Freezing Future- Lots In Magic Box

Author- Dr Richa Sharma(Senior IVF Consultant Mumbai)

Reproductive medicine as subspeciality is not only limited to IUI,IVF besides it has many other lateral and vertical extensions which gives wings to the humans to take planned decisions and control their lives and not just meeting the fate.One such miracle is –Freezing of future fertility at will and on need.

 

What is freezing of fertility ?

It means to preserve fertility for future in the form of freezing of gametes and reproductive tissue.It began with preservation in cancer patients but as per need can be extended in others too.For that IVF lab need to have upto date facilities and embryologist needs to be skilled enough in cryopreservation/vitrification

 

Who all can opt for ?

 

  • Improve the efficiency of IVF
  • Alternative to embryo freezing
  • Oocyte preservation for patients with ovarian hyper
  • stimulation syndrome
  • Oocyte donation programme( for quarantine purpose)
  • The treatment of congenital infertility disorders
  • Prevent fertility loss through surgery
  • Treatment of premature ovarian failure (POF)
  • Also in cancer patients prior to exposure to chemotherapy or radiotherapy(fertility Cryopreservation)
  • In career oriented females who want to plan family later due to other commitments
  • In case male partner not available or not able to give semen sample (ED/refuses)
  • In cases of failure to form embryos esp when repeated risk is there- half of the oocytes can be cryopreserved to find out the reason (as to whether egg or sperm)

 

Is it limited to any particular gender ?

It can be beneficial in males and females both

How long we can freeze ?

As per ICMR it can be stored upto 5 years and depending upon situation term can be extended

What are pros and cons being in freezing temperature ?

Benefits are clear from indications mentioned above and disadvantage is due to the attrition affect of freezing media and post recovery survival especially when the samples frozen are not that great in quality and quantity

 

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Fluid Collection in Ivf-Myths and Facts

 

IVF is a finer treatment option for childless couples but it needs a better understanding before opting for it.It has lots of Myths and Facts associated with it.

Patients often have fear of side effects of medicines used to stimulate their ovaries to grow their eggs.One such side effect is Accumulation of fluid in the body what we call medically as OHSS(Ovarian Hyperstimulation Syndrome) but its not a uniform feature in all IVF patients.OHSS has a tendency to happen in selective group of patients with high risk factors which can be predicted and prevented.So via this write up our focus is on to single out such predisposing factors so that appropriate measures can be taken on time.Its not only duty of a treating doctor but a patient also needs to be aware than landing up with sudden surprises and bitter experiences.

 

Why is it a concern?

  • Marked increase in patient population in infertility clinics
  • Changing lifestyle
  • Advances in the field of ART – act as a Double edged sword with pros and cons
  • ART technology – is morepatient friendly,with less complication with cost still a limiting factor with no 100% gaurantee

 

 

 

 

What is OHSS ?

It is a Life Threatening medical(Iatrogenic,drug induced) Complication

and unique to the treatment of infertility with an an acute onset but reversible in nature with enlarged ovaries with cysts and fluid accumulation in body cavities to variable extent depending on gravity and grade

 

 

What are types of OHSS ?

 

Mild,Moderate,Severe and Critical

 

Who all have risk to develop OHSS ?

  • Young age, Low body mass index
  • Polycystic ovary syndrome (PCOS)
  • Higher doses of exogenous gonadotropins
  • High Estradiol levels with rapid rise
  • Previous episodes of OHSS
  • Multiple developing follicles(20-25)
  • Exogenous hCG for superovulation/ luteal support
  • Multiple Pregnancy
  • Serum factors increasing permeability of blood vessels

 

 

 

 

How it can be prevented ?

Primary or Secondary prevention

  1. Cycle cancellation
  2. Coasting or controlled drift
  3. Drugs – GnRH analogs
  • GnRH antagonists
  • Recombinant LH
  • Insulin sensitizers – Metformin
  • IV albumin 20%
  • ACE inhibitors + Angiotensin II receptor blocker
  • Glucocorticoids
  1. USG Guided Follicular Aspiration
  2. Elective Embryo Cryo Preservation and Transfer in subsequent cycle
  3. In vitro maturation of oocytes (IVM)

 

 

How will my body behave when I Have OHSS ?

