Transition to Manipal Andrology and Reproductive Services, aka MARS - the DFI suprprise

Our first IVF was in Aug 2011. We went in to consult with Dr. Jyothi at MARS late 2011 to discuss our options. She preferred that we take a break of few months to let the drugs wash out of our system.  This is one area we have found a difference in philosophy.  Many doctors are ready to do cycles back to back, if required.  Dr. Jyothi is more conservative when it comes to things like this.

She had me go and do one extra test on my sperm called the DFI (DNA Fragmentation Index). Everybody's sperm has some DNA damage due to oxidizing free radicals and such.  If a large number of sperm have this DNA damage, it reduces your chances of successful conception, though there are people with high DNA fragmentation who went on to have babies without treatment.

This test result for me was a bit shocking.  Firstly, the DFI number was very high. In addition, the sperm motility and morphology numbers came out poorer than earlier.  I was surprised because all the tests on sperm in other places (Gunasheela, Sure) all came back with reasonably normal parameters.  Anyway, after this test I was asked to go and consult Dr. S. S. Vasan who is the andrologist and head of the center.  Dr. Vasan got me to do several hormone blood tests and an ultrasound of my testicles.

He finally told me that the reason for my high DFI is a varicocele which is like a swollen vein in the scrotum.  Since blood flow is impeded, the temperature in the testicular region goes up and causes the DFI increase.  As the reader may know, maintaining testicular temperature is critical in getting sperm production right.

Luckily, there is a simple method to improve DFI which is to take antioxidants.  Dr. Vasan prescribed some injections and some hormone tablets followed by a course of anti oxidants to reduce the DFI.  This worked well and after 45 days or so (sperm takes 60-70 days to mature in the testicle), my DFI was much better.

General reactions

My general reaction to the whole deal was not altogether great.  Dr. Vasan is a man in a hurry.  He will work at jet speed and prescribe medication, but does not do a great job of explaining what does what.  Normally I have found google to be a good tool to understand the prescribed medication and correlate doctor's statements, but here I was not successful at understanding what was going on. The varicocele size from ultrasound test was small.  From what I read online, it was small enough that it did not strictly count as a varicocele

The difference in sperm test results of motility bothers me.  The high value of the DFI bothers me.  Further, some of the medication he prescribed caused some amount of testicular pain.  I stuck with it in the second IVF cycle, but in the next one, I became my own doctor and used a different concoction based on online research. I used vitamin C, E and Cod Liver Oil.  Vitamin C at 1 g a day (500mg x2).  Vitamin E (Evion at 2 x 400 mg a day). Cod Liver Oil 2 tabs x 3 times a day.  That seemed to work pretty well based on subsequent test results. I also started to keep my phone in my shirt pocket instead of the pant pocket.

Disclaimer: I am only sharing my personal opinion and my versions of my experience here.  Clearly, if you go and ask doctors who I may express opinions on, they may agree or disagree to my statements.  The thought process is that this would be helpful and a reference point for some among the many that go through this infertility ordeal.

Dr. Jyothi Menon Experience

I figured that a post on our experience with Dr. Menon requires a separate post.  The fertility specialist has a very important role in the whole process.  This person is going to make a lot of decisions with subtle variations in approach on how to do the procedure.  More importantly, this is the person who is going to explain the procedures to you, recommend tests, interpret results, answer your questions, counsel you etc.  The other person involved is the embryologist and the lab facilities, but the face you are going to see is the specialist. The skill of the specialist is also important at the time of embryo transfer in placing the embryo in the uterus at the right spot without damaging the lining.

We found Dr. Jyothi to be a very kind, caring and personable doctor.  She explained her decisions clearly to us.  She tried to be personally present at the time of the scans or discussed it with the ultrasound tech. She did not ask for un-necessary tests and in general, seemed to try and avoid tests if not required. The other part that endeared her to us was that after procedures like oocyte retrieval which involved anaesthesia, she would ask us to call in the evening and give her an update on how my wife was doing. She also remembered every detail of our "file" during every discussion and could probably reproduce it on a sheet of paper without referring anything.

