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Thursday, December 27, 2012

Why did my IVF cycle fail ?

Try and try again until you succeed !

The first question that arises in a patient’s mind after an IVF failure is ‘Why did my cycle fail ?’ A failed IVF cycle is heart-wrenching. It is painful because your dreams are shattered, your hard-earned money has gone down the tube and you do not know what to do next ! As humans we all need an answer for the failures we encounter. Why did a particular endeavor fail ? If we get an answer for this , then we tend to have peace of mind , because we believe that we can achieve success the next time around if we can rectify what went wrong in the previous attempt. But when an IVF cycle fails unfortunately no one has an answer for the same – not even your doctor ! You might have had a perfect cycle – lots of eggs, good fertilization rate, good quality embryos, excellent endometrium, easy embryo transfer – but no positive pregnancy test !  On the other hand your friend might have had a very poor IVF cycle (with few eggs and poor quality embryos) and they might end up getting pregnant ! IVF is like a gamble – which involves not only your money , but also your fragile baby dreams ! The sad truth is that there is no logical explanation for the outcome of an IVF cycle – be it a success or a failure. This is because we are still not intelligent enough to understand the logic beyond the bio’logical’ process that controls embryo development and implantation. Once the embryo is transferred to the uterus , no one knows what happens to it after this– after all, how can we track the fate of a microscopic ball of cells once they are inside the uterine cavity ? We cannot predict which embryos will implant and why, and hence we do not know why an IVF cycle fails or succeeds ! Fortunately or unfortunately , no one cares the other logical question - ‘Why did my cycle succeed ?’ – this doesn’t have an answer either !

The first person patients turn to when their IVF cycle fails is their doctor. He is the person who performed everything from the ovarian stimulation to the embryo transfer. He is the one who advised them to do IVF ; and reassured them that they had a good chance of succeeding. Patients naturally think that their doctor should have an answer for the most important question that haunts them – ‘Why did my cycle fail ?’ There are patients who are naive about the IVF process , and who get angry with their doctor when he cannot offer a satisfactory answer for the failure. They start imagining the worst – that their doctor did not perform the procedure well, or that the clinic is not competent , which is why the cycle failed. Some might blame themselves , because they start thinking that their body is not conducive for achieving a pregnancy; that their uterus is not good enough to accept the embryo; and that they are not fit to carry a baby. Some believe that their body is defective or that it “rejected” the embryo. Many start obsessing about all the ‘mistakes’ they did during the 2ww – from not taking enough rest to eating certain ‘forbidden’ foods. Many patients start blaming themselves for the IVF failure and might even think that it is a punishment from God !  But a well-informed, IVF literate patient understands that an IVF failure is nobody’s fault. Such mature patients get better emotional protection after an IVF failure because they do not blame others or themselves for the failure. They do not think their body is defective (and hence their self-esteem is not damaged) ; and they accept the failure with a strong heart and mind which will in turn help them to look forward for ways to make their baby dreams come true !

 The most important duty of an IVF doctor is to teach his patients how to prepare themselves for an IVF failure. A good IVF specialist will spend time and energy to educate his patients about the uncertainty inherent in an IVF process. He will not falsely raise the hopes of his patients and he will not promise them a baby. Such a mature doctor not only protects his patients from the emotional assault of failure, but also protects himself from the wrath of his patients ; and also does not need to trot out a plausible lie to satisfy the patient when the cycle fails !

What causes an IVF cycle to fail ?

No one knows the answer ! There are some explanations , for example – poor quality of the embryo ; genetic defects in the embryos ( which we cannot always diagnose); or the presence of an unreceptive endometrium. But the problem with existing IVF technology is that there are no sure ways to find out which embryo is genetically normal and which endometrium is  receptive. Hence giving an exact reason for the IVF failure to an individual patient is not always feasible , because of the limitations inherent in today’s ART. Let us consider a fertile couple who is trying to have a baby in their bedroom. Do their attempts at baby making sex result in a baby every month they have intercourse during their fertile time ? Of course not ! A young fertile couple may take up to one year to achieve a pregnancy - and they have just a 15 – 25 % chance of conceiving in a particular menstrual cycle. This clearly shows that human reproduction is remarkably inefficient. During IVF the chance of achieving a pregnancy in a single attempt is significantly higher- most clinics around the world have a success rate of 40-50 %. But it is impossible to pinpoint why 6 out of 10 women who undergo IVF fail to achieve a pregnancy and why the other 4 are successful in their attempt. 

What will not cause your IVF cycle to fail ?

The following will not cause your IVF cycle to fail :
1)      Not taking bed rest
2)      Coughing during 2ww
3)      Stress
4)      Your food habits (eating the so called ‘heat generating’ foods ! ( for example chicken etc)
5)      Pseudoscientific reasons such as NK cells and HLA matching

What happens when an IVF cycle fails ?