Most frequent symptoms and signs are –

  • Distention of lower abdomen
  • Nausea and vomiting
  • Dyspnea and respiratory distress
  • Diarrhea
  • Quick weight gain
  • Ovaries enlarged up to >12 cm

 

 

 

What to do If I have pregnancy and OHSS Both ?

Course generally unpredictable.That depends on how many pregnancies and response of body and period of onset of OHSS

Can It be 100% Prevented /Eliminated?

No but deterioration can be prevented.There is definitely aim to have OHSS free treatment

How to manage OHSS ?

 

Principles

  • Monitoring
  • Supportive therapy
  • Maintenance of intravascular volume
  • Prevention/treatment of complication
  • Counselling – Signs and symptoms of OHSS
  • Evaluate the baseline status with

– complete history

– complete general and systemic examination

(pelvic examination contraindicated as ovaries are fragile,can rupture or undergo torsion)

Outpatient measures-

 

  • Limit activity
  • Weigh daily
  • Monitor intake(1liter/day) and output
  • Daily follow up
  • Report if symptoms worsen or

weight gain > 2lb/day

Admission needed in hospital as per clinical status of the patient

IVF Success in Regular Vs Irregular Menstrual cycles

Author- Dr Richa Sharma(IVF Consultant Mumbai)

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It’s a general concept even in layman that for pregnancy one needs to have regular and timely menstrual periods.But in certain patients periods may not come regularly ever since menarche.Besides they may have history of weight gain,acne, excessive hairs on skin of face, may need to go for threading more often than required and may have cousins, sisters or evn mother having same issues.Such symptoms and signs point towards –

 

  • PCOS – as the first most diagnosis
  • Hormonal imbalance- FSH,LH ratio change with high LH levels
  • Insulin resistance
  • May have add on Thryoid/prolactin derrangements

 

These patients generally have high body mass Index(BMI)but some fall into category of lean with periods regular.

What all these lead to is a situation called-Chronic anovulation- a common cause of infertility.

Most of such PCOS patients have normal FSH but high LH levels.Its a multifactorial condition with life long implications

 

What we can do about it ?

 

Yes we can do major part especially if weight is more then Lifestyle modifications alone will help to keep things on track but it needs constant action in a well planned manner.So tips to keep a check on PCOS-

 

  • Weight loss- at rate of 5-10% over a period of 5-6 months.If you have 80 kg then you should loose between 4 to max 8 kg only slowly with crash courses/diets or short cuts
  • Daily brisk walking at least for 30 minutes to burn extra calories
  • Moderate exercise on regular basis
  • Joining a structured programme like Gym
  • Take healthy balanced food(if possible with help of dietitician)
  • Cut down carbohydrates like banana,rice,rice products with a check on milk and milk products and less of fats
  • Keep proper hydration(3-4 LITRES of water daily)
  • Avoid junk foods with empty calories

 

Dear readers all these need to be followed as part of life and not till you have pregnancy as PCOS has more of chronic affects also later on due to tendency to gain weight due to hormonal disturbances

Polycystic ovary syndrome (PCOS) is diagnosed in

approximately 60–70%of women with such features.

 

How to plan pregnancy in PCOS?

 

Singleton live birth rates of up to 71% in 2 years can be

achieved in such patients with –

1) Induction of ovulation- it can be by clomiphene citrate as first line of treatment and Injectables gonadotropins as second-line

treatment with success rate varies from 2 to 3%

 

2)IUI- combined induction with IUI increases success rate from 8 -13% to 15-20%

 

3) IVF- not used as first-line therapy in these

patients, except for subgroups with a poor prognosis like-

  • Advanced age group
  • Longer duration of infertility
  • Higher insulin:glucose ratio
  • Failed ovulation induction
  • Other indications of IVF-tubal factor,male factor,unexplained/idiopathic infertility

 

 

Outcome of IVF In PCOS-

 

The outcome of IVF in women with PCOS shows variable outcome as-

Response to Medicines is the main issue- erratic(resistant to hyper) which is generally unpredictable

 

  • More oocytes obtained-with more of immature
  • Less fertilization rate- both mature and immature oocytes

of PCOS patients show reduced fertilization rates, presumably due to endogenous hormonal imbalance