I believe she is now back at Gunasheela where she began her career and would highly recommend her as a doctor.  Finally, I believe that comfort with your care provider is extremely important in something like IVF. It is a stressful process and having a patient, caring, ear is very valuable.

I also found couple of reviews of Dr. Jyothi Menon online which mirrors our experience.  Linking those here for a reader's reference.

Review 1: Click here
Review 2: Click here  Refer to feedback from User: Ecstatic Mom

IVF No. 1 at Sure Fertility

So, after the IUI failed, looking at our low AMH, we decided to go with IVF.  There was some prep work for IVF.  One was measuring our hormone levels again.  The other thing is to look at the uterine cavity carefully.  Since we had done a hysteroscopy and laparoscopy at Gunasheela, Dr. Jyothi did not want to repeat it.  She was unhappy with the uterine lining which has always been a bit on the thicker side and not of a satisfactory appearance in ultrasound (hyper echoic) according to her.  So she wanted to do a DNC (dilation and curretage) to scrape out the endometrium and see if it will grow better fresh.  Since Sure does not do surgical procedures (those are done at Cloud Nine which is the parent organization), we had DNC done by Dr. Jyothi at Agadi hospital in Wilson Garden. A small and nice hospital and the procedure was smooth.  Not fancy, but nice. The other standard tests are for HIV and such.

Then our IVF started.  It started with a day 2 scan and recording the AFC (Antral Follicle Count) in each embryo.  Then the stimulation started.  Given the low AMH, the ovaries were not expected to be great responders. (Somehow are AFCs were always reasonable). So we were given high doses of Gonal-F and a growth hormone.  This consisted of injections every day followed by scans every few days to see how the follicles were developing.  When the follicles grew higher in size the scan frequency became more frequent and after a point another injection was added to prevent accidental ovulation. The doctor would do E2 (Estradiol) tests which are an indicator of quality of the follicles.  If I understood correctly, after a full cycle of stimulation, E2 should measure about 200 per follicle.  So if you have 10 follicles , it should be 2000 (not sure of the units).  The other check is the level of progesterone just before the HCG injection before harvesting the eggs.  There is data that if the progesterone is relatively high (which sometimes happens under the influence of all the meds), the chances of a successful implantation of the embryo reduce quite a bit. I will cover all this in another post.

Short Protocol
To digress a little bit, I want to point out that this protocol is called a short protocol. The other procedure is a long protocol where injection start around the 21st day of the  previous cycle to suppress the pitutary gland and then the pitutary is woken up during stimulation.  It really causes the ovaries to superovulate, apparently.  Please note that I am no doctor!  Just spitting out what I understand.  Please do verify what I write here, if you are among the few that read it.

Back to the IVF cycle

Eventually, the doctor decided to collect the eggs.  They gave us a shot of HCG to trigger maturation of the follicles and in the 36th hour post injection, under general anaesthesia, they went through the vaginal wall with a needle under ultrasound guidance and collected 9 oocytes (eggs).  The whole procedure took very little time, but there was some waiting for the effect of the anesthesia to wear off and for the docs to be sure that there are no side effects like nausea.   In the meantime, I went and gave my stuff in a cup... so easy.  The lab used the sperm to fertilize the eggs.  6 of the 9 eggs were determined to be adequate (average quality, whatever that means).  4 fertilized of which two stopped growing.  We were scheduled for what is called a day 3 transfer.  But on the second day, we got an urgent call to come in and the doctor transferred 2 embryos.  Turns out that the embryos were not that great and they wanted to transfer them instead of risking all of them stopping growing outside.   The human body is a much better incubator than any petri dish.  Then began a 15 day wait full of progesterone injections every few days and micronized vaginal tablets of progesterone along with estrogen and a steroid course.  Some people are given aspirin to increase uterine wall blood flow, but since my wife is sensitive to aspirin, that was avoided. The steroid is used to suppress the immune system which makes implantation of the embryo on the uterus wall easier.