Even though the patient tries to understand that there is no valid explanation for an IVF failure , many a time the heart is not ready to accept what the head says. As it is rightly said , the heart has reasons that reason does not understand.Since there are so many emotions connected with an IVF cycle , the heart of a patient naturally craves for an explanation for the failure , so that the “ fault “ can be rectified in the subsequent cycle. They believe that this will help in achieving the much desired pregnancy. This is where many IVF doctors play games with their patients – some for money, some unable to face patient’s questions, some because of the fear that they might lose the patient to other doctor and some in order to maintain their ‘I know everything’ image  ! 

Patients don’t like being told doctors don’t have all the answers ! This makes them uncomfortable, and they start doubting their doctor’s competence. If he cannot even answer such a basic question, then he must not be very good ? Maybe we need to get a second opinion ?  This is especially true when the doctor over-promises success before starting the IVF cycle ( as many do, to lure the patients into doing IVF  with them).  They promise them the earth and the moon – and when they cycle fails, they often abandon these patients and refuse to see them, as they don’t want to have to answer awkward questions. Even worse, rather than acknowledge the state of their ignorance, many doctors will concoct pseudo-scientific answers for the failure, such as immune rejection because of overactive NK cells in the uterus ; or HLA similarity between the partners. They will then run a panel of expensive and painful tests ( of no proven validity) , and then find “abnormalities” which they will then go on to “treat” before starting the next IVF cycle. The patient is hooked,  because she believes that the doctor has now pinpointed the fault – and now that it has been corrected, the next IVF cycle will definitely succeed ! Many are sadly disillusioned when the next cycle also fails – and they then start belatedly doing their homework !

How do IVF doctors react when their patients demand an explanation for the failure ?

When an immature IVF doctor is confronted with the question – ‘why did my cycle fail ?’ he may feel offended. Many feel that their clinic’s competency is being questioned ! Many doctors will accuse the patients for the IVF failure. They might say : your uterus is not good enough; you didn’t take enough bed rest; you did not follow my orders etc. Such answers will increase the patient’s agony because they start believing that they are the reason for the failed IVF.

There are doctors who have a very paternalistic approach. They feel they are like God and no one should question them. They take pride in their intelligence and in their ability to give answers to all the patient’s questions. When such doctors are confronted with  the ‘why did my cycle fail ?’ question , they order a list of expensive, useless tests and subject the patients to treatments which have never been proven to be helpful. Ironically , this gives immense satisfaction to patients , because they believe their doctor is striving hard to find where the fault is ; and will be able to rectify it with expensive treatments. Patients delude themselves that costly treatments are highly effective and the doctor in turn gets the satisfaction that he has given appropriate answers to the patient’s question ( because many of these test results turn out to be abnormal, even though the abnormality is of no clinical importance). 

Only a mature doctor has the courage to give the honest answer – ‘I do not know’ !Of course , there are patients who are not mature enough to accept this explanation , nor do they appreciate the doctor’s honesty. They think that the doctor is not knowledgeable enough to guide them and look for doctors who will give them an explanation for their IVF failure. They believe that since that particular doctor has an explanation for the failure , he will make sure that the pitfall is corrected and make their next IVF cycle a success !

What are some of the futile treatments employed in the field of IVF ?

The below treatments do not have any scientific proof for their efficiency !
1)      IVIG therapy – Intravenous immunoglobulin therapy
2)      Intralipid therapy
3)      Paternal lymphocyte immunotherapy
4)      Use of heparin

My IVF cycle failed- what should I do ?

Try again ! This is the only good answer and a good IVF doctor’s answer will be exactly this. A good IVF doctor will not order a bunch of expensive tests after each IVF failure. A good IVF doctor will make sure that his patients have realistic expectation about the entire IVF process. If you want to be a mature IVF patient , educate yourself about the process. This will help you to have sensible expectations of IVF treatment.  It will protect you from an emotional breakdown ; and from unnecessary tests and treatments. 

If IVF treatment is like a gamble, are there ways to reap the best out of what I pay ?

There are clinics which want to make the IVF treatment a win-win situation. They offer something called a money back guarantee programme. You pay for a certain number of cycles (for example 3 IVF cycles) and if you do not get pregnant within those 3 cycles , they give you back your money. This is a wonderful option , which could help you preserve your peace of mind , at least as regards the financial aspect. So before starting an IVF cycle make sure that your clinic has such an option and ask them whether you qualify for such a programme.

The field of IVF is highly commercial and you need to protect yourself from being exploited by money-minded and irrational physicians. Your doctor is not always correct and unbiased. So please become well-informed about the process before starting it. Find a good doctor who will have your best interests at heart. If you are constantly diverted from your aim of having a baby by having to do unnecessary tests and treatments , you will get exhausted very soon. It makes going through subsequent IVFs impossible. Being knowledgeable and having realistic expectations about IVF will help you to remain strong , and will keep you going. Be careful not to get fed up before getting pregnant !

Tuesday, December 18, 2012

Is IMSI better than ICSI ?

Sperms attached to egg coat

Myth :  IMSI is better than ICSI

Fact :  This is another unproven claim in the field of ART , another logical fallacy ! 

