A burning question in IVF !

Question # 5

" How are you doing? Hope you are having a good time. Going through second IVF cycle

Kindly help me answer few queries:

1.Could you please guide me if bed rest is recommended (or it has slightest impact) after frozen embryo transfer?

2.Can I go for mild stroll after 2-3 days and resume office?

3. Indian roads are bad and there are lot of bumps/potholes on the road, does travelling in the car negatively affect? "

Answer

I have already written a couple of posts regarding bed rest after embryo transfer. Even after that , I get repeated queries regarding bed rest !

Why are women afraid of carrying out their normal day - to - day activities after embryo transfer ? There are many reasons :

1.  Women turn to internet and online forums for advice - the suggestions they get there are very conflicting. They come across women who swear by bed rest for their IVF success.

2. Irrational fears are normal during IVF - ' what if the embryo falls down , is that light pink tissue on my toilet paper my embryo ! ' Couples who undergo IVF want their cycle to succeed  - their baby love cannot be fathomed. They fear failure , and want to do their best ( anything ! ) to find success. These factors play a major role in preferring bed rest.

3. Lack of knowledge about uterine and embryo morphology can lead to unnatural fears about embryo falling out from uterus .

4. Many clinics still send patients with an instruction to take strict bed rest. Even worse , there are doctors who immobilize their patients and keep them in hospital bed , until pregnancy test. If the pregnancy test comes out positive , and if all goes well ,  the bed rest continues until delivery.  These money - mongering medical professionals make good use of the ignorance and fear of their patients to fill their pockets  - shameful of course !

Why bed rest is not necessary ?

It is very natural to wonder  , " if embryos  can be kept inside the uterus via cervical opening , won't it descend down the same way ? " No , it won't.  Your embryo is microscopic , and is like an invisible dust particle - it can easily fit at the tip of a needle. Your uterus is a pear shaped organ. Assume that the widest part of the pear is the uterus , and the narrow region is the mouth of uterus , aka , cervix. If you cut the pear longitudinally there is no cavity in the upper part , the same applies to your uterus , too. Your uterus walls are like two bread slices touching each other. The endometrium where the embryo implants is akin to the jam applied inbetween the bread slices. Imagine keeping a microscopic dust particle inbetween the bread slices - is there any chance that the dust particle get dislodged or fall down ? The same applies for your embryo too. There is no free space in the uterus for your embryo to roll and fall down. There is no real cavity , the uterus only contains a potential cavity and the cavity develops only when the embryo implants and develops into a fetus. The growing fetus will push the walls of the uterus apart creating a cavity. Hence , gravity cannot act on your microscopic embryo.  The endometrium acts like a sticky jam. Endometrium and the embryo are made for each other ( they communicate with each other , a lot ) , and so they love sticking to each other. Walking , running , jumping , sneezing , coughing , falling down , your dog jumping over your lap , bumpy roads , and not even having sex , will push your embryo out of your uterus.

Won't uterus contractions squeeze the embryo out ?

Although , any increase in the frequency of uterus contractions has the potential to dislodge or expel the embryo , the progesterone which is present in large amounts after embryo transfer , doesn't allow the uterus to contract more than usual. Doctors aim for a very smooth embryo transfer. If the embryo transfer becomes difficult for some reason , it might lead to increased uterine contractions , and these contractions can affect IVF success , most probably due to dislodging of embryo or due to embryo expulsion via cervix. But , your normal day - to - day activities will not cause your uterus to contract , especially when such enormous amounts of progesterone is doing its job in your body.

Is orgasm OK ?

It should be OK. Couples who conceive in their bed room have sex after ovulation. If sex and orgasm could expel the embryo from the uterus , human population would have been a lot less. Once the embryo is inside the uterus , it doesn't remember how it came in. Once inside the uterus , they are as safe as the embryos formed during natural intercourse. There are women who orgasm in dream during their IVF 2WW and worry whether they have caused any harm. You can be very sure you haven't spoiled your chance of success.

What does scientific evidence say about bed rest ?

Studies showed no correlation between bed rest and IVF success. Some studies even pointed out that bed rest could actually decrease your chance of success. Even more , if you apply your common sense -  during and after IVF there are enormous amount of different hormones in our body ( much higher than what will be present during a natural cycle ) . This increased amount of hormones increases the risk of blood clots. If someone keeps on lying down without enough movements , it can actually cause much harm  - especially , in women who are prone to blood clots.

What about the ladies who swear by bed rest ?

