Egg donation in IVF

A common scene in IVF clinics is when we fertility doctors have to break the news to the couple that the lady has exhausted her own eggs and egg donation would be the best/only way to have a child. Unfortunately the threshold for using donated/shared eggs is reducing very rapidly.In some clinics the doctor has to only see the lady's age at 40 to solemnly nod her head and say a “NO” to IVF with her own gametes. While most women at or just above 40 do have a poor ovarian reserve, there are some who still have a few good ones left. Especially the women with a shorter duration of infertility like a 40 year old who is married only for a couple of years versus someone her age who has been trying for say 15 years.
Recently a lady41 year old who had been refused IVF with her own eggs at two clinics came to us for IVF. While the ovarian reserve was borderline, we took her up for IVF. Some tweaks in our usual protocol and we got 4 follicles which gave us 4 good quality oocytes. All four fertilized after Intracytoplasmic sperm injection and resulting four embryos were transferred to her uterus on day 2. The reason for transferring four embryos was her age (usually we transfer about two or three embryos). And on day 18 post egg pickup it was what patients call a “BFP”: a Big Fat Positive with beta HCG value of about 480 IU/ml.
A transvaginal scan done today showed a single gestational sac with a good embryo and steady embryonic heartbeat.
It is days like these which make the toil and tears worthwhile.
And reaffirms our belief that third party reproduction with donated gametes or surrogacy is always the LAST option.
So, if your doctor suggests that your best chance is with donated eggs, wait before you take the plunge. Take a second opinion, do your research and hunt for a clinic that respects your right to genetic procreation. Who knows, your own baby may be waiting for you at the end of that long dark tunnel.

Right to records

It baffles me to no end when patients who have done IVF cycles come without any records of the treatment.
All of us know that IVF is not successful 100% of the times. So any patient who has one cycle, is likely to need another one in future. Whenever we plan the first IVF cycle, the protocol chosen is an educated guess from the details like the cause of infertility, age, condition of the ovaries and the hormonal profile. What we always cannot predict accurately is how the patient will respond to the drugs, the quality of resulting eggs, number of fertilized embryos and their quality. In the second cycle, we know all these details from the previous cycle ( provided they are recorded and given to the patient by the clinic!).
I always compare the first cycle of IVF to choosing a dress of your size in a shop: you choose the closest fit: Small, medium or large and buy it. It might fit you very well, or might sag in some places. The second cycle can be tailor made exactly to your response: the dose, protocol, culture protocol all can be modified learning from the first cycle  to optimize the cycle so that it fits you like a glove.
As a doctor, it is our duty to give the details of the dose of medications, protocol, number and quality of eggs, hormonal levels during treatment, fertilization rate and embryo number and pictures to our patients. This information is priceless. God forbid if the treatment doesn't result in a pregnancy, this information can help us ( or another clinic, should they decide to switch doctors!) tailor anther ivf cycle much better.
As a patient, it is your right to receive all this information. Always ask before you start the treatment if the clinic parts with this information.
If not, maybe you are not seeing the right doctor. Know your rights to get it treatment right!

Why I don't like to show baby pictures...

Enter any fertility clinic and you will be inundated with pictures of babies. They stare at you on the walls of the waiting area, in the consultation room, on the websites and in the newspaper ads for these clinics.
And why not? The doctors running these clinics feel that these babies born out of IVF are their best testimonials. After all, the doctor 'made' them. They feel that these pictures inspire confidence in the patients waiting for consultation and treatments. Give them hope that there is a baby waiting for them at the end of the agony. Some clinics go so far as advertising their IVF success with the names and pictures of couples with their babies ( even mobile numbers!). In what could be the last travesty, a clinic advertised their monthly success in IVF with a photo of beaming couples with their pregnancy test card in their hands showing two lines! ( Not withstanding the fact that success in IVF is not achieving a pregnancy, but birth of a healthy child).
We consciously keep away from displaying pictures of babies born after IVF in our clinic. Babies are little people. They came thorough us, but we do not own them. They are individuals and just because we happened to be with them in a small part of their journey to life, it does not give us any right to use them as publicity props.
This does not mean that we don't love receiving baby pictures. Everyday, my day begins with pictures of IVF babies sent on watsapp. Its an overwhelming feeling to see them grow and feel a part of their journey.
Neither do we have anything against clinics who publish the baby photos in ads or display them in clinics. But we respect your privacy. I welcome couples who want to share their fertility story with other couples who are struggling with infertility. I think it is best way to add good karma to your life. But your baby is your own.We were with you on the wonderful journey for a while, but we will never showcase it for our selfish gains.