A sperm is the smallest cell in a human body and an egg the largest. The union of the sperm and the egg brings the genetic material from the male and female together , to allow the creation of a new life.  A normal human semen sample consists of anywhere between 20 – 150 million sperms and not all sperms look alike ! Human sperms are very heterogeneous in their appearance and they have many different shapes. This is in sharp contrast to animals, most of whom have perfect looking sperm.  When we test a sperm sample in the lab, we check the shape ( morphology) of the sperm by staining them and examining them under high magnification. When studying male fertility , researchers were very interested to understand whether the shape of the sperm is in any way connected to the man’s fertility potential. This led to lots of studies aimed at determining what normal human sperm morphology is !

What does a normal (fertile men’s sperm) sperm look like ? – Actually, no one knows the answer !

This is a question which still doesn’t have a good, solid answer. A human semen sample consists of sperms which exhibit significant intra (within a single ejaculate) and inter variability (when ejaculates from different fertile men; and even ejaculates from the same fertile man at different times, are compared) in their morphology. Hence , determining the criteria to say whether a sperm is normal in its morphology is very difficult.  In the animal world, fertile animals have sperm which look identical , and this  makes it easy to determine what an abnormally shaped sperm looks like . Infertile animals have sperm which are abnormally shaped. On the other hand , when you compare the ejaculates of two fertile human males , their semen sample contains sperm of widely varying shapes, even though they are both fertile. As a result of this , it is hard to find a benchmark as to whether a particular sperm shape is normal or abnormal ! Hence characterizing the fertility potential of men based on sperm morphology became a hard task. 

In earlier times , researchers observed human sperms under the microscope carefully. When they felt that a particular sperm looked very different from the rest,  they considered such a sperm as being abnormally shaped  and recorded such sperm shapes in the form of schematic representation and drawings (which lacked accurate details). By using such an approach , sperms which are not considered to be abnormal are considered as normal ; and normal sperms are thus identified as being normal by default , because of the absence of any gross defect. This method , which is used to classify sperms as being morphologically normal, is called the liberal approach.

Then came the method of identifying sperm morphology using strict criteria or Tygerberg criteria (Kruger’s strict criteria). According to this approach , the morphology of sperms which are found at the internal cervical os (the part of the cervix closest to the uterus) and the sperms which are found attached to the zona pellucida (egg coat) of the human egg are considered to be the gold standards for labeling a sperm as normal. The sperm present in the above places are found to be homogenous in their morphology , although they still exhibited differences in their head shapes. This method of sperm morphology evaluation also included the functional capability of the sperm , because sperms which are able to reach the egg are used as a benchmark for determining what normal sperm morphology is. This means that studying sperm morphology is still not perfect , and there are still several arguments as to the right approach!

What is the cut-off value for evaluating normal sperm morphology in a semen sample?

The standard textbook for evaluating sperm is the WHO laboratory manual for the examination and processing of human semen. In the first World Health Organization (WHO) manual published in 1980 , the cut-off value for mean normal sperm morphology was 80.5%, with a range of 48.0%–98.0%. In the second WHO manual published in 1987 the cut-off was lowered to 50%. Both the cut-off values were determined based on the liberal approach for sperm morphology evaluation. In the third edition, the value for normal sperm morphology was changed to ≥ 30% morphologically normal spermatozoa , based on strict criteria for sperm morphology evaluation.  In the fourth  edition of the WHO manual , no cut-off value was provided but it stated that 'Multicentre population-based studies utilising the methods of morphology assessment in this manual are now in progress. Data from assisted reproductive technology programmes suggest that, as sperm morphology falls below 15% normal forms using the methods and definitions described in this manual, the fertilisation rate in vitro decreases.' And in the newest ( fifth ) edition the proposed cut-off value for normal sperm morphology is just 4% based on strict criteria for sperm evaluation!

This means a man needs only 4% of normal shaped sperms in his semen to achieve a pregnancy (PMID: 1550422).This evolution of cut-off value for evaluating normal sperm morphology clearly shows the confusion which exists in determining what a normal looking sperm is ; and with the strict criteria which are used now for sperm evaluation , more and more sperms are classified as being abnormal. Actually the decline in the cut-off value for morphologically normal sperm doesn’t mean that the semen quality is declining, it just means that the sperm morphology evaluation criteria have changed ! Sperms which were considered normal in the 1980s are considered abnormal now ( the field of sperm morphology evaluation is very confusing !)

Can a sperm shape predict the quality of DNA it is carrying?

It is tempting to assume that an ugly sperm (morphologically abnormal sperm) carries defective DNA , which is not competent enough to create a beautiful baby. But looks can be deceiving as always. A high amount of morphologically abnormal sperm might indicate poor sperm function but it doesn’t automatically mean that a morphologically normal sperm  is functionally competent , or that the DNA it carries is normal. It also doesn’t mean that sperms with abnormal morphology carry chromosomal defects.
With this background in mind, let’s see what IMSI is !

What is IMSI ?

