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

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

4. USG Guided Follicular Aspiration
5. Elective Embryo Cryo Preservation and Transfer in subsequent cycle
6. 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 RegularVs Irregular Menstrual cycle

IVF Success in Regular Vs Irregular  Menstrual cycles

Author- Dr Richa Sharma(IVF Consultant Mumbai)

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