How to handle
infertility treatment

First stage. Very understandable. Imagine being young and healthy and never having to see a doctor for anything. Imagine being told by one and all why delaying getting pregnant is so much important. And then imagine that when you are ready and trying it's not happening. Something one does not even think of ever. As infertility is not usually associated with any outward symptoms, it is difficult for couples to accept that it could exist in their case.

To add to the confusion, when the couples see gynaecologist for the first time, they are usually told that all seems to be right. This is taken at face value by most couples. So when faced with any adverse information, there is a sense of denial that works overtime.

Why is it so?

See, infertility is an outcome when any of the following factors are not working out. The semen may not be optimum, the eggs may not be growing or of good quality, the tubes may not be working, uterus may have some issue or even sex may not be happening correctly.

It is never possible to comment what is wrong just by looking at a couple or by running some tests. Even tests do not reveal everything. Semen analysis done at three different times shall show three completely different reports. Which one to trust? Whether tubes are ok or not are very tricky to check.

Hysterosalpingogram is not always reliable. Laparoscopy may be better but even then tubes may be internally damaged. We check the AMH values to assess the ovarian reserve i.e. number of eggs in the ovaries to plan treatments accordingly. This AMH value varies widely from lab to lab due to various kits being used. So the net result is total confusion.

In such a scenario, I have to tread very carefully. What I do in my first meeting is to establish that pregnancy depends on a host of factors some of which cannot be checked by conventional tools. This is done by explaining how a pregnancy actually happens. Then I state something that seems obvious. The fact that they are seeing me means that something/s are not working for them. We need to keep this premise in mind when planning a treatment protocol.

Keeping this in mind we try to counsel for 3-4 cycles of trying naturally with medications to make eggs grow up. If the eggs were not growing up properly or sex was not happening at the right time, then this shall suffice.

Next step is two to three cycles of insemination. This takes care of a lot many couples. Once pregnant we can come back and claim that they were not conceiving as they had sex issues or the sperms were not getting to go into the uterus via the cervix.

If both fail, laparoscopy or IVF is indicated. Put together, trying naturally, inseminations laparoscopies and IVF would ensure pregnancy for most. There still be a minuscule population left who may need donor sperms/eggs to get a pregnancy and rarer still may be a surrogacy. Very very few people would still not be blessed by now.

Good news is that about 12% couples have children even after failed IVF. This is not as strange as it may sound. When we do IVF, we work with the eggs generated in that month. If they are bad for some reason, the cycle goes bad. The same person can very well make good eggs the very next month and conceive naturally. Having this knowledge can actually prepare you for the road ahead.

This is the best case scenario as far as the selfish me is concerned. The couple walks in aware that they have a problem and more importantly, willing to consider a solution to their problem; be it natural or assisted.

We face a different kind of stress or challenge here. The challenge of matching expectations with reality. The real picture of the inseminations working once in 6 cycles or an IVF working once in three cycles is a major one. Most people, quite justifiably expect more from us. The breaking down of the success rates into patient types and age group is vital. They have been on web and read of fantastic too-good- to-be true results and that has to be explained sensitively.

My take on success rates is as follows: someone with mechanical reasons like tubal disease is much better off than someone with egg quality issues. And of course younger person is better off as she has better eggs.

So for IVF cycles

Egg donation or embryo donation has very good per cycle results in excess of 70% with two grade a/b blastocysts being transferred. Of these some 15% will miscarry and so about 55% would end up with a child birth. This is for per attempt. Chances increase over number of attempts. This kind of results is never possible in self IVF patients unless we are looking at a young woman of 27-28 age group with tubal disease as the reason for IVF.

I would peg IVF result in my clinic around 45% per attempt with severely compromised sperms. However the miscarriage rates are higher in this group to the tune of 20% leading to 25% couples giving birth with every attempt.

For poor quality eggs, IVF results are pretty low. Less than 20% pregnancy rates per attempt. Here again I would divide patients into two age related categories: younger women with fewer eggs due to endometriosis are still doing ok. About 30% or more results per cycle. But women more than 36 years age and low ovarian reserve somehow fare only 15% or thereabouts.

For IUI patients

There is a debate whether IUI is to be considered Assisted conception method or not. With an IUI, we introduce the patient to the world of assisted conception. But there are so many answers not known when we attempt an IUI. So while it works fine as an initial tool, its results are very unpredictable. If we ask a PCO woman to undergo IUI, she stands a good chance about 25% per cycle as because she has a problem growing eggs and not anything else. In fact she could do without IUI as well but we do so as that ensures delivery of sperms. Sex may be erratic after so much effort has gone into growing the eggs via medicines and injections.

