Embryo transfer to Rita and the plight of surrogates in India

The day of embryo transfer came. My two frozen-refrozen embies were thawed.  I was not a bit nervous about the thawing process. I know Dr.Sai is competent enough to do it in a good way. I was just waiting for the photos of the embryos.  Actually, I felt a lot more relaxed than if I have to accept those little embies in my uterus. In other words, nothing appeared real. We were in Tirupathi on the day of ET, praying to Lord Venkateswara ( ridiculous right, you outsource your duty to someone and pray to God ;). I was wondering about Rita! How will she be feeling? Does she really know what it means by embryo transfer? I mailed Dr. Malpani requesting him to  show her the embryos. What will she think seeing those minute blasts? I had no way of talking to her. I don’t know to speak Hindi, Rajender could speak (this is a very big disadvantage!).  Inspite of Dr. Malpani’s insistence that I must meet Rita, I was very reluctant to do so. At those times my thinking was like this: I must never get involved in any way in my surrogate’s pregnancy. I shouldn’t develop a bond with the baby or the surrogate. Once upon a time I even told Dr, I don’t even want to see the ultrasound photos. I thought naively, I will see my surrogate when I have my baby in hand. The pain I have gone through and the pain I saw in Rajender when we lost our babies wanted me so badly to protect myself and my husband against any further pain brought about by any untoward happening. My thinking is - if we are in no way involved in this pregnancy (other than giving our gametes) our pain will be less if something unfortunate happens!  I didn’t realize at that time that my thoughts were too childish and it can never be like that in reality.

Dr. Sai promptly sent me the photos of my embryos after the transfer. They looked perfect; I would say Dr. Sai managed to thaw them perfectly, close to 100%. Dr. Malpani sent me a mail saying that everything went well. I entered into a 2ww which is completely new to me. I was so relieved that I will not have any restriction in my activities from my loved ones (actually in every restriction they put for me I feel their insecurity and pain, it is very difficult to face it); I was relieved that I don’t have to obsess all the time about my uterus area; I was extremely relieved that I don’t have to perform that evil urine pregnancy test at the end of 2ww and nervously wait for a tiny pink line which will decide our future. I was also so relieved that I am in no way involved in the outcome of this FET cycle (although this thought is a kind of delusion) - may it be a positive or negative! What a pleasant 2ww! I was wondering what kind of instructions were given to Rita after embryo transfer. I wanted Rita to go on with her daily life and not lying down even for a day after the transfer.  I hope she didn’t!

During the 2ww, I thought more about Rita than my embies. What it means for her to carry my baby? How will she feel when the pregnancy test comes back positive? Being a first time surrogate, will she be happy or scared if the test comes back positive? I thought, perhaps only when she gets a positive pregnancy test, she will start to realize the real impact of the job that she will be doing for me. I must admit that Rita will get only a meager 2 lakh rupees (less than 4000 dollars!) for the tough and altruistic job she will be doing for us.  But I and Rajender have always thought, when she gives us our baby, her children’s education will be our responsibility (she has two lovely children-a boy and a girl). Rita will be a member of our family, she will be there with us during all the important happenings in our family and we will be there for her through thick and thin (if she wants it that way!) I wanted her to be one among us and my child will grow up knowing that he/she has two mom’s – the one who carried in her womb and the one who unfortunately couldn’t carry him/her in her uterus but who will always carry them in her heart ! After all Rita is doing something for me which my sister wouldn’t or couldn’t do. Treating her the right way is the best compensation I could give her for what she will be doing for us. Loving her and not using her is the way to go!

Surrogay in India is 10 times cheaper than in USA. If an US surrogate receives 40,000 dollars for her altruistic act, Indian surrogate gets only 4000-8000 dollars! This has turned India into a surrogacy hub. This is what attracts lots of foreign couples towards India for reproductive tourism. Such reproductive tourism benefits India as it earns lots of foreign exchange; it benefits doctors as they do see a good amount of profit; it benefits the tourists as they have a chance to get the baby they yearn for in just 1/10^th of the price when compared to surrogacy in their own country; but does it benefit the surrogate? I would say yes, that is why they are ready to undergo the whole process. In a poor surrogate’s point of view 2 lakhs is a big money. It helps to alleviate their poverty at least a bit.  Of course those few thousand dollars will not be enough to buy even a piece of land or a flat. It will not be enough to give their children the best education possible. Maximum they can do with that money is to live well for a year or pay their children’s school fees for two years (for a decent education)! Or they could pay the debt they have got from someone at a huge interest which is handicapping their normal life. This is all they could do! On the other hand, a rich person in Mumbai will easily spend more than 2 lakhs in a night for a party! If it is so, then is the compensation an Indian surrogate gets is unfair? Is it financial exploitation of poor women? I would say, yes and no. If surrogates are able to do some other job which could give them this amount of money, many wouldn’t prefer to carry someone’s baby due to the social stigma involved in it, especially in a society like India. Just because they have no source to earn that little money, is it OK to pay just 2 lakhs - 4 lakhs for Indian surrogates? I don’t know what others think about this but for me it does appear unfair and I think instead of discussing what is wrong, who is wrong and getting on with my own life, it is wise to do what is just in my eyes to my surrogate! Will I be able to keep my word?! :)

