Finally, what next

It was a terrible period after losing the pregnancy by our choice.  In addition, we had the other health issue which came as collateral (?) damage to deal with.  Anyway. after much thought, we tried an ayurvedic treatment which worked out for us.  The story is long and I will share another day.

Place is in a small village near Palakkad in Kerala.  Details are here: http://miracleofherbs.wordpress.com/

Cycle 3 of ICSI at Manipal followed by FET

So the cycle 3 of ICSI of Manipal went the same way.  Starts with a briefing by Dr. Bina.  Then the efficient Dr. Manju Nair takes over (there is another junior doctor who came in the place of Shyamala who scared the heck out of us.  She just does not come across well).

One thing to note this time was that the oocytes became ready pretty fast this time (no of days of stimulation).  Same number of eggs were retrieved and for the first time, doctors said that the oocytes were good and not "average".  One incident happened which bothered me.  Egg retrieval and embryo transfer are typically the stages where Dr. Bina does the procedure.  We pay the big bucks for her, after all.  In our case, Dr. Bina was not in the hospital in time (there is a very strict time period between ovulation induction and oocyte retrieval - 35-36 hours).  So Dr. Manju did the retrieval.  Everything went smooth, and I am sure Dr. Manju is skilled, but I was disappointed in not receiving even a mention of this from Dr. Bina.

Three good embryos resulted.The uterine layer was not thick enough, so once more, the option was FET.

The FET cycle has been described, except for us, in the first attempt a uterine polyp was discovered.  Then a hysteroscopic polypectomy had to be scheduled.  My take is that all the hormones being used had a role to play in the polyp developing.  They also made some changes where the pitutary suppression was not done this time.  it was natural cycle FET. Anyway, eventually, we were able to do a FET, all embryos survived the freezing, and in due course discover ourselves to be pregnant!

For us however, the joy of pregnancy was diluted by a strange problem that occurred almost simultaneously.  Without going into the details, let me just say that it was a disaster for us.  We do not know why whatever happened did happen.  I am also not too happy with the way Dr. Bina handled the situation, in terms of some of her inputs to us. I do not want to go into details, but only share an opinion.

Anyway, we were pregnant and initially everything appeared okay.  However, in an ultrasound scan, a possibility of a genetic anomaly was discovered along with other problems.  After further testing, very serious, life altering, incurable problems were discovered. We were forced to make the hardest ever decision on saying good bye to our child considering the sheer magnitude of issues.

Prep Work for the Third Cycle

After the first cycle, and even before, one focus was to try and improve our general health.  That effort continued.  After some research, we made the following changes.  (a) More Omega fatty acids - which means we started cod liver oil for both of us. (b) Vitamins (anti oxidants) for improving sperm DFI - I started on the Vitamin C and E and did not take any of Dr. Vasan's medication such as paternia.  In fact, this time, when I went to test I had been having these meds.  So the DFI was already good enough for him. My wife started having a supplement called Co-Q 10  _ Coenzyme Q 10.

Please see this blog from a doctor practicing in Chicago about this supplement - click here.  Based on this and other data, we simply decided that it could not hurt!  Confession: we did not inform our doctors about this either.

In the preparation for this cycle of IVF, Dr. Bina recommended an AMH test, though I could not think of an earthly reason for doing it.  Guess what - we got an AMH slightly higher than 2.0, the magic number.

What next, and some comments about Manipal experience

After the second cycle was a decision making time for us.  Do we try another IVF/ICSI/ The huge dose of medications was a worry.  How many more times do we go through this? What are the long term effects? Is there a problem with us?  Other ideas such as surrogate and donor eggs and all those floated around.  We thought about all of these. We have to admit that lot of these thoughts went through our heads.

Finally, we made a decision to do one last IVF/ICSI and then abandon the effort if it does not work.  Dr. Jyothi had recommended at the time of our second cycle beginning that ideally we should not do a third cycle in her opinion.  She was concerned about the high doses required to stimulate in our case.  However, Dr. Bina did not seem worried and there was nothing online indicating otherwise either. Our back up plan was to consider adoption.  In our case, we ended up regretting this decision even though our next UVF resulted in a pregnancy.   But that is for later.

Right now, I wanted to share some comments about IVF clinics in general and IVF at Manipal specifically.

At Manipal hospital, this clinic is on the 9th floor (as of our visits and even now).  The space available is in no way sufficient to handle the volume of people that go through there.

There are three consult rooms.  Two of the rooms have a shared room with the ultrasound equipment.  This same u/s is rolled into the back room which is a OT plus couple of beds to prep patients as well as a file storage area.

There is another lab for the endocrinology as well as a separate lab for semen analysis, cryogenic storage etc.  Finally, there is the semen "collection"room.

The space is tight which is a shame because there is certainly a lot of money being made per sq. ft.  Once the chairs become full, people start sitting in chairs in the corridor.  This is the same corridor through which patients are taken from the OT to the ward/  Consequently. when the gurney comes, folks have to get off the chairs to allow it to pass. The sperm collection room is a disgrace compared to all the other ones I have seen. The fancy ones have a nice bed along with a DVR with some helpful material.  Overall, a shame in my opinion.  Some basic aspects can certainly be improved.

