How can a husband support his wife when undergoing an IVF cycle?

The best support for a woman who is going through an IVF cycle is her husband. The IVF journey is exciting and exhausting at the same time. The process is more physically demanding for a woman than for a man. When a woman lacks a supportive husband, it is almost impossible for her to sustain her energy and enthusiasm during the extremely draining IVF process. What can a husband do to make the process easier for his wife? What does a wife expect from her husband when undergoing an IVF cycle?

1)  Infertility is ‘ours’ , not ‘yours’ or ‘mine’

 IVF is a costly process and the outcome of an IVF cycle is highly uncertain too.  This creates a lot of mental stress for couples who are undergoing the process. For a man this can be extremely frustrating and humiliating. He feels that the situation is out of his control and the financial strain can make him panic about the future. Suddenly, routine life comes to a full stop and everything seems to be revolving around creating a baby. In such a situation, most men feel powerless. They do not know how to express their helplessness and may resort to anger. When in anger, you may spill words which are out of your control and can emotionally scar your wife. If your wife is having problems with her fertility, and if you tell her during your angry moment that it is because of her inability to conceive a child that you are suffering emotionally and financially, then it can create lots of heartache for your wife. This kind of blaming will make her feel more guilty and unloved. This can in turn cause enormous damage to your relationship. You should remember that she is already bearing the entire physical brunt of the IVF process and her infertility is not her fault. Infertility and IVF treatment are testing times for your relationship. If you keep in mind that infertility is not an individual’s problem, you tend to support each other better. You are each other’s better-half’s and being the best-half (a thoughtful, supportive, understanding husband) will help your spouse to go through this IVF journey with minimal heart-ache , which in turn will help you too to cope with this journey better.

2)      Get involved in the process

A man’s role in the IVF process is much less arduous when compared with the woman’s. In fact, the entire IVF process revolves around the woman. From the beginning of ovarian stimulation to embryo transfer; a woman has to take many injections; have many vaginal ultrasound scans and blood tests; and then go to the OT for egg collection and embryo transfer. All these processes can be very exciting - and physically and emotionally stressful too. Many men think that their only job is to act as a ‘sperm donor’. While their wife is busy taking all the prescribed medicines and travelling to the clinic frequently for undergoing vaginal ultrasound scans, most men are totally clueless as to what is going on. They prefer to keep themselves detached. It’s not that they are unkind – it’s just that this is the commonest coping mechanism men deploy. This will make his wife feel lonely and abandoned in the process. She may jump to the erroneous conclusion that her husband does not care about her – or about the deep desire she has for a baby! Actually, baby-making is exciting when both the partners’ involve themselves completely - let it be in the privacy of your bed room, or in an IVF clinic. The best support a man can provide to his wife when undergoing IVF is to dive deeply in the process. As a husband you can do many simple things which will make the IVF process less stressful for your wife. You can remember the medicine schedule; ask your wife whether she took them at the proper time and in a proper dosage, you can give her the injections yourself, accompany her to the clinic, be with her during the vaginal ultrasounds and hold her hand during the embryo transfer. All this will help to make the IVF baby-making process come alive for you too. Being involved will also help you to appreciate the pains your wife is undergoing for the sake of the much yearned baby. In this way, you will also be able to empathize with her, and your emotional connection will be much deeper.  

 

3)      Communication is the key to coping better!

 I agree that it is not easy for a man to be as expressive as a woman, but communication is very important for a good relationship and couples who have good communication skills fare far better in times of crisis. IVF process is draining and most wives are clueless about what their husbands are going through emotionally! I myself used to wonder what is going on in my husband’s mind. Even if I coax him to be a bit more expressive it just doesn’t seem to work – and he feels I am nagging him. As a result, I worry for myself and for him too! If he shares what he is going through with me, I can extend my emotional support to him - and as a result I get better emotional protection too! The coping mechanism for stress is very different for a woman and for a man. This greatly adds to the chaos. As a woman, when I talk about my fears and insecurities about my IVF journey , and when my husband listens patiently , I feel instantly better , because I can see he cares for me. This is all I want – I understand the outcome is not in my hands or his, but unburdening myself helps me cope better with my anxieties. But my husband’s view is different. He feels that instead of talking about the problem (which is stressful according to him!), it’s better to just forget about it and immerse yourself in some kind of entertainment. He wants to distract himself with something else which will give him happiness. If this is the scenario in your situation too then it is very important to strike a balance between your needs and your wife’s. Just sit with her like a friend and discuss the IVF journey – or let her just vent. Remember she does not expect solutions – just a kind ear and a shoulder to cry on! Even if your wife’s concerns appear to be unreasonable, take time to listen to them patiently and try to clear her fears and doubts. When an IVF cycle fails, the best help you can provide your wife is to talk about it! (Many men avoid talking about it altogether, because they find this too painful!) Tell her that an IVF failure is not her fault and even though it is difficult for you too, the pain of it will not last long. Assure her that you love her as always and infertility cannot come in between you. Try sharing with her your worries too. Sharing your emotional insecurities with your wife will assist her in understanding you better and offer you her support. This will give her immense satisfaction because women love to act as ‘emotional caretakers’! 

4)      Express your love and affection

 The best time to show your spouse that you care is during the difficult moments of your life. Many men empathize with their wife because of the pains they need to endure during an IVF cycle. But they do not know how to express what they feel. There are many cute little ways to show that you love and care. A bunch of roses or a cute little card with some nice words, a genuine compliment or a surprise dinner can bring back her smile and happiness during stressful IVF times. Taking part in the daily house hold chores will also make her sense that you really care! It will make her feel loved and appreciated. It will also erase her fears and worries concerning your emotional well-being. Your kind actions will tell her that you are emotionally OK and you are able to cope well and take care of her too! 