The Doctors of Desire

A doctor is supposed to know. That is what they are paid for. They have supposedly spent precious decades of their lives learning all about the maladies that afflict the body and mind. And so they should know why the disease occurred, how bad/advanced it is and how to treat it. And of course they should be able to tell us when it will get better and how.
Everyday I encounter patients in my OPD who at the end of the consultation bend forward in their seats and ask me only one question, Doctor will I have a baby? and to be honest, I don’t know. I don’t know when they will conceive, I often don’t know why they can’t conceive and sometimes I even don’t know whether they will ever conceive at all.
Welcome to the world of infertility, where even the best doctor and the best clinic can most times  give you only an estimate of your chances to conceive.
This is baffling for most of us. But look at it this way, infertility is not a disease. Conception, the meeting of an egg and sperm and subsequent implantation and growth in the uterus is just a coincidence. There are many things that could go wrong with the meeting of the sperm and the egg. The sperm may not turn up while the egg waits for it in the fallopian tube. Or there is no way the twain can meet as the passage ( the tube) is blocked.  and there are hundreds of other things that could go wrong and result in another period..
The chances that a couple could conceive in a month ( when there is nothing wrong with the tubes/egg/sperm/uterus) is only 25%. If there is something wrong with either or both of them, the chances dwindle.
When the estimated chances for a couple are less than 5% when they try naturally, we advise them to go for In Vitro Fertilization. Couples who agree for an IVF cycle are in for some more surprises. Their treating doctor does not know for sure how many eggs would be produced, how many would be fertilized and how many embryos would be formed. And the biggest surprise, the doctor doesn’t know if they will fall pregnant this cycle.
We throw figures and estimates and percentages at every question ( ‘we expect 8 to 10 eggs’, ‘usually 70% of the eggs retrieved fertilize’ and ‘you have a 40% chance of conceiving this month’). A worse situation is a patients coming after a failed IVF cycle for a repeat cycle with the same question and getting the same answer, ‘I don’t know if you will conceive this time around’.
I once told a share broker who came for IVF that IVF is a lot like the stock market. There are experts who study, analyze and opine about the likely way in which the market will turn. But their opinions, based on a lot of study and analysis remain conjectures or educated guesses and no one for sure can predict which way the stocks will go. That doesn’t diminish the importance of the market gurus though.
In IVF too, an experienced and qualified doctor will tell you an estimate of your chances on the basis of your clinical profile. But because infertility is not a disease, it is difficult to know when exactly it will be ‘cured’. We are out to create a new life and with all our technology, experience and skill we can not tell you if that pregnancy test will be positive this month. We are the doctors who don’t know. The doctors of desire.
But we know one thing, if you try the right way, the right place and the right time with the right doctor, the answer to the question ” Can I conceive?” is “YES”

'con'ference 'in'ference

There are various reasons why doctors attend conferences. A break in the monotony of work, a vacation with family, a chance to showcase ones work, to network with colleagues, sometimes all of these.Rarely, it is for learning.

For beginners like me, it is most often latter.People like me do not harbour political ambitions(yet), and most of our socializing is done on facebook. And in my case it is always out of hard earned money(mine!).The last year was a disappointing one for me. Every time, the purpose was defeated and I returned fearing that I had forgotten  whatever little I knew, leave alone learning something new.A mega conference on a focused topic in infertility actually turned out to be a mish mash of all the topics under the Sun with confusion reigning supreme. Another one had more faculty than delegates.Still another one had the same old wine in old bottles with new labels, served by same old faces.
This was enough to put me off conferencing for a while. Meanwhile, the flyers/brochures/emails/sms alerts about impending conferences continue unabated.
Some DVDs of conferences had been lying around. I saw them today and thoroughly enjoyed the experience. Here I could choose the topic and speaker, skip across the bits that drag, repeat what I liked. No hopping from hall to hall, schedule in hand, bumping into an acquaintance and missing the whole session while catching up. The only theoretical advantage of attending one in person is that of interacting with the speakers and faculty. But almost always, the lectures are long drawn and leave no time for questions or interaction. The sessions start late, the speakers overshoot time limits, chairpersons eat up whatever remains with their sanguine remarks and by that time the attention span of the author is vastly overstretched. So what began as a tryst for knowledge ends as a quest for the nearest coffee table to stave off sleep.
So one resolution for next year is going to be to be to go green. Leave a smaller carbon footprint and attend more conferences virtually.So that no one can 'con' me out of my hard earned money, and I can still be 'in' touch with whats going on in the field of infertility and assisted reproduction. That is the 'Con'ference 'In'ference for this year!

