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.