5)      Let us learn together

 The IVF process will be less stressful if you are well-informed about it. You might be busy with your work, but even then it is wise to spend some time with your wife so that both of you can learn about the process. Learning will be easier and fun when it is done together. Please do not discourage your wife from understanding the intricacies of the process. Learning is not obsessing!  Acquiring knowledge about the IVF process will give your wife the satisfaction that everything is going on well with the cycle. Even if troubles arise during the IVF cycle, she will be able to cope emotionally better when she is knowledgeable. The same applies to you too. Only when you both understand what is going on during an IVF cycle can the two of you have a rational discussion with your doctor and get involved in the process. Otherwise you will be left with a feeling that you are not in charge of the situation, and will feel betrayed and miserable when the treatment fails!

6)      Please do not allow your parents to interfere!

 This will be the sincere wish of many women undergoing IVF, including me. Does it mean that we see our in-laws as an unwanted intervention in our life? Definitely not! The comfort level of a woman with her in-laws is very different from the comfort level she shares with her own parents. Any husband will understand this if he compares the comfort level he shares between his own in-laws and his parents. IVF is an emotionally challenging process and unsympathetic in-laws can add a ton of stress to the already difficult IVF treatment. Many do not understand the process scientifically. It is hard to explain this to them and clear their unreasonable doubts and fears. Because of the concern and fear they have, they make a lot of well-meaning suggestions, as to what to eat and what not to; and what precautions to take during the IVF process. This might force us to behave in ways which we are not actually comfortable with. For example, my mom gets very tensed and fearful after my embryo transfer. She will say ‘Manju, walk slowly, sleep with your legs straight, do not climb stairs, do not lift any weight (even if it a few grams!), do not eat chicken (or certain foods!)’. Whatever she says is out of love, but the mental stress such constant pestering (especially when you know that all these things will not stop an embryo from implanting!) creates is hard to describe in words. All this talk constantly reminds me of the embryos within my womb! This makes me worry about myself - and I end up worrying about her too! I keep on thinking, what will happen if this cycle fails; how my mom will cope with it; and there is a tremendous sense of guilt, because of my belief that it is because of my defective reproductive system that she has to undergo this kind of emotional roller-coaster at this age!). I feel inadequate that I cannot give her the grand child she yearns for. On the other hand, if it is ‘MY MOM’ I have the freedom to tell her to shut up. I can either pacify her with my kind words or vent my anger. She will understand what I am going through. Is it possible to act like this with your in-laws? The stress levels during the IVF treatment and the 2ww are very high, and it nearly impossible to keep silent and be polite all the time. Another important point is, if the cycle fails my mother will not blame me but if I do not act according to my in-law’s advice and if the cycle fails, I will be blamed for the failure all the time! This will make the relationship between me and my in-laws bitter and unmendable. There are also in-laws who can act in spiteful ways which can be very hurting during the IVF journey. So please avoid telling your parents all the gory details about the IVF treatment. This will definitely help you and your wife to get along better during stressful times!

7)      I am emotionally vulnerable- please realize this!

 Women are ruled by their hormones-especially during an IVF cycle! Because of all the drugs she is taking , there is be a hormonal roller-coaster going on inside her body. Some hormones drop, rise high and then drop again. These kinds of rapid changes in hormone levels can contribute to increased anxiety and depression in many women. Women can experience lots of crying spells and moodiness during this time. She might get irritated for no valid reason. I have personally experienced that these are the times I am very vulnerable to a variety of negative emotions and as a result I make my husband’s condition miserable. I agree that your wife might be getting on your nerves at such times. She might behave totally irrationally and maybe emotionally uncontrollable (like a ‘raving lunatic’!). The best thing you can do during such moments is to offer her a shoulder to cry on and patiently hear her fears and concerns. Even if you are right about your viewpoint, please do not argue. Choose to be kind over being right at these times and it will avoid many further heart aches for you and your wife! 

8)      It is hard for your wife not to obsess- please understand this!

 During the IVF treatment, especially during the 2ww, you will find that a new person has taken over your wife-a soul which is totally lost in its own thoughts, a person who wants to sit in front of the computer and search on the internet for pregnancy symptoms, forgetting the whole world, a woman who is constantly concentrating on all the small signs and signals her body might be giving and panicking about the same. She might even emotionally retract from you. I agree that it is very uncomfortable for a husband to see his wife like that. You might want her to forget about the embryo transfer and be normal as usual. You might want her to take notice of you, take care of you and get on with normal life. You might want to make the situation easier for your wife but none of your efforts to distract her from obsessing seems to work. You might feel totally helpless. You will fear that she is totally stressed out and might wonder about the negative impact of stress on embryo implantation. Please understand that there are psychological and emotional differences between men and women and your way of coping with the stresses of IVF is very different from your wife’s way of coping. So try to accept her style, and give her the space she needs. Trying to criticize her for being too emotional or sensitive will just add to her stress levels. Constantly accusing her for obsessing during the 2ww or saying that her way of dealing with the 2ww is ‘crazy’ will interfere with her way of coping and might leave her totally anxious and depressed. Allow her to obsess since this actually helps her to cope with the 2ww! 

 9)       Don’t be overprotective

 During the ‘2ww’ many husbands tend to become overprotective. They want their wives to be careful about everything they do. Some don’t even want their wife to get out of bed! Although you might think that you are being kind and caring, this kind of overprotection can make your wife uncomfortable. Your actions might remind her all the time about the embryos inside her uterus. Once the embryos are inside the uterus, nothing she does will affect the chance of implantation. If the embryo is good enough and the uterine receptivity is optimum the embryo will implant - otherwise it will not! This is the only truth, as established by medical science. So do not force her to do things with which she is not comfortable. Keeping an eye on her all the time and forcing her to rest in bed all day long (because of your insecurity!) will put unnecessary stress on her. Allowing her to do the normal day-to-day activities will help her to take time off from obsessing. It will be also helpful if you avoid unreasonable questions like-‘are you feeling anything?’, ‘do you feel pregnant?’ etc!

Can metformin prevent embryo aneuploidy?

A dividing cell - microtubules in 'green' and chromosomes in 'red'

Metformin is an anti-diabetic drug used to treat type II diabetes alongside diet and exercise. It functions by increasing the sensitivity of our body’s cells to insulin (decreases insulin resistance) and thus by helps in the proper utilization of glucose.  It has no direct effect on insulin secretion from pancreas and so it does not alter the insulin level in our body. Hence the risk of dangerous hypoglycemic episodes is very low when compared to other anti-diabetic drugs. Metformin has a very high safety record and is used in clinical practice for more than 50 years. 

