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We normally do a blood test for HCG 2 weeks after the embryo transfer to find out if the embryos have implanted and if the cycle has been successful or not.

This can be a very long 2 weeks , and many women will start doing pregnancy tests 5 days after the embryo transfer.

The problem is that even if the embryo has implanted and you are pregnant, the embryo produce such small quantities of HCG for the first few days after it implants ( remember that it's just a microscopic ball of about hundreds of cells or so at this time), that it's not possible to detect this HCG in the blood . To be able to detect the HCG in the urine will take even more time, which is why you need to be patient.

Of course, many patients will cheat :) - and this is an email I got from a patient today. A picture is worth a 1000 words, and this image clearly shows how her pregnancy tests have now become strongly positive ( C stands for Control and T stands for Test). The stripe on C means you have done the test properly. Once the stripe on T shows up ( is positive) , this means you are
pregnant !

She's now ready to start her baby album !

One of the most difficult things IVF patients have to deal with is the fact that there are no external symptoms or signs of what’s happening inside their bodies. Are the follicles growing well ? Is the uterine lining maturing properly ? Are you responding well to the medications ? Are the eggs of good quality ? Are the embryos implanting ?

An important marker of the reproductive cycle is bleeding – and this can become a major source of stress during an IVF cycle !

The start of the menstrual period is an event most IVF patients look forward to, because finally the IVF cycle is ready to commence – and you are now ready to take your best shot at having your long desired baby ! You are all pumped up and ready ! You’ve spent a long time waiting for your treatment to begin ( with waiting lists and getting appointments with busy doctors, it can take 2-6 months to actually start the IVF cycle , no matter how ready you are – and this waiting can be very stressful !) Is the period on time ? Early delayed ? Does it look any different ? If it comes too early, does this mean you’ll have to cancel because the doctor is not available ? If it’s delayed, does this mean you doctor will have to postpone your cycle ? When you are 2 days overdue, you wonder if you should ask the doctor to induce a period – or should you just keep on waiting ?

Remember that the day the period starts – or the quality and quantity of flow are completely unimportant ! Day 1 of your cycle is just a marker which informs the doctor that you are ready to start your superovulation, that’s all ! The bleeding is just the shedding of the old uterine lining – and has no impact on the IVF treatment itself.

While a very early or delayed period will not affect the outcome of the IVF treatment , this can be a problem if you are travelling abroad for your IVF treatment; or if your IVF doctor does treatments by batching patients ! This is why many clinics will put patients on birth control pills to regulate their cycle, in order to make scheduling the cycle easier !
You may have some spotting or bleeding after the egg collection. This is because the doctor has stuck a needle through your vaginal wall in order to retrieve your eggs. This is usually minimal, and stops very soon. Excessive bleeding is extremely unusual – and if you do experience this, you should report to your doctor.

Some women may also have some spotting after the embryo transfer. This can be very scary, but can occur if the doctor had technical difficulty during your transfer and had to manipulate your cervix. This is bleeding which comes from the cervix ( the mouth of the uterus); and will not harm your embryos !

What about bleeding during the 2 week wait ? This is not common, because you are taking luteal phase support with estrogen and progesterone to help support your uterine lining. This is why when bleeding occurs, thus can cause panic because you are worried that this represents the start of your period , which means that your IVF cycle has failed ! Your worst nightmare may be coming true ! Women will often obsess over every drop of blood they see – and some will even imagine that they can see their fetus being expelled with the clot. However, remember that the embryos as this stage are microscopic, and cannot be seen with the naked eye !

Also, this bleeding does not always mean that the cycle has failed . In many women, this bleeding is self-limited and stops as suddenly as it started , which means we can never figure out where it came from or why. In others, it is actually a good sign, because it represents an implantation bleed. Unfortunately, there’s no way a doctor can judge what’s happening because ultrasound scanning does not give us any useful information. It may be a good idea to do a blood test to check your progesterone levels ; and if these are low, the doctor can increase your dose of progesterone to provide additional support to the endometrium.

If you get a period in less than 12 days after your embryo transfer inspite of your medications, you should request your doctor to test your progesterone levels 3 days after your embryo transfer in your next IVF cycle . If these are low, then he may want to change the way he is giving you progesterone by using an alternative route ( by switching from vaginal progesterone to IM progesterone or vice versa)

I see many patients who have failed IVF cycles in other clinics. In order to improve their chances of success, I ask them basic questions about their earlier cycle: How many follicles did you grow ? How many eggs were retrieved ? What was your embryo quality ? Surprisingly, many are quite clueless , and know very little about the medical details of their treatment cycle, because " my doctor did not tell me anything " ! They are often upset and angry- and resentful that their doctor did not share more information with them.

After realising how much their doctor has kept them in the dark, they conclude that they made a mistake in the doctor they selected. They feel cheated and start believing that they can no longer trust any doctor.

One of the reasons for their bad choice is because they did not do any research or homework before starting their IVF treatment. Many people just go to the nearest IVF clinic - or just blindly follow their family doctor's advise.

