Saturday 23 April 2016

Story of One Embryo...

It’s the embryo in the room, the one we rarely talk about. It’s been almost four years since I did my last and final embryo transfer, resulting in our second (and final) beautiful boy. I was 36 the first time I did IVF, and a few weeks shy of 41 when I gave birth to baby number two. My husband and I had already agreed to stop at two children, and a grueling and painful pregnancy and labor sealed the deal.

Now, one embryo remains.

The first time the bill came, my husband paid the storage fee without discussion. It’s expensive, hundreds of dollars, but I was still pregnant and it was an unspoken insurance policy after years of infertility struggles, a miscarriage, two ectopic pregnancies, two emergency surgeries, and a ruptured (and decimated) fallopian tube.

By the second time the bill showed up, our newest baby was successfully part of the human world. My husband called me at work. He is a straight shooter, not a man of trepidation, but even he was cautious. “We need to decide whether to pay the fee for the embryo storage,” he said carefully. I begged him to just pay it, and we could talk about it the following year. I had two beautiful children—one an infant—and was a mess of exhaustion and hormones. I didn’t even want to think about this embryo.

He paid the next year’s bill without asking.

And now, on the eve of my youngest son’s 3rd birthday, I dread the thought that my husband might be ready to stop paying this bill and might call me any day now to discuss the embryo that remains.

It’s inexplicable, in many ways, this dread that I feel. I am adamantly pro-choice, and strongly believe that an embryo is just a little ball of cells with as much potential for a wonderful future baby as the egg that painfully bursts out of a cyst and bleeds out of me every month or the sperm that comes out of my husband on an indeterminate and none-of-your-business basis.

Before she performed my first IVF transfer (resulting in our oldest son), the doctor showed me a picture via a magical projecting microscope of the two blastocysts that she was about to insert into my cervix. I was high on valium and giggled at the images on the wall that looked like balls of spider eggs. I didn’t feel attached to these cells, just hopeful that they would stick and I would finally be a mom. When one did stick, I didn’t shed a tear for the one that didn’t—I cried with elation for the one that did, and I reveled in a joyful, fairly easy pregnancy.

But when it was time for our second, my husband and I were struggling in our marriage and in disagreement about when (and if) we should try for our second. After a year of therapy, we were ready, but I was a year older, and the stakes felt high.

We’d had three embryos frozen after my first transfer. After months of shots and pills and patches to prepare my body (more than the first go-round, as my body had aged), the day of transfer number two arrived.

I was again high on valium, but anxious this time instead of eager. My husband, in a great display of magnanimity, told me before the doctors came in that we could implant two embryos, if that’s what I wanted. Two! We could have twins! I kissed him and was trying to process the appeal of this through my foggy brain when the doctor came in.

“I’m sorry to tell you, but only one of your embryos survived the thawing and is ready for transfer.”

I burst into tears.

Suddenly, I was devastated. This would be our last try. We would not spend another $20,000 or go through the entire process again. Had another embryo survived, we could have tried again if this failed—the transfer alone is less work than the whole IVF process, and much less expensive.

This time, instead of being elated with the projection of the single blastocyst on the wall, I was terrified. After we returned home, I lay on the couch with my legs up for the next 24 hours, taking no risks of harming this one blastocyst or preventing it from implanting itself firmly into my uterus and into our family.

I cried. I cried all day, all through the night, and all the next morning. My husband occupied our toddler, doing who knows what, so Mommy could cry.

And then, the call came. It was the fertility lab—the people who thaw things, the scientists who seem to me like wizards.

“Ms. Swanson, we are calling to tell you some exciting news! One of your other embryos survived after all! It just needed a little more time to thaw, but it fought its way through! Since you already did your transfer, we just need your permission to freeze this one again for the future.”

I cried harder, a feat I didn’t think possible, with tears that I thought were spent. Yes, yes, I told them. Of course! A little fighter! Save it!

Suddenly, my little ball of cells was a fighter—a fighter that I would keep frozen for as long as I could. Rational thought was lost in an instant, and this embryo became more important than I had ever imagined.