Metformin is now used widely used for treating Polycystic Ovarian Disease (PCOD). Insulin resistance and obesity are common among women with PCOD. They have high levels of androgens in their body. They suffer from absence of ovulation and hence lack regular menstrual cycles too. Metformin treatment of PCOD women decreased circulating insulin levels, corrected hyperandrogenism (presence of high level of androgens) and helped in the resumption of regular ovulation. As a result many PCOD women are able to conceive with the help of metformin. Continuation of metformin during the first trimester reduced miscarriage rates in women having PCOD (women with PCOD are prone to miscarriages) and continuation of metformin throughout pregnancy prevented gestational diabetes.  PCOD is a multifaceted disease and the exact mode of metformin action in helping PCOD patients is still unknown. Another interesting information regarding metformin is, it is touted as a gerosuppressant (anti-aging drug) and it prevented reproductive aging too (estrous cycle in mouse treated with metformin remained regular even in older age while in control animals estrous cycle became irregular with age!) (PMID: 18728386).  Metformin works as a calorie restriction mimetic.

Several studies have been carried out to find whether metformin treatment of women with and without PCOD increases the implantation rate and pregnancy rate during IVF treatment. Some studies found that metformin increased egg quality, pregnancy rate and implantation rate in women with PCOD and some failed to show any benefit. But metformin treatment of women with PCOD during IVF was found to prevent ovarian hyperstimulationsyndrome. A multi-centre, prospective, randomized, double-blind study conducted in 2011 showed that metformin treatment of non-obese PCOD women undergoing ART cycles improved pregnancy rate and live birth rate but the clinical pregnancy rate remained the same between the metformin treated and the placebo group.

The exact mode of action of metformin in preventing miscarriages, improving pregnancy and live birth rates remains unknown. It is hypothesized that decreased insulin and androgen levels contribute to this beneficial effect. It is known that more that 60% of miscarriages happen because of embryo aneuploidy (a form of genetic aberration leading to abnormal chromosome number in the embryo). So the question arises whether metformin does something to prevent embryo aneuploidy. To answer this question I tried to look into the signaling pathway activated by metformin and its effect on cell division. 

 Metformin activates a signaling pathway called AMP Kinase. AMP Kinase is called the energy sensor of the cell. When the energy level is low within the cell AMP Kinase senses this energy deficit and switches on activities within the cell which produces more energy and switches off activities which consumes energy. AMP Kinase also functions as a tumour suppressor and metformin which activates AMP Kinase has been proved to posses anti-cancer properties. Interestingly it was found that, AMP Kinase is necessary for proper cell division in drosophila and lack of functional AMP Kinase subunits lead to abnormal chromosome segregation during mitosis (which is the reason for chromosomal abnormalities or aneuploidy) and increased polyploid cells. It was also found that AMP kinase regulates the stability of spindlemicrotubules, the structures responsible for proper chromosomal segregation during cell division. Another publication stated that AMP Kinase activators like metformin can selectively induce apoptosis in aneuploid cells. 

A couple of studies were also done by adding metformin to the culture medium in which embryos of experimental animals were grown. They observed increased blastocyst formation when metformin is present in the culture medium containing insulin (PMID: 16107611). When AMP Kinase was activated using metformin in mouse embryos there was decreased apoptosis and increased pregnancy rates (PMID:17575082).

Can the beneficial effect of metformin (decreased miscarriage rates) in human reproduction be due to the result of metformin’s ability to prevent cell division errors by activating AMP Kinase? Isn’t aneuploidy the major reason for miscarriages? Are laboratory culture conditions (like excess nutrients in the culture medium, over activation of IGF-1 pathway as a result and complete supression of AMP Kinase pathway) a culprit for producing lot of aneuploid embryos? Can adding metformin to embryo culture medium prevent aneuploidies arising due to mitosis? Does metformin uptake by women improve reproductive outcome by reducing aneuploidy in their oocytes? There are many unanswered questions and perhaps research in this area will help in finding the plausible connection between metformin use and embryo anueploidy prevention!

Comprehensive Chromosome Screening (CCS) - panacea or pipe dream? - Part III

Trophectoderm biopsy

You can read the first part here and  the second part here.

Which biopsy is the best for detecting genetic errors in an embryo?

The removal of polar bodies from oocyctes or removal of one or more cells from pre-implantation embryo provides the material for the genetic screening of an embryo. Usually an embryo is biopsied on day 3 or day 5 of development. Day 3 embryo biopsy is called early cleavage stage biopsy and day 5 embryo biopsy is called trophectoderm biopsy or blastocyst biopsy.

Polar bodies are meiotic by products of an embryo. Polar body biopsy is considered to be less invasive and hence protects embryo against extensive mechanical damage. It gives information about the genetic status of the oocyte and not of the sperm, but this is acceptable in clinical practice because 90% of the genetic abnormality in an embryo arises from meiotic non-disjunction in the oocyte. Also, polar body biopsy does not give information about embryo mosaicism ( which arises due to mitotic cell divisions in an embryo).

Day 3 embryo biopsy is performed on one or two blastomeres. Because of embryo mosaicism arising due to mitotic non-disjunction,some cells on day 3 might have a normal karyotype and some may not. So when a single blastomere is biopsied on day 3 , there are chances that the result of CCS comes from the cell carrying a normal chromosomal make-up. This will lead to the labeling of entire embryo as euploid while it can be a mosaic embryo (diploid-aneuploid mosaic). Also, not all day 3 embryo develop into blastocysts , even if it carries a normal karyotype. Biopsy itself can be detrimental to its further development into a blastocyst, so there are chances of having no genetically normal embryo for transfer on day 5 when a day 3 biopsy is performed. On the other hand, when a biopsy is performed on day 3 and when the embryo is grown until day 5 before transfer, then it allows for a kind of double selection, because you get to transfer CCS normal day 3 embryos which had the potential to develop into blasts , giving a much higher chance of transferring the best embryo.