This is not a happy situation, and ends up hurting both good doctors and patients. It's especially tragic when IVF patients who have had a bad experience refuse to try another doctor, because they then lose the opportunity to take treatment with a good doctor !

When you make a mistake, you should learn from it; forgive yourself; and move on. I tell all my patients - It's OK to make a mistake once - just make sure you don't make it again !

Many IVF patients get very confused about how the doctor calculates the age of their pregnancy
( = gestational age, in medical jargon). Logically, shouldn't it be from the day of the embryo transfer ? After all, it's only after the embryos are transferred that a woman can be considered to be pregnant !

However, doctors are not always logical, and we usually use the menstrual age when talking about the length of the pregnancy. This is because obstetricians usually see women who have got pregnant after having sex in their bedroom. Very few of them will know the exact date they ovulated , which is why we use the menstrual age in clinical practise. This does not change just because you have had an IVF pregnancy - the clinical rules remain the same !

This creates a lot of confusion in patient's minds - especially when they are trying to make sense of their ultrasound scan results or their HCG levels.

Remember that your OB is always talking about the menstrual age - not the age of the
embryo ! This is purely for clinical convenience and is a well-accepted universal convention.

So how do you convert the date of embryo transfer to menstrual age. This is very simple ! The key reproductive event you need to focus on is ovulation ! It makes much more sense to talk about the pregnancy in terms of DPO ( days post ovulation), rather than the menstrual age or the day of the embryo transfer. This is because we can use this landmark for all situations
( including IUI pregnancies; and for Day 3 embryo transfers and Day 5 embryo transfers as
well !)

Since every IVF patient knows the date they ovulated ( = the day of egg collection), it's easy to calculate your menstrual age. Just subtract 14 from your date of ovulation. This is your
" corrected LMP" ( last menstrual period) .

( Corrected) LMP = Date of egg collection minus 14

The reason we do this is simple - it's because text books assume the follicular phase is exactly 14 days ! Once you know your corrected LMP, it's then easy to use this as the anchor, based on which your OB can calculate your gestational age.

This means that the menstrual age will always be 14 days more than the actual age of the embryo.

Confused ? Let's look at an example.

Let's suppose your LMP was 5 Jan; and your egg collection was done on 24 Jan ( let's assume you took a long time to grow eggs); and your embryo transfer was done on 29 Jan ( Day 5 transfer). The HCG pregnancy test will be usually done about 14 days post ovulation ( DPO), which is 7 Feb. If it's positive - say 120 mIU/ml, the doctor will confirm you are pregnant ! This means that even though you are only 14 DPO ( and your embryo's age is only 14 days ) , he will calculate your corrected LMP as 10 Jan ( date of ovulation , 24 Jan, minus 14 days) - which means your clinical gestational age ( or menstrual age) will become 4 weeks ( 28 days) ! Once you understand this " 2 week gap" and the rationale behind it , you'll find it much easier to date your pregnancy !

This is an email a patient from Nigeria sent me today.

" I have set aside this morning to commend you and your beautiful wife on the good work you are doing for humanity. You give hope to the hopeless, healing our wounds of years by showing commitment and concern, even when the situation looks gloomy. You are ready to even pray for mercy and help for your patients! I am impressed.

I have discovered that IVF is a journey. The travellers are the patients, but all of us will have to travel by different means of transportation, The luckiest by air, some by sea, others by road. It means there will be travellers by jet, speedboat, canoe, ships, cars, bikes, rail or even trucks and cartwheels! I am happy you guys are the drivers and my prayer is that the Almighty Creator will always grant you the wisdom to choose the right means of transportation, and the patience/perseverance to convey your travellers to their desired destination.

Please keep up the good work. I love you both and appreciate you."

I just saw a patient who was 40 years old; she had had 2 miscarriages; and she wanted me to do surrogacy for her. I spent a long time explaining to her why I did not think this was her best choice. Surrogacy is an expensive and complex treatment option, which is best reserved for
women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem.

Her reasoning was completely different. The fact I got pregnant means my eggs are OK ! The fact I miscarried means my uterus is defective because it could not hold the baby. This means that if use a surrogate uterus, I will have a baby !

The reality is completely different. The fact that she conceived means her uterus is fine because it allowed the embryo to implant ! However, because the embryo was genetically abnormal, it could not grow any further ! We know that the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for. From a purely medical perspective, using donor eggs would be a much better option as it would give her a much better chance of having a baby ! This was my recommendation to her, which she found quite hard to accept.

Logically, it makes no sense for me to clear her misconceptions. After all, I should be quite happy to do surrogacy for her - this is what she wants and I can charge her much more for it ! However, I refused to treat her, and suggested she find another doctor.

I have observed that there are 2 kinds of patients. One group treats me as a professional. They are looking for medical advise and guidance; and want my professional inputs. They have an open mind, and are seeking to form a partnership with me. They want to tap into my professional knowledgebase, so they can make the right decision.