Other then the meager compensation an Indian surrogate gets, there is one more danger Indian surrogates are always exposed to: lack of freedom of choice! Indian surrogates are not highly educated women. Many are illiterate and even if they know to read and write, it doesn’t mean they could understand the medical terms or medical details that are shared with them.  Many lack basic medical knowledge; like many of us, they suffer from health illiteracy too. Many find it difficult to grasp the medical information provided to them and make use of it aptly. This makes them highly vulnerable to exploitation in many ways.  For example, consider this situation: there comes a couple to an IVF doctor with a demand that they need twins via surrogacy. They promise to offer him more money for that. Remember, doctors work for the commissioning parents as they are the one who is paying him. So naturally many doctor’s aim will be to take into consideration the best interest of the commissioning parents. In order to achieve a twin pregnancy or in order to achieve a pregnancy, the doctor transfers multiple embryos to the surrogate. The decision how many embryos to transfer to surrogate’s uterus is not left to Indian surrogate’s hand. Only the doctor and the commissioning parents decide that, but the risk of multiple pregnancy has to be borne by the surrogate and her body! There is no one for an Indian surrogate who will act on her best interest, someone who could talk on behalf of her and help her to take decisions which benefit her the most. I read in a blog where the prospective parent wants her surrogate to take a particular vitamin. She writes, 'I am not sure whether my surrogate is taking what I give her. So I asked her to take the vitamin in front of my eyes'! This might appear as a trivial issue but this clearly shows how helpless and vulnerable Indian surrogates are! If it is in USA, no surrogate will heed to your orders. If they think that particular vitamin is not going to do any good or if they find it uncomfortable to take it, they can politely refuse your request. They have the freedom to choose! Another example: a surrogate’s early first trimester TSH level is 2.63. The biological parent reads in a scientific journal that the TSH must be within 2.5 during the first trimester and that gives the baby the best possible environment to grow. She gets very nervous and asks the IVF doctor to put her surrogate on thyroxine therapy. A TSH of 2.62 will not harm the baby or hinder its development in any way. As the pregnancy progresses the surrogate’s body will start producing more thyroxine to meet the growing needs.  There is no rationale to give the surrogate thyroxine therapy as it is a hormone which in excess can create lots of problem for the surrogate as well as the baby. But the commissioning parent is adamant that the surrogate’s TSH level must be corrected. Obviously most doctors who work on the best interest of their patient will put the surrogate on thyroxine therapy in order to satisfy his patient. An Indian surrogate will obviously not know what thyroxine is and what effects it will have on her body! If I could give one more example, a surrogate is in her 37^th week of pregnancy, the commissioning parent want the baby to be removed from the surrogate via c-section as she was paranoid for many different reasons about vaginal delivey’s effect on her baby. Or, one of the commissioning parents has his/her birthday on a particular date and they want their baby to be born on that particular date. Or, the commissioning parent’s family believes that if the baby comes into the world on a particular day and in a particular time (auspicious day and time fixed by the astrologer!), it will do the family good (yes such people still exist!). The commissioning parent demands a c-section on a particular day. They ask the surrogate whether she would like to have a c-section and the surrogate was too tired to carry the pregnancy for many different reasons (she is eager to get back to her family and children instead of lying in the hospital for 3 more weeks). She says that she will agree to c-section and she desires that too! It is a well-known scientific fact that c-section posses additional risks to the mother. Should the surrogate’s wish be considered and a c-section ordered? Is she wise enough to take her own medical decision by weighing the pros and cons? I hope these examples will make you understand how easily an Indian surrogate could be exploited. I wish every Indian surrogate has a patient advocate with her who works on her best interests! 

There is another view about Indian surrogates too. An Indian surrogate is poor and illiterate. She will do anything for money. Since she works as a surrogate in want of money she doesn’t deserve to be treated well. She has no moral values whatsoever. If you give her more space, she will demand from you more money (yeah, she will build a palace by looting you!). If you get increased vaginal discharge it is overgrowth of your vaginal flora, but if your surrogate gets increased vaginal discharge, it is STD! And even more, there are people who shout at their surrogate instead of thanking her when she was lying in pain after the c-section!  No more a poor woman, who is risking her health and life to carry your baby, for the beggarly compensation you provide could be insulted! Actually, the reality is, Indian surrogates are highly desired because they live in a family setting, don’t use intoxicants, they are humane, friendly and humble than women elsewhere.

Please remember, your relationship with your surrogate is a two way street. Loving your surrogate instead of using her as a baby-making machine will makes a lot of difference in the way she cares for your baby! 

So what happened at the end of 2ww? Did Rita conceive?

We signed the surrogacy contract and our time in MADURAI

I am a South Indian, Tamilian and my native is Madurai.  I am sure you would have captured my haughtiness in the previous line. Who wouldn’t be proud of their roots? The day we left for Madurai from Rajender’s place I was so happy. I was going to see my mom - is there anything else needed to be happy ? My mom was eagerly waiting for me too. She was heartbroken about whatever happened.  She went from temple to temple all those 5 months of my pregnancy. She lived with the thought of her grandchildren whom she never saw. I know she carried them in her heart and to let go of such a beautiful dream at the age of 60 is painful, very painful. 