15 days later, there was a test for Beta HCG which is produced by the embryo implanted on the uterus wall.  Our result came back as 5.2 which meant that something is happening, but not high enough to declare a pregnancy.  On the instructions of the doc, we continued progesterone for 48 hours and retested.  If there was hope, the HCG should have increased, but it stayed at 5 and the doctor declared that this attempt was a failure.

Nothing really prepares you for the disappointment of a negative result.  It is like you were trying to push a big heavy stone to the top of a hill and after a lot of effort, the damned stone just rolled back down and ran over your body.  A slight negative was that the doctor fell ill nearly coinciding with the end of our cycle... so we really did not have a good debriefing with her.  We called her and she informed us that she was exhausted from running across town to the various clinics she practiced at and that she had decided to restrict IVF consultations to only Manipal hospital.  We finally went and met her there to review this cycle after couple months.

Costs
The cost of this whole business came to about 1.8 lakhs.  There was the package fees, admission fees and tests which came to about 80,000. The cost of the medicines which in our case was fairly high doses was about another 80,000.  Then there were other things which I do not remember today, but the total was about 1.8.

Intra Uterine Insemination

The next attempt we made was a technique known as Intra Uterine Insemination. We were still with Dr. Jyothi menon at Sure Fertility.  The thinking behind this technique is that the sperms have a long way to go to reach the egg.  For example, the first major obstacle is the cervix (the opening into the uterus).  The cervix opening has mucus through which the sperm has to swim.  On fertile days around ovulation, this mucus is thinner and easier to swim through.  I remember reading somewhere that only one in hundred sperm get through the cervix to the uterus.  Then the sperm has to swim up the uterus to the fallopian tubes and fertilize the egg.

In IUI, they take the best sperm and deliver it through the cervix into the uterus.The sperm presumably has a shorter path now to fertilize the egg.  However, IUI only addresses people where the ability of sperm to get past the cervix and swim all the way is low.  Success rates in IUI are typically less than 20%. However, doctors prefer to try it because (a) it does not involve the heavy stimulation and drugs in IVF/ICSI (b) It is a lot easier to do.  They may give you some fertility drugs to stimulate the follicle development process and then when they are of the right size, a shot of HCG will be used to cause the follicle to mature and for an oocyte to be released.  At the same time, the doctor will schedule a coinciding time to deliver a sample of concentrated sperm from the male partner into the uterus to do its work.  The doc may give some progesterone support to help implantation.

We only did IUI once and it did not succeed.  Given our low AMH and probably looking at the ovarian response to the drugs, we hurried on to an IVF cycle after the IUI.

Looking at the female reproductive system- Inside and Outside

The HSG film at Gunasheela was read by a junior doctor.  The doctor looked at the film and told us that it was not looking good.  She then explained the problem with the picture.  Then her recommendation was to do a laparohysteroscopy.  However the process was a bit confusing.  She recommended the laparo-hyscteroscopy, but was reluctant to state it out loud the first time.  She said that the file had to be looked at by Dr. Devika Gunasheela before she is allowed to give us a recommendation.  Overall, we felt like were in a giant processing machine.  The overall advice was correct and made sense with whatever research we did, but it just felt too impersonal.

Now, having blocked tubes is quite possible.  It happens in many cases where people have some sort of abdominal infection.  Abdominal TB is a very common reason for this in India. For people with abdominal TB, treating it could restore functionality of the tubes. In our case, TB had been ruled out due to testing and medical history.

The hysterolaparoscopy was done by the doyen of infertility treatment in Bangalore, the late Dr. Sulochana Gunasheela.  I did not know that she was doing the procedure or I would have been very nervous. We got face to face with her one time and it was another assembly line process.  The poor lady looked so old... I would have not been sure of the steadiness of her hands.

