Here’s my advise. A lot of this is applied common sense , but it's worth going through carefully to make sure that you and your doctor have dotted all the i's and crossed all the t’s, so that no matter what the outcome of the cycle is (something over which you have no control ), at least you have peace of mind that you give it your best shot.
The most important first step is a dose of what I call information therapy. You need to do as much homework as possible - not only about the IVF treatment itself , but also about the IVF clinic where you are taking your treatment. In fact , which clinic you select for your IVF treatment is one of the most important decisions which you can make - and this is one decision which is often in your control ! You should spend a lot of time and energy thinking about it carefully. A lot of patients are very casual about this and will often just go to the nearest clinic ; or to the clinic which has the largest ad in the Yellow Pages ; or to a doctor who's been recommended by a friend. While these are all alternative options for identifying possible IVF clinics, these are not very good criteria for selecting the best possible IVF clinic.
Sometimes it's very tempting to pick a clinic simply because it's the cheapest; , or the nearest ; or the most convenient. However, these are not good criteria for making such an important decision. While it's sometimes hard to differentiate between a good IVF clinic and a not so good IVF clinic, one of the things you should definitely insist on is that that your doctor provide you with photographs of the embryos, which he creates for you during your IVF cycle. If for any reason the doctor refuses to do so ( for example, by claiming that it’s not “ clinic policy” to do so ), this should raise a red flag , and you should seriously consider looking for an alternative option. The only tangible deliverable which an IVF clinic can provide is embryos. After transferring these embryos into your uterus, whether they will implant and become a baby on not is not something which the clinic can control - but documenting the fact that they produced good-quality embryos for you is something which every IVF clinic worth its salt is proud of doing , and will be happy to share with you.
It's important that you organize your medical records properly so that you are sure that your doctor understands all the important variables in your case. If you are well organized, it helps the doctor to be better organized as well , so that he can individualize his treatment protocol to optimize your success.
You need to try and optimize your general physical health by stopping smoking ; and by ensuring you are at your best possible bodyweight . It's useful to have an active lifestyle , and you should be taking folic acid supplementation on a regular basis. There are lots of other nutritional supplements you can use, if you believe they help you remain healthier. These can include: vitamins; anti-oxidants; DHEA and wheat germ. Just because there is no scientific evidence to back them does not mean you should not follow what your heart tells you to ! What about any don'ts ? Is there anything you must not eat ? Hot or cold foods you should abstain from ? The simple answer is - No. But if you believe that certain dietary restrictions help to improve fertility, them please go ahead and honour your personal beliefs.
Along with optimizing your physical health , you need to spend time and energy preparing yourself emotionally and mentally. There's no question that an IVF cycle can be quite stressful , especially because the outcome itself is always uncertain and unpredictable. This is why learning stress management skills such as meditation and yoga can help you cope with the ups and downs of an IVF cycle much more efficiently.
Finally, start thinking about Plan B - what will you do in case the cycle fails ? While most patients spend a lot of time and energy on positive imagery and visualization, and I do think it helps being optimistic and hoping for the best , in reality there's very little point in preparing for success ! After all, if you are successful , everything falls into place automatically - what you really need to do is prepare for failure. This does not mean that you have to be pessimistic and negative - just that its best to take a realistic perspective , so that you don't do your treatment on an ad hoc basis ! It’s best to be prepared for all eventualities, no matter what !
Dear Dr,
ReplyDeleteI have written a small write-up regarding oocyte quality. I will post it to you in parts. Will you read it? If you find it interesting and useful will you post it in your blog (not as a comment:D)? You can correct it and edit it (add or remove anything). Actually it is a bit longer. I wish it will be useful for many IVFers. But ultimately the decission is yours :). Pleaaaaseeee!!!
What does scientific research say about improving oocyte/egg quality?
ReplyDeleteOocyte quality is the most important determinant of IVF success. As a result of aging more chromosomal and spindle abnormalities accumulate in oocytes leading to increased incidence of infertility, foetal loss and birth defects like trisomy 21 or Down syndrome. Eggs obtained from younger woman carry less genetic abnormalities and hence have higher chance of implanting and becoming a healthy baby. This is evident by the fact that women even after their menopause are able to get pregnant and carry the baby to term using donor eggs obtained from younger women.