Please remember that correlation doesn't mean causation ! I ate bananas today , I met with an accident - but that doesn't mean eating bananas lead to the accident !  Anecdotal stories are not proofs. For every lady who got success after lying down in bed all the time , there are ten more who didn't rest and got pregnant. Instead of searching ' bed rest and success ' , search for ' no bed rest and success ' . Google gives you what you want - always be aware of this ( never believe everything what Dr. Google says )  ! If you want a good advice which can be trusted , talk to someone who is knowledgeable (  most probably that person must be your doctor ! )

Shouldn't I rest at all ?

Take rest - but do not overdo it ! For the first 15 minutes after embryo transfer , lie down. Then for the next two days treat yourself like a queen ( don't do what you do routinely , for example , avoid laundry or anything you find difficult ) . After that ,  get on with your routine. Lying down 24*7 will only make you emotionally sick - it will allow your mind to play games with you. Keeping yourself busy , yet , not doing something which you will regret if the IVF fails , is the key.

I felt wet down after embryo transfer ? Is it the liquid within which my embryo was present ? Does that mean my embryo came along with that liquid ,  I found a red dot in the tissue paper after wiping - is it my embryo ?

No , that's not your embryo. You cannot see your embryo with naked eyes. And definitely , your embryo is not red in colour. So , do not panic. The liquid in which your embryo is present during transfer is just a minute drop of cell culture medium . That cannot flow out of your uterus and wet your inner pants. The liquid that comes out after embryo transfer is the one which is used to wash your vaginal canal. It is just a mixture of water and disinfectant. Any wet sensation you feel down doesn't come from any dripping from your uterus.

I wish , before embryo transfer , doctor or the embryologist shows the patient the embryos ,  embryo transfer catheter , the amount of liquid in which the embryo will be kept etc , so that the patient will have some piece of mind. There are many patients who are afraid to ask questions , and suffer the entire 2WW with unnatural fears about losing their precious embryos !

All I can say is , after embryo transfer , close your eyes , imagine a seed in a fertile soil and visualize it rooting and growing , everyday. Your embryos are within you - they are safe !

The Easy Breezy 2WW

A view of Mumbai from the hotel we stayed (Photo courtesy: Virender)

We entered the most exciting yet dreaded part of an IVF cycle - the 2ww! Surprisingly it felt good, I was happy that I got one more chance to enjoy the thrill of a two week wait. Rajender was adamant that we must stay in Mumbai for five more days. I told him that it would be very expensive to stay back but he said, "we are together on our own after long, long time, we have spent a lot until now, what will happen if we spend a bit more?" True, after coming to India we were either in his home or in my home. Even worse, the last couple of weeks I was in Madurai and he was with his parents. We did miss our togetherness without any interference. So, we stayed back. Five days just flew by. We used get up late, have breakfast, troddle around the hotel area, do window shopping, drink tender coconuts, go back to our room, sleep. I also got to eat lots of Jamuns, one of my favourite berries! It is a seasonal fruit and I was lucky to have them everyday. In the evening he would take me to a nearby small restaurant, I would taste different chaat items (an assorted savoury snack) each day, while he would sit and watch me devour it with a cup of tea. He is such a picky eater. He wouldn't touch any food he is not familiar with (even if it is presented to him in the most tempting manner). New food and new tastes never pleases him. I, on the other hand, will never say no to new food varieties; I could taste and even enjoy them all. The agreement between us is, I can eat whatever I would like to, but I must not force him to have it :) He is not greedy for food or for anything else in his life. This attitude of him has made my life much peaceful, pleasant and enjoyable. 

In the hotel, where we stayed, everyone knows us; they even know the reason for our visit. We stay in the same hotel during each of our visit. Everyone there is very friendly. They try their level best to keep our spirits high. This time everyone were saying, "The room you stay now is a very lucky one, for sure you will come with your little one next time". The most beautiful place in that hotel is the terrace restaurant. They have aptly named it as serenity restaurant and the view of Mumbai from there, during night, will be so beautiful. You do feel serene when you sit there for some time.

After five days of stay in Mumbai, we were gettig ready to leave to the airport. It was early morning and I was brushing my teeth. When I touched the inner corners of the mouth with my brush, I gagged violently. Rajender came and peeked inside. What happened was the question in his eyes. This gagging sound, when I brush, was very familiar to him. I gagged when brushing teeth all the five months of my pregnancy with our twins. He got to hear it every day, every morning. We both looked at each other but we dared not to talk about it. I knew what he was thinking and he knew my thoughts too. Then, I was trying to wear a new top which I brought there a week before and it didn't fit me quite nicely as it fitted the day when I brought it. I was quite frustrated. We got ready, went to the airport, and boarded the flight to Madurai. I sat and tried to fasten the seat belt. I looked at my tummy and was shocked! It looked as if I was three months pregnant. Slowly I touched it, it was hard. I remembered that I decided not to take cabergoline, a prolactin suppressing pill, which was prescribed in the clinic to prevent ovarian hyperstimulation syndrome. Rajender told me several times to have it. Dr. Anjali asked me too whether I was taking it after egg collection. But, my stand was that, it makes me depressed and even more I have gone through 6 IVFs and I never suffered OHSS once. So, I decided not to take it!  I regretted my decision. Am I developing OHSS ? I was scared.