Day 5 biopsy is performed on a group of cells (2-10 cells) obtained from trophectoderm. Since more cells are obtained for biopsy , the chance of detecting chromosomal abnormality with precision is higher. But the trophectoderm is the layer which develops into the placenta, while the embryo develops from the inner cell mass . This means that it’s possible that the inner cell mass could have euploid cells , while the and the cells from the trophectoderm are aneuploid. This phenomenon is called as confined placental mosaicism, as a result of which trophectoderm biopsy can lead to the labeling of a chromosomally normal embryo as chromosomally abnormal.

Also, an embryo which seems to be genetically defective on day 3 may ‘self-correct’ itself on day 5. So doing a day 5 biopsy might help in obtaining accurate results. Trophoectoderm biopsy is considered to be less traumatic to the embryo as only a few cells out of over 100 cells are removed ).

Are we over-testing, just because we have the technology to do so?

As a biologist, I do have a critical view of all the new technologies and its effectiveness. Reading the scientific literature regarding embryo aneuploidy and comprehensive chromosome screening have raised a number of unanswered questions. It is true that this technology is a blessing for patients who carry genetic abnormalities , because it will prevent the genetic disorder from being transferred to their offspring. But, will this extensive genetic screening of embryos do any good for patients who undergo IVF for other reasons? Can older women who undergo repeated implantation failure or recurrent pregnancy loss benefit from it?

It was shown that greater than 50% of the embryos (even from younger women) created via IVF carry genetic abnormalities. It was hypothesized that, if we could select embryos which are genetically normal then the chance of implantation and pregnancy rate per embryo transfer will increase significantly. Since most miscarriages are the result of embryo aneuploidy, the rate of miscarriage is thought to decrease dramatically with aneuploidy screening. This seems to be logical but the data from PGS testing failed to show any clear benefit. A very nice review of literature which includes the biggest and best scientific study can be found here. But the genetic screening technique used in those studies is FISH (which cannot screen abnormalities in all 23 chromosomes) and not CCS and this might explain in-part the lack of improvement in pregnancy rate even after PGS testing. A recent (2011) meta-analysis of randomized controlled trials failed to show improved live birth rates after PGS. Paradoxically, it showed that for women of advanced maternal age PGS significantly lowers the live birth rate (PMID: 21531751).

Can we say that all genetically abnormal embryos are doomed to perish? There is no definite answer for this question. Since more than 60% of miscarriages show some form of chromosomal abnormality it is logical to think that aneuploidy arising either in the egg or embryo has to be blamed. But we should not also forget that an embryo has the ability to ‘self-correct’. There is lots of evidence in favor of thus ‘self-correction’ hypothesis and just 20% of euploid cells present in the inner cell mass of a mouse blastocyst can give rise to a genetically normal mouse. Embryonic stem cells created from genetically abnormal embryos (found to be genetically defective via PGS) produced stem cell lines which have a normal karyotype. There is proof that tetraploid blastocysts (genetically abnormal blastocyst) transferred into uterus gave rise to a genetically normal baby. Does this say something? This shows that an embryo which is designated as genetically defective might actually have the potential to develop into a normal baby. Then does it mean we are discarding embryos which could develop into much desired babies just because of technology over use?

What if faulty earlier cell division in embryo is just a physiological mechanism and not really a pathological mechanism? An embryo in its initial stages may be designed by evolution to divide very rapidly , so that it reaches the uterus at the appropriate stage to implant itself into the endometrium(it might be that slow and steady embryos fail in this situation!). We should not forget that our uterus is receptive to the embryo only for a short period of time. If the embryo is under the scrutiny of strict cell cycle control , it is possible that the time taken for cell division would be too long, and result in a failure to implant . So nature might inherently allow replication errors (by relaxing the cell cycle control), and the errors introduced in the genome can be ‘self-corrected’ later when cell differentiation starts. Should higher miscarriage rates in women of advanced maternal age be linked to higher aneuploidy rates due to replication errors? Isn’t there a possibility of ‘self-correction’ mechanisms being defective in their embryos because of aged oocytes? If this is true , are we really doing any good by screening and discarding the genetically abnormal embryos? We can check the embryo for its competency upto the blastocyst stage, but an embryo implanting and developing in the uterus also undergoes rapid cell division for the next few weeks during which organogenesis takes place. If there are genetic errors introduced at that time point and if the ‘self-correction’ machinery is defective will the embryo survive? Doesn’t this explain the lack of improvement in miscarriage rates in older women even with PGS? All these are questions which still need to be answered !

Should I opt for comprehensive chromosome screening?

It depends for what reason you are doing it. CCS is extremely useful for couples who are carriers of rare genetic disorders. Selecting embryos which do not carry that particular genetic defect will guarantee them a normal pregnancy and a genetically normal baby. Until now , this is the most reasonable indication for doing CCS on an oocyte or an embryo. All other conditions for which CCS is indicated are still not proved to be effective with larger, well-controlled studies. This technique is extremely costly, time consuming (when there are no appropriate labs nearby for doing CCS) and can be very emotionally draining too. So it is advisable to undergo such genetic screening tests only when absolutely necessary.

Comprehensive Chromosome Screening (CCS)-panacea or pipe dream? - Part II

You can read the first part of this series here.

Karyotype showing aneuploidy of chromosome 21

 Embryo aneuploidy

An aneuploid embryo contains abnormal number of chromosomes in their cells. A human embryo should contain 23 pairs of chromosomes (46 chromosomes) in every cell. Chromosomes carry the genes. Genes encode the information for producing proteins. So when abnormal number (more or less)  of chromosomes are present in a cell more or less than the required amounts of proteins are produced. This can either kill the embryo by arresting its development (embryo doesn’t implant or even if it implants the pregnancy gets terminated spontaneously!) or can cause severe abnormalities in babies which are born out of an aneuploid embryo. For example a baby with Down’s syndrome carries three copies of 21^st chromosome (an entire extra chromosome or part of it!)  in its cells.

Aneuploid embryos can arise as the result of:

1) Errors in cell division during oocyte (egg) development.
2) Errors in cell division during sperm development.
3) Errors in cell division during an embryo development.

