An expert patient's medical treatment summary

Doctors sometimes underestimate how well-informed and intelligent patients can be. Here is an unedited description of his medical treatment by one of our patients - in his own words. I don't think a doctor could have done a better job summarising their medical course !

My wife and I visited Dr. Malpani’s clinic for infertility treatment in April, 2014. I am 38 years old and my wife is 36. Due to very low sperm counts accompanied with low sperm motility levels, my wife had not been unable to conceive naturally. Prior to coming to Dr. Malpani, we had a couple of ICSI procedures performed at another clinic over a span of 1.5 years, with unsuccessful outcomes.
My wife underwent superovulation with a medication regimen comprising Lupride along with 4 ampoules of Menogon (300 IU) daily from day 4 of the cycle. 24 eggs were retrieved. However, only one motile sperm was found in a semen sample provided by me two days prior to the day of egg retrieval. On the day of egg retrieval, the semen sample provided showed no sperm. A TESA procedure was conducted to attempt sperm collection from the testes. However, there was no sperm found in testicular tissues either. I was classified as azoospermic, and we were advised to go in for sperm donation. The retrieved eggs were frozen.

It was a wrenching decision to take, and prior to reconciling ourselves to the situation, we wanted to see whether there were any medication options available to restore sperm generation. Dr. Malpani referred us to Dr. Rupin Shah, who put me on Adova 1 mg. The prognosis by Dr. Shah was that there was only about a 10% chance that a regenerative process could kick in, and we needed to give the medicine a trial of about 6 months before we would see positive effects, if any. At this point, we decided to wait till October, and in the meanwhile mentally prepared ourselves for sperm donation.
Two events happened between the first visit to Dr. Malpani, and the next one which was in January, 2015. Around July 2014, my wife was diagnosed with Polycystic Ovarian Syndrome (PCOS). She had very regular periods till then with the cycle duration being 28-32 days. When she overshot her regular period date by over a month, we consulted a doctor, and the diagnosis of PCOS was made. The other critical event was that I developed diabetes (October 2014), and was put on medications to manage the same.

In January, 2015, when we visited Dr. Malpani again, we had mentally readied ourselves for sperm donation. However, a semen analysis revealed a count of 10 million/ ml and a motility level of around 50%. Of course, such a finding was wholly unexpected and an unbelievable positive surprise for us. It seemed an incredible stroke of luck flying in the face of accepted medical wisdom. We expected a smooth course of treatment from hereon, but there were to be more hurdles on our path.
Since we had frozen eggs, the availability of sperm meant that embryos could be generated via ICSI. In spite of having more than 20 eggs, only two viable early-stage blastocysts were obtained. An additional complication was that my wife’s endometrium was not growing to the desired level of thickness. A thickness of at least 7.5 mm is desirable, but the growth was stunted and did not exceed 6 mm. The first planned transfer had to be postponed due to inadequate thickness of the endometrium.

In the subsequent cycles, multiple interventions were undertaken including hysteroscopy to grow the endometrium to a minimum desired level of thickness. The pharmacological aspect of the treatment comprised high (and increasing) doses of Progynova coupled with vaginal pessaries. After a couple of unfruitful cycles where the endometrium failed to grow to a desired level in spite of all treatments, finally we opted for an embryo transfer in May, 2015 when the endometrial thickness had grown to above 7 mm+ - this level of endometrial thickness was achieved only after getting the medication dose up to a whopping 16 tablets of Progynova and 16 tabs of Valest (vaginal pessary) a day. The embryo transfer was unsuccessful.

In July 2015, again we returned to Dr. Malpani. Superovulation was done in the normal way to retrieve eggs and my semen sample yielded a sperm count of ~2 million/ml. This was enough to generate embryos via ICSI. The total number of mature eggs retrieved was 17, and we had two blastocycsts of grade AA4 (6th day), one of grade AA1 (5th day), and  two of grade BB (5th day). The embryos were frozen.

This time around, a rather benign protocol was followed for trying to induce endometrial growth. Letrozole 2.5 mg was started from day 2 for 6 days. At the end of this period, the endometrium had still grown to only a level of under 6.5 mm on day 10. At this point, Gonal-F (1 ampoule) was introduced. In what seemed to be a miraculous transformation, the endometrial thickness shot up to 13 mm in 5 days. We went for an embryo transfer – the best two blastocysts (AA4) were transferred.
A pregnancy did result after all, but the joy was short-lived. The beta-HCG levels on day 12 were 156 mIU/ml, and moved up to 330 at the end of another three days. However, the rise in beta-HCG levels started to slow down after that. On day 18 after the embryo transfer, the levels were around 550 mIU/ml. This represented a rise in levels of less than 60% over the last three days, an ominous sign. This signaled quite strongly at an unviable pregnancy, with either an ectopic implantation or a miscarriage coming down the line. As luck would have it, it was an ectopic pregnancy in the left fallopian tube.

On the 19th day after embryo transfer, my wife complained of unbearable abdominal pain and had to be hospitalized. Tests revealed a lesion in the fallopian tube with bleeding in the tube. She was under observation for two days, as there is always a chance that a disturbed ectopic pregnancy may spontaneously resolve, particularly if the beta-HCG levels show a diminishing trend. This was indeed the case for two days in hospital, and we obtained a discharge. An expectant treatment protocol was to be followed, with regular monitoring of beta-HCG levels.

Unfortunately, the beta-HCG levels started rising again, immediately after hospital discharge, and rose to 900 mIU/ml within two days. We were back to hospital. A laparoscopic intervention was prescribed by the attending gynecologist. The approach was to perform a salpingostomy (using suction to remove the matter in the fallopian tube but not removing the tube). The doctor stated that during the laparoscopic procedure, if there was persistent blood oozing from any area, then she would opt for salpingectomy (excision of the fallopian tube).  In the end, a salpingectomy was required and the left fallopian tube was removed. My wife has recuperated from the procedure, and we are planning for another ICSI. 
 
This is an unusually complex case - one of the most challenging we have treated in our career !   Everything which could possibly go wrong seems to have done so for them - but the fact that she did conceive means there is still hope for them !

Patients can learn a lot  from such couples - about how to be resilient ; well-organised and well-informed !


Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !