such features.

How to plan pregnancy in PCOS?

Singleton live birth rates of up to 71% in 2 years can be

achieved in such patients with –

1) Induction of ovulation- it can be by clomiphene citrate as first line of treatment and  Injectables gonadotropins as second-line

treatment with success rate varies from 2 to 3%

2)IUI- combined induction with IUI increases success rate from 8 -13% to 15-20%

3) IVF- not used as  first-line therapy in these

patients, except for subgroups with a poor prognosis like-

• • • Advanced age group
    • Longer duration of infertility
    • Higher insulin:glucose ratio
    • Failed ovulation induction  
    • Other indications of IVF-tubal factor,male factor,unexplained/idiopathic infertility

Outcome of IVF In PCOS-

The outcome of IVF in women with PCOS  shows variable outcome as-

Response to Medicines is the main issue- erratic(resistant to hyper) which is generally unpredictable

• More oocytes obtained-with more of immature
• Less fertilization rate- both mature and immature oocytes

PCOS patients show reduced fertilization rates, presumably due to endogenous hormonal imbalance

• More chances to have poor quality eggs
• Chances of abnormal(aneuploidy)embryos is high
• Inc chances to form endometrial polyp with recurrence
• Inc chances of cancellation of cycle/use of high dose of medicines
• High chances of first trimester miscarriage
• But good part is despite reduced overall fertilization, IVF pregnancy rates in PCOS patients appeared to be comparable to normo-ovulatory women
• Also  live birth rates  are comparable  

Female reproductive organs comprise of – Uterus,Fallopian tubes and ovaries.Altered function in any of these can land up into Assisted Reproduction with IVF as the last option with maximum success rates.

Any discussion of the potential risks and benefits should also highlight the potential effect of delaying IVF treatment, especially in older patients where other factors may play the determining role.

Whenever we as patients are told about the status of fallopian tubes which normally need to be functional and dynamic for natural pregnancy to happen but when affected then it can vary from-

• Complete blockage of both tubes
• Unilateral blockage
• Patent but non functional
• Spastic
• Blockage can be due to spasm,debris or pathology
• Damage can be by Infection like Tuberculosis,scarring,post surgical impact,adhesions
• Fluid accumulation intubes-Hydrosalpinx

Depending on the status next step will be either-As whether its damage or dysfunction

• Try to open them by laparoscopy
• Or Directly go for IVF

 But the dilemma is as whether to carry out IVF  directly or undertake tubal surgery – answer to this is based on –

• Clinical assessment of the severity of tubal damage
• Age of the patient
• Availability of specialized surgical services and IVF

Similarly second doubt which comes in mind is the impact of tubal dysfunction on IVF outcome  .Although tubal disease in general is not associated with poor outcome from IVF, there is increasing evidence that distal tubal disease associated with hydrosalpinx may affect the chances of success from IVF treatment. Many studies have shown that it can negatively influence the chance of success with IVF by decreasing implantation rates such that as per a combined study it was observed that there were differences in pregnancy rates after IVF in tubal infertility with and without hydrosalpinx, pregnancy rates of 31.2% were observed in the absence of hydrosalpinx and 19.7% in the presence of hydrosalpinx

Conclusion- Each patient is different so cannot apply blanket treatment to all.Need a basic work up and scrutiny before planning treatment protocol.If beginning is correct then we can have best outcome at end.Needs a systematic and Individualised approach.

When Should We Opt for Ivf

 IVF is the most refined treatment but not the first of treatment.

It has to be done as per the indication only.Sometimes delay in taking decisions may end up in opting for third party measures so what one need is correct and guided approach.

As patient we have many queries as why IVF only so here are the reasons as to when your clinician will advise you for same- 

1)Fallopian tube damage or pathology-

Tubal block on X RAY(HSG) doesn’t always mean opt for IVF directly.In that case decision is taken as per level and grade of block ,age of female and married years besides cofactors 

•If tubal surgery is not  possible then,IVF is method of choice.