Magnified sperms (7000X)

Intracytoplasmic morphologically selected sperm injection (IMSI) is a new technique which is also called as ‘super ICSI’.  In IMSI technique,  the sperms are magnified 7000X (whereas in ICSI the sperms are magnified only 400X).  Evaluation of sperm morphology at this high magnification enables the embryologist to select sperms which are devoid of any obvious morphological defects. For example any defect in (DNA compaction) is visible in the form of vacuoles in the sperm’s head , and the IMSI technique identifies such ‘defective’ sperm (those are the sperms which are supposed to carry a defect in their DNA !) . Such sperms are excluded from being used for fertilizing the egg. Selecting a sperm which is morphologically perfect from a semen sample high contains a high number of abnormal sperms is thought to help in achieving and maintaining pregnancy via ART technique. This is what the IMSI technique promises us.

Isn’t it logical to use IMSI in place of ICSI ?

Theoretically , it appears logical to use IMSI , but this is not true in real life for a variety of reasons :
  1. Just because a sperm is morphologically normal doesn’t guarantee that its DNA is normal. Similarly, just because the sperm is morphologically abnormal doesn’t mean that its DNA integrity is compromised and that it will fail to give rise to a healthy baby. You can’t judge a book by its cover !
  2. Sperm DNA integrity is not as important as we think. It is a well-established fact that sperm contribute only 10% to embryo aneuploidy ( abnormal chromosomal content) ; and that 90% of aneuploidy defects in embryos arise as a result of abnormal eggs. It has also been proven that the sperm’s DNA is extensively repaired (any defects in sperm DNA integrity is set right) and remodeled by the egg’s ‘error correction’ machinery after fertilization(PMID: 21546611)(PMID: 22541549)(PMID: 17978187). Although it is surprising to know that such a mechanism exists , it is very logical from nature’s point of view. Nature provide an egg with much more power to control the embryo’s development ! A woman is the one who is going to carry the baby to term and take care of the baby until it becomes independent. This is perhaps why nature has given the egg an upper hand in deciding a baby’s developmental fate ! An egg from a young woman can efficiently repair damaged DNA of a sperm ! So when the egg is young , even poor sperms can give rise to healthy babies.
  3. There is no solid scientific proof to say IMSI is better than ICSI! There are no well-controlled randomized studies to prove this claim.
IMSI is not a magical solution for couples with multiple IVF failures, with poor sperm morphology or with recurrent pregnancy loss. In fact, abnormal sperm morphology cannot even be the only indication for performing ICSI because men labeled as having abnormal sperm morphology are able to father a child without any medical help many a time ! Today, a man who has 96% abnormal sperms and only 4% normal sperms is still considered to be fertile . If your husband has only 2% normal sperm morphology ,then should he be labeled as infertile ? My logical answer will be a ‘NO’. Can 96% abnormal sperm and 98% abnormal sperm really make a difference ?

Saturday, December 15, 2012

When making babies becomes a challenge !

 All of us want our life to be perfect. For most of us , a perfect life consists of growing up comfortably, earning well, getting married to the love of our life, having children and dying peacefully at a ripe, old age. Since we are so used to viewing life through rose-tinted glasses, it is hard for us to accept life’s bitter realities. As a result, any deviation from a so-called ‘perfect’ life is viewed as a time of crisis. The inability to have a baby is one such life crisis which can have enormous emotional impact on the individuals concerned.

The sweetest dream of many married couples is to have a baby - a baby who will be proof of their love and oneness, a baby who will make their life a celebration by making it interesting and worthwhile, a baby on whom they can shower all their love and affection, a baby from whom they can get lots of unconditional love and a baby who will propagate their genes and make them immortals. For most married couples,  their ‘baby dream’ comes true even though they are not aware of the scientific details of the reproductive process. They get married; enjoy physical intimacy; and one fine day , the woman misses her menstrual cycle followed by a positive pregnancy test. The moment a couple learns that they are going to be parents, is one of the happiest and most exciting periods of their life. It gives them immense satisfaction because one of their main goals in life is fulfilled – to procreate! For many couples reproduction is a pleasurable pursuit, which brings a lot of happiness and celebration in their lives. But for some, it becomes a Herculean task , filled with desperation and heart-breaks. What happens when this basic life goal is threatened? 

Infertility is one of the most difficult emotional crises one can go through and is hard to cope with for many reasons. Infertility is a challenge which you face during the prime of your life. Shouldn’t it be easier to fight it as you have the necessary power and vigour to do so? A logical answer should be yes, but the time we have to tackle infertility is also the period during which we come out of our safe cocoon, get married, accept responsibilities and try to build a family. That is the time period during which our sense of superiority is highest. Everything in life seems to be achievable. Life appears rosy. During that time infertility comes as a big blow to all the optimism you posses about life. When people around you seem to achieve their reproductive goal so easily, you are dismayed when you realise that this is going to be an uphill task for you. Your pride dies and humility sets in ! Infertility gives a hard blow to our ego and to face such harshness during our salad days makes life’s journey appear extremely strenuous !