Madurai is a very small, beautiful city. It is famous for the temples situated there (every street has a small temple!). The most famous temple is called Madurai Meenakshi Amman temple and the above picture shows one of the temple’s towers, magnificent isn’t it? Every time I go there the temple’s architecture never ceases to amaze me. I love roaming around the streets situated close to the temple rather than going inside. Oh, I simply love Madurai for its liveliness. 

We reached Madurai at early morning 4:30. We took an auto from the railway station to our home. The auto driver was a young lad and was chatting happily. The moment we were to enter our village border, the auto driver turned to me and asked, are you wearing slippers. I was not sure whether I heard it right, his question didn’t make any sense to me. So I asked him to repeat his question. He again asked, do you have slippers in your feet? I was so confused; what kind of question is this! I reluctantly said yes and he replied, I will tell you the reason for this question later. When we were nearing our home he said, sister, there is a graveyard at that turning. If you do not wear something in your feet, the spirits (ghosts) which live there will catch hold of you and come along with you. I always make sure I wear something on my feet when I cross that area. A big smile appeared on my face and I knew at that moment that I was In Madurai, a city with gullible, friendly people. I looked at Rajender and he was smiling at me, no actually grinning at me and I know the meaning of it! He just said with his eyes, is there a bigger ghost than you, will anything even dare to come near you!

My mom was waiting for us. At 5’o clock in the morning she has made hot, hot idlies, chutney and sambhar. Another name for mother is love; no one can take her place. In my in-law’s place I have nothing to complain but I was never as happy and comfortable as I am with my mom. In my place I am the queen, I can get up whenever I want, I can eat whatever I like, I can sleep whenever I want and I can be myself. In my in-law’s place I have to behave well and it is very, very hard to be someone else all the time. At 5 AM, I ate the breakfast which I love most and slept happily until 10 only to wake up and ask, ‘what’s for lunch amma!’ 

When I said to my mom that we are going to take the surrogacy route she was very happy. She said, ‘Manju how long will you suffer like this. How many injections, how many injuries to your body and mind! I think surrogacy is a better option’.  She wanted her daughter not to suffer anymore. My sister is a gynecologist, when I asked her opinion, she said, do whatever appears right for you. With such a fear about carrying a pregnancy, it is not wise to try to get pregnant again. I support you both completely regarding your decision to opt for surrogacy. 

My dad is no more, but if he is alive he would have guided me in a very wise manner. When I have to take important decisions in life I miss him dearly.  He was a Judge, a very honest Judge. In every nook and corner of my home I feel my dad’s presence.  If someone says that I am courageous or appreciate my perseverance, I owe all such praises to my dad. He is the one who brought me up with all these qualities. I take after my dad not physically but mentally. I strongly believe that the good life me and my sister live now is just because of my dad, because of his honesty and good deeds. 

I mailed Dr. Malpani regarding our decision to opt for surrogacy.  Between the times I lost my twins and the decision regarding surrogacy, I might have asked innumerous questions to my Dr! He was very, very patient with me. He understood my fears and insecurities. He did his best to help me. He would say,’ Manju, we will do our best to help you have a baby’, and those words mean a lot to me. He never, ever said an uncompassionate word, nothing which would hurt me even unintentionally. He took the role of my counselor too! I owe my ability to live normally and happily even after whatever I went through to him, perhaps only to him!

I was not patient; I wanted everything to happen quickly. Dr.Malpani told me that they have to search for a surrogate first and then have to prepare the agreement. I was wondering how long it might take. But I received the surrogacy contract in my hand within a few weeks. I was reading it page by page and for the first time I got to see Rita, my surrogate! There was a passport size photo of her and her husband. I kept on looking at the photo. She appeared shy, calm and humble. I knew that she has two children and she is a first time surrogate.  I had so many questions in my mind : Why she opted to be a surrogate? What is her husband doing? How old are her children? Does her husband treat her well? Where does she live, in a slum? Will she take care of my baby well? I am going to take a great leap of faith and trust her, am I doing everything right?  In my quest for a baby, am I putting my baby itself at risk? So many questions haunted me and I asked Dr. Malpani everything. All he said was, Manju you must come and visit Rita, and then many of your fears will vanish. 

I didn’t sign the contract at that time. The reason is, my name is misspelled in the document. So I sent it back to the lawyer. In between the time I sent the contract back and received a new contract, we went for a pilgrimage, yes a pilgrimage in search of baby luck!

Did I meet Rita in person?  Where was the pilgrimage to? A lot more to share! :)

India and the decision regarding surrogacy!

