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Thursday, 30 January 2014

Polycystic Ovary Disease: what is it?

Irregular ovulation is a major hurdle on the road to conception. The rule of thumb is that if periods are regular with a cycle length of twenty two to thirty five days, then ovulation is assured. The most common cause of irregular ovulation is Polycystic ovary syndrome (PCOS) or Polycystic ovary disease (PCOD). This condition occurs in 5-10% of women in the general population and up to 30% of women with subfertility. There are a lot of misconceptions around this diagnosis and women generally get very concerned when they are told that they have PCOD. 

How it is diagnosed?
Women who have PCOD may have a varying severity and types of symptoms and in order to be given a diagnosis of PCOD, there must be two of the three following criteria present: 

  • Infrequent or absent periods
  • Acne, hirsuitism (excessive hair in those parts of the body where thick, long, dark hair do not normally exist in women) or hair thinning.
  • At least one of the ovaries having more than 12 antral follicles on pelvic ultrasound scan.
Does polycystic ovaries on scan mean I have PCOD?
I come across girls and women who have had a scan and have been handed over a report saying that they have a POLYCYSTIC OVARY DISEASE! Please do not pay heed to this report as PCOD is a clinical diagnosis based on the criteria mentioned above. Ovaries may have an increased number of antral follicles in as many as one-thirds of normal women. In other words ovaries with a higher number of antral follicles can be a normal finding and in the absence of other symptoms, there is no cause for concern. Please see your doctor for clarification. 

Weight gain and PCOD
Nearly 50% of women and girls with PCOD are obese. Almost all relate their weight with the fact that they have PCOD. It is important to realise that it works the other way around and it is obesity which causes the manifestation of the symptoms of PCOD. Diet and Exercise have been shown to benefit obese PCOD women and as little as 5-10% of weight loss can result in regular menstruation and ovulation. Incorporating lifestyle changes to achieve a healthy body mass index would also decrease the risk of miscarriage and the reduction of possibility of heart disease and diabetes in later life.

Can PCOD be cured? 
The answer is no. However the problems that are faced can be overcome with expert advice. The disease is by no means the end of the road to conception. Medications such as Metformin can be given to women who have a high insulin level. Ovulation can also be induced through either tablets such as Clomiphene or injections. Women with PCOD generally have more sensitive ovaries and these ovaries therefore can mount too strong response when it is attempted to induce ovulation. None of these medications are without side-effects and it is therefore best to let the experts (either IVF specialists or endocrinologists) to treat this condition.

Do not despair if you have been handed a diagnosis of PCOD. 


                       You just need to find it!

Monday, 27 January 2014

Egg quality

In my last three blogs, I have attempted to shed light on how conception occurs and I am now moving on to the causes of why some people face difficulty in conceiving. For now I will focus on where it all starts, the ovary. For what happens normally, please refer to my earlier blog on role of ovary in conception. Please do feel free to ask questions on any aspect of fertility through the comment section below.

If we think logically, two things can go wrong at the ovary level. First, the egg is not of good quality and second, the egg is not released (or released infrequently). Let me talk about the first problem in this post. 

Poor egg quality is usually age related. The best eggs are recruited and released first and as age advances, the eggs that are released deteriorate in quality. What quality really implies is the competence to form an embryo with potential to implant and lead to a pregnancy. 

All our body cells have two copies of each chromosome (that carry the genetic information) and a total of 23 pairs of chromosomes. When an egg and a sperm unite the resulting embryo that will eventually grow into a baby should have a normal number of chromosomes. This can only happen if the egg and the sperms have reduced their chromosomes to one chromosome each of the 23 chromosomes. This is achieved through reduction division also called meiosis. The movement of the chromosomes is achieved with the help of a delicate structure called the meiotic spindle. The spindle is composed of an assembly of elastic threads arranged in an ellipsoid manner (with two poles or ends) and each thread pulls one chromosome towards one pole. The regulatory mechanisms responsible for the assembly of the spindle is altered significantly in older women and this leads to an increasing number of eggs with abnormal number of chromosomes (called aneuploidy), i.e. either one less or one more than the normal figure of 23. 