For many women , including me , having a baby is a long cherished dream. Have you ever watched a girl play with her dolls ? I have eagerly watched them and most of the time the little ones like to role play as mothers. The love for nurturing young ones is very much inherent in a female’s psyche , even from a very young age (even from the age of 3 or so). I am sure many of us were a loving and caring mom to our pretty dolls (and I am sure many of us are still so !) and the longing for experiencing motherhood is deep-seated in a female’s mind, heart and genes. I grew up in an Indian setting where motherhood is looked upon with awe, respect and admiration. The air of secrecy surrounding a pregnant woman, the sudden attention she gets, the amount of pampering given to her,  the delight she takes in her growing tummy, the way her face glows day by day, the ceremonies performed to highlight her motherhood and all the celebrations associated with pregnancy and child-birth made me dream of motherhood from a very young age. For example, in my hometown they conduct a ceremony at the 7th or 9th month of pregnancy (just like a baby shower) to welcome the young one and to honour the mother-to-be. It is a very colourful ceremony attended by ladies and the best part of the ceremony is that they decorate the arms of pregnant woman with so many colourful glass bangles (it is believed that the clinging sound from the bangles will make the baby happy). The expectant mother with her growing baby bump, glowing face and with the soft sounds arising from her bangles is such a pleasure to look at. I still remember the days where I longed to become a mother just to wear so many bangles in my arms. That beautiful, unfulfilled dream is still alive within me, deeply rooted in my heart. It hurts when that day never seem to come true !

The joy of motherhood becomes complete when a little one arrives. Who wouldn’t love a new born baby ?  Even the most hard-hearted person will melt at the look of a young one. I remember the days where I spent my time with little babies - looking and wondering at their perfect features, the beauty of their sudden flashing smile which travels across their lips when they are asleep (my elders used to say that God is showing a bunch of flowers to the young one and playing with her,  and that is the reason for that smile), their warmth and their milky smell ! Those were the days during which my passion for having a young one for myself grew steadily. A baby is a wonderful gift which God leaves by your side when you are asleep - that is what I was taught when I was a child and asked where did the baby come from !

My love for young ones did not develop solely by looking at human babies ! We always had pets at home, mostly cats-sometimes several of them. None of our male cats were neutered and female cats spayed. So you can imagine the amount of (re)productive activity that goes on. At least twice a year our female cat gave birth to kittens. The mother cat and her kittens are such a pleasure to watch-the way the mother cat feeds the young ones, the struggle it undergoes to protect them, the happiness with which it plays with them, the effort it puts in to teach them the much needed life skills (like hunting and self-protection) ! Once I even saw my cat give birth and that was a breath-taking moment for me! More than the birth of the kittens, the birth of a mother amazed me ! Our playful cat suddenly became a responsible mom! I have sat nearby a new born calf for hours just to touch it and watch it; ignoring my parents pleas to return home ! All these experiences taught me the happiness of motherhood.  I understood that the joy of having young ones is manifold and I naturally craved for it. I felt happy to be a female, I felt happy to be a potential mother-to-be !

I am sure most women, like me, are proud of their womanhood. Many have beautiful baby dreams. What happens when such delicate dreams are threatened? After marriage the only thought I had in mind was to get pregnant as early as possible. When every month passed without anything happening, there was more and more panic. Every menstrual cycle became emotionally painful. I started dreading the arrival of AF. Can buying sanitary napkins become this hurtful ?! Sex became a joyless act which was performed solely to get pregnant. When I was told that without fertility treatment it is impossible for me to get pregnant , I broke down. I stepped into the world of infertility, no, no infertility stepped into my beautiful world and the first thing infertility did was to shatter my beautiful dream - a dream of decorating my arms with many colourful glass bangles !

In the beginning the most difficult thing for me to accept was the word ‘infertile’. This word carries lots of stigma with it. The dictionary gives many meanings for this word like ‘barren - sterile - fruitless - unfruitful – unproductive’. I am sure none of it seems to fit the image I have for myself. Am I barren and fruitless? I remember the day when a papaya tree was planted in my home when I was young. I and my dad planted it. I saw it grow in front of my eyes. We are eagerly expecting the fruits from it. But unfortunately nothing happened. It flowered but no fruits. My grandfather brought some men one day and took away its life ! I was upset and asked my granddad for an explanation and I still remember the words he said ‘what use is a barren tree which cannot produce fruits ? It is just occupying the space.’ Am I barren? Am I just like that papaya tree? Don’t I have a fertile heart and a fertile mind ? How could someone label me as ‘infertile’? I despised infertility and the word ‘infertile’. As time went by I started to accept reality and tried to look for ways to escape from infertility’s grip. But unfortunately infertility loved me so dearly, it did embrace me very strongly !

After infertility set in, my whole world changed completely. Life started to revolve around only one thought - ‘a baby’. Doctor appointments became the norm. Injections don’t cause anxiety anymore. 99 % of internet searches are about infertility treatments. My body suddenly become an object of experimentation  (several vials of blood taken, several novel tests are conducted, different drugs are tried on me and what not !)  My private parts are poked and prodded by the infertility specialists – ‘do I really feel feminine enough now-a-days’ ?  Conversation with my in-laws became very uneasy. The pleasure associated with eating favourite foods are gone, food is divided mainly into two category-foods that help with fertility and foods that harm fertility ! Love-making became a chore – the fruitlessness of the act brought in a sense of guilt. Making love with a baby in mind is the most absurd side-effect of infertility- I wish no one should ever go through it !