We landed in India on December 31^st, 2013. We slept so well that night in the comfort of our homeland and relatives. We have accumulated a huge sleep debt. We lost our little ones on November 5^th, 2013 or I would rather prefer to say, our twins were born on November 5^th, 2013. From that day on wards our life changed completely.  We rarely had a good sleep after that. The last few days in Germany were too hectic too - getting relieved from work; vacating our home; selling our car; saying bye to friends…there was so much to do! I was so proud of Rajender. He stood strong the entire time. After so many years of hesitation and planning (it is hard to find money amidst infertility treatment expenses!) he brought his car. He enjoyed driving it so much. He took care of his car like a child. On the day when he sold it and returned home, I asked him whether it hurts. He replied, ‘nothing is more painful than losing my children’. I wanted to tell you all this because I realized a very naked truth – life can change upside down in a moment. Nothing is permanent, nothing! Life is too unpredictable. I think, if we realize this, we will learn to live a better life, enjoying every moment. Until 2013 we both were working, we had not one but two children (a boy and a girl) who were the result of many years of emotionally, financially and physically draining infertility treatment; we were planning to move into a bigger home, even gave advance for it and suddenly we were ripped-off everything.  You can call it 'bad karma' or simply 'bad luck' but I would prefer to call it 'LIFE' - there is nothing good or bad in it. I believe that life has a beginning and an end and everything in between is just a continuum. There are no happy endings or sad endings; good or bad in whatever happens - there is only 'LIFE'!

We woke up in India on January 1^st, 2014. The first thought I had when I opened my eyes was: we no more have a nest of our own! To be very honest, it was very scary, but only for a moment. When I came out and stood in the balcony, bright,warm sun light hit my face (nothing is as healing as SUN). The smell of Indian breakfast hit my nostrils. I could see my sister-in-law with a warm smile. All my insecurity vanished immediately. I happily got ready to enjoy my time in India.

We went to Rajender’s place first. His native is a village, a very remote village in India. People who live there are so innocent, warm and friendly. Everyday so many women came to visit us. They cried hearing what happened, said so many comforting words, they told me stories of  many women who had children after going through many miscarriages. I no more felt alone. Everyone told us how our mother and father in-law suffered during the time when we lost our twins. They said, your mother-in-law cried for days together, almost all the time. I looked at my mother-in-law; she looked at me with utmost warmth and I thanked God for keeping me amongst such affectionate people. One of Rajender’s relative, a very old woman, came to see us. She didn’t have children. She lost her eyesight recently too. She sat near me with tears in her eyes. Her hands were trying to feel mine. She pulled me close to her and gave a warm kiss. I felt safe, very safe after many months! I felt appreciated for the suffering I underwent.

I waited patiently for a week, yes one long week for Rajender’s words regarding surrogacy. Then I asked him, when we can start the process. He said, first we have to tell my parents. I was angry, felt somehow humiliated. Why would you want to tell them? Until now we never explained them anything and why now! My most important fear was, why to make them go through the roller coaster which we are going through, aren’t they too naive to understand all that? My in-laws would never interfere in our life; eventhough they are not so educated and live in a remote village they clearly know their limits. Rajender looked at me angrily and asked, are you out of your senses, will you just bring a baby out of nowhere and tell them that it is ours! True, I didn’t even think about it. He said, look at them: there were lots of village women, his relatives, who were sitting and chatting with my mother-in-law. Rajender said, only when we entered this infertility journey I came to know what surrogacy means!  How to explain my parents and relatives who are scientifically ignorant, what surrogacy is ! If  you can, try and do it! Rajender’s face was full of confusion. I was taken aback.

How did we make Rajender’s parents understand what surrogacy is, was it that difficult ? Keep reading :)

How to become a good IVF patient ?

If you are told that you need IVF to conceive,you naturally tend to spend a lot of time and energy in finding the best IVF doctor.  This is because you know that finding a good IVF doctor will help you in getting the best treatment possible. You want a good IVF doctor who runs a competent clinic; respects you and your needs; will be intelligent enough to tailor the treatment according to your individual requirements ; and is empathetic enough to provide emotional support during your time of distress.

This is quite reasonable, but are you also willing to put in at least half the effort which you took to find a good doctor in becoming a good IVF patient ? Many of us still naively believe that, once we find a good doctor , our responsibility in our treatment gets over , and the doctor will take care of all our needs.  This is not true; getting the best treatment possible and the ease with which you can go through an IVF treatment rests in your hands too. Just like you expect your doctor to be competent, a knowledgeable patient is a good IVF doctor’s delight ! If you learn to be an ideal patient you can reap the best of your doctor and treatment. An ideal patient makes an IVF doctor’s life much easier. Remember, good patients beget good doctors , and vice versa !

How many of you go to watch a movie without reading its review ? If you are willing to do your homework before watching a movie, isn’t it wise to do your homework when undergoing one of the most important and expensive medical treatments you will need  ? It is your responsibility to understand what your treatment is all about , and how it works.  The internet is a boon for patients who want to learn more and there are many authentic websites and blogs written by IVF specialists and IVF patients which will help you to get reliable information. If you become a well-informed patient, you no longer have to be dependent on your doctor for taking treatment decisions; you can work as an intelligent partner with your doctor. This will increase your confidence levels, protect you from medical fraud ( such as unnecessary tests and unproven treatments !) ; and will also act as a shield to protect you against medical errors. If you are a knowledgeable patient your doctor is much more likely to respect you and treat you well. 