When a woman undergoing IVF faces repeated failure, naturally the issue of egg quality crops up in the mind of infertility specialist and the patient. Unfortunately even after dramatic improvement in ART techniques, there is no sure way of saying whether an egg is competent enough (without genetic abnormalities) to produce an embryo which will subsequently implant and produce a baby. Although embryologists are able to select good embryos by observing their morphology under the microscope it doesn’t guarantee that the embryos are without abnormalities. A beautiful looking embryo of an older woman has more chance of being genetically defective than that of a younger woman.
As a result older women as well as younger women who undergo repeated IVF failures are desperately searching for ways which would increase their egg quality and give them their most wanted wish-a baby! Infertility bulletin boards are filled with women who are determined to find a cure for their bad quality eggs. DHEA, metformin, melatonin, myo-inositol, wheat grass, anti-oxidants, fish oil, co-enzyme Q10, vitamins, especially vitamin D and other nutritional supplements are now-a-days extensively used by women to improve egg quality. Some of these substances used have scientific proof but some not. Selling supplements to improve egg quality is growing into huge market as many businessmen try to make cash of our desperate mindset of having a baby. This led me to screen the scientific literature to find out what does science say really! Most of the experiments concerning oocyte quality are conducted in mice as it is difficult to do such experiments in humans for a number of reasons.
Anti-oxidants
ReplyDeleteOxidative stress contributes to somatic aging and it is also implicated in reproductive aging. So experiments were done to see whether using anti-oxidants improve egg quality and reproductive parameters. The researchers supplemented mice with pharmacological doses of vitamin C and E (both are well-known antioxidants) during their early or late life. They found that administration of oral anti-oxidants counteracted the negative effects of female aging on oocyte number and quality (PMID: 11835584). Good news right! Please do not rush to the pharmacy. Their research finding is not yet complete! Even though they found a positive effect of these supplements on the oocyte level they also found that oral administration of pharmacological doses of vitamin C and E reduced reproductive fitness and impaired ovarian and uterine function of female mice. They also said that the antioxidant diet decreased the frequency of litters, litter size, total number of offspring born and survival of male pups to weaning (PMID:12054212). Shocking or? A very recent publication suggested that, when mice are given low concentration of N-acetyl-L-cysteine the quality of fertilized oocytes and early embryo development improved. It also improved the quality of oocytes in older mice (PMID: 22357770).
Now the question is how seriously we should take these experiments? First we should keep in mind that these experiments are performed in mice. The next thing to remember is ‘nothing equals a good diet’. Do you feel that you are not able to eat enough vegetables and fruits a day? Is your medical condition preventing you from getting appropriate amounts of nutrition from your diet? Supplementing with a good vitamin pill is a nice thing to do. Otherwise the best way is to add colour to your life by eating different coloured vegetables and fruits. Remember darker their colour more is the anti-oxidant content in them.
DHEA
ReplyDeleteI am sure most of you will be aware of DHEA. If you google you will find lots of information about DHEA. Please visit CHR (Center for Human Reproduction) website for further details. DHEA was found to increase oocyte production (PMID: 16169414). The mechanism behind it is not so clear. DHEA is used in mice to induce PCOS phenotype in previously normal ovaries (PMID: 16514202). DHEA supplementation was also shown to decrease embryo aneuploidy (genetic defects) (PMID: 21067609).
I have seen women who swear on DHEA for their IVF success. Many women even achieved natural pregnancies after taking DHEA. Will DHEA work for me? It might work. It worked for many but we should not also forget that it didn’t work for so many others. I am not trying to be negative, just trying to be cautiously optimistic. Try to monitor your thyroid levels and insulin levels when on DHEA (as it is found to affect both either in a positive or negative manner). Please remember that it is a steroid hormone and it is wise to be safe than sorry!
Melatonin and myo-inositol
ReplyDeleteMelatonin is a hormone produced in our body and it regulates circadian rhythm. It has very powerful anti-oxidant properties and is found to protect nuclear and mitochondrial DNA (hence less genetic abnormalities) (PMID: 16217125). A recent publication concluded that melatonin is likely to improve oocyte and embryo quality in women undergoing IVF or ICSI but they found no statistical significance between the treated and non-treated group (PMID: 21770829). Melatonin was found to significantly improve thyroid function, reduce gonodotrophin levels, and in some women it helped in the re-acquisition of normal menstrual cycle. Furthermore, an abrogation of menopause-related depression, amelioration of hot-flashes and improvement of quality and duration of sleep has been reported. Myo-inositol is involved in several aspects of human reproduction. Elevated concentrations of myo-inositol in human follicular fluids appear to play a positive role in follicular maturity and also act as a marker for good quality oocytes. (I got this information from clinical trials.gov identifier: NCT01115127)
Should I try it?