  • More chances to have poor quality eggs
  • Chances of abnormal(aneuploidy)embryos is high
  • Inc chances to form endometrial polyp with recurrence
  • Inc chances of cancellation of cycle/use of high dose of medicines
  • High chances of first trimester miscarriage
  • But good part is despite reduced overall fertilization, IVF pregnancy rates in PCOS patients appeared to be comparable to normo-ovulatory women
  • Also live birth rates are comparable

Tubal Damage and Impact On IVF

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Female reproductive organs comprise of – Uterus,Fallopian tubes and ovaries.Altered function in any of these can land up into Assisted Reproduction with IVF as the last option with maximum success rates

Any discussion of the potential risks and benefits should also highlight the potential effect of delaying IVF treatment,

especially in older patients where other factors may

play the determining role.

Whenever we as patients are told about the status of fallopian tubes which normally need to be functional and dynamic for natural pregnancy to happen but when affected then it can vary from-

 

 

  • Complete blockage of both tubes
  • Unilateral blockage
  • Patent but non functional
  • Spastic
  • Blockage can be due to spasm,debris or pathology
  • Damage can be by Infection like Tuberculosis,scarring,post surgical impact,adhesions
  • Fluid accumulation intubes-Hydrosalpinx

 

Depending on the status next step will be either-As whether its damage or dysfunction

 

  • Try to open them by laparoscopy
  • Or Directly go for IVF

 

But the dilemma is as whether to carry out IVF directly or undertake tubal surgery – answer to this is based on –

 

  • Clinical assessment of the severity of tubal damage
  • Age of the patient
  • Availability of specialized surgical services and IVF

 

Similarly second doubt which comes in mind is the impact of tubal dysfunction on IVF outcome .Although tubal disease in

general is not associated with poor outcome from IVF,

there is increasing evidence that distal tubal disease

associated with hydrosalpinx may affect the chances

of success from IVF treatment. Many studies have shown that it can negatively influence the chance of success with IVF by decreasing implantation rates such that as per a combined study it was observed that there were

differences in pregnancy rates after IVF in tubal

infertility with and without hydrosalpinx, pregnancy

rates of 31.2% were observed in the absence of

hydrosalpinx and 19.7% in the presence of hydrosalpinx

 

Conclusion- Each patient is different so cannot apply blanket treatment to all.Need a basic work up and scrutiny before planning treatment protocol.If beginning is correct then we can have best outcome at end.Needs a systematic and Individualised approach

When Should We Opt For IVF

When Should We Opt For IVF –

 

IVF is the most refined treatment but not the first line of treatment.It has to be done as per the indication only.Sometimes delay in taking decisions may end up in opting for third party measures so what one need is correct and guided approach.

As patient we have many queries as why IVF only so here are the reasons as to when your clinician will advise you for same-

 

1)Fallopian tube damage or pathology-

Tubal block on X RAY(HSG) doesn’t always mean opt for IVF directly.In that case decision is taken as per level and grade of block ,age of female and married years besides cofactors

 

  • If tubal surgery is not possible then, IVF is method of choice.
  • In case of impaired tubal function but no occlusion is present, or following tubal surgery, IVF is method of choice after an infertility duration of 2 years or longer. Depending on the female age IVF can be done after a shorter duration of infertility.

2) Unexplained infertility (idiopathic)-

When exact obvious cause cannot be diagnosed after all basic work up of couple

  • IVF is indicated if the duration is 3 years or longer.

If the woman is older than 36 years, IVF may be

considered earlier.

  1. Male infertility-
  • Total motile sperm count < 1 million: first treatment of choice is ICSI
  • TMC > 1 and < 10 million: IVF can be performed if infertility duration is 2 years or longer
  • TMC > 10 million: treat as unexplained infertility

 

  1. Endometriosis
  • In case of mild or moderate endometriosis treat as unexplained infertility.
  • In case of severe endometriosis policy treat as tubal pathology

5) Cervical factor / immunological infertility-

 

  • After an infertility duration of 2 years, IVF is indicated. This may be considered sooner if the woman is over 36 years of age.
  1. Hormonal disturbances-

Like in PCOS if after multiple ovulation induction cycles patient fails to get pregnant then one has to plan IVF.No of cycles of Ovulation induction vary as per female age partner but shouldn’t exceed 4 cycles as after that there is no benefit of doing so

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Can I freeze Till Find Mr Right !!