The other group treats me as a technician. They already know what they want - they just want me to do this for them. While this may not be great for my ego ( after all, doctors expect patients to do everything they tell them to !), I am mature enough not to get offended, and am happy to listen to my patients and weight their inputs.

Does this mean I am wishy-washy and will do everything my patients ask me to ? No !

I use a combination of rigidity and flexibility. I am happy to accept patient inputs and preferences and modify my protocols, as as long as they do not affect the outcome ! For example, if patients want us to use the long protocol rather than the short ( which we prefer because it needs fewer injections !)

Similarly, some patients want to use rec FSH for superovulation, instead of the urinary HMG we prefer ( because it's as good and much less expensive !) and I am happy to comply.

However, I will not allow them to do anything which I feel is not right ! I am a professional , and
the buck still stops with me. I will not let them make a wrong decision, no matter what. Thus, if a patient asks me to transfer 5 embryos , I will request them to find another doctor.

Many patients come to me with preconceived notions, especially if they have done IVF treatment elsewhere. Websites and Bulletin Boards are also powerful sources of information - both good and bad ! These patients can be quite a challenge for doctors . If they are well-informed, we can learn a lot from them - but if they are not, it can be quite frustrating to get them to separate facts from reality !

Unfortunately, most patients doing IVF treatment are quite clueless about the most important end-result of the IVF cycle - the embryos ! This atlas will help you understand what your eggs and embryos should look like, so you have a better understanding of what happens in the IVF lab !

DAY 0 ( the day of egg collection)

MATURE OOCYTE CUMULUS COMPLEXES

THESE ARE MATURE OOCYTE CUMULUS COMPLEXES, IDENTIFIED IN THE FOLLICULAR FLUID ASPIRATED DURING EGG COLLECTION.

POST MATURE OCCYTE CUMULUS COMPLEX

STRIPPED EGGS
MATURE EGGS :


THIS IS A MATURE EGG (SURROUNDING CUMULUS CELLS HAVE BEEN STRIPPED OFF)

POLAR BODY AT 12 O CLOCK POSITION INDICATES THAT THIS IS A MATURE EGG AT METAPHASE II
STRIPPING IS MANDATORY FOR PERFORMING ICSI ON THEM.
CUMULUS NEED NOT BE STRIPPED FOR CONVENTIONAL IVF.

THIS EGG IS NOT A MATURE EGG. BUT A TINY POLAR BODY WHICH IS PROTRUDING OUT AT 12 O CLOCK POSITION, INDICATES THAT IT WILL SOON BECOME MATURE.

IMMATURE EGGS

Metaphase I egg

We can perform ICSI on Metaphase I eggs. The fertilization rate for Metaphase I eggs is 50 %.


Egg with Germinal Vescicle

THIS EGG HAS A CLEAR GERMINAL VESCICLE IN IT, WHICH INDICATES IT IS AN IMMATURE EGG. WE CANNOT DO ICSI ON THIS EGG. WE CAN USE IVM ( IN VITRO MATURATION) FOR THESE EGGS. AFTER 24 HOURS, SOME OF THEM MAY MATURE AND BECOME M2 ( METAPHASE II) AT WHICH TIME WE CAN DO ICSI FOR THEM

ABNORMAL EGGS


EGG WITH ABNORMAL ZONA EGG WITH ABNORMAL CYTOPLASM.

EGG WITH 2 POLAR BODIES.

POOR QUALITY EGGS

EGGS WITH DARK CENTRAL GRANULATION IN CYTOPLASM.

EGG WITH VACUOLATION IN CYTOPLASM

UNFORTUNATELY, THERE IS NO WAY WE CAN PREDICT THE QUALITY OF EGGS BEFORE WE STRIP THEM.
THIS IS WHY STRIPPING THE EGGS FOR ICSI PROVIDES US WITH VALUABLE INFORMATION ABOUT EGG QUALITY !

DAY 1
DAY 1 EMBRYOS ( ALSO CALLED ZYGOTES) ARE SCORED CONSIDERING

• THE PRESCENCE OF CYTOPLASMIC HALO
• NUCLEAR SIZE AND ALIGNMENT, NUCLEOLI NUMBER AND DISTRIBUTION.

• PRESCENCE OF CYTOPLASMIC HALO

PICTURE A – HALO POSITIVE ZYGOTE PICTURE B – HALO NEGATIVE ZYGOTE

2) NUCLEOLI NUMBER AND DISTRIBUTION

ZYGOTES ARE SCORED ACCORDING TO THE Z-SCORING SYSTEM.

• PICTURE A IS Z1 ZYGOTE WITH EQUAL NUMBER OF NUCLEOLI, ALIGNED AT THE PRONUCLEAR JUNCTION.
• PICTURE B IS A Z2 ZYGOTE WITH EQUAL NUMBER OF NUCLEOLI, SCATTERED IN THE TWO NUCLEI.
• PICTURE C IS A Z3 ZYGOTE WITH UNEQUAL NUMBER (DIFFERENCE OF MORE THAN 2 NUCLEUS) AND / OR SIZES OF NUCLEOLI.
• PICTURE D IS A Z4 ZYGOTE WITH SEPERATED PRONUCLEI AND UNEQUAL NUMBER OF NUCLEOLI SCATTERED IN THE TWO NUCLEI.