Money suddenly became the utmost priority in life. No job - no money - no baby; there is a baby connection to everything in life. Life started to appear very insecure. When everyone around us is striving hard to earn money in order to secure their future, buy a car, and buy a home , we are stuck in a costly ‘baby-making’ process !  Life is no longer under our control and everything has become uncertain. The smooth flow of life is suddenly interrupted and only a baby seems to be a solution for all the craziness infertility has planted in our life.

Babies are gifts from God – this is the thought with which I grew up. That is what the culture in which I am brought up taught me. When baby making became a challenge , the question that naturally came to my mind is– why is God denying me the gift which he gives to everyone around me ? What did I do wrong? Am I a sinner ? Most religions preach that if you do wrong you will be punished by God. Hinduism talks about how your past life ‘bad karma’ could affect your present life. Religion instilled only one thought in my mind - you are a sinner ! Suddenly all my present life wrong-doings (thank God I am not aware of my past life !) became magnified out of proportion. Is there anything else which could damage your self-esteem so badly ?

Infertility did rob me and my dear one’s of many of life’s natural happiness. How will someone react when they hear that their little sibling is pregnant ? That is one of the happiest news to be shared and celebrated,  right? For me it brought tears to my eyes ! Even now I feel guilty for how I reacted at that moment ! I was not as mature as I am now.  I was not jealous - I just didn’t know how to react. A sudden attack of happiness and sadness at the same time made me cry. I felt toppled from my ‘big sister’ position suddenly. My own misfortune came as a hindrance for the happiness I felt for my sister. I could also sense how difficult it is for her to share life’s very important and very happy news with me – after all, she is my little one who is naturally worried about my emotional safety ! It didn’t end there, and throughout her pregnancy I couldn’t ask her many of the questions a ‘big sister’ would ask. I didn’t have any wisdom about pregnancy to share with her. She didn’t know what to ask me or what to share with me. Throughout her entire pregnancy there was an ‘iron curtain’ between her and me which both of us were very reluctant to lift. But the day I saw her little one , my heart just melted away - haven’t I become a mom too ! Aren’t they my children too?

Infertility is very, very hard to deal with – physically, financially and emotionally. It can shatter your routine, so-called ‘perfect’ life beyond belief. If you are not careful enough , it can leave you bitter and full of scars at a very young age. It can play havoc with your relationships. Is infertility bad ? Of course it is , when you don’t have the right attitude towards it ! As Khalil Gibran said ‘Your living is determined not so much by what life brings to you as by the attitude you bring to life; not so much by what happens to you as by the way your mind looks at what happens’.

I am a good person. I love children. Why am I doomed to go through the pain of infertility ? Why do bad things happen to good people ? There are many different answers for this question and hopefully my next post will be on this – ‘When bad things happen to good people – how infertile couples can find the strength to cope’!

Friday, December 14, 2012

In the past , the standard was – Transfer the best, freeze the rest ! Is a freeze all policy better today ?


In a conventional IVF cycle , usually several embryos are generated and the best looking embryos (usually a couple of embryos ) are transferred to the uterus.  The remaining embryos are frozen and are used during subsequent embryo transfer attempts. 

How is an embryo frozen ? What happens to the embryo when it is frozen ? Freezing of embryo involves the use of cryogenic temperatures (below -150°C) and cryoprotectants
( substances which are used to protect the biological materials from damage due to freezing) .  Embryos which are frozen at such cold temperatures remain without any change in their functionality or in their genetic make-up for centuries. The embryos remain ‘frozen in time’ – metabolically inactive ! The length of time an embryo is frozen will not affect its quality in anyway.

What are the methods used for freezing embryos ?

There are two methods which are widely used for freezing embryos : slow freezing and vitrification.

The older slow-freezing techniques used a lower concentration of cryoprotectants. As the name suggests, freezing is achieved slowly, in a step-by-step manner and such programmed cooling requires costly instruments which could cool the embryos steadily by maintaining appropriate temperatures. It is also a time-consuming process and this technique doesn’t prevent the formation of ice crystals in embryos. These ice crystal can kill the embryo during freezing and thawing, as a result of which their survival rate was never optimal.

Vitrification is a technique in which the cells are cooled ultrarapidly (at an extremely high cooling rate) . It needs a much higher concentration of cryoprotectants. The advantage of vitrification is that ice crystal formation within the cells is totally prevented. It transforms the cytoplasm within the cells into an amorphous glassy state. This technique doesn’t need expensive equipment; but does require experience and expertise.

Which embryo freezing technique is the best ?

Scientific studies have showed that vitrifying embryos resulted in better embryo survival after thawing. Vitrified embryos also had a much higher proportion of intact blastomeres (individual cells of cleavage stage embryos) when compared to embryos frozen using slow freezing technique. The post-warming morphology of the embryos is excellent and the pregnancy rate and implantation rate is found to be better with vitrified embryos. All these beneficial effects are attributed to the lack of ice crystal formation in vitrified embryos which in turn prevents injuries due to ice formation. Hence vitrification is the current preferred method of freezing embryos in most IVF clinics world-wide.

Why is embryo freezing important ?

