Treatments of Infertility
Young couples enter into a relationship and start to explore the ways ahead. In the Indian culture, sex is a taboo and is hardly discussed openly in any family. There is an element of negativity attached to it, especially in women. This can have a detrimental effect in the new couple’s life. For some couples, the struggles start at that stage. There is so much on the minds of a newlywed bride when she goes to stay with the husband’s family at the in-laws house. Apart from handling the emotional turmoil of leaving her parents home, she is faced with a new start of numerous other relations. She has to adjust to her husband’s ways. She may or may not be working. This may add a completely new dimension to the new couple’s life at the in-law’s house. After all this, they have to start their married life.
It is very common that physical relations may not happen well. This is an issue that they cannot discuss openly in the family and friends. Hence, they get very little proper advice which can help them. They suffer in silence. In some cases, the jobs may be demanding or the husband and wife may be traveling and may not be able to spend enough time together to be able to conceive. If all is well, the couple may have planned their life and might want to deliberately delay their conception. This may not be acceptable to the family and pressure may start to build on the couple. The brunt of the anger is taken by the woman. The Indian tradition of considering periods to be unholy means that the woman has to declare to the whole world that she is having her periods. Even if she wishes to keep it to herself, she has to, unfortunately, declare to the whole world that even this month has not been successful. This may even lead to a family discussion on the subject and the politics may start amongst the various family members.
If a couple has tried to conceive by regular natural relations for a duration of about 2 years, conception is expected to happen. If not, the worries start at this stage. Numerous advises are given to visit the doctors and the couple gets inundated with recommendations. Finally, they choose to visit a doctor. They find it embarrassing to enter a fertility clinic because the purpose of the visit becomes obvious. Amidst this, when they meet the doctor, their anxiety levels would shoot up. They would hope that they would be sorted by simple advice of some tablets. This is when their personal life is explored by the doctor. No one would like this, but they have no choice but to share this information. If they are in the right place, this discussion may be gentle and they may walk out feeling good. On the other hand, if they are treated as a vegetable, then their pains have just started. This journey could involve 5, 10, 15, 20 or 30 years visits to the doctors.
The next thing that the couple has to do is medical reports. The wife has to do blood tests and unpleasant internal sonography. The husband undergoes blood tests and is asked to collect semen samples in toilets in most places. This marks the beginning of the couple’s agony. In some cases, this becomes the routine of their lives for many more years to come. The only difference is that it may happen at different clinics and at different intervals with different doctors.
Once the test reports are available, the couple visits the doctors to understand the reports and make suggestions for their treatment. This can be a very nervous moment for the couple. Doctors who do this 15 times a day may forget that this is the first time for this couple in their life. They are unaware of the future implications and are now very scared. They want reassurance hope and comfort feeling that the doctor will help them without making it very difficult for them.
This is where standardization of care would matter. The communication skills and the doctor’s ability to reassure the couple would make a big difference. The reports are informed to the couple and the underlying cause may be found. As seen in the chart, the treatment starts with simple natural cycles that may be aided with tablets for egg formation to be given for just 5 days. The worst part is that doctors start advising the couple to maintain natural relations on certain days of the woman’s menstrual cycle. This leads the couple to look at the calendar and mark the days to keep relations, irrespective of whether they feel like or not. Now the natural act has become a treatment for this couple. Like taking pills, relations are also kind of prescribed. The natural act becomes a mechanical event for the sperms to be deposited in the right place with the hope that the test comes positive. Imagine the tension on the couple at the end of the month waiting for the day of the next period so that they can do a test. In the meantime, if the woman starts getting symptoms of a period, she has already started going into depression. From now on, this may happen every month end for years to come. It is not surprising that the couple loses interest in relations, because the natural act is based on emotional satisfaction and not for just baby-making.