Many patients tend to think that they are not intelligent enough to understand medical science. This is why they are afraid to ask their doctor questions, and prefer to bottle these up, thinking that their questions are stupid. . The truth is that you do not need special talents to understand how your body works - you just need to be curious and ask questions. Never be afraid to ask questions; it is the duty of your doctor to explain in terms which you can understand , and clarify all your doubts. When talking to your doctor , make sure that you ask relevant questions , and this can only be achieved if you have done your homework – don’t expect him to spoonfeed you ! When you understand the science behind your treatment , you will be able to understand what your doctor can do for you , and what he cannot. Having realistic expectations of the treatment process  will protect you from emotional breakdown if the cycle fails; and will also safe-guard your doctor from your unreasonable wrath if the treatment does not give the expected result.

Every patient wants her doctor to remember her as a person. You want him to take special interest in your treatment and work extra hard for your success. This can happen only when you work together with your doctor , and show an intelligent interest in what he is doing for you. You should understand that medical science is a rapidly growing field , and there are many different treatment options. When you remain passive, you put all the responsibility on your doctor and he is forced to decide what is best for you. Even though a good doctor works for your best interests, many a time they are biased too ( sometimes without even being aware of their personal prejudices) . They may end up selecting a cookie cutter , generic treatment plan for you, without customizing it to your special circumstances, because this is easier for your doctor , and saves him valuable time. However, this puts you at a risk of receiving sub-optimal treatment. On the other hand, when you understand the niceties of your treatment , you can delight your doctor with your input and ideas, and he is much more likely to understand your needs better. When you contribute to your treatment decisions in an intelligent way, you are more likely to be able to formulate a treatment plan which suits you best – after all, your doctor is not a mind-reader and does not know what your personal preferences are.

A well-informed patient understands that his doctor works for her best interests. If you are totally clueless about your treatment , you will not be able to appreciate what your doctor does for you. It’s only when you appreciate his technical skills and expertise that you will develop respect for him as a professional . Otherwise, you tend to treat him as a person who works for you only because of the money you pay him . A good doctor-patient relationship is important for a good treatment outcome. Like any relationship, a doctor-patient relationship is also a two-way street and it tends to blossom beautifully only when there is mutual trust and respect. A good patient understands this and is ready to do what he can do to make the relationship beneficial for both.

A good IVF patient is patient! She understands that IVF treatment might need more than few attempts to be successful. She doesn’t get disheartened, suspicious and bitter after a single IVF failure. She tends to value and respect her doctor’s advice and act accordingly.  This will help her to remain resilient and carry on with the treatment until she finds success.

In short a good IVF patient has the following characteristics :

•       She has the passion to learn about her treatment 
•       She actively participates in her treatment decisions
•       She respects her doctor and strives hard to maintain a good doctor-patient relationship
•       She engages the doctor by providing inputs
•       She is patient and does not expect that the only acceptable result is a baby !
•       She allows her doctor to earn her trust and follows his advice

Successful IVF treatment needs not only good doctors , but good patients too ! Once you select a competent doctor , you need to work on making yourself competent. This work will pay rich dividends ! The equation is simple - Good IVF doctor plus Good IVF patient = High chances of IVF success !

This I wrote after Dr. Malpani provided me with an outline of what an IVF doctor will expect from his patients. You can read the full article here : http://www.drmalpani.com/good_ivf_patient.htm

What can I do if my IVF doctor does not show me photos of my embryos? Why is it important to see and get photos of your embryos when undergoing IVF ?

What is an embryo and how it is formed?

We all began our life as a microscopic embryo.  An embryo is formed when a sperm produced by the male enters into the egg (when the sperm fuses with the egg) which is produced by the female. The sperm carries half of the information (genetic information) needed for creating a baby and the egg carries the remaining information. The sperm’s function is to deliver the genetic information it is carrying in the form of chromosomes to the egg so that a new life can be created. When a sperm successfully delivers the information it is carrying to the egg by entering inside it, an embryo is formed. On the first day of its genesis (formation) an embryo is called a zygote. The process which results in the formation of an embryo is called fertilization and when couples copulate (have sex) they provide their sperm and the egg a chance to meet each other ( this event takes place inside the fallopian tube of the female) which might or might not end in successful fertilization. The life of your baby begins the moment when an embryo is formed. All living organisms develop from an embryo. All babies come from an embryo but not all embryos have the potential to develop into babies.  This is the reason for IVF failure – not all embryos transferred into the uterus implant; and not all the embryos which implant in the uterus continue to grow. In humans, the term ‘embryo’ is used to refer to the new life that is created as a result of fertilization upto the end of the eighth week of pregnancy. After this, the embryo is called a fetus.

The above picture is just a dust particle resting in the ear of a needle. This can be used as a pictorial representation of an embryo’s size. You cannot see an embryo with your naked eye. You need a microscope which could magnify the embryo several times to have a closer look at it.

How does an IVF clinic create embryos?