It has been estimated that the number of eggs that have an abnormal number of chromosomes is low (<10%) below the age of thirty-five, reaches 30% by age forty, 50% by forty-two and is almost 100% by the age of forty-five. This can explain the rise in the miscarriage rates and the incidence of abnormalities in the babies such as Down's Syndrome with increasing maternal age. It is for this reason that IVF with own eggs is very rarely successful after the age of 43yrs and hence IVF with donor eggs is recommended.

There is very limited that can be done to reverse this decline in egg quality and ovarian reserve. The latest medication which MAY help women with low ovarian reserve is DHEA (dehydroepiandrosterone). 

Ovulation disturbances in the next post....

Saturday, 25 January 2014

Implantation : A miracle begins

Pregnancy starts with implantation of an embryo in the tissue that lines the womb cavity. This is the most intriguing part of conception and this process is still not fully understood. 

Blastocyst formation
Embryo forms when a sperm and an egg combine. Just like the egg, the embryo remains encased in a shell and grows within it. The cell that results then starts to divide. The number of cells increases to 2,4,8 and so on till the a tight ball of cells forms. A fluid filled cavity develops that divides the cells into two groups: one group lines the cavity all around (these give rise to the placenta and help in implantation) while at one pole the rest of the cells remain in the form of a tight pack of cells (these form the baby eventually). This stage is called blastocyst. At this stage the embryo hatches out and is ready for the next stage, the implantation.
The lining of the uterine cavity undergoes cyclical changes in an attempt to get the ground ready for an embryo to stick and when it does not, the lining is shed (during a period) and starts growing all over again. 
In the first part of a menstrual cycle, follicles grow in the ovary and release estrogen hormone. Estrogen causes the lining to grow and become thick. Once ovulation occurs, the follicle from which the egg is released restructures itself and starts secreting progesterone hormone. Progesterone changes the lining such that it is able to provide a nutritious and friendly environment for the embryo. It is the release of progesterone that triggers the opening of the 'implantation window' which is a limited time period during which the endometrium will be in a state of acceptance of an embryo.

Embryo-Endometrium interaction
The interaction of the embryo and the tissue lining the womb cavity is very complex and the successful conclusion depends on the presence of a 'good' embryo, a 'receptive' endometrium and their synchronization.

The embryo first finds a location in a specific area of the endometrium. The cross-talk between the embryo and the endometrium is the key to the initiation of implantation. The embryo snuggles close to this point (called apposition). Then the embryo sticks to the cells of the endometrium (called adhesion). The hatched blastocyst then causes destruction of the surface cells and invades the deeper levels of the endometrium. The cells that form the early placenta invade into the blood vessels that will provide nutrition to the growing pregnancy.

At the time that the next period is expected, some women may get minimal to small amount of bleeding. This is called implantation bleeding. Many (but not all) women also get tenderness in the breast or sore nipples when they become pregnant. However this is not a constant feature and the absence of these symptoms should not cause concern.

Monday, 20 January 2014

Role of tubes in conception

The fallopian tubes are two narrow tubes or ducts whose function is to enable an egg released from ovary to reach the uterus. It would be erroneous and simplistic to think of tubes like hose pipes and presume that as long as the tubes are 'open', all is well! 

The end of the tubes have delicate fringe-like structures (called fimbria) which enables the tube to 'pick up' the egg on ovulation. The tube has muscle fibres in its wall and the inside of the tube has two types of cells, those that give out secretions to keep the sperms, egg and the embryo alive; and cells with hair like structures called cilia. Secretions from the cells lining the tube create an environment where sperms can interact with the egg and form embryo. The embryo so formed is nurtured in the tube while being eased towards the cavity of the uterus by the fourth day of its life at which time it is ready to implant. Rhythmic muscular contractions of the tube and the swaying motions of the cilia enable the movement of the egg and embryo.

Tubes thus have a very important and delicate role to play and it is just not enough for the tubes to be 'open'. Unfortunately, it is not possible to assess the inside of the tube, all that is normally done is to check for patency and if a laparoscopy (keyhole surgery) is done, the outside of the tube and the fimbria can be assessed. 

