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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 !

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 !

HCG ( also known as beta HCG or just beta) is a very special molecule. It's unique in that it's produced only by the placenta ( very very rarely, it's also produced by some ovarian and testicular tumours). This means that for all practical purposes, it's found only in pregnant women and is therefore a very good marker for pregnancy.

Since the HCG is produced by the placenta, the levels of HCG rise as the pregnancy develops, and there is very good correlation between the health of the pregnancy and the HCG level for the first few weeks of the pregnancy ( from about week 4 - week 7, as calculated from the LMP, last menstrual period).

However , it can be hard to make sense of your HCG blood levels. Let's look at some of the pitfalls in monitoring your beta levels.

Most patients naively assume that a beta of more than 1 mIU/ml means that it's positive and that they are pregnant. This is not true. The new kits are very sensitive , and even men can have levels of upto 10. This means that a level of less than 10 mIU/ml should be considered to be negative.

Secondly, remember that the HCG is produced by the placenta and not by the fetus. This means that the HCG levels may rise , even if the pregnancy is not viable ( such as an anembryonic pregnancy or a missed abortion).

Since HCG levels rises exponentially, there is a very very wide range of normal. This is why it's very hard to interpret just one level in isolation . It's important to check at least 2 levels at least 48 hours apart to determine the trend . In a healthy pregnancy, the levels should double every 48 - 72 hours. If they do not do so, this suggests your pregnancy may not be healthy.

It's not possible to determine whether the pregnancy is single or multiple based only on the HCG level. While it's true that HCG levels are higher in multiple pregnancies than in singletons, because there is so much overlap, you cannot jump to any conclusions based on the HCG level alone. This is why it's important to interpret the HCG level in conjunction with vaginal ultrasound scanning results.

Also, normal ranges can vary widely from lab to lab, because they use different kits. This is why it is important to check your HCG level from the same lab each time !

Finally, HCG levels are useful only in the first 7 weeks of pregnancy. After this, ultrasound scans are far more useful because they provide much more information about the location of the pregnancy; how many sacs there are; and whether the fetus is growing or not.

NORMAL SINGLE PREGNANCIES

Day after HCG or LH ( DPO)	Average mIU/ml	High mIU/ml	Low mIU/ml	#
14	48	119	17	12
15	59	147	17	18
16	95	223	33	23
17	132	429	17	21
18	292	758	70	19
19	303	514	111	23
20	522	1690	135	13
21	1061	4130	324	12
22	1287	3279	185	22
23	2034	4660	506	13
24	2637	10000	540	16

The information in the table above is part of a study carried out by Dr. Sherbahn

Both my husband and I, born in India but raised almost entirely abroad (he in US, myself all over the world), met purely by chance in 2007 and got married soon after. I'm a career woman who got married very young and had put off having children when I became single again at 25. My husband had also married young and had 4 children, and found himself suddenly single again. After a whirlwind courtship and traditional Indian wedding, I was overwhelmed by gaining an instant family, but also felt a deep longing to experience motherhood for myself. However, I also had a complicated gynecological history and age was not on my side (I am 47), so did not share my husband's hopes that I would ever become a mother (other than through adoption). My husband and I tried one (very expensive) IVF cycle in the US which our doctor advised us against as he knew I had poor ovarian reserve due to age. I was ready to move on with our lives, but my resourceful husband did a lot of research and found Dr. Malpani. We struggled with the many decisions we had to make, whether to proceed, whether we would be comfortable with an Indian clinic, how many times we were willing to try, whether we would be comfortable with going through the donor process and many other factors such as being an older mother, but my husband gave me the love, reassurance and support to move ahead.