•In case of problem in tubal function  even after tubal surgery, IVF is method of choice after an infertility duration of 2 years or longer.

 Depending on the female age IVF can be done after a shorter duration of infertility.

Actually Tubal factor was the first indication when IVF was started in world to help childless couples

2) Unexplained infertility (idiopathic)-

When exact obvious cause cannot be diagnosed after all basic work up of couple.This is considered as most frustrating condition for both the doctor and the couples and adds to stress.It contributes to 10-15% of all infertility cases

  IVF is indicated if the duration  of infertility is 3 years or longer.  But If the woman is older than 36 years, IVF maybe   considered earlier.

3)Male factor-

Here couple has two options- Either go for donor sperm or Go for IVF/ICSI as per the Sperm count.

Other option is SSR(Surgical sperm retreival) Provided doctor has expertise to do the same

What we focus in the semen is TMC-Total Motile Sperm count-This is the basis to take decision like mentioned below-

Total motile sperm count   < 1 million: first treatment of choice isICSI•

TMC > 1 and < 10 million: IVF can be performed if infertility duration is 2 years or longer•

TMC > 10 million: treat as unexplained infertility 

4) Endometriosis-

In case of mild or moderate endometriosis treat as unexplained infertility.•In case of severe endometriosis policy treat as tubal pathology

5)Cervical factor / immunological infertility- After an infertility duration of 2 years, IVF is indicated. This may be considered sooner if the woman is over 36 years of age.

6.Hormonal disturbances-

Like in PCOS if after multiple ovulation induction cycles patient fails to get pregnant then one has to plan IVF.No of cycles of Ovulation induction vary asper female age partner but shouldn’t exceed 4 cycles as after that there is no benefit of doing so.

Stress, anxiety, and depression have been linked to lower IVF outcomes, and psychological intervention improves the chance of success. Paying attention to these factors will also improve interactions ofpatients and staff, and will help adjustment to the stresses of child rearing.Multiple pregnancies have been shown to cause considerable personal and marital stress. Early intervention may enhance the long-term well-being of these families.  

Cancer is increasing in prevalence with improved detection and diagnostic techniques so prolonging the life and improving the quality of life.It has been observed to be affecting more of younger age groups so can have a lethal effect of the future fertility by destruction of their gametes (sperm or eggs). As doctor we feel need of spreading awareness at multidisciplinary level regarding preservation of future fertility which needs counseling and guidance at preliminary stages only before the damage happens.

Various Methods-

• Oocyte/Egg cryopreservation
• Sperm Cryopreservation
• Embryo freezing

Method will vary as per the clinical status

Oocyte  cryopreservation.

Egg freezing means removing mature eggs and freezing them for later. This process may also be called egg banking . Its done in cancer patients preferably before exposure to chemo and radiotherapy.Its same like an IVF cycle except that embryos are not formed.Here  medications are given  to stimulate the development of multiple follicles in the ovaries.

Type of cancer can also decide the protocols.

Besides there are now more patient friendly mild stimulation protocol especially in estrogen sensitive cancers

The eggs are retrieved from the patient using a transvaginal technique under anesthesia and are kept frozen for future use by a method called vitrification.  

Frozen eggs can be kept frozen for years(5 years as per ICMR but not specified for cancer cases) till the woman decides to use them for conception  and once the patient is ready to get pregnant, the eggs are thawed and then fertilized using ICSI, an assisted reproductive technology that injects one sperm directly into the egg. The embryos (fertilized eggs) will then be transferred into the woman’s uterus (womb) in order to achieve a pregnancy.

Embryo Freezing 

 It has the highest success rate compared to any other treatment.  Its like normal IVF when eggs are retrieved and mixed with sperms. Once fertilized, the embryos (fertilized eggs) grow in the laboratory for 3-5 days until they are suitable for freezing.  