As this starts happening, the couple starts planning their work commitments around the days of their treatment. The number of leaves starts going up. The performance at work drops. This is even more in the case of the woman who needs to take more time off from work. In the process, some take the disastrous decision of resigning from work. This now means that every moment of their life is about the period dates, sonographies, injections, timed relations, and pregnancy tests. How long can one tolerate this? The relation starts getting the dents. The happiness of marriage and the excitement of wanting a family has disappeared in thin air. The couple starts to have excessive sex, they go on holidays and try to bury their emotions. When this approach does not work, the couple is now getting impatient, and finally anger sets in. They get disappointed by their own bodies, their families, doctors and even god.
This leads the family machinery to come into play. Visits to temples, Babaji’s, fasts at regular intervals, pujas, and all ways to bring good fortune are tried. The couple starts to feel that science may not be just enough. Any rational person also may start becoming superstitious under these circumstances. It is hard to convince them to avoid such actions because the family pressures are now very high on them.
A pregnancy test may come positive at any stage and then it could be in the tube, ectopic pregnancy, which has to be removed as it is dangerous. If it is in the womb, the couple waits anxiously for 3 weeks to perform the first sonography. This may not show a heartbeat and the couple’s excitement crashes. They go blank and are unable to understand anything that is being explained to them. The woman may undergo the curetting procedure to clear the unhealthy remains of the pregnancy. This becomes emotionally challenging for the couple because all their hopes have just got shattered and they now have to restart the whole process again. Some women go into depression. The men also suffer silently. They have to continue their jobs and have to keep earning to be able to run their home and also to fund further treatment. At some stage, the couple must feel that they are earning only to spend on their medical treatment.
If the simple approach does not work, the couple is advised to take the next step, which is normally IUI (Intrauterine insemination). This involves taking the tablets again for 5 days, followed by regular scans to check the growth of the egg. When the egg is ready as per the scan, an injection is given to release it at a fixed time. At this time, the husband gives a semen sample. This is then processed to select the best sperms to put in the right place (womb) at the right time (egg release time) by a fine catheter. This has a nominal success rate of 15 to 17%. This means that the chances of failure are very high and the treatment has to be done repeatedly sometimes.
If this is not working, the couple may lose their faith in the doctor and go to another clinic. Unfortunately, the tests may have become old and the doctors may wish to repeat the tests. Now this clinic may its own different arrangements. The couple is now dealing with new staff and doctors and that must be challenging. Sometimes, couples travel a long distance to undergo the treatment from a particular clinic and this can have a serious impact on their sufferings.
If three to four IUIs do not work, the couple is getting fed up and may take a break to relax a little. If they are not counseled properly at this stage, they may keep doing too many IUIs. In the process, they start taking excessive medications, which can harm them later and reduce the chances of success using advanced treatment. This must be avoided at all costs. It is very important that the couple understands the full process and is doing the treatment with complete knowledge.
When they are ready to restart their treatment, they are now faced with some difficult choices. The first is to consider one or two more IUIs to keep the treatment simple and the second is to perform a laparoscopy and hysteroscopy and then some more IUIs. Laparoscopy and Hysteroscopy is an operation involving small cuts on the woman’s tummy. A fine telescope is introduced inside the tummy to check if the tubes are open and if there are any other undetected issues. If any problem, such as a tubal block, fibroid or endometriosis is found, it should be treated at the same sitting. In some center’s, such facilities and skills may not exist for the operative part and that part is performed at a later date again. This leads to doubling the effort and should be avoided preferably. In some women, this operation gets performed repeatedly and leads to increased pain sufferings and costs.
In the process of trying tablets, IUIs and maybe laparoscopy and hysteroscopy, most of the time two more years have gone by. The couple may be about 5 years into the marriage. The age of the woman and the family pressures are increasing. They are fed up an tired of doing the IUIs and follicular sonographies. This may appear to be a simple form of treatment, but it starts appearing to be meaningless. They are now getting mentally ready to move further into the advanced form of the treatment (IVF-test-tube baby). They start to gather the information and then visit the doctor to understand the treatment and its costs. At this stage, the couple has started to wonder if the medications are going to have any side effects of the woman. Once they are reassured, they are now willing to do the test-tube baby treatment sooner or later. Some couples have to discuss this at home and convince them to agree for this treatment. Sometimes, the parents and in-laws may discuss the cost burden to be shared. If the understanding is low, the friction can start at this stage.
