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.

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.

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.