Most women are  choosing to delay child-bearing and giving priority to their professinoal life .This also shows that the change in mindset and system in India and also suggests that women have an incredible level of control over their lives

With the miracle of science especially in the field of reproductive medicine has strengthened women to have more control on their body and lives especially in a stubborn society like India where though there is lot of hue and cry about saving girl child with minus output practically rather used as a marketing stunt only by the government and NGOs besides other greedy ones

Thanks for power of IVF which has actually empowered women and given her right to plan family and not to worry by the runing biological clock

That’s the miracle of modern Science

What is egg freezing ?

Its a technology in  which after basic work up of the female is first done and counselled about all steps she will undergo clearing all doubts.Then certain consents are taken and she will be planned for the ovarian stimulation

Once she gets her menstrual periods then ultrasound is done to check AFC along with basal hormones like Estradiol,Progestrone and LH.If all with in range the she will be given injectable medicines called Gonadotropins on daily basis keeping a check on growth of folllices.Finally she will be given ovulation trigger and the mature eggs are extracted, frozen and stored (oocyte bank). Later, when she is ready to become pregnant, the eggs can be thawed, fertilized, and transferred to the uterus as embryos after fertilizing with thePartner”s sperm

What are the indications of egg freezing and who all can undertake it ?

It started mainly for cancer patients but now its indications have extended over in cases o lack of male partner, single women,poor endometrium,alternate to embryo freezing, for research purposes, in certain countries where law doesnt permit embryos freezing, for export of eggs, in cases of Total fertilization failure recurrence

How safe it is ?

Its definitely very much safe and make sure you go for a lab with good results with good cryopereservation facilities as ultimately what we freeze we should be able to recover also else its all a futile exercise

How long we can store?

Depends on law of your nation and also the indication.Like In India we can freeze upto 1-5 years but there are reports of freezing even upto 24-25 years

 

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Cancer and Future Fertility-How To Preserve !!

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                                     Author-Dr Richa Sharma(IVF Consultant Mumbai)

 

Cancer is increasing in prevalence with improved detection and diagnostic techniques so prolonging the life and improving the quality of life.It has been observed to be affecting more of younger age groups so can have a lethal effect of the future fertility by destruction of their gametes (sperm or eggs). As doctor we feel need of spreading awareness at multidisciplinary level regarding preservation of future fertility which needs counseling and guidance at preliminary stages only before the damage happens.

Various Methods-

  • Oocyte/Egg cryopreservation
  • Sperm Cryopreservation
  • Embryo freezing

Method will vary as per the clinical status

Oocyte  cryopreservation.

Egg freezing means removing mature eggs and freezing them for later. This process may also be called egg banking . Its done in cancer patients preferably before exposure to chemo and radiotherapy.Its same like an IVF cycle except that embryos are not formed.Here  medications are given  to stimulate the development of multiple follicles in the ovaries.

Type of cancer can also decide the protocols.

Besides there are now more patient friendly mild stimulation protocol especially in estrogen sensitive cancers

The eggs are retrieved from the patient using a transvaginal technique under anesthesia and are kept frozen for future use by a method called vitrification.

Frozen eggs can be kept frozen for years(5 years as per ICMR but not specified for cancer cases) till the woman decides to use them for conception  and once the patient is ready to get pregnant, the eggs are thawed and then fertilized using ICSI, an assisted reproductive technology that injects one sperm directly into the egg. The embryos (fertilized eggs) will then be transferred into the woman’s uterus (womb) in order to achieve a pregnancy.

 

 

Embryo Freezing 

 

It has the highest success rate compared to any other treatment.  Its like normal IVF when eggs are retrieved and mixed with sperms. Once fertilized, the embryos (fertilized eggs) grow in the laboratory for 3-5 days until they are suitable for freezing.

 

Sperm Freezing


Sperm Freezing is an effective and simplest way for men who have gone through puberty to store sperm for future use. Many men can store sperm (either from natural ejaculate or from a TESA sample