NORMAL ZYGOTE


Z1 EMBRYO

POOR QUALITY ZYGOTE

Z3 EMBRYO

ABNORMAL ZYGOTES

ZYGOTE WITH 3 PRONUCLEI

ZYGOTE WITH 2 PRONUCLEI WITHOUT NUCLEOLI

ZYGOTE WITH 1 PRONUCLEUS

All doctors know that the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for. This means that the usual reason for a miscarriage is a problem with the embryo - and most women who miscarry have a completely normal and healthy uterus !

However, a patient who had early recurrent pregnancy losses has a completely different world view ! She feels that the fact that she got pregnant in her bedroom means her eggs must be fine. She usually has regular cycles , and since all her blood tests for ovarian reserve and ultrasound scans for follicular monitoring are normal as well, she has medical evidence to back up this belief ! ( Little does she realise how inefficient human reproduction is; and how common random genetic errors are, even in health fertile women ! )

In her opinion, the fact that she could not grow any of her babies in her uterus beyond 8 weeks clearly proves that it's her uterus which is faulty. This is why the "common sense" approach is - let's change the uterus !

It's true that surrogacy seems to be a logical choice - but this logic is flawed ! In reality , the fact that she got pregnant means her embryo implanted successfully, which is very strong evidence that her uterus is normal ! Using a surrogate's uterus will not improve her chances of having a baby at all ! After all, if her uterus is normal, how will using another woman's normal uterus help her ? However, because implantation is a "black box" area which we do not have the scientific tools to explore, there are still a lot of myths and misconceptions which surround the reasons behind a failed pregnancy. A woman who has had recurrent pregnancy losses has very low self-esteem. She naively believes that if the surrogate has had a normal birth in the past, this proves that her uterus and her body works better than her own - and this is why she chooses surrogacy as a treatment option.

In reality, she would be much better off using donor eggs or donor embryos ! Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus; or whose uterus is irreparably damaged ( as proven by hysteroscopy).

Sadly, most doctors will not bother to educate her ! They are quite happy to do surrogacy for her, because this is much more profitable for them !

Try and try till you succeed....i think this mantra holds not only in your professional life but personal too....

After two years of trying for baby and undergoing two laproscopies ,two iuis and one failed ivf we were devastated....we thought we can never have a child of our own....but then by God's grace we came across the web site of Dr Malpani..Oh it was so informative! i posted my history and there came a very positive reply..there was a ray of hope...we made up our minds to give ourselves one more chance so that we don't repent later.

We visited Dr Malpani clinic in May 2009 for the first time and i must say there is something in his clinic..i think its God's blessing to them...the environment is so positive and cordial and Dr Malpani is so very approachable and positive too that we immediately felt we had come in right place and were in right hands.

We underwent two IVF cycles one in July and other one in Oct 09 but unfortunately both resulted in chemical pregnancies....however we were still happy that atleast something was happening..i was getting pregnant which had never happened before! Then our 3rd cycle was a ZIFT in Feb10 which also did not work out....but atleast our embryos were frozen for future. Our 4th cycle was planned in Aug10 ie IVF with frozen embryo transfer.I must say since our embryos were frozen so this cycle was very very less stressful and required just two visits to the clinic!...AND THIS TIME GOD WAS WITH US..

YES i got pregnant in this cycle that too with twins!! Our joys knew no bounds...we were on CLOUD9!! We immediately informed Dr Malpani about it..he was also very happy for us.
Presently i am in 32 weeks of pregnancy and just waiting to hold my babies in my arms and even now Dr Malpani calls up and asks for my well being and answers all our queries inspite of his busy schedule and mad rush in his clinic. This shows his true dedication for his patients.
I WOULD RECOMMEND Dr MALPANI TO EVERYONE TRYING FOR THE BABY.THEY ARE TRUE PROFESSIONALS.

I must also mention about Dr Anjali who has an equal or rather more role to play along with her husband.She is a sweetheart and very professional.She is the one who did all my transfers and finally made me pregnant! Also Dr Sai,the embryologist and all the staff in the clinic are true professionals and do their jobs very well....that's why the success rates are so high. I would like to wish them all the best for future and may they continue to do the noble cause.

neha_sh1980@rediffmail.com

This is one of the commonest questions patients ask me. A good IVF clinic is quite good at making good embryos in the lab. However, once they are transferred into the uterus, then whether they will implant to not is a biological process which is not in anyone's control ! It can be quite scary to think that the fate of your embryos is in your hands - and that if you make a false move, you may lose the embryos !

The actual IVF treatment, leading upto the egg collection is full of action ! You are taking injections every day and the doctor monitors you closely. It's fun watching your follicles grow on the ultrasound screen and actually seeing your embryos can be a very emotional moment in your life ! However, after the embryos are transferred, you are pretty much on your own. You have no idea what's happening to your precious embryos inside your uterus and there's no medical monitoring or contact, so you are pretty much in limbo until the day of the HCG test. Not for nothing do women dread the IVF 2ww !