Sperm Freezing
Sperm Freezing is an effective and simplest way for men who have gone through puberty to store sperm for future use. Many men can store sperm (either from natural ejaculate or from a TESA sample

This is the success story of adopting an embryo which was frozen for 24 years.

Its no Less than a miracle but it also proves that THERE IS ALWAYS A HOPE 

What we consider end may be a begining

Here via this platform we are sharing success story with our readers

The baby that was conceived just 18 months after its mother: Woman, 26, gives birth to baby girl from a donated embryo that was frozen for 24 YEARS - the longest ever Emma Wren, born on November 25 this year, was conceived in 1992 Her adoptive mother Tina Gibson, 26, was conceived in 1991 Tina married her husband Benjamin when she was 19 and he was 26 because he has cystic fibrosis (CF), a fatal disease with a life expectancy in the 30s Fertility is often an issue with CF so they decided they would adopt, and they fostered several children to prepare for itThen they heard they could adopt an embryo and have a pregnancy experience

The embryo was cryopreserved until March this year, making it 24 years frozen It is the longest time an embryo has been frozen, after one in Virginia which was frozen for 19 years and a few months Experts say this successful birth 'suggests the shelf life of an embryo could be infinite'  

HOW DOES EMBRYO DONATION WORK?

•  Couples who go through IVF tend to have extra embryos leftover, which are frozen and stored for later use. Eventually, when families decide they don't want any more children, they have to decide what to do with the leftover frozen embryos.
• IVF couples have a few options for their left over embryos:-
• donate the embryos to research 
• thaw them and let them die
• keep them frozen donate them to a couple who can't conceive

IVF(Invitrofertilization) is   considered as most successful ART.But as patients its important that you should know that it has limitations even in the best circumstances and is guarded by certain confounding factors ranging from your age to clinical skills  with proper training of your treating doctor to the lab parameters. If you are claimed 100 or 200% results then that must be God’s Promise as its beyond limitation of a human at least.So don’t get carried away by the Google ads and other advertisement and brand names and age only –do your proper homework before you get treated.What is more important and expected is not just to start you on injectable medicines but the right guidance with cafeteria choice with definitely paying due respect to what you decide as a couple with open mind.Availability of different tests and glamourous equipments with fancy medicines doesn’t mean you need all.

Here are few things you should learn before stepping into any clinic to have a smooth journey of parenthood
1)    Your clinical profile- 
Success of an IVF revolves around as what is the age of female partner because as the age advances(more than 35 years) quality and quantity of eggs(ovarian reserve) will decline so further compromising the success rate.Chances range between 30 to 45%  with own eggs and sperms and 50 to 60% in Surrogacy and donor gametes
2)    Get basic check up done-
You should get at least ovarian reserve and semen test done before you reach Doctor
3)    Preconceptional advise- (Prevention is better than cure)
Start Folic acid(Prenatal Vitamins) before you plan pregnancy at least one month prior .It will help save your baby against brain and spinal disorders because at the end we want you to have healthy baby
4)    Medical clearance-
If you are more than 40 years age or if you have any history of medical ailments associated so get yourself treated prior hand only .Purpose is to see that you are medically fit to carry the pregnancy or you don’t carry any disease which can impact your baby.No hurry is more precious than being safe first.
5)     Know Your Problem First-
Term Infertility or labeling someone as Infertile looks very harsh.Its important you should know the difference.If you had any pregnancy or abortion earlier then you are subfertile-it means you have decreased fertility but still you have much better chances of having baby than the couple who never had any pregnancy
6)    Donor not always an answer to nil sperms-
 Even if your husband has zero sperms(azoopsermia), it doesn’t mean that you have to opt only for donor sperms.Still healthy sperms can be obtained from his testes by a minor surgery called SSR(Surgical sperm retrieval) like TESA,PEAS,MESA,TESE,MICROTESE.