90% of embryo aneuploidy are due to cell division errors in oocytes and only 10% of the errors are contributed by the problems arising during sperm development. As a woman age the number of eggs with abnormal chromosome number increases.

Eggs and sperms are formed by a special type of cell division called meiosis.  The reason why we are so different from our parents and ancestors (in physical and mental traits) is because of genetic recombinations taking place during meiosis. Meiosis introduces genetic variations in offspring. Meiotic division is reponsible for the production of eggs and sperms. Eggs and sperms carry only half the number of chromosome (23 unpaired chromosomes) and during fertilization the full chromosome complement (46 chromosomes) is restored. When a chromosomally abnormal egg is fertilized by a normal sperm or vice versa (or if a chromosomally abnormal egg is fertilized by a chromosomally abnormal sperm) the resulting embryo will be genetically defective or aneuploid. When chromosomal errors occur during meiosis it affects the entire embryo. All the cells within the embryo will be aneuploid. Aneuploidy of meiotic origin is almost always lethal to the embryo or to the fetus. But approximately one third of aneuploid oocytes derived from sequential errors in the first and second meiotic divisions resulted in a balanced karyotype, representing a possible phenomenon of “aneuploidy rescue”

An embryo can also acquire genetic errors during its cell division. The embryo divides by a type of cell division called mitosis. The first three cell division of an embryo is extremely prone to genetic errors. An embryo activates its own genome when it reaches the 8-cell stage. Until then the embryo depends on maternally derived gene transcripts and proteins stored in the oocyte. For the prevention of aneuploidy formation high levels of mitotic and cell cycle proteins are necessary. The quality of the stored gene transcripts and protein could diminish over time by the accumulation of radiation or toxic agents, oxidative stress, compromised mitochondria or telomere shortening. This can lead to a defective cell cycle checkpoint mechanisms (especially in women of advanced maternal age), which may lead to chromosomal segregation errors in the first few cell division of human preimplantation embryos. When a zygote (embryo in 2pn stage) divides it gives rise to a two celled embryo. When genetic error occur in the first division then the entire embryo will be aneuploid. When a two celled embryo divides one cell division can be normal and the other defective. If such an error occurs one-half of the embryo will carry cells which will contain chromosomal abnormality and the other half of the cells will have a normal genetic make-up. When one-quarter of the cells in an embryo are chromosomally abnormal then it means that the chromosomal aggregation error occured in the third division. An embryo which carries both genetically normal (euploid cells) and geneticall abnormal cells (aneuploid cells) is said to be mosaic and the phenomenon which leads to the formation of mosaic embryos is called mosaicism.

Can mosaic embryos develop into normal babies?

Single cell comparative genomic hybridization analyses of normal IVF embryos showed that 75% of all the IVF embryos were mosaic. Out of these embryos 55% were diploid-aneuploid mosaic and 55% of all blastomeres from these embryos were diploid (PMID: 21531753). Mosaicism is found to be more in blastocysts when compared to cleavage stage embryos. This implies that mitotic errors could have occurred in later cell divisions and not necessarily in the first three mitotic division of a zygote. High rate of diploid-aneuploid mosaicism in blastocysts also implies that mosaic embryos more easily reach blastocyst stage as compared to embryos containing only aneuploid blastomeres. Do these mosaic embryos develop into normal babies? An experiment conducted in mice showed that only 20% of euploid cells in the blastocyst are enough to give rise to a normal mouse. This shows that blastocysts might have inherent mechanisms to correct their genetic defects. There are many speculations regarding such mechanisms. It is assumed that the blastocyst rearrange their blastomeres in such a way that the aneuploid cells are pushed towards the periphery forming the trophectoderm leaving only the diploid or euploid cells in the inner cell mass. This could explain the phenomenon of confined placental mosaicism. The other school of thought is abnormal cells are removed from the blastocysts via apoptosis and only the euploid cells survive. This leads to the accumulation of normal cells in the embryo.

It was also shown that frozen-thawed human embryos that lost nearly half of their blastomeres are still able to result in live births. This clearly shows that not all blastomeres of human pre-implantation embryos are necessary for developing into a full-fledged baby. Transfer of two tetraploid blastocysts (as identified by trophectoderm biopsy) in a woman has resulted in the birth of a normal male infant (PMID: 19608167). Embryonic stem cell lines developed from aneuploid embryos were found to have normal chromosomal make-up.These evidences clearly show that mosaic embryos have the potential to ‘self-correct’ and develop into normal babies. Might be, the type of mosaicism, the percentage of mosaic cells in an embryo and the inherent ability of the embryo to correct itself, determines whether a mosaic embryo could develop into a baby or not.

Further researches are needed at this point to determine whether embryo mosaicism is actually a pathological or physiological mechanism.

 

Array Comparative Genome Hybridisation

Fluorescence in situ hybridization (FISH) used to be technique for screening genetic abnormalities in pre-implantation embryos. However, this was unable to screen all the chromosomes in an embryo for genetic abnormality ; and was  also highly labor intensive. This has led to the development of advanced cytogenetic techniques which can scan all the 23 pair of chromosomes for genetic errors. One such technique is called array comparative genome hybridization (aCGH). The primary advantage of CGH is its ability to detect aneuploidies, deletions, duplications and/or amplifications of any locus represented in an array. One assay using this technique is equivalent to thousands of FISH experiments. Array-CGH has been successfully used to detect submicroscopic chromosomal aberrations which are also called as copy number variants (CNV).

Advantages of aCGH

1) Useful for comprehensive chromosome screening (CCS).

2) It has very high resolution (can detect submicroscopic variations in genome).

3) Quicker results and it is not labor intensive, since it is automated

Limitations of aCGH 
 
1) Whole genome screening using aCGH can generate data that may be difficult to interpret.

2) It can detect even minute alterations in genome which might have no established clinical relevance.

3) Clinical confidence of aCGH is still in question. Many researchers advocate FISH confirmation of the results obtained using aCGH.

You can read the next part here.