Your mind plays all kinds of games with you ! Are your breasts feeling fuller than usual ? Was that a uterine cramp ? Does the discharge you are getting mean the embryos are falling out ? Does the backache mean the cycle has failed ? Is the bloating PMS or an early symptom of pregnancy ?

You try to compare notes with other women - but realise that there is so much variability and so many old wive's tales, that it's hard to make sense of anything which is happening to you. Your imagination runs riot - and your husband can be completely unhelpful when he tells you to "stop stressing out" and to "just relax" !

It's difficult to find anyone who can empathise with the suspense and anxiety you find yourself in - and every hour seems to last for one day . You are petrified that a false move will jeopardise your precious embryos ! Is it safe to run to catch the bus ? Is it OK to drive ? Does straining in the bathroom cause the embryos to get dislodged ?

Just what's happening in your uterus ? Are the embryos implanting ? Or dying ?

The truth is that there's very little you - or anyone else - can do to affect the outcome of the cycle after the transfer is over - it's very much a "no-woman's " land ! Because human reproduction is an inefficient process, most embryos do not implant to become babies. This is true in the bedroom as well, but when the embryos do not implant after an IVF cycle , women always blame themselves !

" I killed my embryos ! I let my family down ! I will never give my husband a baby ! I am cursed ! I failed again !" These are familiar refrains you may hear, even though you do your best to remain calm and collected.

What makes a bad situation worse is how clueless your husband can be ! He often does not know what to say - and what he does say, he often does badly. He may say things like - " Don't worry - it's not the end of the world ! " " I am sure it will work the next time !" And you feel like saying - " You are an idiot if you do not realise it is the end of my world ! " " And how do you know it will work the next time ? " The poor guy is just trying to provide moral support, but you may find yourself taking our your anger on him !

And the "well-wishers" who blame the IVF failure on the fact that you did not rest or took too much stress are often the last straw which can break your back !

Please do not beat up on yourself ! While doctors do provide luteal phase support with hormones to try to improve the chances of successful embryo implantation, the truth is that the outcome of every IVF cycle is always unknown. All you can do is to improve your odds by finding a good clinic - the rest is outside your hands !

Please remember the Serenity Prayer
God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

Donor Embryos: Biologically , embryo adoption is exactly the same as a traditional adoption , in that the child and the parents have no genetic linkage. However , here the resemblance ends. Whereas with traditional adoption it is a child who is adopted after birth, in embryo adoption the infertile couple adopts an embryo before pregnancy.

However , the sad tragedy is that there are just not enough babies available for adoption. Not only is the demand for adopting babies increasing day by day as infertility becomes more prevalent , the supply of unwanted babies being put up for adoption by the mother has become drastically reduced.

It is ironic that while the technology of contraception and abortion has reduced the availability of adoptable children, assisted reproductive technology now offers a new option to infertile couples. This is the option of embryo adoption.

There are many advantages to embryo adoption. There is no waiting list; and the infertile woman gets to experience the pleasure of pregnancy and birth. This obviously enhances bonding between the infertile couple and the child. Another major advantage is that there is no social stigmata involved ; and the couple does not need to get permission from family members or disapproving in-laws. Also , since these embryos are usually of high quality, the success rates are better than 50% per cycle. The only disadvantage is that the treatment can be quite expensive.

One of my patients recently asked me - Which protocol is better for IVF - the Letrozole Antagonist Protocol vs the Estrogen Priming Protocol ?

( In passing, I'd like to point out how impressive it is that patients are so well informed about medical minutiae ! Most gynecologists are quite unaware of all these finer details !)

Actually, the principles of any superovulation protocol for IVF are extremely simple. Superovulation forms the heart of modern IVF. We use medications to help you grow more eggs. Every month you start to grow about 30-40 follicles, but in a natural cycle, most of these undergo atresia (die), so that only one matures every month, in the normal course of events. With the help of medications, we are able to rescue follicles which would otherwise have died, so that we can help you to grow many mature eggs in one cycle.

Since follicles grow in response to the hormone FSH ( follicle stimulating hormone), this is the most important medication we use for IVF. This comes in many different forms . The traditional medicine has been urinary gonadotropin ( menotropin or human menopausal gonadotropin). Brand names include Menogon and Repronex ). This has been the work-horse of IVF for many years and is still the most cost effective medication available !

The gonadotropins now come in many new ( and much more expensive !) flavours, including the recombinant ( rec) gonadotropins, which are produced in vitro in a bioreactor. These are the rec-FSH and rec-LH preparations, and brand names include Gonal-F and Follistim. All these are very similar as far as their clinical activity goes , though the recombinant drugs are much more expensive ( and are therefore promoted much more actively, even though they are no better !)