We reached Madurai. I was so happy to meet my mom again. On that day night, I had a dream, an erotic dream. I woke up being close to an orgasm. I touched my lower abdomen - is my uterus contracting was the immediate question in my mind. This has happened to me now a few times. It happens during 2ww (when you are on hormones after IVF) or during pregnancy and never on other times. In short, it happens when you are afraid to have sex or orgasm. Is it due to all the hormones we take, or due to long abstinence from sex? Is it our body's way of saying that we are in need of increased blood supply to uterus and hence it coaxes our brain to produce images which ultimately leads to an orgasm? Then, does it mean orgasms are actually beneficial and are we avoiding them? I would be happy if someone could share their experience - does an orgasm in 2ww lead to your BFP? 

Seven days after my transfer I couldn't bear the suspense anymore. I just want to do a pregnancy test and move on. It was becoming unbearable. During all my previous 2ww I got the nerves not to test early. I never tested until 12 days after transfer. But, this 2ww was killing me. I just want the suspense to end so that I could plan further. The thought that I have 6 frozen blastocysts, and the possibility of transferring them to Rita did give me some peace of mind; after all, I have a plan B! So I decided to test on 7dp5dt. Dr told me to buy two different brands of home pregnancy tests to be sure. In the morning I collected urine, added few drops of it to the test kit. I and Rajender held our hands and waited anxiously. And ...

The 2ww !

On Saturday, we transferred three day 3 embryos. Ofcourse they looked beyond perfect. My lining was not something an IVF specialist would admire. It was around 7 mm. But I respect my uterus capability to grow this lining and believe in it's ability to accept my little ones. So now I am in the glorious 2ww. I feel so peaceful. The transfer went on well and people around me made that day very special. I am waiting to pen it down. Thanks everyone for all the good wishes and kind words - It made me feel so good ! I am waiting - patiently and joyfully ! I am enjoying my days with the recent Khaled Hosseini's novel - And the Mountains Echoed :) Malpani review

Will my symptoms during the 2ww tell me whether I am pregnant or not ?

During the 2ww it is very natural to wonder about the fate of the embryos which are transferred to the uterus. Every woman who has had an embryo transfer longs to know the outcome of her IVF cycle.  Every minute of the 2ww lasts an hour – and the 2ww is the longest wait for any woman who has undergone IVF.

When going through the 2ww, women become aware of even the slightest change that happens to their body. “ I am feeling warmer than usual; I have a tingling feeling in my breast; my nipples are sore; I could sense a muscle being pulled in my pelvic region; I have a strange vaginal discharge; I urinate frequently; I feel nauseous – does this mean I am pregnant ?” This is the question that lingers in the mind of every woman – whether they explicitly acknowledge it or not . This can be made worse by a worried spouse who solicitously asks every day – How are you feeling ? Many women constantly surf the web to read about the 2ww symptoms of women who got pregnant after an embryo transfer. Although this can make the 2ww interesting , and can help some women to cope with it, many women start to panic too when they do not experience any symptoms . Others start imagining that they are pregnant of if they have any of the about symptoms. Are there really any symptoms which could tell you whether you are pregnant or not , before taking a pregnancy test ?

Sadly , the answer is no. While every woman is different, the reality is that your body cannot provide you with any clue during the 2ww which could tell you whether you are pregnant or not . Women who do not have any symptoms at all find they are pregnant – while women who experience all the symptoms can end up getting a negative pregnancy test. During the 2ww, your body is under the influence of the two most important sex hormones – estrogen and progesterone.  These sex hormones have an influence on many of your body functions. Because of excess progesterone, your body becomes warmer than usual; your digestive system become sluggish and you can suffer from constipation; water accumulates in your tissues leading to sore breasts and nipples; you might have low-back pain, cramps and so on. High estrogen can make you nauseous; can cause breast pain; and might make you sensitive to smells. So the symptoms you experience during 2ww are only due to the high levels of these hormones, which is why they are so similar to the symptoms of PMS ( premenstrual syndrome) . The only proof whether you are pregnant or not is a positive blood pregnancy test.