I know the day will come when my phone will ring and it will be my husband, sighing, holding yet another bill in his hand. I know, objectively, that my little fighter is simply a pile of cells. But for now, I long for my husband to quietly continue to pay the bill and wait for the day that maybe, just maybe, I will simply forget that this embryo is waiting. The one that remains.

Thursday 21 April 2016

Nothing is Impossible... IVF makes 52-year-old from Meerut a mother again:


Fifty-year-old Venu and her husband Captain Sanjeev Juneja were shattered to lose their only child, Harsh Juneja, to a botched surgery at a Delhi hospital in 2012. Their son was just 27. Venu slid into depression soon afterwards, and her 57-year-old husband was haunted by the possibility of losing her too. On October 9, however, after something of a medical miracle, the couple had a baby girl. They named her Harshita in remembrance of their dead son.

To recover from the loss of their son, the two had earlier considered adoption. Under guidelines of the Central Adoption Resource Authority (CARA), the added age of parents seeking to adopt a child less than four years old must not be over 90. A couple seeking to adopt a child up to eight years old must not have ages that add up to over 100. The added age of the Junejas was 107. That made them ineligible for a young child. The two were wary of adopting an older child, fearing he or she would face problems adapting to them.

The Junejas are residents of Hong Kong. Capt Juneja, since his retirement from the Indian Navy over a decade ago, had been working as a consultant at a merchant navy firm in that country. They had also applied for adoption in Hong Kong, but were told the minimum waiting period would be two years.

Keen not to delay the process, the couple decided to try In Vitro Fertilization (IVF). An emotional Venu told TOI, "We were left with no option, but the odds were against us. The medical reports showed that I was not fit enough to be a mother again. We were literally shunted out and mocked by the medical fraternity for even thinking on those lines."

The two visited hospitals and clinics in Australia, the US, New Zealand and Hong Kong. Everywhere, they were turned away. Venu had multiple fibrosis and suffered from adenomyosis (a condition in which the inner lining breaks through the muscle wall of the uterus). Doctors examining told her that far from conception, what she should really be considering was hysterectomy (removal of uterus) as her condition was worsening.

Just when the couple was beginning to grow despondent, a friend of their dead son came with some hope - he convinced them to try visiting IVF specialists in Meerut, who held the rare distinction of assisting a genetically male individual (with XY karyotype) deliver twins (TOI reported this on February 9).

The couple met Sunil and Anshu Jindal, IVF specialists at one of Meerut's top hospitals.

"They came to us two-and-a-half years ago. Venu's condition was really pathetic. Apart from failing uterine health, she felt hatred towards the medical world, which she held responsible for her son's premature death. We had to tackle both these problems."

Sunil Jindal explained: "Venu's uterus was full of fibroids. She had the scars of a previous myoma (benign growth) surgery. To save her uterus was our primary concern. To clean it, we had to remove eight tumours. We treated the adenomyosis. After one year of treatment, she conceived. In the fourth month, she began to bleed, but with God's grace, we succeeded in the end."

Two-and-a-half years after they landed in Meerut and a series of complications later, Venu, at the age of 52, delivered a healthy girl on October 9. With tears in her eyes, Venu said, "The system that took away my Harshit has now given me my Harshita."

Asked how it felt to be a father again at 60, Juneja smiled, "I have forgiven the doctor whose negligence took my son away. Now I have to make plans for my daughter."

Dr Narender Malhotra, president-elect, Indian Assisted Reproduction Society, told TOI, "Doctors abroad observe stringent laws and are cautious. India offers a ray of hope to people desperate to be parents."

Source: TOI

Two biomedical advances are going to change how humans reproduce: whole genome sequencing and stem cell technology.

I confidently predict that people will still be having sex in 20 to 40 years’ time, but they will be using sex to conceive their babies much less often.

For over 25 years now, some babies have been born after something called pre-implantation genetic diagnosis (PGD). Three- to five-day-old embryos have some of their cells removed and subjected to genetic testing. Parents and doctors then decide, based on the test results, which embryos to transfer into the womb in the hope of making a baby. Last year 3,000 to 4,000 babies were born in the US after PGD without any obvious safety problems.