If the tube is damaged, then it may not be able to transport the embryo to the uterus and the pregnancy may settle in the tube. This condition is called ectopic pregnancy and unless dealt with appropriately can be life-threatening.  If there are any indications that one  or both of the tubes may be damaged, it is best to keep trial of treatments other than IVF short, lest precious time is lost along concomitant decline in fertility.

Do not despair....There is always a way.


How does pregnancy settle in the uterus in the next post......

Wednesday, 15 January 2014

Role of ovary in Conception: Back to Basics

The process of conception is intricate and a series of events must happen in the right order and at right time for success. Ovary is where it all starts.  

Egg Reserve
The eggs start to develop in the ovaries while we are still in our mother's womb. The egg cells multiply to the tune of 6-7 million Unfortunately, our natural egg bank (ovary) is not very good at saving too many eggs for future use!
From midpregnancy onward the reserve of eggs starts depleting rapidly such that by the time we are born only 1-2 million eggs are left in the ovaries – a loss of 80%! The depletion continues through childhood and by the time puberty arrives, the figure is between 300,000 and 500,000. To put things in perspective, only about 300 to 500 eggs are released in a woman's lifetime. So nature is not being too inefficient either.
As the number decreases, there comes a point when only a few hundred eggs are left in the ovaries and this is when menopause happens. The speed at which the egg count diminishes varies and that is why menopause occurs variably. 
Ovarian reserve is a reflection of the number of resting eggs in the ovary.What is sad is that the best eggs start getting used up first and as we come towards the end of our reproductive careers, it is the ones that are not good that are left with us!

What are Antral follicles?
Once the eggs are formed they are surrounded by flat cells and this structure is called a primordial or a very early follicle. The eggs remain in a state of sleep or dormancy and in this stage cannot be ‘stimulated’ to grow. An internal signal causes a small number of these sleeping follicles to become active. The flat cells change shape and start multiplying. The follicle develops a fluid filled cavity within. This fluid makes these follicles visible on ultrasound. When you hear your doctors talking about antral follicles at the time of ultrasound scans, they are talking about these ones. What is special about the antral follicles is that at this stage these follicles can be ‘stimulated’ into growing.
The growth of follicles from when it ‘wakes up’ to when it is ready to be ‘stimulated takes place over a period of 70 days and if at this stage there are no hormones to make them grow further, the follicles die. Only those antral follicles that are ‘ready to go’ at the beginning of the menstrual cycle are the ones which have a chance at ovulation.

FSH and LH
The two hormones that play a role in making the ovary work are Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH). These hormones are released by a small organ in the brain called Pituitary Gland (which in turn is stimulated by another part of brain called Hypothalamus). Just as pituitary gland releases FSH and LH to control the ovary, the follicles that are growing in the ovary release the hormones Estrogen and Progesterone. Estrogen and progesterone have a role in cyclical development of the lining of the uterus in preparation of an anticipated pregnancy. Once estrogen starts increasing, the brain responds by decreasing the FSH and LH that are released.

Follicular development and Ovulation
The hormone FSH and to a certain extent LH rise at the beginning of the menstrual cycle and cause the growth of a number of follicles (this is termed as recruitment of follicles). One of these follicles is more efficient in taking up the FSH hormone - the food for growth and as such takes the lead. The others start lagging behind. As all the ‘recruited’ follicles grow, they release estrogen hormone into the blood stream.  The rising levels of estrogen sends a signal to the pituitary to decrease the amount of FSH and LH. With the increasingly hard competition in getting FSH (without which growth cannot continue), the follicles that are lagging behind slowly wither away while the dominant follicle continues to grow. Levels of oestrogen released from the growing follicle reaches a threshold which ‘triggers’ a response from the pituitary gland (a small organ in the brain) in the form of release of a large amount of LH hormone. This release is called LH surge and is crucial for triggering ovulation. It leads to the final maturation of the egg in the follicle which is destined to ovulate and also triggers a chain of processes that culminate in the expulsion of the egg from the dominant follicle.