Read more at : http://blog.drmalpani.com/2012/03/symptoms-after-embryo-transfer.html

Some FAQs about embryo trasnfer

What if I bleed after the embryo transfer ?

Most embryo transfers are very smooth, and do not create any trauma to your cervix or endometrium, which is why you should not experience bleeding or spotting after an embryo transfer. However, some patients have cervical stenosis (a narrow cervical opening), and if their embryo transfer is technically difficult, there may be bleeding after the transfer. Please do not panic. The blood is not coming from your uterus and your embryos are not affected in any way. The tiny drop of blood is not your embryo. So keep calm and carry on with your everyday activity. If you experience severe bleeding after the transfer please contact your clinic (but this is very unlikely to happen !)

Why did I feel a wet discharge after the embryo tarnsfer ?

During embryo transfer , the doctor cleans your vaginal canal and the cervix with a sterile fluid. When you get up after the embryo transfer you might experience a wet feeling, because this fluid leaks out. Do not panic – this doesn’t mean that your embryos are being washed out ! The fluid that comes out is not from your uterus. Your embryos are transferred inside your uterus in a tiny droplet of culture medium , which cannot flow out – your embryo are safe in your uterus !

Do I need to take any special precautions after the embryo transfer ?

Once your embryos are transferred to your uterus they are safe inside. If they are genetically competent and if your uterus is conducive for implantation, the embryos will implant , no matter what you do ! Stress, food habits, coughing, sneezing, climbing stairs or not taking bed rest will not stop you from conceiving. In short, anything you do during 2ww will not stop you from conceiving . Conversely, nothing you do during the 2ww (like changing food habits, bed rest etc) will help you in conceiving. Do not do something which will cause regrets,  if the cycle does not succeed (for example, if you are going to think - I had a glass of wine , and that is why my IVF cycle failed, then please do not have a glass of wine ! )  Try to have a healthy diet, take your folic acid, continue with your normal, daily activities ; take your prescribed medicines.

Nothing you do can harm your embryos. Please do not let your mind play games with you. Read more at http://drmalpani.com/care-after-embryo-transfer.htm

Can I fly home straight after embryo transfer ?

Yes, you can travel immediately after embryo transfer. Air travel or any other mode of transport has not been shown to affect embryo implantation , and it will not affect your chances of achieving a pregnancy. Take measures to make yourself comfortable during air travel – keep yourself well-hydrated and move frequently to enable proper blood circulation.

Do’s and don’ts during 2ww

Do’s

• Take your medicines properly.
• Continue with your everyday normal activity.
• Surround yourself with people who will make you feel relaxed and happy.
• Do not do anything which you are not comfortable with. This will help to avoid self-blame if the IVF cycle did not succeed.

Dont’s

• Do not use sauna, hot tubs ( you can have showers !) or do any vigorous activity (like strenuous exercise)  which could raise your basal body temperature.
• Don’t change your diet drastically.
• Do not restrict your daily activity-do not take bed rest !
• Do not raise your hopes too much – have realistic expectations !
• Avoid people who can raise your insecurity and stress levels.

Read more at : http://blog.drmalpani.com/2010/09/what-precautions-should-i-take-after.html

http://blog.drmalpani.com/2012/01/dos-and-donts-during-ivf-2-ww.html

Will embryo(s) fall out after embryo transfer ?

A fear which is wide-spread among IVF patients is – will my embryo fall out if I stand up or walk around after the embryo transfer ? This is quite a reasonable worry – after all, if the embryos are transferred through the uterus through the cervix, then why can’t they come out through the same route?  However, if you understand the anatomy of the uterus , these doubts will vanish and you will fell much more confident and comfortable during your 2ww.

Women imagine that when the doctor puts the embryos inside the uterus, they are deposited inside a space within the uterus in which the microscopic embryos can roll freely!  They believe that if they rest, the embryos will settle down and stick to the wall of the cavity. After all, when you stick two pages together with glue, don’t you leave them undisturbed for some time to allow the glue to set ? They are worried that if they walk about, the embryos will be disturbed from their resting place , and may fall out of the cavity.