From the first meeting, Dr. Malpani's optimism and the lack of judgmental attitude in his clinic put me at ease. I am not going to lie, physically IVF is very tough on a woman's body, even when you use donor eggs. The drug protocol is harsh, and the side effects can be very discouraging. I persisted through 2 cycles, one done with fresh specimens, the second with frozen embryos. Neither was successful and because each involved so much juggling of our work and personal schedules, not to mention the fact that I had moved from one city to another and taken a more senior and stressful position for work, I began to despair that we would ever succeed. Through it all, Dr. Malpani never expressed doubt, and merely advised me to take a break after the 2 back-to-back cycles. Then I started to have irregular cycles and thought this would be another strike against me. However, I took a break and approached the 3rd cycle almost with an attitude of "it's probably not going to work, but what the heck." I was consequently very relaxed throughout the cycle and my husband and I had a very short belated honeymoon in Goa before going to Dr. Malpani's clinic for the third, all fresh, cycle. After some discussion, Dr. Malpani transferred 4 embryos, 2 Grade A, 2 Grade B, and I flew back to the US 2and a half days later and returned to work almost immediately. After 7 days, I was dismayed to find some staining and though I could not possibly be pregnant. On day 16, I went to my ob/gyn for the HCG blood test. A day later, I was advised that the test result was POSITIVE. Because I could not wait until the end of the day to tell him the fantastic news, I called my husband with the test results and he thought I was joking!!! In the meantime, between days 7 and 16, poor Dr. Malpani was living through the tortuous wait with us. At one point he suggested we not wait for the HCG test but take a home pregnancy test on day 14 (in the US, day 14 fell on a Saturday when all medical facilities are closed for the weekend). I was so convinced that I was not pregnant that I did not take the home test.

So now, I am getting into my second trimester. Two ultrasounds have revealed a healthy baby and God willing, everything will continue to progress well. I am due in July 2011, and am feeling great. To all of you out there, I know God will work a miracle as he did for us. And without Dr. Malpani, Dr. Anjali and their caring staff, the miracle might never have happened. My husband and I wish you all the best of luck and a healthy and baby-filled 2011.

It's success stories like this which make being an IVF specialist so meaningful - the fact that we change people's lives for the better ! And the fact that we get so many blessings daily every time our patients see their children is an added bonus :)

While all IVF patients understand with their heads that not every IVF cycle results in success, in their heart of hearts, every patient expects to get pregnant every time they do IVF ! This is why the 2ww after the embryo transfer can be so nerve-wracking ! Am I pregnant or not ? Have the embryos implanted or not ? The suspense during the 2ww can be even worse than the pain of the IVF injections !

Most patients would love to have a test which will allow them to find out if they are pregnant immediately after the embryo transfer ! Have the embryos stuck or not ? Why can’t we do a pregnancy test and find out right now ? Even if I am not pregnant, at least it’s better to know than to be unsure.

To understand why patients ( and their doctors ) still have to suffer through a 2 week wait to find out the outcome of an IVF cycle, let’s look at the biological basis of pregnancy tests and how they work.

A pregnancy test measures the amount of beta hCG ( human chorionic gonadotropin) that is in your body. HCG is a hormone which is produced by the trophectoderm cells of the embryo. It is produced in detectable quantities only after the embryo implants. Since implantation occurs 3 - 8 days after the embryo transfer ( depending upon whether you have had a Day 3 transfer or a blastocyst transfer), this means that the HCG produced by your embryo will be first detectable in your bloodstream only after this time.

As your pregnancy progresses, the amount of hCG in your system will increase. At 10 days past ovulation ( DPO) , for example, the average woman has an hCG measurement of around 25 mIU. This amount doubles to 50 mIU at 12 days past ovulation, and then doubles again to 100 mIU at around two weeks past ovulation. Every woman’s body is different, and there’s a lot of variation in HCG levels from woman to woman !

Home pregnancy tests measure the level of HCG in urine. Different pregnancy tests have different levels of sensitivity which means if you use a home pregnancy test that is sensitive to 100 mIU, it will not tell you that you are pregnant if your level of hCG is only 75 mIU. These tests cannot measure a level lower than 25, so they do not become accurate until a few days after embryo implantation. A negative result before then is meaningless, since there would not be a high enough level of HCG to detect even if you were pregnant. If your test is negative, you should retest after 2 days. This is why taking a pregnancy test too early can lead to inaccurate results. I know it’s hard to wait those extra days and you may want to try much earlier. It’s fine to do this, but please don’t assume that a negative results means that you are not pregnant.
This is also why blood tests for HCG are much better than urine tests. Not only are they more reliable, accurate and sensitive, they also give the doctor a number which he can measure and monitor.