Role of tubes and formation of embryo in the next post.....

Saturday, 11 January 2014

Trying to Conceive?

Once a couple decide to start "trying", they set out on a journey with the belief that pregnancy will happen very soon.  Each month when pregnancy does not happen, the couple start again with a new hope and vigour, search the internet for tips and tricks and try everything that they are advised by friends, family, colleagues or for that matter anyone! And when the pregnancy test comes negative again and yet again, this hope turns into despair.The journey becomes intimidating and lonely.

Negativity creeps into the mindset and life becomes hell. Romance goes out of the window and making a baby becomes a job. Endless questions come to mind, "Why me?", "Am I ever going to have a baby?", "When?", "Am I doing everything right?"....... Doctors usually have no time to answer the questions which the couple think are too silly to ask anyway! Old wives tales, misconceptions abound. And then there are people who patronize and tell them "Don't worry, It will happen!". 

I have no advise to offer that you have not been offered before. I will however endeavour to place the facts before you and answer any questions that need to be answered. Remember there is no such thing as a dumb question. So please do feel free to ask anything. 
  • Nature is not very efficient in the process of conception. At the most 20-30% of women will fall pregnant in a cycle. That puts the odds of failing at atleast 70%! This also means that it can take at least a year to conceive even if everything is normal.
  • Timing of intercourse does not have to coincide with ovulation. The egg once released is viable for about 24 hours while sperms may be viable for up to 5 days. The bottom-line is that the frequency does not need to be more than once in every two to three days. Throw away your ovulation kits and hold on to spontaneity! Your husband will certainly thank you for it!
  • Pregnancy is physiological and will occur whether you are resting, working or exercising. There is no role of bed rest in improving your chances. In fact distractions may make the waiting game a bit more bearable.
If after one year of attempts (or 6 months if you are over 35), conception has not occurred please seek the advice of an infertility specialist. 

Accept finite disappointment but never lose infinite hope......
Martin Luther King Jr.

Wednesday, 8 January 2014

Introduction to Infertility Simplified

Am I fertile? This question often comes to mind whether you are planning for a pregnancy or desperately trying to delay this important milestone due to a host of reasons. As a postgraduate student, I remember my confusion and embarrassment at the mere prospect of asking some of the most personal and sensitive questions to the couple in question and this continued for a while. Over the years, I have met with couples, single men and single women who either experience difficulty in conceiving or have doubts related to their fertility. I have come to understand the thought processes and fears, insecurities and frustrations of people who find themselves or worry about being "infertile".

Internet has a sea of information on every topic and infertility is no exception.Through this blog, I am venturing to engage with you and share my knowledge with you.Through this forum, I hope to clear some of your doubts, answer questions, reassure and point you in the right direction.

Conception is a very complicated and delicate process and many hurdles need to be overcome before this culminates in a pregnancy. (Information about the anatomy or You Tube video on the reproductive system) The events that occur are: egg is released from the ovary, one of the Fallopian tubes suck egg from the body cavity, sperms reach the tube, sperm fertilizes the egg and the embryo so formed is nurtured in the tubes while it is dividing, the embryo moves along towards the womb or uterine cavity and reaches a 'receptive' endometrium (the inner lining of the womb), the embryo sticks and eventually burrows into the lining. These events lead on to a pregnancy and a baby if the growth continues normally.

Many factors can therefore affect conception and the impediments may be present in either the man or the woman or sometimes both. Those with irregular cycles may not ovulate regularly, psycho-sexual problems may preclude intercourse, occupation or travel or lack of libido may lead to a sub-optimal frequency of intercourse (once every two to three days), number or vitality of sperms may be reduced or absent, the tubes may be blocked preventing the sperms from reaching the egg or there may be a problem with the womb. The recommended advice is when a cohabiting couple are unable to achieve pregnancy within a year of trying they should seek expert advice. I confess I do not like the term 'Infertile'. I prefer sub-fertile as fertility is below par in these people and there are ways to overcome this situation, THERE IS HOPE......