For donor sperm inseminations we would expect much higher results but unfortunately it is only about 13% in my clinic. Is it because of frozen sperms? I really do not know. For the rest of the patients, IUI has a dismal record. About 6-8 % results per cycle. What it does however it to rule out sexual dysfunction as a cause as most people with sexual dysfunction would conceive with IUI, even if they have not owned up to it during our conversation.

Here, I must mention that the first IUI failure is the most painful one. While rationally all of us understand the limitations of IUI, when a couple actually takes an IUI procedure, they still believe that this time it is going to work for them. When it does not, there is disappointment and a tendency to delay or drop out of treatment. Please allow yourself time for grief but do not give up. As I keep saying, we do not even know why the pregnancy is not happening and unless something is seriously wrong somewhere; most couples would actually get pregnant some day. So hanging in there is most important at this juncture.

Sometimes the stress is to do with the spiralling costs. Here a cold headed calculation is needed to understand the least costly way to a pregnancy. In most cases that is best via IVF cycles. IUI is fine for trying but for real results and cost benefit it is IVF that works far better. Even with IVF in some cases when the age is on higher side or AMH values are low and the age is high, it is more cost effective to consider egg donation rather than self IVF. Of course one could choose not to go with egg donation and I absolutely respect that.

In fact, for people not so concerned with costs, I keep saying that IVF is sometimes done for satisfaction and not always for success. We all would ideally want all IVF patients to conceive in their very first attempt. But it does not pan out this way in real life. Especially in women with age more than 37 and AMH low, as mentioned before there would be more failures than successes. But then we do go ahead after counselling with self eggs in these women. Reason being that everyone deserves a chance and having tried and failed is still more satisfying than not having tried at all.

Most critical stage. Thousands of thoughts play in the mind regarding success rates and how to improve that. Are we with the right doctor/ team? What is it that is best for us? etc etc.

Let's get some things clear. There is no perfect doctor as there is no perfect patient. We have to choose wisely. And take time to choose. But once decided it's a rollercoaster where we both have to be together.

How to choose a doctor or a team to take care of you?

This is a million dollar question really. In today's age of advertising and self promotion, be sure that all clinics and doctors have put out wonderful things about themselves for you to read and hopefully believe!

And then you have trollers who prey on successful clinics and doctors and put out horrible reviews so thatthey make some money out of this by blackmailing the doctors/clinic.

Either ways, it is apparent that over time, reviews etc are becoming unreliable as people find out ways to manipulate the same. And people also realise that.

So how does one choose the right doctor or clinic?

There is no real test. Anyone can shout from rooftops saying his or her results are the best; they are not verifiable in our country. Different doctors have different thresholds; for I have seen and read of clinics advertising their labs being the best but they are decidedly not so. So there is always an element of being economical with truth.

I feel that people who resort to aggressive advertising are to be avoided. I do not know why but I cannot associate advertising with healthcare. Not comfortable... if you know what I mean. But that does not mean that all who advertise are bad.

There are numerous websites which list a few points you could check on to choose the right one. Even then you may end up with a couple of choices. Please see them all for the right vibes prior to finalising.

I find Google very trustworthy. We could always be wrong in choosing the right doctor but then once treatment starts and that is not matching with what Google says then it is time to rethink. Do not be ashamed to change. It is lot of money and lot of emotion. Some doctors may speak very warmly but may be hiding unpleasant truths, some may be blunt but laying out facts as they are. You need to corroborate what you are told with what the reports say and what is Google saying on same. Best links to look up in Google are again not clinic websites but those which are run by societies or government sites. I have made a list of reliable websites for you to refer to.

List of reliable websites:

• First Visit IVF
  Includes a helpful general Introduction to terms and expectations for new IVF participants
• American Society for Reproductive Medicine: HIGHLY RECOMMENDED
  Please find time to read the patient documents carefully. Loaded with accurate information in lucid language.
• The American Fertility Association (AFA)
  A national, non-profit organization which provides reproductive information, a national newsletter, support groups, advocacy support, and research support.
• RESOLVE: HIGHLY RECOMMENDED.
  The National Infertility Association since 1974. A non-profit consumer organization serving the unique needs of individuals experiencing infertility with support, education and advocacy.
• Polycystic Ovarian Syndrome Association
  A national, non-profit organization operated by women with Polycystic Ovarian Syndrome.
• MEDLINE PLUS - Infertility - Health Information
  A service of the National Library of Medicine.