If blood tests are so sensitive, then why not do a blood test for HCG 1 week after the embryo transfer ? Unfortunately, doing a blood test for HCG so soon does not make any sense. This is because there will still be some HCG in your body as a result of the HCG trigger shot ( Choragon or Ovidrel) which the doctor gave you to trigger off ovulation 36 hours prior to egg collection. If you test too early, the test will always be positive, as this HCG will show up in the test and give rise to false hopes ! This is why the doctor needs to repeat the blood test for HCG after 48-72 hours. In a healthy pregnancy, the HCG levels will continue to rise. If they do not do so, this means this is not a viable pregnancy.

Finally, remember that you should do the test even if you bleed. Bleeding can sometimes occur during pregnancy as well – and just because you have had bleeding or spotting does not mean you are not pregnant !

Blood tests for checking the beta HCG level are better than home urine pregnancy tests for the following reasons.

1. They are more accurate , sensitive and reliable. A negative test ( HCG level of less than 10 mIU/ml) can reliably rule out a pregnancy with 100% accuracy. Urine tests are not as reliable or accurate. This is because they can have false negatives. A false negative is the situation when a woman is pregnant, but the urine pregnancy test comes back as negative. This can be because her HCG levels are low, so that they cannot be picked up by the urine test ( which becomes positive only after the blood HCG levels cross more than about 30-50 mIU/ml). Other reasons the urine test can be incorrectly negative is when it’s not done properly by the patient ( who is not an expert, after all, and can make errors !); and if the urine is too dilute ( so that the concentration of the HCG in the urine is too low for it to be picked up by the urine test). This is why an IVF clinic will never rely on a urine pregnancy test and will insist that the patient do a blood test to check their HCG level.

2. They are quantitative. The other major advantage of a blood test over a urine test is that a urine test is only qualitative – it just gives a yes or no ( positive or negative) result. The blood test, on the other hand, provides a number. This is especially useful when the doctor needs to do serial tests to monitor the health of the pregnancy. Thus, in a healthy pregnancy, the HCG level should double every 48 hours. If it fails to do so, this gives the doctor an idea that there maybe a problem with the pregnancy. Similarly, a very high level can help the doctor to suspect a multiple pregnancy !

If you need help in interpreting your HCG levels, please send me your medical details by filling in the free second opinion form at www.drmalpani.com/malpaniform.htm and I'll be happy to help !

PCOD ( polycystic ovarian disease) is one of the commoner causes of infertility. It's a chronic disease, which patients need to learn to manage themselves. Sadly, lots of patients with PCOD are very confused. They seem to understand very little about their own problem and I think this is partly because their doctors are very confused themselves and do not take the time and trouble to teach patients about their disease.

Patients with PCOD have irregular periods ; and they know that their irregular periods also means that they will be infertile. How the irregular periods cause infertility is something they are not clear about . They also know that they have a "hormonal imbalance" - but are clueless about which hormones are not in balance.

Because they miss their periods every month, many of them go to the doctor regularly so that he can prescribe medications for them to take in order to induce a period. While many know that the medicine the doctor prescribes is progesterone, they are very scared to take this for themselves on their own. For one thing, most patients are scared to self-medicate; and they are worried about the side effects of these hormones. Also, their doctors do not empower them with information because they prefer keeping their patients dependent on them ( ensuring them a regular monthly income for these repeat visits).

This is not a happy state of affairs. PCOD is a chronic illness, just like diabetes is; and patients need to learn to manage this for themselves, rather than have to depend upon their doctor !

Here are some basic principles which every PCO patient needs to learn !

Firstly, you should plan to get 12 periods every year. There's no point in waiting week after week for the period to come on its own - you are just wasting time and adding to your anxiety levels. Every time you miss your period, you are hopeful that you are pregnant at last - and when the pregnancy test comes back as negative , you get depressed and disheartened again . Why break your heart every month - you need to be proactive ! Getting regular periods is good for your self-esteem and helps you to plan your life. The good news is that there's no risk or downside to doing so !

Having irregular periods reduces your fertility ( because you cannot get pregnant until you induce a period). It also messes up the quality your life ( because you are never sure when your period is going to start); and it also also impairs your health ( a period which comes after many weeks is likely to be very heavy and may lead to your becoming anemic.)

The good news is that it's quite easy to learn to self-manage your problem. Why waste time waiting for the period to come when it's so easy and safe to induce one ? Unfortunately, many patients are scared to self-medicate because of ignorance.

