1) After repeated attempts, which are also cost-consuming, many couples opt out of in-vitro fertilisation (IVF) treatments, losing their hope for pregnancy. Can pregnancy be successful after multiple failed IVF attempts?
An IVF cycle can fail because of a few reasons — Improper diagnosis of the cause of infertility, improper treatment, chromosomal abnormalities in embryo and failure of implantation/endometrial receptivity. One of the first things that IVF requires is that both the male and female partners go through a few tests, including blood tests and ultrasound, to determine the root cause of infertility. It is only after a thorough investigation of each unique patient case that a treatment can be charted out. In many cases, the couple is required to take up medication to treat underlying health conditions or even other procedures such as removal of uterine fibroids.
Once fertilisation of the egg and sperm takes place and an embryo is formed, pre-implantation genetic testing (or PGT) is performed to check for any genetic anomalies in the embryo; these anomalies can act as a barrier to conception or lead to miscarriage. Thus, PGT helps in two ways—a) transfer of the best graded embryo into the uterus, and b) single embryo transfer (multiple embryo transfers can be done in some cases to increase the probability of pregnancy but can lead to complications later). The technology used — including minute details such as the temperature and humidity at which gametes are handled — can also make a significant difference to the success of an IVF cycle. In most cases, the gap is bridged by understanding the history of the patient, taking a unique approach to the case and choosing the right technology.
2) You had a patient who got pregnant after the 14th attempt. Can you share details?
After repeated cycles of failed in-vitro fertilisation (IVF), Nashik couple Vibha and Abhik (names changed) were successful with a twin pregnancy on their 15th attempt. Married for 15 years, the couple exhibited secondary infertility since they already had an elder child. Hoping to complete their family with more children, they tried to conceive naturally as well as using assisted reproductive technology (ART). Then they opted for IVF.
Vibha (36) reported having chronic hypertension and hypothyroidism. Upon testing for fertility parameters, it was found that the uterine lining, endometrium, had grown into the uterus (called adenomyosis). Additionally, the left fallopian tube was blocked with fluids (left terminal hydrosalpinx) and had less number of viable eggs (poor antral follicular count). On analysing Abhik’s semen sample, it was found that he had severe oligoasthenoteratozoospermia or OAT. This condition is marked by three characteristic defects in sperm – low sperm count, poor sperm movement and abnormal shape.
The couple had attempted ART 12 times with their own eggs, all of which failed. Given the couple’s compromised levels of healthy egg reserve and sperm, the best alternative was to opt for donor embryos. Donor embryos are genetically and physically healthy and have better chances of implanting in the uterus, and subsequently leading to a live birth.
In order to prepare Vibha’s uterus for implantation, she was given platelet-rich plasma (PRP) 10 days before embryo transfer. Laser assisted hatching also helped to prepare her womb. Two donor embryos were transferred. Levels of human chorionic gonadotropin (hCG) and an ultrasound confirmed the presence of two growing foetuses. But they didn’t last full term. This is called recurrent implantation failure. This is a complex problem that occurs due to a number of reasons. The treatment plan varies, depending on the source of the problem. In such cases, the best solution that provides light at the end of the tunnel is personalised treatment, depending on the unique nature of each case.
3) What is the success rate of IVF per cycle according to the age of the couples?
Age has a variety of effects on fertility in general and the efficacy of IVF. According to the Centres for Disease Control and Prevention (CDC), the average percentages of ART cycles that lead to a live birth are:
– 31 per cent in women younger than 35 years of age
– 24 per cent in women aged 35 to 37
– 16 per cent in women aged 38 to 40
– 8 per cent in women aged 41 to 44
– 3 per cent in women age 43 and older
These success rates have historically been associated with the biological clock of women and their limited reproductive window. However, new studies on the relation of age and male infertility have found that men, too, have a similar limitation. Men above the age of 40 have been found to have deteriorated sperm quality and reduced fertility.