PGD will soon get much better, becoming what I call “easy PGD.” Cheap whole genome sequencing is one reason. The first whole human genome was sequenced in 2003 at a cost of about £350m. Today, a whole human genome sequence costs around £1,000; in 20 to 40 years, it will be far less. Before, PGD was able to look at one or a handful of genetic traits; it can now look at an embryo’s whole genome and the futures that genome implies. That will make PGD much more useful to parents.

The big problem with PGD, though, has been that it requires in vitro fertilisation (IVF). Invented in the UK nearly 40 years ago, IVF has been a godsend for millions, but it has not been easy. Harvesting eggs from a woman’s ovaries is expensive, uncomfortable, and somewhat risky (life is unfair – sperm collection usually has none of those problems).

Stem cell technologies will bypass egg harvesting. Instead we will take a woman’s skin cells; turn them into so-called “induced pluripotent stem cells” (cells very similar to the famous embryonic stem cells but made from living people); turn those cells into eggs, and mature the eggs in the lab. This would not only greatly reduce the cost, discomfort and risk of IVF, but would allow each woman reliably to produce hundreds of eggs (or more). It already has worked in mice and the first steps have been taken with humans.

The result will be easy PGD. A couple who wants children will visit a clinic – he will leave a sperm sample; she will leave a skin sample. A week or two later, the prospective parents will receive information on 100 embryos created from their cells, telling them what the embryos’ genomes predict about their future. Prospective parents will then be asked what they want to be told about each embryo – serious early onset genetic diseases, other diseases, cosmetic traits, behaviours, and, easiest but important to many: gender. Then they will select which embryos to move into the womb for possible pregnancy and birth.

Easy PGD will not produce super-babies. Genes aren’t that important. But it will produce children who have little or no chance of some serious diseases; better than normal chances of avoiding other diseases; preferred hair or eye colours; slightly better chances of high maths, sports, or musical ability; and who are of the parents’ preferred sex. The health and behaviour differences are likely to be about the same as the average differences between being born to rich parents and poor parents – not enormous, but not trivial.

These would not be designer babies. Parents could only select from the genetic traits they carry. New gene-editing technologies such as CRISPR may eventually make it possible to edit embryos, but easy PGD, and its selected embryos, will be safe, effective, and available years sooner. I suspect selection also will be more attractive to those many parents who want children “like themselves” – but like the best of themselves, not the worst.

It will be attractive to those many parents who want children like themselves – but like the best, not the worst
To many people this sounds like fiction. And of course, it does raise difficult and important questions – from safety, fairness, and coercion, to family structures and whether it’s “just plain wrong”.

Could it really happen? I think so. Many parents will want it, if only to avoid the 1-2% risk of having a child with a severe early genetic disease. Health systems will find it cost-effective to no longer have to provide care for children who are born sick. Clinics will want the business, and governments will be reluctant to interfere in parental choice – at least in some places.

Its reception will vary from country to country. I expect the US, much of east Asia, Australia, and some other countries to allow or even encourage easy PGD. Germany and Italy, probably not. The UK will be interesting. As opposed to America’s wild west, the UK has the Human Fertilisation and Embryology Authority, which has allowed, with limits, new reproductive technologies based on both safety and perceived moral concerns. What will it do with easy PGD?

Before long many countries – as well as individual couples – will have to make these choices. Cheap sequencing and stem cell technologies are inevitable, driven mainly by non-reproductive uses. To choose wisely, for ourselves and for our countries, we all need to learn more about this burgeoning of genetic choice, its likely paths and consequences. The time to begin is now.

Couple who lost young sons, become grandparents by surrogacy:

ALIGARH: In spite of grieving the loss of their two unwed sons, a couple in their early 50's here broke all the shackles of social stigma to become grandparents with the help of IVF technology.
Due to the societal pressure of a small town, they have refused to come out in open to revel the birth of their twin granddaughters. In vitro fertilization (IVF) is a process by which an egg is fertilized by sperm outside the body.
The couple lost both their sons within a period of three years. A road accident claimed the life of their elder son three years ago, while their second son died of blood cancer in his early 20s. The couple took the bold step to preserve the semen of their younger son on the advice of doctors in Delhi. Ahead of his chemotherapy, the doctors in Delhi advised the boy's parents that they should have his semen frozen because the treatment will adversely affect its quality. The family took the advice seriously.
Unfortunately, the younger son also died. The shattered parents approached a private IVF centre in Aligarh and met the doctors telling them about the "frozen semen and their dead son." The centre implanted the semen into a surrogate mother. Dr Jayant Sharma of Jeevan Hospital said, "The couple came to us with their problem. Since sperm quality falls after chemotherapy they had acted on the advice of the doctors of cancer center and got it frozen. It was transferred to us in a canister and was preserved. Later embryo was made and implanted in the surrogate mother. Here, posthumous reproductive technique was used."
Dr Divya Choudhury told TOI, "It was a challenge because the parents wanted it to happen from their own son's semen. They did not even want to adopt children. So we need to take care of this. There was no second chance here." "They were born on the night of April 8," she said. The doctors said that the couple is wary of coming out in the open because the society is conservative and will raise questions about the "source" of the child. The grandmother told TOI that she would not be comfortable to talk about the matter right now.
Though they are wary of the stigma that might follow regarding the "source of the children and reaction of the conservative society", the couple is celebrating the joys of being grandparents in complete anonymity.

Credits; TOI

6 Common Questions from My Fertility Patients;


Dr. Albert Peters Fertility Doctor in New Jersey and Lehigh Valley
The following are some of the most common questions that I hear from patients that I consult with. I have given simple responses to each one, but clearly, the answer for any individual patient will be much more complex. This is why we stress an individualized approach to diagnosis and treatment for our infertility patients.  I urge you to use these as basic guidelines only, and consult with a Reproductive Endocrinologist for an individual diagnosis and treatment plan.
– Dr. Albert Peters

1. Does my age affect my fertility?

Age does affect fertility, more so in women than in men. Women are born with all of the eggs they will ever have.  Men make sperm on an ongoing basis.  Because of this, eggs wear out as age increases.  We see this with increases in infertility and miscarriage as well as aneuploidy (abnormalities in chromosome numbers) in the offspring of older women.  While we cannot change the genetic make up of the eggs, we can screen for genetically normal vs. abnormal eggs and embryos, thus increasing the chances for a successful pregnancy.

2. I have had 3 normal pregnancies, why am I now having trouble with miscarriages or trouble getting pregnant?

Having had previous pregnancies or children is a good sign, however it does not necessarily translate into continued fertility.  Aging generally plays the biggest role in not getting pregnant.  The aging process decreases the quality of the eggs.  This can be seen in decreasing fertility as well as increasing rates of miscarriages.  In Vitro Fertilization can help by providing more aggressive stimulation to the ovaries in order to generate more eggs, of which some might have better quality than others.
Another area of concern could be the immune system.  There are cases where the immune system tries to reject the pregnancy.  This can be detected through blood work.  Treatments are available to help this problem.

3. Can stress contribute to my infertility problems?
Stress is a difficult thing to measure, let alone control.

We all have stressors in our lives.  I do believe that stress plays a role in reproductive failure.  Think about it: Stress has been shown to cause heart attacks!  Why can’t it affect the reproductive system?
It is important to try to reduce stress during treatment.  This begins with feeling comfortable with your fertility clinic, doctor and staff.  You should have time to ask questions and thoroughly understand your condition and treatment options before you move forward.  There are also stress coping options such as counseling, massage therapy, yoga and acupuncture which I wrote about in a previous blog, and other things which can help.

4. When is most fertile time and how often should we have intercourse in order to get pregnant?

The most fertile time is just after ovulation.  In a typical regular menstrual cycle of about 28 days, ovulation generally occurs around day 14 (counting from the first day of the period).  The best way to know when ovulation is going to occur is to use a home ovulation predictor kit which measures LH hormone in the urine.  Once the kit turns positive, the next day and the day after are the best times to have intercourse. If the egg is not fertilized in this time, then pregnancy will not occur.
Remember, these kits are prospective, meaning they will tell you when ovulation is going to occur.  There is no need to have intercourse for prolonged periods of time. If the kit is not showing a positive result, this could mean that you have an ovulation disorder.  If this occurs, you should consult a fertility specialist.