How do you induce a period ? It's very simple - all you need to do is to take a 5-day course of a natural hormone called progesterone. This is available in many forms .One of the safest is medroxyprogesterone acetate ( MPA). This can be hard to pronounce; and fortunately, pharmaceutical companies sell this drug under many brand names which are much easier to remember ! These include: Provera; Deviry; and Regesterone. The dose is 10 mg, twice a day, for 5 days. You only need to take 10 tablets- and your period will start about 2-7 days after taking the last tablet. This is called a progesterone withdrawal bleed. By taking this, you are just mimicking nature, which means it's very safe to do this every month !

Many women are scared of hormones. They are worried that these hormones will make them fat or cause side effects . Please remember that this is a natural hormone which you are taking only because your own ovaries ( which should normally have produced this every month) are not behaving themselves and producing this important hormone . It's very similar to managing diabetes. Just like a diabetic needs to take insulin to keep his blood sugar under control ( because his pancreas does not produce the insulin it normally should have) , you need to take the progesterone every month to induce a period. The good news is that it's not an injection - and you need to take it for only 5 days every month !

Every time you miss your period, do a pregnancy test to confirm you are not pregnant. Once this is negative, take your course of MPA. Many patients are scared that if they are in fact pregnant, and they then take the medicine by mistake during pregnancy ,this will harm their baby. After all, if the tablet is being used to induce a period, won't it also induce a miscarriage ? No, this is not true. The good news is that it's perfectly safe to take MPA during pregnancy as well. In fact, many doctors routinely prescribe this during pregnancy to provide luteal phase hormonal support. Don't forget that progesterone is a natural hormone which is produced during pregnancy - and as the name suggests, it supports gestation ! If you take it inadvertently during your pregnancy, you will not harm your baby - and in fact if you do not get a withdrawal bleed after taking this course of tablets, one possibility your doctor will need to rule out is a pregnancy. ( The other is a functional ovarian cyst, and a blood test for beta HCG and an ultrasound scan will allow him to make the right diagnosis).

I tell my PCOD patients to do a urine pregnancy test on the first of every month ; and when this is negative, to take the course of tablets. This helps them to remember to take the tablets every month !

Some patients get upset at the idea of having to take the tablets every month . They do not like the idea of having to take hormonal tablets every month because they are scared they will get "addicted" to these. Also, they want a cure - a treatment which will fix their problem once and for all !

Sadly, while we are very good at treating the irregular periods you get as a result of your PCOD, we cannot cure it at present. Just like a diabetic's blood sugar will remain controlled as long as he takes his insulin regularly, your periods will remain regular as long as you take the progesterone. If you stop taking it , the periods will become irregular again. The good news is that it's possible for you to regularise your cycles - and that this treatment is simple, safe,inexpensive and effective !

Remember that while this is effective for regularising your periods, it will not help you to have a baby. This is because all the progesterone does is induce a period - it does not help you to ovulate. If you want a baby, you will also need ovulation induction treatment ! Some patients believe that if they take this "course of tablets " and regularise their cycle , this will then fix the problem and allow them to get pregnant. This is not true.

If you forget to take your progestins, and get a heavy period, how do you manage this heavy bleeding ? Taking a high dose of antiprostaglandins for 3-4 days ( such as ibuprofen or indomethacin 3-4 times a day) can help to reduce the amount you bleed, and its safe to take these as needed.

Many young girls with irregular cycles with PCOD are told not to worry - and their doctor tells them that their cycles will become regular once they get married. This is unhelpful advise because it is not true ! The PCOD will need to be treated - and the good news is that safe and effective treatment is easily available - both for regularising the period - and for having a baby !

In normal healthy fertile females, ovulation with rupture of the mature ovarian follicle and release of the eggs occurs within 38 hours of the surge in luteinizing hormone (LH). However, in a small percentage of women, the dominant follicle will undergo the luteinization process but will not rupture following the midcycle LH surge. This is called LUF (luteinized unruptured follicle syndrome). As a result of the increased progesterone secretion, the endometrium undergoes the secretory changes, but, obviously, without the release of the oocyte , pregnancy cannot occur. This means that the cycles are regular; and hormonal studies ( Day 21 progesterone level) , the basal body temperature curve, and the findings in an endometrial biopsy will all be consistent with ovulation.

