Test
Tube Babies - IVF & GIFT
from
the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha
Malpani, MD and Dr. Anjali Malpani, MD..
table
of contents·
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Risks
and Complications of IVF and GIFT
Many
couples are still worried that babies born after IVF are abnormal
or weak. You need to remember that in one sense there is nothing "artificial"
about these babies - they aren’t synthetic babies which are being
manufactured in the laboratory ! Remember that IVF is a form of assisted
reproductive technology, where technology is being used to assist
Nature to accomplish what it has failed to do for the infertile couple
! Over a hundred thousand babies have now been born after IVF treatment,
and the risk for birth defects is not increased after IVF treatment.
The most
worrisome complication of IVF is that of ovarian hyperstimulation
syndrome ( OHSS), because of superovulation. The cause of "hyperstimulation
syndrome" is that superovulated ovaries contain many follicles which
are loaded with estrogen. After ovulation, a huge amount of estrogen-rich
fluid is poured directly out of the enlarged and fragile ovaries into
the abdominal cavity. This fluid also contains chemicals like kallikrein-kinin
and VEGF ( vascular endothelial growth factor), which then coat the
lining of the abdominal cavity ( called the peritoneum) and cause
it to become very permeable ( leaky) . Fluid (serum) literally pours
out of your bloodstream into the peritoneal cavity because of the
"leakiness" of the abdominal cavity’s lining. The ovaries balloon
in size, your abdomen swells, you get lightheaded with relatively
low blood pressure, and you may get dizzy because of the decreased
blood volume. Many women will have mild degrees of hyperstimulation
syndrome with a little bit of lower abdominal swelling, discomfort,
and dizziness. This does not require hospitalization, just bed rest
at home. It is only the rare, severe cases that require hospitalization.
The occasional patient today who develops severe hyperstimulation
must go into the hospital, have intravenous fluids for several days,
and wait for her ovaries to reduce in size and for her body to readjust.
Some patients may even need to be admitted into an intensive care
unit for monitoring and observation, since this can be life-threatening.
At one
time this was a very dangerous condition only because it was not fully
understood. We now know that by putting a small "paracentesis" catheter
into the abdomen and draining all of this fluid, the patient is made
much more comfortable, she can breathe more easily, and by getting
rid of this estrogen irritation, fluid leakage into the abdomen slows
down dramatically. Thus, even in the very rare cases of severe hyperstimulation
syndrome, knowledgeable treatment makes the likelihood of any dangerous
outcome very remote.
Interestingly,
the worst cases of hyperstimulation syndrome occur when a woman becomes
pregnant. This is because her placenta is making HCG and stimulating
the ovaries to continue to pour out large amounts of estrogen-rich
fluid. So although it is a very unpleasant side effect to endure,
hyperstimulation syndrome often means good news.
If you
grow too many follicles ( more than 25) , or if your estradiol level
is very high, the doctor may be forced to cancel the IVF cycle, because
of the high risk you run of developing ovarian hyperstimulation syndrome.
In some clinics, doctors can salvage this cycle by collecting all
the eggs and freezing all the embryos. Since the embryos are not transferred,
the risk of hyperstimulation is reduced; and the frozen embryos can
then be transferred in a future cycle.
Complications
can also occur during the egg harvest procedure. The removal of eggs
through an aspirating needle entails a slight risk of bleeding, infection,
and damage to the bowel, bladder, or a blood vessel.
In all
techniques of assisted reproductive technology, the chance of multiple
pregnancy is increased when more than one embryo or egg is transferred.
Although some would consider having twins to be a happy result, there
are many problems associated with multiple pregnancy, and problems
become progressively more severe and common with triplets and each
additional fetus thereafter. Women carrying a multiple pregnancy may
need to spend weeks or even months in bed or in the hospital. There
may be enormous bills for the prolonged and intensive care for premature
babies. There is also a greater risk of late miscarriages or premature
delivery in multiple pregnancies.
A recent
treatment option for women with multiple pregnancies is that of selective
fetal reduction, in which one or more of the fetuses is selectively
destroyed ( usually by injecting a toxic chemical, potassium chloride
, into its heart under ultrasound guidance). In most cases, the killed
fetus is then reabsorbed by the body - and the other fetuses continue
to grow. Of course, the risk of all the fetuses being lost because
of a miscarriage ( as a result of inadvertent trauma during the procedure
) is also present, and is about 10% in experienced hands.
There
is approximately a five percent chance of an ectopic pregnancy with
IVF and GIFT. This is not because of the procedure, but rather because
women going through IVF already have damaged tubes, which predisposes
them to having an ectopic.
IVF is
physically demanding - and stressful ! The effects of blood tests,
anesthetic and operation are tough on your body. Hormone stimulation
causes lethargy and fatigue, not withstanding the sometimes extensive
travelling required each day. Some people find treatment conflicts
with their employment or other commitments.
A final
risk is not physical, but psychological. The major risk for most patients
is that even after spending all the time, money and energy required
for a treatment cycle, they will not get pregnant. Couples undergoing
IVF and GIFT have described the experience as an emotional roller
coaster. The treatments are lengthy, involved, and costly. These procedures
often create high expectations but are more likely to fail than to
succeed in a given cycle. The unsuccessful couples will feel frustrated
in their quest for pregnancy. It is common to feel angry , isolated,
and resentful toward both the spouse and the medical team. At times,
this feeling of frustration leads to depression and feelings of low
self-esteem. The support of friends and family members is very important
at this time.