Freezing embryos helps in utilizing the extra embryos produced during an IVF cycle in an efficient manner and hence the need for discarding supernumerary embryos is prevented.  When an embryo is discarded a life that might have the potential to develop into a full-fledged baby is lost. Since we still do not have accurate technology to pinpoint which embryo will develop into a baby, discarding human embryos becomes an ethical issue. Embryo freezing helps in addressing this ethical issue effectively. Freezing embryos also alleviates the need for further ovarian stimulation cycles when an embryo transfer attempt fails. Hence the financial and physical distress associated with a new IVF cycle is circumvented. The success rate of an IVF cycle naturally increases when there are many frozen embryos available since many more embryo transfer attempts could be made.

Is a fresh embryo transfer better than frozen embryo transfer ?

Before the introduction of vitrification for human embryo freezing, fresh embryo transfer had a higher success rate. With the introduction of vitrification , this scenario has changed dramatically.  When embryos are vitrified , the success rate of a frozen embryo transfer is equal to that of a fresh embryo transfer - or is even higher. Hence the statement ‘ Transfer the best, freeze the rest’ is no longer valid today !

Why is a frozen embryo transfer better than a fresh embryo transfer in terms of IVF success rates ?

1)  Vitrification for embryo freezing has led to a better survival rate of post-thawed embryos ; in good clinics, the survival is nearly 100% , and not a single blastomere is lost as a result of the freezing and   thawing.
2)  The endometrial receptivity is found to be excellent during a frozen embryo transfer cycle. During an IVF stimulation cycle (fresh cycle) the estrogen level in the body rises too high and such high estrogen levels are shown to be deleterious for optimal endometrial receptivity. A FET simulates a better and more natural endometrial environment when compared to a fresh IVF cycle. Embryo-endometrial synchrony can also be better achieved in a FET cycle.

If this is so, then is a freeze all policy better today ?

The data from randomised trials favour frozen embryo transfer as compared to a fresh embryo transfer (although larger trials are needed to confirm these results). Kato clinic in Japan , which does about 10000 cycles per year , performs only FET for all its patients and their reported success rate is very high ! It’s high time that all the IVF clinics and patients think of freezing all the embryos obtained during an IVF cycle and transfer them sequentially so that the chance of achieving a pregnancy increases. Apart from the positive aspects of FET described above , there is one more valid reason for opting to do a frozen embryo transfer. We still do not have a valid, fool-proof technique to determine which embryo has the potential to develop into a baby. Embryos which are selected to be transferred to the uterus using microscopic morphological criteria fail to achieve a viable pregnancy many a time. Many good looking embryos fail to implant  and many poor looking embryos do turn into a much desired baby. In such a situation, freezing all the embryos and transferring them sequentially might improve the odds of pregnancy when undergoing an IVF cycle.

Hence a freeze all policy is definitely a better option today and FET will soon replace fresh embryo transfer in the near future !

So if your fresh embryo transfer did not work, do not panic. A frozen embryo transfer is no less efficient than a fresh embryo transfer. Before starting an IVF cycle it is important for you to make sure that the IVF clinic you select has an embryo freezing facility - and , more importantly , that they use the vitrification technique for embryo freezing.

Tuesday, December 11, 2012

Wednesday, December 5, 2012

How to prepare yourself emotionally for an IVFcycle ?

Emotional preparation for an IVF cycle is as important as preparing yourself physically. Our mental and physical health is intertwined and any adverse change in one can affect the other too. Actually an IVF cycle is much more emotionally draining when compared to the physical discomfort it can cause. There are so many fears and concerns before starting an IVF cycle – and you are likely to feel excited and terrified at the same time. For most people the first IVF cycle (and for some every cycle) will be a scary emotional roller-coaster ride , filled with lots of uncertainty and heart-breaks. Of course there are a fortunate few who go through their IVF cycle smoothly and achieve success in their first attempt. But remember , this is not true for everyone. While we all want our first IVF cycle to be our last as well, if you are not hardy enough , an IVF cycle can play havoc with your mental health, sometimes irreversibly. So how should you prepare yourself mentally to deal with such an emotionally challenging journey ? How can you through an IVF cycle and come out successfully with minimal heart-breaks and few emotional scars ?

Acquire knowledge about the process
This is the first and foremost requirement which will safe guard your emotional health when going through IVF. Being literate about the IVF process gives you lots of confidence and a sense of control over the entire treatment. If you are knowledgeable , you will able to deal with the uncertainty inherent in the process more effectively.  Many first time IVFers find it hard to go through an IVF cycle because most of them are naïve about the process. The only thought they have in their mind is a baby , and they believe that every IVF cycle ends in a baby. They believe that all the medical nitty gritty of their IVF cycle will be taken care of by their doctor , and that everything will be fine if they are optimistic and have faith, so why should they worry about the technical minutiae of the process ? When their cycle doesn’t progress as expected , or if it fails , they are very vulnerable and may suffer from an emotional breakdown. Their belief in the entire process disappears into thin air and they find it very hard to cope. The best way to prevent this is to learn as much as you can about the IVF process. This will help in preparing yourself emotionally , because you will know : what to believe; what to expect; what can go wrong; how far your doctor can help you; how to deal with the cycle if something goes wrong; and why your cycle is different than that of your friends. The knowledge you acquire will act as a shield in protecting your emotional well-being. It will also aid you in designing a plan B if plan A doesn’t work. 
Prepare your mind for the failure