The final frontier as it was. Not really, none of the treatments are finite and can definitely be repeated. So failing one attempt is not really as heartbreaking as it seems at first sight. Factually speaking, more than 80% IUI treatment cycles fail. So failures are so much commoner than successes. But for the couple who have just about convinced themselves that they need IUI to get pregnant which happens easily and often unwantingly to all their friends and then to encounter failure is understandably difficult. But this is the way it is and quicker one is back on their feet, the better it is for them.

Basically in IUI all that is being done is that the woman is stimulated with medications to help grow her eggs and then the partner’s sperms are deposited in the womb at the time of release of the egg/s. Scope of going wrong exist at different levels. The egg that has grown may not be of good quality and this cannot even be predicted from outside. The egg that does develop may not be released from the follicle in which case of course it shall not be picked up by the tube and no pregnancy shall occur. This is rarely seen and even more rarely confirmed. So if this does happen, IVF may be needed. In any case, eggs that form every month are probably not picked up the tube/s every month even in normal circumstances.

What options does one have if IUI fails?

You could try again. And again. Most couples can actually try till 3-4 attempts to see if the process works or not.

But sometimes even 3-4 attempts do not work. That’s ok. Remember you walked in for a child, not to get a pregnancy via IUI or IVF or any such acronym. Anything that works for you is ok. Sometimes when you have been offered IUI, you should consider yourself lucky. Maybe the doctor feels that you may not need IVF. So when IUI does not work, please do not despair. It is by no means end of the road.

First of all, let’s try to understand why IVF fails?

IVF involves putting together eggs and sperms to form embryos and then replacing them into the womb. If the eggs or sperms used to make the embryos are not healthy, then the embryos shall not be viable i.e. not yield results. If the womb is not receptive, then the embryos shall not implant and finally if one is not able to replace the embryos properly ten also the result would be negative.

Most of times the failure is linked to bad embryo quality. Judging embryo is tricky. We put egg and sperm together. We hope the embryo thus formed shall be of good quality. But if we were to bet our last penny on it, we would run away. As no one is really sure that the one embryo we describe as good is actually good or not. Why so? The embryo formed out of the sperm and egg is monitored in the lab periodically under microscope. During this monitoring, all we can do is to count the number of cells that have formed. So if the embryo has grown to 4 cells 48 hours after formation or to 8 cells 70 hours after formation, we call it a good embryo. Most of the times embryos are put back at this stage. This is too little information to judge an embryo. It’s like predicting that someone would be a top footballer by seeing him kicking a ball when he is two years old! The least we can do is to allow the embryo to grow longer at least till we can. The ones that are really bad would stop growing and so we would have a better selection.

Even if they have survived till the stage of blastocyst (Day 5 after formation), we still nowhere near surety. They could be genetically not right. At present, we are unable to check for that. We can do PGS which is preimplantation genetic screening of embryos to find out the gross chromosomal errors but by and large this is not a perfect or a fully predictive technology. Even then there is a choice that does exist.

And when we do PGS for so called good looking blastocysts, we realise that younger women have much higher proportion of healthier embryos than women in their late thirties explaining partly why results are worse in such women inspite of good number of embryos.

Finally even those which have grown to blastocyst stage and are predicted normal by PGS are not necessarily functionally alright. There could be metabolic or digestive errors which may prevent the embryo from turning into a successful pregnancy.

Let's look at the loss of eggs all through the IVF process and the corresponding pregnancy rates:

So as you now understand, making embryos is the easy part. Selecting them is the tough part. Once we are there as far as selecting embryos is concerned, our results would be lot better than they are now.

The uterine lining receptivity is another area of discussion. Every month, there is a new lining that develops inside the womb. This lining is dotted with numerous so called pinopodes whose job is to attach the embryo. But these pinopodes are shy creatures. They appear for a brief time. If the embryo is replaced during this time, good for the embryo it can attach itself. If not then even the best embryos shall fail to attach and go waste.

The expression of these pinopodes is not consistent in some women so at times embryos transferred at the non matched time may be the reason why IVF fails. This is a rare reason and needs to be investigated only when we have ruled out other issues.

And then once in awhile the embryos which have been placed inside the cavity are not rally placed properly. We rely on either instinct or check with an USG while placing the embryo. But sometimes the embryos are not released properly in the right place or the embryos may get trapped in the mucus plugs blocking the cervical canal in the path of entry into the uterus. But this is the rarest of the causes.

So as you see it is the embryo that largely determines the outcome of the cycle. And this embryo/s is not a fixed phenomenon. Someone who forms bad embryos this month can always form good ones next cycle.