This is obviously a difficult diagnosis to make; and can only be made by serial vaginal ultrasound scans to track ovulation. These scans show that the follicle matures; but the dominant follicle fails to rupture. The lack of follicle rupture and the lack of free peritoneal fluid around the time of ovulation are used to establish the diagnosis of LUF. This condition is also called “trapped egg syndrome”.

LUF is more commonly seen in women with endometriosis; and PCOD. Often the diagnosis is made only when patients are being monitored for follicle tracking with serial ultrasound scans. LUF is a “silent” problem; and because it does not cause any symptoms or signs, it’s very easy to miss the diagnosis as well ! Since LH is responsible for inducing follicular rupture, LUF can be treated by giving an injection of Human Chorionic Gonadotropin (hCG) in a dose of 10,000 IU intramuscularly, when the lead follicle reaches 18-20 mm in diameter. Ultrasound can be used to document ovulation. It takes about 36 to 40 hours for the oocyte to be released after the injection. Intercourse or insemination should be timed accordingly. If it still does not take place, the dose of the hCG injection can be increased. If ovulation still cannot be achieved even with an increased dose of 20000 IU , then IVF is the best solution.

In our clinic, we really do not bother to make a diagnosis of LUF ! This is because this diagnosis does not really change your treatment options . After all, if you are infertile, this means the eggs and sperm are not meeting. The next step logically is to then do an IUI – and since an HCG injection is routinely given during IUI treatment to induce ovulation, the IUI automatically helps to treat patients who have LUF !

This is a guest post from Dr. Sai, Senior Embryologist, Malpani Infertility Clinic Pvt. Ltd.

Mrs. Bhatt had very poor ovarian reserve. Her AMH level was 0.3 ng/ml and she had reached the oopause . We advised her to use donor eggs but she was quite certain she wanted to have a baby with her own eggs. We explained to her that her prognosis was bleak, but she was determined, and requested us to do our best to help her to have a baby with her own eggs.

We superovulated her aggressively using a letrozole – antagon protocol, with 750 IU of HMG daily. She had a very poor ovarian response as expected, and grew only one follicle. We advised her to cancel the cycle, but she was very keen on getting pregnant and requested us to proceed with the treatment. Dr. Anjali did the egg collection and retrieved one oocycte cumulus complex from the follicle after flushing it multiple times. When I stripped the oocyte, it unfortunately turned out to be immature – it was a germinal vesicle stage egg.

We decided to keep the egg for In vitro Maturation ( IVM) .The egg matured exactly after 20 hours. I performed ICSI on that egg. It fertilized and we transferred the embryo back into the uterus on day 2. It was a gorgeous 4-Cell Embryo.

Even though we got only one embryo, the patient was very happy that at least we had helped her to reach this stage. She had been mentally prepared to get zero eggs and zero embryos, so this was quite a positive development from her point of view. Thanks to the technique of In vitro Maturation, they got a beautiful embryo to transfer.

We kept our fingers crossed – and 14 days after the transfer, she was on top of the moon when the HCG result was positive, confirming that she was pregnant ! Her pregnancy is now progressing well !

So what is in vitro maturation ? and how do we do it ?

In vitro maturation, as the name suggests, refers to the process of maturing immature oocytes outside human ovaries, in the IVF lab.

Applications of In vitro maturationof oocytes :

• Oocyte donors, to preserve their eggs in egg bank.
• Fertility preservation for women with cancer who are undergoing gonadotoxic chemotherapy.
• Fertility preservation for young women without partners needing IVF treatment.
• Poor responders to ovarian stimulation.
• Patients with lots of immature eggs after egg collection.
• Patients with PCOS syndrome, leading to retrieval of lots of immature eggs, after being hyperstimulated.

Mature Oocyte Immature oocytes

In vitro Maturation medium is now commercially available.

At our centre we use "SAGE In vitro Maturation medium”

It is not a ready to use medium. One has to prepare it.

Maturation media is usually supplemented with recombinant FSH and hCG.

The protocol for preparation of In vitro maturation medium is as follows :

Solution A = 1 ml IVF culture medium

Solution B = We use Menogon ( HMG). This powder contains a mixture of 75 IU
FSH and 75 IU LH. Dissolve this in 1 ml of IVF culture medium (A).