Comprehensive Chromosome Screening - panacea or pipe dream? - Part-1



Chromosomal screening of human blastocyst using CGH

I have had 19 embryos transferred  to my uteurs. Only one of it implanted but it failed to develop into a healthy infant. This shows that not all embryos produced via IVF are able to develop into a much desired baby. Many women who have undergone IVF ask this question frequently 'why didn't my embryo implant?' Although there is no easy answer for this question scientists are trying hard to decipher this puzzle. Why don't all embryos develop into a baby? What can be done to improve the success rate of IVF? Can we achieve 100% success rate in ART? Is there a way to determine which embryo will develop into a healthy baby? A very recent technological advancement which appears to be promising in improving IVF success rate is Comprehensive Chromosome Screening (CCS). It utilizes modern genetic techniques to find out embryos which are genetically normal. Will such modern genetic screening techniques take IVF to new heights? Will the success rate of IVF improve dramatically in the coming years? These are all very interesting questions and I have a made a review which might answer some of the above questions atleast partly. My next couple of posts will talk about embryo aneuploidy, aneuploidy detection techniques and whether it will really make a difference in the field of ART. This topic might be a bit more scientific and difficult to understand. Please write to me if you want to clarify any doubts.



Why do we need to screen embryos for genetic defects?

Not all the embryos which enter the uterine cavity will implant and develop into a baby. If we are able to pinpoint which embryo has the potential to develop into healthy infant then the success rate of an IVFcycle will greatly improve. This will also pave way for elective single embryo transfer (e-SET) which in turn will prevent the dangers associated with multiple gestations. The universally accepted truth in reproductive biology is, younger the women; greater is her ability to conceive and carry a baby to term. As a women age the quantity and quality (genetic quality!) of her eggs decline. As a result it becomes difficult for older women to conceive and even if she conceives many pregnancies are lost in the earlier stages of gestation. They are also prone to giving birth to babies with genetic abnormalities. The genetic analysis of fetal remains from spontaneous abortion samples (from younger and older women) revealed that more than 60% of fetuses stopped developing because of the presence of chromosomal aberrations (incorrect chomosomal number or content in the cells). Aneuploidy is the most common genetic aberration present. Oocytes from older woman are more prone to develop chromosomal aneuploidies. This knowledge and the failure of most of the embryos generated via Artificial Reproductive Technology (ART) to develop into babies (only 19% of transferred embryos were delivered) lead to the genetic screening of embryos for chromosomal defects. The field which deals with the screening of embryos for their aneuploidy status is called preimplantation genetic diagnosis (PGD). Until recently, the widely used screening technique in the field of PGD is called Fluorescence in situ hybridization (FISH). Preimplantation genetic screening (PGS) using FISH failed to show improvement in the implantation rates and delivery rate for women of advanced maternal age. This lack of improvement in pregnancy rate was attributed to the limitation of FISH technique itself. Using FISH it is only possible to screen a very limited amount of chromosomes (5-12 chromosomes) for genetic abnormality or aneuploidy. An anueploidy can strike any of the 24 different chromosomes present in a human embryo. It is argued that FISH failed to detect embryo aneuploidy in many of the embryos and as a result there is no improvement in pregnancy rate of women of advanced maternal age even with PGS. Recently limitations in FISH technique are overcome by the introduction of genetic screening techniques which could screen all 23 pairs of chromosomes in human embryos. This screening technique is called Comprehensive Chromosome Screening (CCS) and it employs genetic screening techniques like whole genome amplification combined with qPCR,SNP microarray-based analysis or array-comparitive genomic hybridization (aCGH).

More than 50% of embryos generated via IVF are found to carry some forms of aneuploidy. ( This is true of embryos created in the bedroom as well ! Human reproduction is remarkably inefficient). Even embryos which appear perfectly normal under the microscope (scored using cell size and number, presence of multinucleation, percentage of fragmentation and cleavage rate) are found to carry genetic abnormalities. Surprisingly, an ugly looking embryo under the microscope can be genetically normal and a beautiful looking embryo can be genetically abnormal. The high aneuploidy rates found in embryos might explain the low implantation rate and birth rate per embryo transfer. Most clinics around the world have a success rate of 40-45% per IVF cycle. This rate goes down drastically for women over 38 years of age. Advanced maternal age also leads to high level of spontaneous abortion because of the implantation of genetically defective embryos which fail to progress normally in utero .The embryo chromosomal abnormality rate is about 40% for women aged up to 29 ; and it increases up to 80% for those aged 40 or above. This increase in genetically defective embryos in older woman is usually due to the increase in trisomies. More than 50% of aneuploid embryos have the capacity to develop and implant. Some of these embryos can even develop into babies , which are genetically abnormal. Aneuploidies that can result in viable pregnancies include chromosome 13, 18, 21, X and Y. The common genetic anomalies present in embryos are:

1)      Trisomy (62%)

2)      Triploidy (12.4%)

3)      Monosomy X (10.5%)

4)      Tetraploidy (9.2%)

5)      Structural anomalies (4.7%)

 

Transferring euploid (chromosomally normal) embryos might result in:

1) Increased implantation rates and live birth rate per embryo transfer and hence encourage the use of elective single embryo transfer (e-SET). This in turn will prevent multiple pregnancies and the risks associated with this.

2) Decreased incidence of spontaneous abortions (60%-70% reduction in spontaneous abortion rate)

3) Reduced risk of carrying and delivering a genetically abnormal baby.

Who might benefit from embryo screening?

1) Patients with inherited genetic disorders.

2) Patients who suffer recurrent pregnancy loss (RPL) because of advanced maternal age or from rare chromosomal translocations.

3) Women of advanced maternal age (AMA) who are at increased risk for carrying a genetically abnormal child.

4) Patients with recurrent implantation failure (RIF) or repeated IVF failure. Patients who have had more than 10 good looking embryos transferred into their uterus without ever achieving a pregnancy are considered as having recurrent implantation failure.

5) For patients who suffer from unexplained infertility. Genetic screening of embryos might help in understanding whether unexplained infertility is embryo related or implantation related. 

You can read the next part here.

Are men the silent sufferers of infertility? What can a wife do to make her husband feel better and well-cared for during the infertility struggle?