Why not? Both melatonin and myo-inositol are naturally synthesized in our body and supplementing them won’t be a bad idea (but please read about the side-effects of melatonin supplementation). But better way is to optimize your health and get sound sleep.
Diet or calorie restriction
ReplyDeleteThis section is the most interesting part of the article. I found a very high quality publication on this topic and this is means it is more reliable. Calorie restriction in the absence of malnutrition is found to slow down the aging process and extend lifespan. If calorie restriction can slow down the aging process of somatic cells does it has the ability to slow down oocyte aging too? The research says YES. Recently a publication in PNAS, which is a, reputed, high-ranked journal, showed that calorie restriction showed striking beneficial effects on chromosomal, spindle and mitochondrial dynamics in mature oocytes of adult female mice at ages normally associated with poor reproductive parameters. The study said that calorie restriction vastly improved fertility in aged animals. When initiated during adulthood calorie restriction significantly extended reproductive lifespan and increased the survival rate of offsprings conceived by aging females. This study clearly states that old age induced oocyte aneuploidy and spindle defects can be safely circumvented using calorie restriction (PMID:21730149). The study is well-designed and very promising. Rhesus monkey maintained on calorie restriction diet into advanced age showed the same health benefits as in mice.
Should I start a calorie restricted diet?
Why not? But you should also remember that this study is done in mice. Sometimes animal studies cannot be translated to humans. Please remember to take a good nutritional supplement (especially folic acid and iron) when you are on a calorie restricted diet. Our ancestors are wise enough to starve themselves (do a fast) atleast once a week. Calorie restriction comes with an added benefit, who wouldn’t love to look younger than their real age!!!
Metformin
ReplyDeleteMetformin is a calorie restriction mimetic. It induces a dietary restriction like state (PMID: 20090912). It extends life span and is considered to be an anti-aging drug. It possesses anti-tumour properties. It activates genes which are induced during calorie restriction. So if calorie restriction preserves oocyte quality metformin can also do it! Hyperinsulinemic conditions are detrimental for oocyte quality. Metformin is found to reduce insulin levels by decreasing insulin resistance and hence increasing egg quality of women suffering with PCOD.
Should I start metformin?
Are you diagnosed with PCOD? Do you have insulin resistance? Are you having poor egg quality because of PCOD? Metformin is for you. Do you have diminished ovarian reserve? Are you struggling to produce enough eggs? Then metformin is not for you. Metformin is known to reduce antral follicle count and when you are undergoing IVF number of eggs collected matters too!
Does lowering FSH and increasing AMH help me if I have poor egg quality?
ReplyDeleteFSH and AMH help to determine our ovarian reserve and not egg quality. But as you age both egg quantity and egg quality starts to decrease simultaneously. This does not mean that egg quantity and quality are related. I think egg quantity and quality are two different events which has no connection to each other. This can be substantiated by the fact that younger women with diminished ovarian reserve are more likely to get pregnant and carry the baby to term even though they produce less amount of eggs during IVF stimulation. On the other hand older women with low ovarian reserve are less likely to conceive. So both FSH and AMH should be just looked as markers for poor ovarian reserve and nothing more. This can be understood if the actual modes of action of these two hormones are studied in detail. Egg quality is something to do with our genetic machinery which has no connection to these two hormones. Decreasing FSH or increasing AMH is also less likely to increase follicle numbers. Actually increasing AMH artificially can bring down your antral follicle count.
These are some of the important scientific information which every woman undergoing multiple IVFs should understand. I wish this will reduce their tension about what supplements to take and what not to take, what is realistic and what is not. But at the end if you think taking certain supplements (because your friend took a supplement and fell pregnant miraculously!) increases your confidence level go ahead and take it, provided it should be from a reliable pharmaceutical company. You should also know for sure that the particular supplement does not have any negative side-effects that will compromise your health. Good luck for every woman who is searching for that single good egg which will make their dream come true!