Some readers may find this advise absurd. Others may even get angry and think that I am a very pessimistic person. After all , who wants to hear about failure before starting their IVF cycle ? Everyone loves to talk to a person who encourages them and fills them with tons of positive thought. Everyone loves to hear that their cycle will have a positive outcome and they will take home a baby. Many refuse to even consider the idea of failure , because they dread the very possibility. They are worried that negative thoughts reduce the chances of success – or that they will create an unlucky jinx if they think about failure. Remember, you do not need any emotional preparation to face success but you need lots of emotional groundwork to face failure. The scientific truth is that only about 40 % of perfect IVF cycles end in pregnancy ! This means that only 4 out of 10 women who undergo one IVF cycle find success. Everyone , including me , wants to be one of those 4 ! But what if you are one of the 6 who fails to conceive after an IVF cycle? If you always obsess about success and a baby, how will you be able to face failure ? Many women who go through IVF are constantly advised by their friends, kith and kin ( and even their IVF doctors ) to remain optimistic. As a result of this, many women will train their brain to visualize only a positive outcome. They believe that if they do so they will end up becoming pregnant. I don’t know whether it will help you in getting pregnant , but it will definitely shatter you totally if the cycle fails. The pain a failed IVF cycle creates is enormous , and if you are a weak-hearted person it can paralyze you completely. So take care to prepare yourself for the worst. Write down how you will cope in case your IVF cycle fails. This will help your mind to be prepared for failure and hence the pain becomes a lot easier to deal with. Preparing yourself for failure will speed up your emotional recovery and will help you to plan for the next IVF cycle. 

Build a good emotional support system

It’s easier to handle difficult situations if you have a good emotional support system and family and friends can play a pivotal role in decreasing the stress of an IVF cycle. However, it is not wise to tell everyone that you are going through IVF and you need to decide who should know about your IVF journey. You might have lots of friends and family members but you might feel close and comfortable only with a few of them. Select people who really understand what you are going through, who are empathetic and who can whole-heartedly take part in your happiness and sadness. Surrounding yourself with friends and relatives who understand you will make a positive difference in your emotional well-being. This in turn will make your IVF journey a lot easier. My friends took away the stress of my IVF cycle by chatting with me (I forget to obsess when I am with them), by their compassion and by their kind words and deeds. During my recent failed IVF , my friends and their comforting words helped me a lot in regaining my routine. They patiently allowed me to grieve; and when I started to feel better , they came home and spent some quality time with me. One of my friends brought me a plant which is full of blooms and gave me a hug and that is all I needed to feel better instantly. I understand that many of you may be reluctant to share your IVF journey with anyone. I was also like that when I did my first IVF cycle, but it’s only later on that I realized that it is impossible to bear the brunt of an IVF cycle alone.  Happiness shared is multiplied , while shared pain is divided – share your IVF journey with your loved ones so that you get more emotional protection.If you have busybodies and nosy-parkers  in your life, please stay away from them. They just add to your stress levels and make coping with the IVF cycle much harder.
Turn to online infertility support groups
The best way to feel good is to talk to women who are going through the same infertility struggle as you are. There are so many online support groups where you can meet women who are knowledgeable about the IVF process . Most importantly , they are ready to help you both intellectually and emotionally. Another advantage with such support groups is that you do not have to reveal your identity and so you feel more comfortable sharing your journey with them. When you express your fears and concerns , you feel better emotionally. You don’t have to worry whether you will be ridiculed for your silly doubts because the other women have gone through the same situation you are in . You can also help other women with the knowledge you have gained. This will make you feel appreciated ; and this increased self-esteem will improve your emotional competence and strengthen your ability to face the next IVF cycle.
Prepare yourself physically
It is a well-known fact that a healthy body harbors a healthy mind, so take time to prepare yourself physically.  Please see my post on ‘How to prepare yourself physically for an IVF cycle?’

An IVF cycle is emotionally very stressful.  The most difficult challenge is to relax amidst that emotional stress. But when you relax , you will feel definitely better. You need to use relaxation techniques, and the good news is that there are many available, such as like breathing exercises ( pranayama); meditation; yoga and so on. But will they help ? How can a woman undergoing IVF relax her mind and get relief from the worries and doubts which constantly assail you. While yoga and pranayama will help you to relax physically , how far will they help you deal with your emotional stress ? I have found that the best way to relax is to address what is bothering you directly, instead of trying to suppress your fears and concentrating on something else. The major worry for a woman who is going through IVF is - ‘What will happen if my cycle fails?’ This question is the starting point of all stress, so try answering this along with your partner. Design a plan B ! It can be anything depending on individual circumstances – it can be another IVF cycle, it can be adoption or it can be child-free living. Once you decide what you will do if the IVF cycle fails , then it will be several times easier to relax mentally – and having a healthy conversation with your partner about what is bothering you will help you to relax as well !
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