We women talk a lot about infertility, express our emotions associated with it, cry a lot and as a result get better emotional protection too! I have seen women complaining about their DH (dear husband)’s attitude to their infertility in many bulletin boards. They get lots of comforting words and support from fellow women. But I have never seen any men venting about their infertility struggles, their view of it or how they cope with it. Even my DH never expresses what is in his mind. I want to hear from him how it feels not to have a baby when everyone around him seems to be fathering a child. What does he think when he hears someone in his friend’s group announce their pregnancy? How does he feel when he sees couples with a cute little child? How does he manage when some of his friends just drop in and ask ‘is there any good news?’ These are all grey areas for me. Sometimes when one our friends say that they are pregnant, I tell my DH ‘does it hurt? Do not worry our turn will come too’, he smiles and replies very naughtily ‘when I am not responsible for that pregnancy why should I worry’ :) Although, he tries to make light of the issue for my sake, I understand that it is of course painful for him too!

The intense desire to have children is not just a women thing. Most men like most women love to have children. When a man is with the company of a young child you can experience the tender side of him. We went to India both the times when my little sister had her baby. I was a bit tensed how my husband will handle the situation. I was worried about his emotional safety. How would he react to the presence of a new-born child especially when we are going through infertility? Will he feel uncomfortable? To my surprise, I was amazed by his fatherly skills. He handled the new born with so much care and affection. Sometimes when the little one cries uncontrollably my sister will give the baby to him. He used to hold the baby in a comfortable position and shake him gently; the little one stops crying and goes to sleep within the warmth of his embrace. At those times, I could see his face soften with a motherly affection. Everyone in my home are proud of him but the only soul which is left weeping on seeing all this is me. I know he loves children. Whenever he sees a naughty, young child his face becomes bright with a smile. His eyes would follow the child as long as the little one is within the viewable distance. When he is eagerly looking at the child my eyes will be concentrating on his face trying to read his mind.  I will be caught in a swirl of emotions. My inability to give him a much desired baby strikes me so hard; my eyes will fill with tears unable to bear those emotions. So if someone says that the longing for a baby is a womanly thing and men are unaffected by infertility I can never ever agree with them.

I would like to share one of my experiences with an infertile couple who lives in my husband’s village. They are very young. They do not have children and I happened to hear from that woman (her name is Manju too!) why they are not able to have a child. She said at the age of 23 or so her uterus was removed because of a tumour! I was shocked! I guessed it may have been a fibroid and might be because of an over-enthusiastic or money-minded physician that this tragedy happened. She is not literate enough to explain her actual problem. Then I started to question her further and asked what she thinks about adopting a child. She said, ‘my health is not that great and we do not have good income too. In this situation, I do not want to take any additional responsibility’. She is not crying her eyes out and that is the best thing about village women. They are emotionally very strong and have enormous resiliency. Actually, city-dwelling, very modern, highly educated women are emotionally very fragile! Although the topic is uncomfortable for her she is able to share her opinion with me very matter-of-factly. I insisted that it will be wise to have a child at home as it would bring new hopes into their life and a sense of responsibility and happiness. She said, ‘my husband always wanted to adopt a child but I am adamant and I refused his wish’. This conversation was hard for me too. I started to think about myself and my infertility. I have seen her husband. He comes home very late after finishing his job. I have never seen him stand and talk to anyone. He seemed to be very silent. The next day Manju came to me. She said, ‘yesterday I told my husband what you suggested’.  I said to him that you wanted us to adopt a child. She told me, ‘you should see the glow in his face; he immediately started to talk about adopting a baby. For a long time afterwards, he talked about the adoption topic non-stop’. She continued, ‘he told me that, ‘see how Manju has understood our problem; what she said is very correct’! When we were returning back to Germany, while taking leave from everyone, Manju’s husband was standing at one corner. I will never forget the look in his eyes; the gratitude in them told me what he is going through!

Just because a man is not expressive doesn’t mean he is devoid of all the feelings women claim to possess. Many women tell me, ‘Manju we are women and our heart always yearns for a baby but my husband doesn’t feel like this!’ Can this be true? The problem with us is; the first thing we do when talking about infertility (or for that matter any sensitive topic!) is to cry. It is very uncomfortable for a man to see his wife cry and break down emotionally. A man thinks it is his responsibility to keep his wife happy and when he sees that his wife is not as happy as he would like her to be, he feels very frustrated and his ego gets hurt too. They really do not know how to react to such situations and their silence makes us think that they are cold, unfeeling and uncaring. From an evolutionary point of view, there is one more interesting reason why men can’t tolerate crying spells and high pitched voices. I happened to listen to a psychologist on TV and she was telling ‘if you want a man to listen to what you say, talk to him softly without becoming too emotional’. She also gave a beautiful explanation why it is so! When humans lived in caves, it was the man’s job is to hunt and gather food. Women took care of the children. When a man goes hunting, he has to be aware of all the danger signals around him. He used to listen keenly to the sounds made by wild animals so that he could avoid places which were perilous. He also has to be emotionally strong when he has to hunt animals. His sole intention should be to provide food for his wife and children and he should not get carried away by the pathetic sounds made by animals and their young ones when he kills them. A woman, on the other hand, has to be very sensitive to the cries of her children, so that she can feed them and take care of them well. These differences in their activities can explain why men’s brains and women’s brain respond to the same cues in such a different manner. A man is unable to tolerate high pitch voices as it is like a danger signal for him. The psychologist said, ‘please keep two things in mind if you want a man to listen to what you say-do not raise your voice, and talk slowly so that his brain can imbibe what you are saying. Never cry because it will make him uncomfortable and he will try to move away from that place’. I found that explanation to be very interesting.