The
danger of overtreatment and undertreatment
IVF techniques
have now become well established, and most towns in India have one
or more IVF clinics today. This is all for the best, because infertile
couples no longer need to travel long distances for IVF treatment.
However, because offering IVF has become a fashionable trend, there
are now too many IVF clinics in competition with each other. Many
of these clinics are poorly equipped, and the staff inadequately trained,
with the results that pregnancy rates are poor. Many clinics have
started, and then closed down in a few months, without being able
to achieve even a single pregnancy - dashing many patient’s hopes
in the process. Unfortunately, this often means that all IVF clinics
start getting a bad reputation. In order to protect yourself, it’s
a good idea to ask the clinic staff to actually show you the embryos
under the microscope. Most good clinics do this routinely, and some
even offer video records. Not only is this reassuring for the patient,
it also helps them to "bond" with the embryos !
Another
danger of too many IVF clinics is the risk of overtreatment. In order
to remain profitable, many clinics now offer IVF to infertile couples
as a treatment of first choice ( rather than reserving it for patients
who truly need it). While this does help them to keep their financial
bottomline healthy and to increase their pregnancy rates ( since many
of these patients are young couples, who never needed IVF in the first
place !) , it is an inappropriate use of limited medical resources.
IVF treatment should be reserved only for patients who really need
it. Paradoxically, while rich patients end up getting IVF even when
they don’t need it, poor patients are often deprived of this treatment
even though they need it, because of the expense involved. Unfortunately,
the Government still does not consider that providing infertility
treatment should be a part of its family planning program. Hopefully,
this will change in the future, and providing infertility services
will be seen to be a part of comprehensive reproductive care services.
This will provide many more infertile couples access to assisted reproductive
technology.
Supporting
each other
You may
not be able to comfort each other enough at times of disappointment,
especially when you are both upset. If you don't have a family or
a friend who can provide support (without pressure), then the positive
and sensitive assistance offered by a support group may be very suitable,
either in the short term or longer. Yet other people may seek the
more specialized assistance of a counselor, who is either attached
to the clinic or based in the community.
Going
through an IVF cycle can be very stressful, and you need to be prepared
for the ups and downs. Many clinics have found that optimistic and
well-prepared patients do have better pregnancy rates, and counselling
and emotional support can be very helpful in improving your chances
of getting pregnant !
Every
time you start a cycle, you have to hope for the best and be prepared
for the worst. It literally is like gambling - and hoping that you
hit the jackpot ! Many patients find the first cycle the most stressful
- and find it much easier to do a second cycle, because they are more
in control and understand much better what they are going through.
If you
judge the outcome of an IVF cycle only on the basis of whether or
not you get pregnant, then with the limitations of today’s technology,
you are more likely to be disappointed than otherwise. However, do
remember that each cycle also provides you with valuable information,
such as whether the sperm fertilise the egg or not, so that you can
plan your future course of treatment. Going through an IVF cycle can
also give you peace of mind that you tried your best !
Selecting
an IVF/GIFT Programme
When
selecting an IVF/GIFT program, information is crucial. Important points
for consideration include the qualifications and experience of personnel,
types of patients being treated, support services available, cost,
convenience, and rate of successful pregnancies. Older programs have
established live birth rates based on years of experience. Although
new programs won't have as much experience and may still be determining
their live birth rates, their personnel may be equally qualified.
The range
of services offered by an IVF program should be carefully considered.
Not all programs are equipped to provide all services, such as tubal
transfer, ZIFT, sperm donors , ICSI and cryopreservation of embryos.
It is best to select a full-service clinic, which offers all the possible
treatment options, so that the one which is best for you can be used.
The above
considerations and answers to the following questions, which may be
asked of the program, will help you make an informed decision when
choosing an IVF/GIFT program.
Cost
and Convenience
- How
much does the entire procedure cost, including drugs per treatment
cycle?
- Do
we pay in advance? How much?
- What
are the modes of payment?
- How
much do we pay if my treatment cycle is cancelled before egg recovery?
Before embryo replacement?
- What
are the costs for embryo freezing, storage, and transfer?
- How
will the treatment schedule affect our commitments at work?
- If
I must have lodging, is there a low cost place for me to stay? Do
you help arrange this?
- If
I do not get pregnant, when do I make my next appointment for further
evaluatuation and counseling ?
Details
About the Program
- How
many doctors will be involved in my treatment?
- To
what degree can my own doctor participate in my treatment?
- What
types of counselling and support services are available?
- Whom
do I call day or night if I have a problem?
- Do
you freeze embryos (cryopreservation)?
- Is
donor sperm available in your program? Donor eggs?
- Do
you have an age limit?
Success
of the Program
- When
did this program perform its first IVF procedure? First GIFT procedure?
- How
many babies have been born from this program's IVF efforts? GIFT
efforts?
- In
the past two years, how many treatment cycle have been initiated
for IVF? For GIFT?
- How
many deliveries were twins or other multiple births?
If you
are going through an IVF cycle, you will find the following tracking
chart very useful in monitoring your treatment.
Click
on chart below to print
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