We can also use tablets such as letrozole to help you grow more eggs. These act by boosting the prodction of your own gonadotropins, thus helping you to grow more eggs.These are much gentler and much less expensive , and are very useful for the minimal stimulation IVF programs.

So if all we need to make you produce more eggs is to superovulate you with medications, why is this such a big deal ?

Remember that we also also need to prevent the eggs from bursting on their own. We need to time egg collection in an IVF cycle very precisely. We want to collect mature eggs before the follicles rupture. We cannot afford to go in too early ( or we will get only immature eggs); and neither can we wait too late ( or the follicles will rupture and we will lose the eggs).

Since we know that spontaneous follicular rupture is triggered off by an endogenous LH surge which is initiated by the pituitary gland, the drugs we traditionally use to prevent this spontaneous follicular rupture are the GnRH agonists. Brand names include Lupron and Buserelin ; and these switch off your pituitary gland, preventing it from producing any LH. However, they take a long time to act and need to be given for at least 10 days in order to be effective. These were administered as either a long protocol ( from Day 21 of the earlier cycle; or a short protocol ( starting from Day 1 of the cycle).

The newer generation of drugs which allow us to equally effectively prevent the spontaneous LH surge are GnRH antagonists, such as Ovurelix and Cetrotide. These act much more quickly, which means they can be started from Day 7 onwards, which means you need to take fewer shots ! However, these are much more expensive , as compared to the GnRH agonists, and are no better than them as regards their clinical efficacy.

In reality, pretty much any protocol works well for patients with good ovarian reserve, so there's not much to pick and choose between them, and most clinics get good results with whichever protocol they are comfortable with.

However, some patients can be quite tricky. These include patients with PCOD, who have a high risk of getting OHSS. They need much gentler superovulation, and closer monitoring.

The really difficult patients are the ones with poor ovarian reserve. They have fewer eggs left in their ovaries, which means they respond poorly to the standard superovulation protocols.

It is for these patients that doctors have developed newer protocols, in the hope that we will be able to coax these ovaries to produce more eggs !

A lot of the emphasis is on precycle preparation. The hypothesis is that if we treat patients prior to starting their IVF cycle with estrogens ( the estrogen priming protocol) or androgens ( such as DHEA) , they will produce more eggs because more follicles will be recruited when we start the superovulation . Many doctors will also use supplements like wheatgerm , Vit D3 and CoQ 10; as well as alternative medicine ( yoga and acupuncture) to boost ovarian response.

So much for the basics . However, I find many IVF doctors seem to deliberately complicate matters . They love coining fancy new names for their "new" protocols ( which are actually very similar to each other in reality !)

Why do they do this ? I think there are 2 reasons. If you use long complex technical names, this helps to put patients in their place . If you make it complex, patients don't ask too many questions because they are out of their depth, and they respect you even more because you are the expert who has mastered all these esoteric medical details !

Doctors also have a fascination for anything which is new . Doctors like to innovate - and it's fun to design and do something new !

Finally, it's a clever marketing ploy, because it helps to attract patients who have failed IVF cycles elsewhere. Patients who have failed IVF are desperate to do something different ( and preferably something new !)

Just remember that new is not always better - and please try to understand the principles behind the treatment, so you do not get taken for a ride !

Everyone loves advising infertile couples ! ( After all, if they've had a baby in their bedroom and proven their fertility , this makes them fertility experts, right ? )

The commonest advise is - Just relax ! Do not stress - do not take any tension ! This advise is even more pronounced during an IVF treatment cycle. If you want your IVF to succeed and the embryos to stick, you've got to "go with the flow" and not stress out. If you get too stressed out, your uterus will reject the embryos and they will not implant !

This is very unhelpful advise ! Of course there's a lot of stress in an IVF cycle - after all, no one wants to come to Dr Malpani to have a baby ! All my IVF patients are stressed out - and even the hyper ones do get pregnant ! It's true that patients need to learn constructive ways of dealing with this stress but to pretend that there's no tension involved is just being unrealistic.

The worry is that this kind of advise leads to blaming the victim. " You did not get pregnant because you were too stressed out ! Your IVF cycle failed ( what a cruel word) because you did do not relax enough !" This is hogwash. Don't forget that even a woman who gets raped ( whose stress levels must be through the roof) can get pregnant !

IVF patients understand the importance of optimism. However, many of them are very scared of getting their hopes up . They have been let down too many times in the past so far; and they are worried that if they become too optimistic, the crash down to reality will be much more painful if the cycle fails. This is why many patients keep their expectations low - so that they are better able to cope with failure .

Personally, I find a balanced approach the best option.

I request my patients to remember the Serenity Prayer -
God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

Having a Plan B ready even before starting the IVF cycle can help you better cope with the IVF emotional roller coaster ride !

I see patients who have done IVF cycles in other clinics all the time. How they responded in the earlier IVF treatment cycle provides me with valuable information, based on which I can tailor a better treatment protocol for them.