Solution C = 1 ml of Fresh Oocyte Maturation Medium in a test tube.

Solution D = Add 10 ul Solution B into Solution C

Solution D is now prepared Oocyte Maturation Medium.

In Vitro Maturation of Oocytes :
In Vitro Maturation on cumulus-enclosed oocytes :

• Done on oocytes retrieved from small sized follicles.
• Done on oocytes with apparently compact cumulus complexes

Immature oocyte cumulus complex

• Immediately after retrieval, cumulus-enclosed immature oocytes are placed in a specialized IVM medium for 24–48 hours.
• Generally germinal vesicle–stage oocytes that matured within 30 hours of culture are developmentally more competent than are oocytes necessitating longer time to mature.
• After IVM, mature oocytes are transferred to traditional IVF media for insemination and embryo culture.
• Insemination of IVM-Mature oocytes can be done by either Conventional IVF technique or ICSI. ICSI has been our preferred method as oocytes are frequently denuded of granulosa cells for evaluation of maturational status. ICSI has been used to increase the chances of fertilization whether or not a male factor has been detected.

In Vitro Maturation on Stripped oocytes :

• Done on Germinal Vesicle stage oocytes (confirmed after denuding them of the surrounding cumulus cells)
• All Germinal Vesicle Stage oocytes are kept in Specialized IVM medium for 24-48 hours.
• After IVM, Mature ( metaphase II) oocytes are transferred to traditional IVF Medium for ICSI.

Germinal Vesicle Stage oocyte. The germinal vesicle is the clear vacuole within the cytoplasm.

Photo of the egg after IVM. It has now become mature ( metaphase II – MII) . You can see that the germinal vesicle has dissolved and the polar body can be seen at 12 o'clock.

IVM is not a panacea for all problems – and not all immature eggs will mature in vitro using this technique. However, it does allow us an additional option, and can be very helpful when treating poor ovarian responders !

Image via Wikipedia

One of the most frustrating things an infertile woman can experience is having a late period and a negative pregnancy test! If you are trying-to-conceive , every time you miss your period, your hopes that you are now finally pregnant go up. You do the pregnancy test with a lot of hope - and lots of prayers. You are scared to do it, because you do not want to get your hopes up, and you are worried that it maybe negative once again . You finally screw up your courage - even if the news is bad, it's best to know the truth, you tell yourself - and then do the test.

When it's negative, you are depressed, disappointed and disheartened. But then you start hoping against hope ! Maybe I didn't do the test properly ? Maybe I drank too much water and the HCG is not showing up in the urine ? Maybe I did the test too early ? Maybe I ovulated late this cycle ? Maybe this brand is not reliable ? Aren't these tests fallible ? Maybe the test kits have expired ? Should I test again ? Should I use another brand ?

What happens if the test is repeatedly negative ? A late period and recurring negative pregnancy test results can lead to a great deal of stress, worry, confusion, and conjecture on what might be happening.... If I'm not pregnant, then where is my period?!? Have I stopped ovulating all together ? What's happened to my eggs ? Is my body going crazy ?

One possibility is that you are in fact pregnant , but the urine test result comes back negative. This is called a "false negative pregnancy test"? First, read all the instructions again and make sure you are doing the test properly. If you are, then a false negative result can occur if the test kit you are using is of low sensitivity. This means that the test is capable of detecting pregnancy only when the level of hCG reaches a certain threshold, and the test is simply not sensitive enough to yield the positive result.The best option is to do a blood test for checking your HCG level. This is very reliable ! If this is less than 10 mIU/ml, this confirms you are definitely not pregnant.If the test is negative , this means the reason you missed your periods is because you did not ovulate. This is called anovulation. You can read more about this at www.drmalpani.com/anovulation.htm !

Many factors can cause a missed period because they disrupt your hormonal balance. These include increased stress, anxiety, travel, jet-lag, weight loss, exercise and sleeplessness. The doctor may need to do an ultrasound scan to find out why you have missed your period. This vaginal ultrasound scan should check for the following.

a. ovarian volume
b. antral follicle count
c. uterus morphology
d. endometrial thickness and texture.

Based on these results, your doctor may prescribe medications for you to induce a period.