The couple prepares their funds, makes arrangements at home for help during the treatment, organizes leave and take a leap into the treatment. They are well aware that this treatment is now appearing to be necessary even though they dislike this choice. It is no more a matter of like or dislike. The worst part of this treatment is that it spans over a period of almost a month and involves almost daily injections and regular blood tests and sonographies. On top, there is no guarantee of success. This is perceived by many as the business of the fertility industry. It is sad that many who do not understand a thing about the couple’s tragedy and about the science of this treatment make such allegations on doctors who are making every effort over prolonged periods to get success for the couple. The treatment needs a good facility, technology, costly medications, skilled staff, and lots of costs. None of this comes cheap. Each fertility clinic has its own arrangements, but if this is not up to the mark, the couple can have a horrible experience. Once the eggs are collected from the lady, they are mixed with the sperms in the laboratory under very sterile culture conditions. This results in the formation of the embryos (early pregnancy). The good embryos are selected and transferred to the womb for the pregnancy to the implant (stick) and grow for nine months. Unfortunately, at this stage, nature takes over and it can fail. A test is performed 15 days after the embryo transfer and the couple’s anxiety is very high. If it comes positive, it is hard for them to believe it at first. This is just the start of another opportunity to have a baby. Unfortunately, the pregnancy can again be in the tube (ectopic) or may miscarry. If all goes well, they are now in a dilemma whether to disclose the information to family and friends. They are afraid that if anything goes wrong in the pregnancy after disclosing to the world, it would be very difficult to handle the situation.
What if the first IVF attempt fails
If the IVF cycle result comes negative, it is a tragedy for the couple. The failure of the first IVF cycle is one of the most difficult moments in the entire treatment of this couple. The first experience feels very intensive as it is all very new for the couple. There is a lot to take in and lot to cope with on the personal front. Even at this stage, they are hoping for a miraculous natural pregnancy. When this first attempt of IVF treatment fails, the couple realizes that the issue is slightly more serious than they thought. Their minds open to undergoing further treatment because this looks like the only way forward. The failure of the first attempt is analyzed and the couple is given feedback about the performance of the cycle and the details regarding the eggs, sperms, and the uterus. On this basis, the couple understands the reason for the failure, the available treatment options and then they decide about the timing of their next treatment. By this time, most couples are clearly rattled by the situation and get mentally disturbed. They may take time to settle and then restart the process. If the experience with the first clinic is unpleasant, the couple is likely to change the doctor. In this case, some tests get repeated and a fresh attempt is then undertaken.
Treatment steps in a progressive systematic manner are as follows:
|Natural relations||-1 to 2 years|
|Determine the cause|
|Ovulation tabs + Natural||-4 months|
|Ovulation tabs + Natural + IUI||– 3 months|
|About 3 years|
|Role of Laparoscopy and Hysteroscopy|
|Ovulation tabs/Inj + Natural + IUI||-3 months|
|About 5 years|
|IVF / ICSI|
The above plan may change as per the woman’s age and other factors
How many attempts of IVF can be done?
It is believed that IVF treatment should be successful by the third attempt. After three attempts, it is obvious that the nature capacity is not looking favorable. The egg, sperm or the uterus could be responsible for the failure, but it is the egg, which is most likely. A change of eggs may become necessary in some cases. This can be a very emotional consultation and each couple responds very differently to this situation. The first feeling is that of denial and disbelief, followed by anger and then acceptance. The couple may get angry for some of the decisions that may have gone wrong. They may have delayed the treatment and the body changes may have started. This phase of transition from self eggs to donor eggs can be of 2 minutes in some cases, few months in some and never in some rare cases. It is a very personal call and it is not about right or wrong. It is about the preparation of the mind to accept borrowed eggs or sperms. The pregnancy will be carried by the wife and no one will know about the change of the eggs or sperms.