For couples who fail to conceive naturally (in their bedroom) IVF technique comes as a boon.  When couples undergo IVF treatment their eggs and sperms are brought together in a petri dish (a sterile plate) which contains appropriate fluids to nourish them. The sperm and the egg which normally meet each other in a fallopian tube are thus allowed to meet each other in an artificial laboratory environment and this facilitates fertilization which ultimately results in the formation of an embryo. During ICSI treatment a single sperm is picked up and injected into a single egg –you can call it ‘assisted fertilization’ which in turn , leads to the formation of an embryo. The embryo or embryos which are formed in such a manner are transferred into the uterus usually after 3 days or 5 days of fertilization. The transferred embryos , if they are competent enough and all goes well, implant in the uterus and develop into beautiful babies. So the entire work of an IVF clinic revolves around creating embryos which are good enough to be transferred into the uterus.

How does your doctor decide which embryos should be transferred into your uterus?

Many women produce several eggs when their ovaries are stimulated with hormones and a good IVF clinic will be able to successfully fertilize most of your eggs (provided your egg quality is good) using your husband’s sperm.  As a result couples undergoing IVF will end up with many embryos. It is a well-known fact that not all embryos result in a baby. If this is the case , how does your doctor decide which embryos should be transferred into your uterus?  Just imagine a beauty pageant , where your embryos are the contestants , and your IVF doctor or embryologist is the judge of that beauty contest. The beauty contest judge has a set of rules to rank the embryos according to their external appearance (by observing them under a microscope) so that the most beautiful embryos are selected to enter the ‘sanctum sanctorum’ (your uterus) , where they originally belong. The remaining embryos , which occupy the next ranks , are frozen so that they can be transferred back to your uterus if the current IVF cycle fails. If you want to know how embryos are graded during their beauty contest please visit this link.

What does an embryo look like during different stages of development?

You can see how your embryo appears during its different stages of development by following this link.

Will my IVF clinic show me my embryos?

It is the duty of your IVF clinic to show you ‘YOUR EMBRYO’ before they transfer it into your uterus. You pay so much money to create beautiful embryos and it is their duty to display their embryo creating skills!  Watching your embryos under the microscope will be a wonderful experience. You will finally get a feeling that the entire process is so real and worth the effort. It is also also your duty to know the basics of embryo development (how an embryo looks during its different developmental stage) so that you can ask the embryologist some reasonable questions. This will help you to judge the clinics competence in creating good quality embryos. For example, a good quality embryo will have 2 pronuclei on day 1 (after 18h of fertilization), 4 cells on day 2, and 8 cells on day 3. On day 4 the embryo will start to compact, so that the individual cells are no longer discernible . On day 5,  embryo becomes a blastocyst which contains approximately 100 cells.  The individual cells (called blastomeres) which make up the embryo should be equal in size and should be free of fragments or with minimum amount of fragments. If you know this basic information and study the ‘beautiful’ and ‘ugly’ embryo pictures on the internet, you can very well become the beauty pageant judge yourself ! If your embryos don’t look as good as expected, ask the embryologist for an explanation. This will keep them on their toes to do their duty well and will also help you to understand whether everything is going on properly with your treatment! So never compromise on your right to have a look at your embryos. If you ask your IVF clinic to show your embryos and if they are reluctant to do so , then it should raise a red flag in your mind. Your clinic should provide you with an opportunity to view your embryos. You are the customer and they are working for the money you pay for them. If they say that embryology lab should be sterile and hence you are barred from entering inside – as a biologist I find this excuse too lame! Going inside and watching your embryos under the microscope will not harm your embryos or the sterile environment of an embryology lab!

Should my IVF clinic provide me with the picture of my embryos?

Definitely! Your embryo pictures are your property. Imagine, when you become pregnant after the embryo transfer and give birth to your much desired baby, won’t it be nice to show your child how he/she looked as embryo? How many people will get the chance to do it?  Won’t the baby album look better with the embryo picture in it? Isn’t the embryo your prospective baby? How can you let go of such a beautiful memory just because your clinic does not provide you with the embryo picture? OK, forget the emotional part, what will happen if you do not succeed and plan to switch clinics? The embryo pictures you can give your new IVF doctor will help him understand whether your embryo quality is good or not. This will give him information about whether the problem is with your fertility or with your previous clinic’s ability to create good-quality embryo. This can also help him to decide whether he must tweak your ovary stimulation regime used by the previous IVF clinic. Why should you lose such invaluable information? If your IVF clinic says that taking a picture of your embryo can damage the embryo do not believe them! Taking a photo of your embryo will not damage them or compromise your IVF success!

What should I do if my clinic doesn’t show me my embryos or provide me with my embryo photos?

Do not be afraid to fight for your rights. First request them, and then demand them. If your IVF clinic is not yielding to your demands , submit your demand in the form of writing. Patients should take a proactive role in their treatment so that they are treated with care and respect. IVF clinics should keep your best interest in mind (you are the customers and they are serving you! They depend on you for their survival) and not theirs.  Remember, the most important work of an IVF clinic is  to produce good-quality embryos and it is their duty to provide you with proof that they are able to do so.  After transferring the embryos inside your uterus , nothing you do can improve your chance of success , but getting good quality IVF treatment is in your hands.  The field of ART is growing into a huge business and as a patient it is your responsibility to get the best out of it.  Being knowledgeable about IVF treatment will protect you from less than optimal medical care you might receive in the field of ART.

