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.