Reproduction is an important natural instinct and it is equally important for people to have their own genes. It is insensitive to advise someone to adopt against their own wish when they can have a child using their own eggs and sperms. It takes a lot of mental preparation for anyone to have a child without their own eggs and sperms. It is very personal and individuals respond to this decision very differently. For a small number of people, this is a very easy decision. A small number would never go ahead, because they would rather remain childless. In majority of the people, their mind agrees to use borrowed eggs and sperms (if medically required), but only after they understand the medical situation and when they are thoroughly counseled about the options available to them. Borrowing of eggs, sperms from a donor or the more advanced options such as surrogacy and adoption are generally undertaken as last options by any couple. As no treatment option guarantees an outcome, it is important to be systematic and progressive in the treatment. Every effort is made by the couple and their doctors to achieve conception quickly and by using their own eggs and sperms in their own womb. If for any reason this is not possible, then they get ready for the next level of treatment. In the process, it gets tougher and tougher for them, because the decisions are getting harder and the costs are rising. The risks of failure are still looming on their head. They have only three options, stop and wait for a miracle to happen, continue further and make further attempts or to adopt.
At all times, the above options are explained to the couple. It is a choice they make on the basis of their personal feelings, circumstances and their risk taking capability. Most couples get successful and this is a unique moment for the couple as well as their treating doctors. Every effort is made by the medical team to achieve success. It is unfortunate that some poor practices bring bad name to the entire fraternity. Regulations will go a long way in achieving higher standards of care and the patients and the other involved parties will all get just and fair treatment.
What to do in case of Repeated IVF treatment failures
In most cases, a pregnancy is achieved during the first three IVF attempts, either using the couples own eggs or borrowed eggs. The multiple attempts take a huge toll on the couples capacity to continue further-emotionally, physically and financially. By this time, the couple could be in the marriage anything between 7 to 20 years. The husband and wife have reached an advanced age and they start felling hopeless. They are faced with difficult decisions about the path ahead almost daily. The temptation to continue never finishes. They still keep hoping that they can have a pregnancy using their own eggs and sperms. Even if they have decided to borrow eggs, they would still like the pregnancy in themselves. The thought of surrogacy is still difficult to accept. Some of them gradually start thinking of the options ahead for them. They meet the doctors, surf the internet and try to find out about surrogacy and even adoption. Even though the couple has undergone numerous years of fertility treatment, they have never understood the way surrogacy works.
To stop the treatment, do surrogacy or to adopt
When the treatment goes to the final stage, the couple is faced with three options-To stop the treatment, Surrogacy or Adoption. This decision is influenced by three factors:
- Their personal feelings
- The family view
- The social acceptance
The couple is open to all options, but they fear the risk of failing and most importantly, social acceptance. India is still ingrained with cultural beliefs and a conservative thought process. The society is unwilling to accept childless couples, surrogate children and adoption. The couple prefers to do something rather than stay childless. This means it comes down to Surrogacy or Adoption
If the strategy goes wrong, it has a disastrous effect on the future treatment of the patient. A lot of valuable time, money and energy may be lost unnecessarily.
Treatments of infertility depend on the actual cause, age of woman and marriage duration. The couple should be able to cope with both medical and emotional aspect of infertility. Thus “counseling” is the integral part of the infertility treatment at all stages
A detailed history and analysis of the past treatment is done to detect the cause of the delay in conception. This knowledge is shared with the couple to ensure that they are fully aware of the past, current, and future process. Thorough counseling helps them to gain confidence, so that future treatment can be undertaken jointly with a true positive mindset.
Advanced Treatment Options
|Option 6||Embryo Donation||Own|