One of the basic questions I ask them is - Please tell me more details about your earlier IVF cycles . What were the meds which were used for superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? How many embryos were transferred ? What was the embryo quality ? DO YOU HAVE PHOTOS OF YOUR EMBRYOS ? What was the endometrial thickness ?
Can you please show me the printed treatment summary from your IVF clinic ?

Many of them look at me blankly. ( I am sure some of them wonder why I expect them to know all this - after all, they are just patients, and not doctors ! )

Others get defensive and say -
" The doctor did not tell us anything. "
" The clinic does not provide medical records. "
" They keep a copy of the medical treatment and do not give the patient anything at all."

Now I think that any clinic which does not routinely give the patient a treatment summary of their IVF cycle at the end of the treatment is a bad clinic . However, while the absence of the medical treatment summary reflects badly on the doctor who provided the treatment, it is also a reflection of the fact that the patient has been a bad patient as well !

" The doctor did not give me a copy of the records " is not a good answer. Getting a copy of your medical treatment details is not only your right, it's your responsibility as well ! And if you do not assert your responsibility, then you are as much to blame as the doctor is !

It takes two to tango - and while you cannot change someone esle's behaviour, you can change your own ! Start off from the first visit by observing what happens in the clinic. Does the doctor give you a copy of your consultation sheet ? your lab tests ? Do other patients have their records with them ? Ask at the first visit itself what the clinic policy is about medical documentation.

If your doctor refuses to give you your records after your treatment is over ( because he does not want you to go to another doctor), then you need to become assertive ! Ask for a copy of your medical records - and make this request in writing, with a copy to the Administrator of the Hospital. If you do not get a reply, then ask your lawyer to write the letter for you - I can guarantee this will produce results !

This is a guest post by Saiprasad Gundeti, Senior Embryologist, Malpani Infertility Clinic.

As an embryologist, I help in making the dreams of infertile couples come true ! Most couples do not know what happens in an IVF lab, so I am happy to describe a day in my life !

This is the daily routine we follow at our centre :

First thing in the morning –

Cleaning

Cleanliness is a very important factor in IVF Lab. We need to make sure everything is sterile ! Because I work alone in our lab, it's much easier for me to ensure that everything is clean !

• Hood and bench work surfaces (including microscope working areas, heat baths, petridish warmer) are cleaned and wiped down with 6% Hydrogen Peroxide.
• Once a week centrifuge rotors and carriers as well as outside area of the centrifuge are cleaned and disinfected using 6 % Hydrogen peroxide
• Floor is nicely cleaned with 6 % Hydrogen Peroxide.

Monitoring and Maintenance of All Equipments

Your embryos can be quite demanding, and we need to keep them happy in the IVF lab ! We do this by ensuring that the conditions in the lab are just right for your embryos !

• The Incubator CO2 % is confirmed with the help of CO2 analyzer. Calibrated if any anomaly seen in the readings. Temperature is measured with the help of digital thermometer. Calibration is done in case of any temperature variation seen.
• Temperature is measured for all heating baths, heating plates of all microscopes and petridish warmer.
• Gas cylinders connected to CO2 incubators are checked. Cylinders are changed if they are found half empty.

Monitoring of embryo development

• Fertilization assessment of each patients eggs on which ICSI was performed a day before.
• Stripping (denudation) of eggs on which IVF was preferred.
• Transferring fertilized eggs to new dishes (prepared, labeled with patients name and incubated a day before)
• Assessment of embryo development grading of day2, day3, day4, day 5, day 6 embryos.
• Documentation in IVF file as hard copy and IVYSITE ( our electronic medical record) as soft copy.
• We routinely give all our patients photos of their embryos. We take pride on our work, and good quality embryos are a testimony to the fact that we are providing a high quality service to our patients !

Preparation for the Cases

• Preparation for ICSI procedure -
1. Preparation of ICSI dishes

1. Preparation of Hylase dishes (for stripping eggs before ICSI procedure)

EMBRYO TRANSFER PROCEDURE

This procedure involves the transfer / placement of day-2 or day-3 embryos to the patient's uterus. It is performed transcervically with or without anesthesia.

Showing embryos to the patient
We at our centre show every patient their embryos before transferring them to their uterus.

• The nurse in charge brings the patient couple to the lab and introduces them to me.
• I walk them through their cycle, giving them details about –
• Number of eggs retrieved
• Procedure done (IVF/ICSI)
• Number of mature eggs
• Details about husband's sperms (fresh/frozen/epidydimal/testicular)
• Number of eggs fertilized
• Quality of embryos
• Number of top quality embryos
• Number of embryos that will be transferred
• Number of embryos that will be cryopreserved

• I show them the embryos and grade them in front of the patient couple. Many women get quite emotional on seeing their embryos !
• Guide them to the operation theatre.
• I select the best embryos and transfer them to "Embryo transfer" dish.
• When the OT is ready, I confirm with the doctor, as to which catheter to be used.
• I load the embryos into the catheter. A nurse stands as a witness while loading.
• I hand over the catheter to the doctor, by verbally confirming the name of the patient.
• The doctor gently guides the catheter through the cervix and gently pushes the embryos into the uterus.