The second complaint is on sharing of records.  In the first cycle at Sure Fertility, we got a detailed record of the medicines prescribed and the results of the regular ultrasound scanning which was a good data on how the response to the stimulation was. At Manipal, unfortunately none of those records are shared.

The final piece was data on the oocytes retrieved and embryos formed.  In retrospect, I think it is very important to share clear, scientific data on this with the patient in writing with photos of the individual embryos and oocytes as well.  This also is a clear indication of quality of the output from what is really a method tried on us as patients. None of the places, Sure or Manipal did a good job here.  One photo of one embryo is all we get with the discharge summary.

The reason why records and photographs and grading are important is because if the patients decide to change doctors, the new place has clear data on what was tried and how it worked.  This is a change we would highly recommend at all IVF clinics that do not do this currently.

The cost of the second round of IVF worked out to Rs90000 for the cycle plus Rs 20000 for freezing plus medicines which were probably in the range of Rs 60 to 70000.

Disclaimer: This posts consist of a mix of opinion and facts.  Whatever is written is purely our feedback.  No medical expertise here.  Also, we do not respond to comments on the post or offer advice.  Just sharing a chronicle of our experience.

Frozen Embryo Transfer (FET) at Manipal

Once our other issues were sorted out, we showed up at Manipal and were greeted by Dr. Jyothi who was wondering as to where we had disappeared.  She had some news for us.  The older Dr. Sulochana Gunasheela at Gunasheela IVF had passed away.  Dr. Jyothi had been invited to come back there as Medical director by the daughter Dr. Devika Gunasheela who was now running the center.

It was a bit of a surprise, but we could not grudge Dr. Jyothi the opportunity.  Dr. Jyoti handed us off to Dr. Bina Vasan, made introductions and updated her about our case, and planned her exit out of Manipal.  We started with Dr. Vasan for the FET.

Dr. Bina Vasan was certainly a busier doctor with a huge patient load.  One aspect is that she sees too many patients to fully know everybody's case in detail. In fact, I am not sure how Dr. Jyothi is at Gunasheela because I am sure her patient load has gone multifold.  Anyway, she gave us a briefing and handed us over to Dr. Manju and Shyamala for the FET.

In FET, they basically give you medication to suppress the pitutary gland which controls the menstrual cycle.  This is followed by estrogen tablets as the cycle begins.  In other words, the doctors control the hormones and growth of the endometrial lining.  Once they had a good lining. Simultaneously, oocytes also grows in the ovary like any normal cycle.  Once the lining is deemed good, once again ovulation is induced by an injection.  Then the progesterone doses start.  Once the age of the progesterone treated lining matches that of the embryo.  The embryos are then unfreezed and thawed and observed as to whether they are alive and multiplying.  If that is established, then a transfer can be executed.

We had all three embryos survive the freeze.  Two were properly divided at 32 cells and the other one was a bit slow and supposedly not all that great.  The embryos were proclaimed to be of good quality and the uterus lining was supposedly beautiful.  Dr. Bina Vasan did the embryo transfer which is a 5 minute process and we were off to the waiting period.

Post embryo transfer period consists of rest and many medications.  Progesterone mainly in the form of suppositories (vaginal tablets) and injections, estrogen tabs, a mild dose of prednisolone (steroid) to lower immunity, folic acid etc.

Unfortunately and devastatingly, not a single one of these guys took hold.  Our serum HCG test after 15 days had nothing.  As usual, nothing prepares you for a situation like this, even though one knows that a negative result is a distinct possibility.

The second IVF/ICSI at Manipal (MARS)

Eventually, after couple of months, we decided to and registered for another ICSI cycle.  This time, Dr. Jyothi opted for a different approach. The first time, she had given growth hormones in addition to stimulation to increase the number of oocytes retrieved.  This time, the philosophy was different: the objective was quality over quantity, so no growth hormones were given.  We went through the cycle and when it was appropriate, the oocytes were retrieved.  There were three oocytes (eggs) retrieved) which fertilized and started growing in the incubator.

However, there was a hitch. Our progesterone levels came a bit high when measured before inducing ovulation.  My understanding here is as follows.  After ovulation, normally the progesterone levels climb causing a change in the endometrium (lining of the uterus).  If this happens too early, the endometrium can start changing too soon and not match with the fertilized egg.  Oh bummer.  So a decision was made to freeze the eggs and do the transfer in a fresh cycle via "Frozen Embryo Transfer" or FET to give the embryos their best chance.

It was a tad disappointing, but that was okay.  Only fear was if the freezing would cause issues to the embryos, given our low number. Few of them do not survive the freeze.  However, the windom was that the embryos that survive the freeze are more robut and have a better success rate as well.

Another note was that before this cycle, we had done an AMH test and found a small improvement to a reading of 1.2.  Still below 2, but 1.2 was better than 0.8!

Few other notes about Manipal: This is a more busy clinic, though Dr. Jyothi had a smaller number of patients.  Dr. Bina Vasan was the busy doctor here with a huge line of patients.  Dr. Manju and Dr. Shyamala were the assistant doctors who did most of the hard work and kept track of things, did the scans etc.  However, in true fashion, Dr. Jyoti kept tabs and things and was up to date.  Similarly, after anesthesia following oocyte retrieval, she checked in with us in the evening and so on.

Another bummer that happened was that we had an unrelated health issue come up which meant that we could not go back for embryo transfer for 2-3 months while sorting that out.