The Blue Bicycle and the Cycle of Want.

Years ago, when I joined a new school in a new city, the parents got me a bicycle. It was a Blue Atlas, a hand me down from a family friend. It was old, but otherwise in perfect working order.Only that it was made for someone half my height. At 5 feet 7, I towered over most kids in my class ( most kids in my school rather).I am sure it must have been an amusing sight, my towering frame perched on that small cycle, paddling away to glory. We accompanied each other to the new school, settled into a routine till the new was not so new anymore. And then, the teasing started. One boy started calling my blue bicycle 'Priya's Ranger '. Ranger was the latest range of Hero cycles... with broad tyres and straight handle and trendy rugged looks. Children can be far more cruel than adults, and the teasing got worse. I started leaving for school earlier and parking my cycle at the back gate of the school. Then I stopped taking the cycle to the school and took a city bus. And finally one day I asked folks to get me a new cycle. Meanwhile, the pressures of exam and other activities meant that I could not waste a couple of hours everyday in the bus, and then again , reluctantly and resentfully, we went to school together. I tired to increase the height by elevating the seat and the handles, and it ended up looking funnier and uncomfortable.
The bicycle became the center of my existence. The first thing I checked in the newspaper was the classified with the offers for the new cycles, their price and the schemes. The first thing I noticed about anyone was their cycle.I hated the blue bicycle like I have never hated anyone or anything in the world. what I remember most about those days is the sense of helplessness at not being able to do anything to get rid it.
Then one day I read somewhere, "Judge someone not by what they have, but what they are". and after that, I tried to find solace in this. But inwardly vowed that when I grew up, there will not be any blue bicycle in my life.
And so it happened. I got what I wished, almost always.And almost always, more than the things that money brought, the empowering feeling that I could buy them was more enjoyable. It was a heady feeling to decide what you want and get it right away.
Till some days ago, when a colleague showed his spanking new gizmo, and I was sold. The apple of temptation beckoned again, and I was more than eager to yield to it. The blue bicycle syndrome was rearing its head again. Somehow this time, I looked at myself and realized that all the buying in the world cannot make up for the blue bicycle. The urgency to distinguish between needs and wants hit me.  
The blue bicycle has finally been returned to where it belonged, in the past. And I am happy with oranges, apples will come when they will.

The Interview

The interview was going well. Except the lady with spectacles who was buried in her file, the three professors nodded and made relevant noises to all I said. Once when I was wandering off to a tangent, the gentleman gently goaded me back and hinted at the right answer. They collectively shifted in their seats, signaling that the encounter was about to end. Just as I relaxed my guard and began thinking about the train that I had to catch that evening to get back home came the last question. Like the typical interview which does not end without an open ended question, the lady asked me " Tell us something about yourself"

And instinctively, I started" I am mother of two kids, they are both boys..." And as if there was a tremor in the ground or a volcano rumbling, the interviewers, suddenly, with all alertness were staring at me. The lady in spectacles was finally looking up from her file, mouth agape. I continued to wax eloquent about my kids...maybe two more sentences and then I realized that it was not probably the right thing to say. Not at the interview for a super specialty course at the top medical College of the country.But by then it was too late. I could see the coveted seat slipping out of my reach. And I inwardly cursed myself for answering without thinking.
Today, almost three years later, the moment is still alive in memory. And even today I wonder what made me answer the question the way I did. But then, I know many women who would answer the same way when asked about their lives ( though not at a job interview). Whatever we may be professionally, we are always 'Mothers first'. The first thought is always about the kids.We may be authors, doctors, singers, actresses, scientists, engineers for some hours in our day... but we are mothers 24X7. Our lives sometimes seem to serve the sole purpose of making their lives easier.The attachment is a visceral one; something like letting your organ grow outside your body.
We may be many things at home and at work. But undoubtedly, the one role that we take on most instinctively and naturally is the role of a Mom. In fact, it isn't a 'role' at all. It is just who we are . And so, even today if you were to ask me who I am, I would say Anurag and Avijits' mother and then may be think of other things that I am.

And yes, I got the seat.I suspect because women outnumbered men in the panel. And I also suspect they thought the same way about themselves :)