Laparoscopy is a process of taking a camera and probe and looking at the abdominal cavity and the uterus and fallopian tubes and ovaries... a visual inspection if you will without making a large incision.  The make 2-3 small cuts and insert a camera/light source and a gripping device.  During laparoscopy, some fluid is pushed through the fallopian tubes to verify which tubes are working. Laparoscopy results are the "gold standard".  Sometime during hysteroscopy, the tubes could clench shut due to the "shock" and a false negative can happen.

Hysteroscopy is the process of taking a camera within the uterus and inspecting the inside walls. For good measure, they also did a DNC (Dilation and Curretage, which is just scraping off the endometrium or inner wall to allow it to grow )

What we learnt was that everything looked normal and only one tube appeared to be blocked even though it "looked" fine to visual inspection. The uterus cavity was also ruled to be normal. Endometrium was ruled "polypoid" and were told that it is not a problem.(And that is what everyone has told us so far). 

The experience with hysterolaparoscopy at Gunasheela was again not too thrilling.  We were not thrilled with the experience with the surgery... simple things such as the nursing and so on.  However, what was really disappointing was the lack of face time and proper counseling with an experienced doctor.  While the diagnosis and next steps told to us is not something we would fault (they recommended an IUI and if that does not work IVF), the fact that we got no facetime with the principals and the fact that the advice came from a couple of doctors who were junior and would not state their opinions without consulting their principals made us very reluctant to keep going there. One thing we have realized is that infertility treatment is an intensely personal process and that one should find the right clinic/doctor that works.  Trust your instincts, ask questions and gather as much information as possible.

Given that all the information pointed to a functional system, we decided to continue to try naturally for some more time.

HSG at Gunasheela

As explained in the previous post, a HSG (Hysterosalpingogram) was recommended.  What this involves is putting a probe in the vagina and filling the uterus with a dye.  Once the uterus fills with the dye, it gets forced into the fallopian tubes and should spill out of the end of both tubes.  By taking couple of X-rays, they can now visualize the uterus and the fallopian tubes.

If the tubes are blocked, the fluid will not spill out and the tubes may not be visible at all.  Similarly, if the uterus has a poor shape, that can also be seen in an HSG.  In other words, this is a cheap, first test before a more detailed and invasive inspection (such as laparascopy or hysterscopy) is carried out, if required.

There is this nice page of the advanced infertility center of Chicago that describes the HSG well here.

This was our first place where trouble showed up.  Our HSG showed a uterus with irrregular boundaries and the fallopian tubes were not visible.  The doctors recommended that we do a more detailed inspection which included a laparoscopy and hysteroscopy, which mainly involves using camera based probes to look at the uterus and ovaries and tubes, both from the inside and outside.

Another information we picked up was that for some women, the HSG which involves forcing dye through the "plumbing" could potentially clear minor blockages in the fallopian tubes and help achieve pregnancy.  So if your HSG comes back normal, this may be a good few cycles to try intensively :-)

First experience at an infertility clinic - Gunasheela

So... we walked in Gunasheela one weekend.  It was quite a drive from where we live, but the clinic itself is located in Basavangudi in a really nice part of the city.  The first thing that struck me when going in was the crowd!  Half of Bangalore's infertile population seemed to be sitting there and it was a lot of people.

As soon as we got in, the process started with a fairly thorough medical history being collected by an assistant type person (not sure of their qualification). They collect name, occupation, height, weight, blood group, blood pressure and so on. We also had some older medical reports with us (basically, one time a pelvic exam and hormone assay was done in the past as well as some reports from a routine annual medical check.  Values from these reports were also noted.

Before reading further, it may be a good idea to familiarize yourself with the female reproductive system - see a WebMD link here.