An Indian woman's IVF experience and how to make the ART field in India better?

This is a guest post from NP who has gone through IVF treatment in India. With her wonderful e-mails and compassion she has become my good friend too! In this post she has shared with us her IVF journey and I am sure it will help many people going through infertility struggle to become more positive and  better person as a whole. This post is a result of hard-earned wisdom. People who undergo infertility treatments do have a lot to learn from this. Thank you very much NP for sharing it with us. We wish you lots of good luck and may all your dreams come true!

The term ‘infertile’ was coined by doctors and thrown on us. In the beginning I and my husband were in denial mode.  He couldn't accept that there was a problem with him and gynaecologists said that I am fine. It took me 3 years to make him understand that indeed there is a problem with him after educating myself about our problems from internet. Yes, the doctors were of no use! They gave me least information and wasted my precious time. After lots of conversations between us, my DH agreed for trying IUI; but it failed and we were told to go for IVF treatment because of poor sperm count and morphology. IVF is an invasive procedure and my DH refused to take that route. He was afraid that there would be a negative effect on the child born via IVF. Because of his conservative view he didn't like this kind of baby making. Again so many months went wasted. I was learning about the IVF treatment; reading; trying to be happy in front of him yet persuading him to visit doctors. Finally, he agreed and when we started our IVF journey, I was 33 years old. I always knew time is precious in infertility treatment and it is passing by. When my first IVF cycle started, the doctor gave us shocking news just a day before the egg retrieval, ‘NP, you just have 4 eggs and they are all luteinized, we will abandon this cycle but we will do the necessary tests for you.’ I am wondering within myself, luteinized? What is that? During the IVF process every time a new terminology cropped out and like kids we have to learn many new things! The test results came back and I was found to have low AMH-1.8 ng/ml. The doctor on seeing my AMH results advised me to take up the donor egg route. What's that? I asked her. What rubbish are you talking doctor? She said excitedly ‘Oh! Don’t worry, I can get u beautiful models, intellectuals, bollywood heroines, young girls with healthy eggs, beauty with brains with similar DNA profile as yours’. In my heart, I cried; in my mind I asked myself, ‘what is all this nonsense’? Am I looking forward to have a child or am I selecting a vegetable from market? Isn’t love the necessary ingredient in baby making? This lead to the discovery that; here in Delhi, donor eggs, donor sperms, surrogacy is a huge market. People sell them for monetary gains. As I used to wait for doctors at the clinics, I could figure out touts, surrogate women, egg donors, customers etc. I never ever thought that infertility could be marketed in such a big way. It shattered my soul beyond my imagination. Is it so difficult to get the basic requirement of a living being? You said it right Manju, people do not even understand the words when they give us suggestion of donor egg or adoption. My heart would sink seeing children abandoned or my friends aborting their babies because they don't want a second child. My God! It was my dream to have 3 kids of my own ever since I was a small child. Being the eldest in the family my kid brothers was born in 1 year and 3 years gap and I had been like a mother to them ever since I was five myself! I took care of my relatives and neighbours children all when I was a kid myself.

Well, Then I went to another doctor. ‘You search and I will come along with you’ were the words of my DH. I searched and searched. We went to Mumbai to visit our relatives and luckily I found myself at Dr. X’s clinic. ‘She is the best’, I was told. I thought to have her opinion too. She scanned my ovaries and said ‘your left ovary is too small; you do have poor ovarian reserve’. You can try ICSI but the best option would be donor eggs’. I asked her ‘What are the chances of success and the cost?’ I was told that my chances are 10% and the cost of ICSI is 2.5 lakhs. It's an absurd amount with such low chance of success and the necessity to stay in an alien city also added to the stress. So I searched in internet again for clinics in Delhi.  This time we did another ICSI cycle using ‘long protocol’. They retrieved 6 eggs, 5 fertilized and all are 4 cell grade B two days after ER.  I was ok with the doctor but I did not like the junior doctors and the environment. The clinic was swarmed by Afghanis and there was complete chaos. I regretted my decision but I was in the middle of the cycle. I did not conceive : (. I was alone when the reports came. I went to see the doctor. I waited from 11 AM untill 6 PM holding my tears and fighting with my emotions. I was getting angry at her because of the lack of time management. When she came, she simply told me to go for donor eggs. I asked her ‘why did it fail, you said embryo quality was fine. She replied that it is because your uterus did not accept the embryo or because of your DH’s sperm which has poor morphology. I never went back to her. I read the information on Dr. Malpani's website and all his blog posts. They gave me a clear understanding of ART field. Coincidentally, whatever happens with me during my IVF cycle, he would write a blog post about it in a few days. So when she said poor morphology was the reason, I knew she thinks I am a fool! I know that sperm’s function is just to fertilize the egg and even sperms with poor morphology can create beautiful babies.