5. When is it time to see a fertility specialist?

Typically, if a couple has not conceived after 12 months of unprotected targeted intercourse, it is time to see a specialist.  However, if a known cause of infertility exists such as advanced maternal age, menstrual abnormalities, problems with sperm production or erectile dysfunction, previous tubal ligation, endometriosis or repetitive miscarriages, you should consult a specialist sooner.  If in doubt, contact our clinic and we can tell you if a consultation is recommended.

6. Can we select to have a boy or a girl?

This is called “gender selection” or “family balancing”.  Yes, we can do this.  For example, some couples have 3 boys or 3 girls and wish to complete their families by having a child of the opposite gender.  This is done through in vitro fertilization and genetic testing of the embryos.

Credits: Sher Institute..

When former Miss World Diana Hayden delivered a baby girl:

In a city hospital on Saturday, a bit of medical marvel was at work. The child was born out of an egg that 42-year-old Hayden had frozen eight years ago.
Arya Hayden's birth proves that egg freezing, deemed technically difficult until a decade ago, works and could liberate Indian women from their great worry: the ticking biological clock.

"A career woman need not think about her biological clock and get pressurized into getting married earlier than she wants to or have a baby when she isn't ready," said Hayden from her hospital suite in Surya Mother and Child Hospital in Santa Cruz.
Hayden was 32 when she read about egg freezing for the first time in 2005. Between October 2007 and March 2008, she froze 16 eggs with infertility specialist Dr Nandita Palshetkar. "I froze my eggs for two reasons: I was busy with my career at that time and, more important, I was very clear that I was going to wait to fall in love and marry before having a baby."

Freezing her eggs proved to be a godsend for the model-actor for another reason. Hayden, who was 40 when she fell in love and married American Collin Dick two years ago, found out that she had endometriosis. "Endometriosis is a painful condition in which the endometrium or the inner lining of the uterus starts growing outside as well. Women with endometriosis may not always produce good quality eggs,'' said Palshetkar. That is when the couple decided to thaw Diana's frozen eggs and attempt a test-tube baby.

"Hayden's daughter weighed 3.7kg and was 55cm long. The average weight and length in India are 2.6kg and 48cm," said paediatrician Dr Bhupendra Avasthi of Surya Hospital.
The infertility specialist team of Palshetkar and Dr Hrishikesh Pai believes Hayden could be a poster girl for egg freezing. "Egg freezing for medical reasons is done frequently, but I would say that Diana is among the first to use it for lifestyle reasons," said Pai. Incidentally, this isn't the first time that the former Femina Miss India who was crowned Miss World in 1997 has been a health ambassador. When her grandmother was diagnosed with breast cancer, she took up the cause of spreading awareness about the disease.

Medically speaking, the big change in egg freezing occurred a decade ago. "The process of vitrification (see box) changed everything," said the doctors. "We suddenly had a technique to fast freeze eggs."

Infertility specialist Dr Firuza Parikh, editor of the Indian edition of the Fertility and Sterility medical journal, said egg freezing has become a standardized procedure and is likely to become common among women who want to defer childbirth. One of her patients who had frozen her eggs in 2005 had a child a couple of years ago. "I remember the case well because the woman froze her eggs and not embryos because she wasn't sure her marriage would last. Her marriage broke up, but she later thawed her eggs to have a baby with her second husband."

Infertility specialist Dr Ameet Patki, who was former president of the Mumbai Obstetric and Gynecological Society, said egg freezing is a boon for women. "Often women come to us on turning 40 for IVF treatment. But they don't have good quality eggs at that time and need to use donor eggs."
Egg freezing isn't without controversies. American corporates kicked off a controversy last year when they promised to pay for egg freezing for their female employees. A study in JAMA (Journal of the American Medical Association) in October 2015 said the freezing and thawing process may damage eggs and reduce a woman's chance of becoming a mother.

The study, done in New York's Centre for Human Reproduction, looked at 93% of all donor IVF cycles in the US in 2013 and found women had a 56% chance of becoming mothers with fresh eggs but just 47% with frozen eggs...