They started off with an ultrasound of the uterus and ovaries (called a transvaginal scan).  The ultrasound gives an idea of the size and shape of the uterus and the endometrium (uterus lining, which gets shed with each menstrual period).  Some cases are due to abnormalities in the uterus and many such cases can be diagnosed from the ultrasound itself. Further, the ovaries can be visualized as well as the follicles (think of them as eggs growing inside the ovary.  In one cycle, normally, one follicle matures and releases an egg into the uterus through what are called fallopian tubes while the others die out in the ovary itself).

This is followed by a request to come for a Day 2 or Day 3 visit.  Day 2/3 is the 2nd or 3rd day after the menstrual cycle starts (which is counted as Day 1).  They measured hormone levels (FSH - Follicle Stimulating Hormone), LH (Leutenizing Hormone) and Prolactin) as well as TSH - Thyroid Stimulating Hormone.  We had a recent TSH results from our annual medical check and so that was not repeated.

One thing they look for in the Day2/3 scan is what is called the Antral Follicle Count (AFC) in the ovaries.  This is the count of "seed" follicles which can develop into follicles during the cycle.  Normally, the AFC goes down as a woman ages. In  If IVF type of treatment is opted for, it is these antral follicles which are stimulated, so the AFC is also a measure of the ovarian reserve of a woman and one measure of the chances of success in IVF.

In our case, all results to this point were good.  So they prescribed a semen analysis for me which also came our normal. Then, the next test was to do a more detailed evaluation of the uterus which is using a method called the HSG.

The Beginning

We were a relatively older couple.  I was 29 and my wife was 27 when we got married.  By the time we settled into our then new jobs, post marriage and started trying for a baby in earnest, it took about 3 years.

My wife is asthmatic and that has implications in terms of having a baby. Bangalore is not really an asthmatic's ideal location.  So it took us some time to get that under control as well and improve general health to the point where trying for pregnancy became attractive.  We consulted an obgyn before beginning trying.  The doc adviced us on the implications of asthma to trying to have a baby.  During pregnancy, as the baby grows and occupies space in the abdomen, the diaphragm which is used for breathing gets restricted which causes some shortness of breath.  So asthma in combination with pregnancy is a bit more difficult.

Anyway, we started trying and even though there were one or two false alarms (driven partly by our anxiety / anticipation, possibly), a pregnancy was not achieved.  After about a year of trying, we decided to consult infertility specialists.  That seemed to be the general advice and age (especially my wife's, since men have a much more limited role) was not on our side. Now there are people who may scoff at this statement.  Having lived outside India as well, I know women (not of Indian origin) who have easily had children into their mid 30s or even early 40s.  So we thought we were perfectly fine! The other conversation we had had with each other was a honest one - that we were running a risk postponing conception and while we would try infertility treatment, adoption was also okay if all else failed!

Anyways... the short version of the story is that we found ourselves at Gunasheela IVF center in Basavanagudi.  This place was recommended to us by a obgyn we knew in my wife's hometown.  The next post will be on our experiences at Gunasheela.

Hello World

Hello World!  I decided to post this blog to discuss our journey through the world of infertility specialists and baby making while living in Bangalore.  We are still going through it, and it is a long and painful journey.  What made the process difficult was the difficulty in getting reliable information and not really knowing what choices to make.

So, I thought that it makes sense to share our experiences out in the open in the hope that it helps other couples making the same journey. I also hope that some of these blog posts are read by people planning to have a baby.  A baby is a big miracle that comes out in a small package.  Most people who get a baby through natural conception do not probably realize the various amazing steps that all worked well for them to hold their little bundle of joy in their hands. If people go through some of these blog posts, I feel it will give them some perspective when it comes to planning their families.  You know the old saying... hope for the best, prepare for the worst!

We have been in and out of clinics for the past 3 odd years. Over the next few weeks or months, whenever time permits or inspiration strikes, I will log my thoughts here.  If you choose to read... welcome and thanks for reading through.