EMBRYO CRYOPRESERVATION PROCEDURE

This procedure involves freezing of supernumerary embryos after transferring the best embryos.
The procedure is done only after taking patient couple's consent.

• This procedure is done at room temperature. So temperature of microscope stage is brought down to room temperature.
• Vitrification (freezing) medium is taken out. Freezing dish is prepared by placing droplets on the dish.
• Cryolocks are labeled with patients name, date of freezing, number of embryos per cryolock.
• After the embryos are frozen, the cryolocks are stored in cryocanisters.
• Details are documented in the register.

COLLECTION OF SEMEN SAMPLE FOR HUSBAND OF PATIENT UNDERGOING OVUM PICK UP PROCEDURE

• The patient is given a pot labeled with his name to collect semen sample.
• Once the sample is collected, it is brought to lab along with the file.
• Sample is processed for the procedure (IVF/ICSI)

PREPARATION FOR OVUM PICK UP ( OPU) PROCEDURE

• Temperature of instruments are checked.
• Patient's ID is checked with doctor/ nurse in charge.
• Petri dishes are arranged on a petridish warmer
• Remind clinician to collect clean follicular fluid (~3-4 ml). I Pour this in warm petri dish.
• subsequent follicular fluid is poured into a fresh warm petridish.
• As soon as egg (Oocyte Cumulus Complex) is located I take clean follicular fluid in to Pasteur pipette and pour 2-3 drops over OCC and then take OCC into the Pasteur pipette and deliver in the dish at 12 O'clock position.
• Inform the clinician by loudly saying "EGG" when the egg is identified.
• I inform Dr. Anjali about presence of egg in the tube by loudly saying "EGG".
• If there is no egg in the tube I inform by loudly saying "NOTHING" and I do inform about the presence of Granulosa cells in the fluid.
• Similarly I identify and collect all the eggs at 12 O' clock position in 60mm petridish.
• I Take out OPU dish labeled with ( Patient Name) and ( Egg Wash)-prepared one day earlier.
• I Rinse all the OCC's in the outer well containing Flushing medium and transfer them in to the centre well of the same dish containing Fertilisation medium
• Following OPU, OCC's are cultured in fertilisation medium in CO2 incubator till IVF or ICSI being done on them.

Continuing medical education

IVF is a field in which technological advances occur very rapidly. I read the journals, Human Reproduction and Fertility Sterility, to ensure that I am uptodate !

Preparation for the Next Day

• I go through the files of all patients that are scheduled for next day.
• Preparation depends on what procedure patient is undergoing.

1. Fertilisation check dishes:
   dishes for each patient



2. Dishes / medium for OVUM PICK UP :


1 tube with Oil (6ml)
1 tube with Flushing medium (6ml)

3. Dishes for IVF (No. of Dishes dependent on no. of follicles):



4. Dishes for ICSI (3 Dishes for each patient):

1. Dishes for Frozen Thaw (2 Dishes for each patient) :
   
   
   
   

   
   

2. Medium for Embryo Transfer :

1 ml for each patient

I want all my IVF patients to become an expert on IVF , which is why we spend a lot of time and energy in educating them; and in creating unique online educational tools to help them to learn more about IVF.

Now, I am not trying to teach my patients how to do IVF in their bedroom ! The reason we want them to know as much about their treatment as possible is because this is the best way of explaining to them why we are so good at what we do - and what makes us better than other IVF clinics . The outcome of any IVF treatment is always uncertain, and no matter how good I am , there is no certainty that the IVF cycle will be successful. Also, it's a very competitive field, and there are over 40 IVF clinics in Bombay itself ! Sadly, most patients are quite clueless, and do not have the ability to differentiate between a good IVF clinic and a bad IVF clinic.

If we actively involve patients in their IVF treatment, they are better able to understand what makes us one of the best IVF clinics in India. When they understand the science behind IVF, they appreciate all the time and effort we take in monitoring them and in personalising their treatment . We work hard in order to help our patients to have a baby, but only well-informed patients can truly appreciate all the effort which goes on behind the scenes !

Also, well-informed patients have realistic expectations from the IVF treatment . They understand that human reproduction is not an efficient enterprise and do not go to pieces when the IVF cycle fails.

Most IVF clinics are extremely stingy about providing patients with information about their medical treatment. They seem to take the approach that patients are stupid and will not be able to understand anything about their IVF treatment because it's very complex ! Some don't even bother to provide a treatment summary - while very few provide photographic documentation of the embryos.

We routinely provide our patients with photos of their embryos . Making embryos is the heart of what an IVF clinic does and we take pride in our work ! This is a tangible end point I can deliver and seeing high quality embryos reassures the patient that they have received high quality medical care - and this helps to build patient loyalty. Many will frame these photos and use them to start their baby's album !

Educating our patients is an investment in helping them to achieve peace of mind that they have received high quality medical care, so that no matter what the final outcome, they know that they have had their best possible chance at having a baby by taking treatment in our clinic !