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Wednesday, 16 September 2015

IVF: Mild Milder Mildest

IVF in the initial days was done in the natural cycle, in other words no medicines were used to boost or prevent ovulation. As a result, the success in getting an egg and achieving a pregnancy was very inefficient. Louise Brown, world’s first IVF baby was conceived after a whopping 102 failed embryo transfers!

In the pursuit of better success, new drugs and protocols were developed so as to enable more number of eggs. To get more eggs, ovarian stimulation was warranted. To prevent premature ovulation required the use of GnRH analogue and antagonist injections.

Ovarian stimulation can get into trouble when the stimulation is too much. Unfortunately, it is not always possible to give the 'right' degree of stimulation. This is especially the case in ladies with PCOS as these women are at higher risk of developing the complication of Ovarian hyperstimulation syndrome or OHSS. The need to make IVF safer has over the years turned the clock back to natural or milder IVF. 

While natural IVF continues to be quite inefficient, Mild IVF can enable a middle path to achieve reasonable pregnancy rates at a cost effective price. Mild IVF is also of benefit to women with lower ovarian reserves who do not respond well to stimulation. In these women, a specially designed protocol using Clomiphene tablets and low doses of FSH/hMG injections. The eggs retrieved are fertilised and frozen. Multiple cycles are usually required to accumulate embryos which are then transferred to enable pregnancy.

It is therefore best to consult an IVF specialist to enable a treatment that is best suited to you that would enable you to achieve your dream in a safe and cost-effective manner. 

Monday, 31 August 2015

Poor ovarian response

When ovarian stimulation is commenced the aim is to get 10-12 follicles. As worrying as overstimulation, is the scenario when too few follicles grow in response to stimulation. The cut off that most doctors adhere to is 6 follicles. So when less than 6 follicles are present the response is said to be low.

When I counsel my patients facing this problem, the commonest questions asked are "Why?", "What are the implications?" and "Does this mean I cannot get pregnant?". Let me answer these one at a time. Please do feel free to write to me if you have any further queries.

The reasons of low response can be :
  • Insufficient dose of FSH/hMG
  • Ineffective Drug (Good quality injections need to be maintained at the right temperatures in order to work well)
  • Unresponsive ovary/Low reserve of eggs in ovary
What are the implications?
The implication of low number of follicles is the retrieval of lower number of eggs and this in turn means a lower number of embryos. On an average, eggs may be retrieved from 70% of follicles. In other words if there are 3 follicles the number of eggs may be only 2. Of these not all eggs may be mature (or usable for making embryos). The outcome would then be a low number of embryos or even no embryo. If there are no embryos there can be no pregnancy! 

Your doctor may advise you to either cancel the cycle in case of a poor response or try Intrauterine Insemination. This may prove to be more cost-effective than an IVF cycle as the success rates are bound to be low. 

Does that mean I cannot get pregnant?
The further course of action after the cycle with poor response depends on the cause. Treatment may be repeated using a higher dose of gonadotrophins or changing the drug. In case of low ovarian reserve being the reason for poor ovarian response, the situation becomes a little tricky. Treatment using drugs like DHEA and Arginine may be tried with variable success. The other option may be Minimal Stimulation IVF using Clomiphene to augment stimulation. The last resort would be Donor egg IVF.
The answer to this question is not easy but is certainly not a "No"!

Tuesday, 14 April 2015

Infrequent periods: causes and effects

After a long hiatus here I am again talking about a very common problem. Irregular and/or infrequent periods is frequently overlooked even if conception is on the cards! I see too many patients who approach me for fertility advice, sometimes a little too late. I attempt to provide a little insight on this topic.

The first question of course would be "why?" Menstruation follows a period of approximately 14 days after ovulation. The the simplest explanation of a delayed period (with the exception of pregnancy) is the delay or absence of ovulation. Thus an obvious next question is what causes the ovulation to get delayed? The reason may be a hormonal imbalance (as in Polycystic ovaries), a fault in the system that stimulates the ovaries or failure of ovaries due to a very low reserve of eggs. 

The next important issue is about the implications of infrequent or absent ovulation. Irregular ovulation will certainly lead to a delay in conception. Another impact would be on the lining of the Uterus - the endometrium which can become thick and unhealthy leading to irregular, heavy and prolonged bleeding. Women who have infrequent periods for a long time are also at risk of cancer of the endometrium. The stoppage of periods that occurs with the failure of ovaries leads to menopause. If this event happens prematurely this can affect the strength of the bones and lead to osteoporosis. 

In short, it is not okay to not have regular periods. Visit a doctor and if you are trying to conceive, see a reproductive endocrinologist or infertility specialist. The doctor can diagnose the reason for irregular cycles and advice on whether the couple need to undergo any treatment. The common advice given to ladies who are overweight and have Polycystic ovary disease will also be advised to lose weight through diet AND exercise. 

The bottom-line is that THERE IS ALWAYS A WAY!

Thursday, 13 November 2014

Fertility in women over 40

Decline in fertility has become a real problem in today's world. Gender differences in terms of ambitions and aspirations are blurring. Nature has been a little unfair with the fairer sex in the department of fertility. The eggs that a woman is born with slowly deplete with age, the better quality eggs first. So as the age advances, the egg reserve gets lower and the quality of eggs that are present in the reserve declines too. Whats worse is that sometimes the so called biological clock may be faster than usual!

Many women are aware of the vagaries of the biological clock, but there is still a large section of women who remain blissfully ignorant. When they do find out, they are left with limited options, many times with no acceptable options! 

In a lady in her forties, Intrauterine Insemination (IUI) should be used only if the ovarian reserve (assessed using Antral follicle count and AMH) is reasonable, there is no associated male factor infertility and the duration of infertility is short. The IUI trial should be short and should be upgraded to IVF if unsuccessful. In case the duration of infertility is longer and/or there is an associated male factor infertility, the couple should be counselled to opt for IVF immediately. If the ovarian reserve is low or if the lady is >43yrs old, the recommended option would be IVF using donor eggs. 

There is always a way......