When a couple deals with infertility, obviously a man gets hurt too. Fathering a child gives him gratification as it is considered as a proof of his manliness. When infertility strikes a couple and the man realises that he is not able to father a child, he starts to feel inferior. His emotional burden becomes worse if the problem is with his own fertility. He feels that he is less masculine, a total failure and his self-esteem goes down. When his wife does not understand what he is going through, and if she is always crying and complaining, then that just adds to his mental torture. I know women who break down in front of their infertile husband and cry thinking about a baby. Is it wise to do so? Have you ever imagined what kind of mental pressure you are subjecting your husband to? When your husband is the one who is having an infertility problem, as his wife, it is your greatest responsibility to make him feel comfortable. But many women fail to give the much needed intellectual and emotional support. When his wife is crying because she cannot have a baby and when a man senses that it is his inability which has caused such suffering to his wife, he naturally goes to pieces. Women have many ways to relieve their infertility related stresses. The best support a woman gets during infertile times is from her mother. She vents out whatever she is undergoing (physically and emotionally) with her mom. When I talk to my mom I have no inhibitions. I have no fear that I will be judged wrongly. All my mental stress clears quickly if I talk to her. But for a man it is impossible to get such emotional support. As a man grows older, he no longer feels comfortable sharing his emotions with his parents like a woman does. Since men are looked upon as being the stronger sex, crying or expressing emotions like a woman is considered to be a sign of his weakness. Hence he maintains his silence and suffers within himself. When a couple faces infertility, the man’s parents also tend to react differently to their daughter-in-law. As a result the connection between the man’s parent and his wife becomes strained. This makes a man’s condition even worse. He is caught in the emotional drama between his parents and wife. This makes him retract from his parents too. Infertility somehow pushes a man’s parents and siblings away from him. This is why coping with infertility can be so much more difficult for a man than for a woman! He is forced to bury himself in his work and pretend that all is well, even though he may be bleeding inside.

Many infertile women behave in ways which can make the life of their husbands a living hell. The first mistake women make is to submerge themselves within their sorrow. They tend to obsess about a baby all the time and they forget all their day to day duties and happiness. It’s very hard for a man to deal with his wife’s crying spells – especially if he loves her. While he can handle his personal pain stoically, seeing his wife suffer leaves vulnerable and heart-broken. Infertility also kills the sex life of couples. It turns a pleasurable act into a ritual which is done only for the sake of a baby. For a woman, the best sex stimulation centre is her brain. When her brain is too occupied with infertility and making babies, the act of making sex becomes very difficult. Women have high libido, but they desire sex only when all the conditions are just right! For a man on the other hand, sex can be like soothing medicine for all his troubles and frustration. This difference in the mental make-up between men and women also adds to the problem. When physical intimacy is denied, a man feels that the emotional bonding with his wife is lost. This further adds to the problem. His only solace during infertility, his wife, seems to move away from him both physically and emotionally. He stops sharing his pain with his wife because he is scared she may break down emotionally. After all, isn’t he meant to provide her a shoulder to cry on? If he starts crying as well, how will she cope?  This makes the situation much more complicated. The other mistake most women tend to do is to talk about her husband’s infertility to her parents. I have seen this happen in many families. The woman’s parents are very happy to tell everyone that their daughter is super fertile and the lack of a baby is due to the problem with their son-in-law (it is actually the fear of social stigma that makes them behave this way!) Sometimes I wonder how ignorant and self-centred people are! How could they even talk about such things without any guilt? Isn’t it the duty of the wife to safeguard her husband’s self-esteem? If a couple faces infertility, is it necessary to reveal whose problem it is? Is it really anyone else’s business? As a couple, doesn’t infertility affect both of them equally? Playing the blame game is emotionally destructive!

Men and women have different coping styles in response to stressors. This may add to what is an already stressful time. Even though men desire to have children , they are usually not afflicted by the “babylust ” which strikes women. They tend to analyse the situation rationally and might have a clearer dispassionate view of the problem .  On the other hand, a woman’s intuition is stronger. Instead of being adamant about your own viewpoint, it is much wiser to work as a team. A baby is not the only solution to the problem of infertility ! You might one day find yourself in a situation where you have to decide when to give up all the draining infertility treatments, stop trying to conceive , and get on with your life. This kind of end to your infertility journey can be very hard for both of you , especially if you do not have alternate plans. So it is always wise to keep other options like child-free living and adoption open. When your husband talks about these topics , try to listen to him patiently and give your views about it. Do not react to such talks with an emotional outburst. If you do so then that will be the end of a rational discussion and this will in turn leave your husband in ambiguity and uncertainty. He will be totally confused how to deal with your emotions. Achieving an emotional closure and moving on with your life is very necessary if the infertility treatment does not work. As his wife it is your duty to provide him the opportunity and space to do so. Chronic grieving can lead to significant psychological damage to you and your partner. Your relationship will get adversely affected as a result of this. If you want your marriage to withstand the tests of time you should learn to weather the storm of storm by climbing the peaks and valleys together. I have seen many infertile couples do this successfully. Caring enough to bring out the best in each other, and wanting his happiness even above yours seems to be the key! Many men when faced with infertility tend to divert their attention to their career and try to excel in it. Support your man during such times and see his self-esteem grow. This will also give you immense happiness. Many infertile women tend to think that their happiness is solely dependent on a baby and as a result tend to suffer and make their man suffer too. Remember “The foolish man seeks happiness in the distance, the wise grows it under his feet”.

When you are tackling infertility, provide emotional support for your husband. Having a rational discussion about your infertility will provide your husband with confidence and strength because he is reassured that you have a mature sensible outlook; can cope well; and have realistic expectations. Crying might give you relief, but, when you make it a habit to cry and get depressed every time the topic of infertility springs up, you will end up making your husband miserable as well. It is not wise to complain about his parents all the time. Just like you need your parents when you are in distress, he needs his parents too (whether they are good to you or not doesn’t matter!). Even though he doesn’t express himself to his parents as you do, he will feel emotionally comfortable if you maintain a good relationship with your in-laws. Taking care of his physical needs will make him feel more secure and cared for. Sex helps to provide emotional catharsis and improves bonding. This helps you as well. Remember that a man’s ego is fragile and it is in your best interests to make him feel strong and comfortable! If your husband is suffering from infertility never discuss it with anyone else - especially not with your parents (if they will go around spreading the news to everyone!). Remember, just like you are his better half, he is your better half as well, and hence infertility cannot be an individual’s problem! Tackle the situation wisely so that your relationship becomes stronger during the crisis of infertility!