In reality, the uterus is a muscular organ , about the size of your fist. When people hear the word ‘uterine cavity’, they imagine that there is a real cavity within the uterus ( like a cave, perhaps) , but this is not true. The cavity we talk about is not a true cavity , but just a potential cavity . The walls of the uterus are in contact with each other – after all, there cannot be any empty areas inside the
body ! For example, press your palms together. There is no real space between them , since your palms are touching each other. What happens when you insert a small ball in between your palms ? The ball has created a space for itself ! In the same way , a uterus which doesn’t have an embryo inside it carries only a potential space. Only when the embryo grows in size will this space enlarge. Do you know that at 5 weeks of gestation your embryo is just the size of a sesame seed ? Imagine what will happen if you keep a seed between your pressed palms and move your hands in whatever way you might wish to ? There is no way the seed will be dislodged  - it is safe , snug and secure in its resting place. This is exactly what happens to your embryos inside your uterus !  Nothing you do can dislodge an embryo – NOTHING (even jumping or running) ! If the embryo is healthy and if your endometrial layer is receptive , the embryo will stick to the wall and bury itself inside the lining (just like a seed does , when planted in fertile soil). External physical activity cannot influence this natural biological process which occurs in utero.

A lot women refuse to go to the bathroom for a few hours after the embryo transfer, because they are scared that if they pee, their embryo will fall out of the uterus. They just end up making themselves completely miserable – and I worry that an overdistended bladder can actually cause uterine contractions needlessly ! Others are scared that if they cough or sneeze after the transfer, they will ruin their chances of success. Please do not obsess – remember that nature has designed the body with enough intelligence, that you don’t need to worry at all !

After the transfer, the uterus can contract (for example , during an orgasm, which often occurs while sleeping during  the 2ww ), but the progesterone produced during the luteal phase will prevent these uterine contractions from dislodging the embryo. Intercourse and orgasm cannot cause any harm after the transfer – after all, fertile couples do have sexual intercourse during the 2ww, and they get pregnant all the time.

After an embryo transfer , bed rest is absolutely unnecessary. I have heard from women who have been forced to spend 2 weeks in bed after the embryo transfer – and many of them have done so because of their doctor’s orders ! ( I think the reason some doctors continue to give this outdated advise is a clever way of subtly blaming the patient if the cycle fails ! “ You didn’t get pregnant even though I did such a good job with your IVF treatment , because you did not rest properly “ is their subliminal message) . Even a couple of days in bed can do you harm , physically and emotionally. Bed rest may increase body aches and back pain , and makes your physically uncomfortable.  Resting may actually reduce uterine blood flow by reducing pelvic circulation. Bed rest creates havoc  with your mental well-being as well ! When you lie down in bed all the time and have nothing to do, your mind will start to play all sorts of games with you. The end result is an unhealthy obsession with your body’s symptoms and signs – and this often causes panic , which does not help after a stressful IVF cycle.  The bed rest, rather than resting your mind, often causes more stress !

Please do not restrict your normal day-to-day activities after an embryo transfer.  Use your common sense, and do not do any strenuous activity which might cause you to blame yourself if your cycle fails ! And what happens if your mother in law enforces house arrest ? Remember that she has been brainwashed , and is following well-meaning but misguided advise, based on centuries of myths and misconceptions about bed rest and pregnancy. She is not trying to harass you – she is just trying to help you to have a baby , based on her personal ( but flawed) world view ! Please don’t rock the boat by flatly refusing to listen to her – just give her this article to read , so she understands why bed rest does not help!  And if she is still unconvinced, please share this with her - Bed rest has not been scientifically proven to improve pregnancy rate after embryo transfer(PMID: 19590224). 

Embryo Transfer

ET was scheduled to 4 PM today. It’s very hard to explain how I feel. My mom left to my native place yesterday. I feel heartbroken without her presence. DH had a hard time controlling my crying spells. I am in the grip of all sorts of blues now. I am excited and at the same time very scared. The result of all the toil will be out in two weeks. Why can’t someone make me to go into coma for two weeks? When I see my DH I feel very sorry for him. I am solely responsible for all the troubles he endures now. All this uncertainty, tension,travelling…….everything is because of me. I am very lucky to have him in my life. If he is not this understanding what would have happened to me? I feel I have a lot to vent. I am depressed probably because of progesterone. I wish I could go back to work so that I can distract myself. I am also dreading thinking about today and tomorrow. I do not believe in rest after ET but my DH will be very upset if I roam around. I have to lie down or sit all the time without doing anything and that is a big torture!

Inspite of all these thoughts, I feel very happy when I see my blasties. I hope they will wake up from their cold sleep happily without loosing any cells, snuggle within me tight and speak with my not so great endometrium for establishing connections. Let the cross-talk between my blasties and endometrium be successful! If someone reads this post send me some positive vibes. I will be very grateful. I am uploading my blastocyst pictures. Don’t they look beautiful? One day we saw a very cute little girl and I said to my DH ‘our child will look as beautiful as this littleone’. He said, ofcourse yes! Our blastocyts look very beautiful so definitely our child will look beautiful too :) These kind of small, sweet nothing talks, keeps us going!