So, I started my IVF again in Bourn Hall Clinic, Gurgaon. The clinic in Gurgaon is a UK based one run by the IVF pioneer who created the first test tube baby.  Though the doctors are Indians they are trained by UK doctors.  I was impressed by their professional attitude and by the stringent rules with which they maintain their laboratories. This time I had antagonist protocol (this July) but the cycle was abandoned due to fewer (only 4) follicles and they were less than 10mm despite a dose of 450 IU Gonal F for 7 days. On seeing my ovaries response to gonadotrophins the doctor is not hopeful. But I am. If I see my entire journey in a broader prospect, I have not lost anything. Money yes, time yes, mental piece yes, relationships yes but nt my fighting spirit. I am a fighter and I can fight against the odds. I will accept it if I cannot have kids of my own in the end, but I am not lost as an individual. I have many aspirations, dreams to fulfil. I lost my smile, my friendly nature, my creative side for a few years now but I am bouncing back with double the energy. I keep meeting wonderful people from all over the world, different age, different struggles but they are all living happily, helping others. This inspired me to LIVE TODAY.

 Now, I am back to my walking schedule which I love, yoga is my passion and I am keen to take up dancing classes, learn driving, interacting with new people from all quarters of life and help many others who are struggling with infertility. I am becoming a better person!

NP’s experience in the field of IVF is an eye-opener for everyone who is going through this process. I am very happy that NP came forward to share with us her journey. I appreciate her good-will and courage. When I read NP’s journey again and again; I note several important points and questions which every couple undergoing infertility treatment should be aware of. I will make a short summary of it:

1)  Indian men (might be males all over the world!) are very reluctant to accept the fact that they can be infertile too. They even refuse to undergo fertility tests! The scientific truth is males account for 40% of infertility issues and females 40%. A combination of both partners may account for 10%, and the other 10% of infertility cases are from unknown origins.

2)  When a man takes long time to come to term with his infertility, he is also indirectly wasting his partner’s precious fertile period by postponing the infertility treatment.  In the field of infertility, the age of women matters the most. Woman’s fertility start to decline rapidly after the age of 35 and by the time a man accepts the fact that he needs fertility treatment to father a child, the woman’s fertility can also be compromised. As a result of this they have to suffer a double whammy - sperm issues + the egg quality issues. This can make the fertility treatment futile and can also destroy your chance of adopting a baby too (The combined age of both the partners should be less than 90 for being eligible to adopt a baby!). Time is too precious as far as infertility is concerned; try not to waste it because of your ego and ignorance!

3)  When you are an infertile partner in a relationship please learn to give proper respect to the rights of your fertile partner. Be open to the treatment options available. This will give a chance for you and your fertile partner to procreate! If you are not open to treatment options you are curbing the basic right of your fertile partner too!

Now some questions to ponder!

4)  Why are many IVF doctors insensitive to human emotions? When a doctor gives a talk about donor egg isn't his or her responsibility to be empathetic and compassionate? Should doctors behave just like a business man or woman? Why is the moral and ethical value associated with doctor profession completely lost?

5)  Why is IVF so expensive? Should money determine the availability of a scientific invention? As patients, what is our responsibility in bringing down the cost of IVF? Should we just be passive and believe foolishly what we are preached by the doctors? Why are IVF rates so variable? Shouldn't there be a fixed price for ART treatment?

6) What can we do to fellow infertile couple who are unable to afford costly infertility treatment? Should we just leave everything to God and foolishly believe the philosophy that having a child is only in God’s hand?

7)   How can we believe the success rates advertised by Indian IVF clinics? What is the proof? Why don’t we have a committee to regulate IVF/ICSI cycles performed in India? Don’t we need a central registry where every infertility clinics ART cycles are recorded and their success rates evaluated? The information thus collected should be freely available to public use. It should be made mandatory for every patient to report their cycle details to the central IVF registry. Who will make that happen?

8)  Why don’t Indian newspapers and magazines write about these problems which are haunting the field of ART in India? Why do they focus only about the emotional and social issues associated with IVF treatment? Who will write about dishonest IVF doctors who just work for the huge amount of money they earn?

9)  Why don’t insurance companies in India fund infertility treatment? Why don’t infertile couples who undergo so much emotional torture and financial problem fight for their rights?

10) Why Indian patients are so reluctant and lazy to learn about the scientific details of the most important and costly process they undergo? Why they allow themselves to get tormented and cheated?

I want every infertile couple who read this come forward and share their ART (IVF/ICSI) experience. Please, make the world know what you are going through! This will help fellow infertile couples to have a better treatment in the future. I wish everyone should make their voice hear by some means - it can be a blog, a newspaper or whatever media is available! If you have a blog please let me know!

If someone who has undergone IVF/ICSI in India is reading this post please share your experience with me (actually with us!). If you want to be anonymous I am perfectly OK with it. My e-mail ID is manjupadmasekar@yahoo.com. Write to me so that you can speak about your experience through my blog. People who want to submit  reviews about Indian IVF doctors are also most welcome to do it; be frank and be honest when you write a review!

Little drops of water make the mighty ocean! Let us do our best to make the field of ART a better place for Indian infertile couples!