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  

Tubal Damage and Impact On IVF

 Tubal Damage and Impact On IVF

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.

3. 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

4. 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.

6. 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