4) It has been observed that even young couples in the age group of 25 and 35 face infertility and are now opting for IVF treatment. What are the reasons behind early infertility?
Young couples in their mid-20s and 30s are increasingly having difficulty conceiving. This can be attributed to the emergence of lifestyle-related diseases such as diabetes, obesity, hypertension, and thyroid disease. Other lifestyle triggers are work-related stress at work, poor eating habits, increase in consumption of alcohol and tobacco and lack of regular exercise. The pandemic-induced lockdowns and work-from-home formats have meant long sedentary hours, which have upset the hormone patterns of young people. Medical conditions such as endometriosis, endometrial tuberculosis and polycystic ovarian syndrome (PCOS) are also to blame.
It is, however, imperative to mention that there is an increased awareness about infertility. The easy access to information on IVF and an openness to accept a medical solution to infertility have played a significant part in changing mindsets. This is also applicable for people who are born with genetic diseases or congenital limitations.
5) What kind of fertility issues are most common among younger couples nowadays?
There has been a spike in cases among couples experiencing infertility wherein women have been diagnosed with polycystic ovarian syndrome (PCOS) and men with azoospermia. It has also been noted that in many young men experiencing infertility, exposure of the pelvic area to continuous heat (such as laptops or engines) has been a contributor. It is known that the testes need to be a few degrees cooler than the rest of the body. This exposure to heat sources impacts sperm production.
Moreover, with six per cent of the adult Indian population living with one or more sexually transmitted diseases (STDs) that can impact reproductive organs and function, it is essential that those with multiple sexual partners get regular STD tests done so that they can be treated early enough. In women, other fertility health issues can include endometriosis, pelvic inflammatory disease and uterine fibroids. In men, other fertility challenges can include erectile dysfunction, retrograde ejaculation and varicoceles.
6. Considering the changing lifestyle of today’s young generation, what suggestions do you have for those who want to marry late?
You must get married or begin a family only when you feel prepared to do so. For young people, especially in urban centres, it has become increasingly common for both partners to become financially independent first before committing to a family. Those who envision having a family in the future can plan their fertility journey ahead in time.
With the help of cryopreservation techniques, they can freeze their eggs and sperm in their 20s to early 30s and use them up to 10 years later when they are ready to get married and/or to start a family. Even for young couples, who are married but would want to focus on their careers or explore the world before bringing in a new life, embryo freezing is a technique that can help them conceive later. This ensures that eggs, sperms and embryos are harvested at a time when they are genetically and morphologically robust.
Additionally, young individuals must also take care of their health to avoid complications. The simple things that one can do is to incorporate a balanced diet, be physically active, maintain a healthy weight, avoid consumption of alcohol and tobacco, take proactive measures to combat stress and anxiety and go for regular health check-ups.
7. Is there a right age for IVF?
Even with technology, age continues to be a major determinant of pregnancy outcomes. Women in their 20s and early 30s, who use IVF, have more chances with pregnancies and single live births. However, after reaching the mid-30s, the success rates begin to drop slowly. Ageing eggs are unable to fertilise with a sperm or have genetic anomalies, reducing chances of a full-term baby. At the age of 30, women have about 12 per cent of the 300,000 eggs that they are born with. By the age of 40, only 9,000 of them remain. As soon as women reach the age of menopause (50-55), there are very less eggs remaining in the ovary and their viability is questionable. Patients are recommended to seek eggs from younger egg donors once they reach the age of 43.
As per the Assisted Reproductive Technology (Regulation) Act, 2021, men and women need to be between the legal age of marriage and 55 respectively to seek treatment. This is essential as conceiving at an older age may also lead to several other complications for both the mother and baby.
Regardless of seeking the entire process of IVF, young couples as well as single men and women have the choice to freeze their sperms and eggs, respectively. This ensures that these gametes are collected early on in their lives and can be utilised when they are ready to have children in the future.
(Why this doctor? Dr Kshitiz Murdia has a fellowship in infertility from Singapore. He has experience of performing more than 15,000 IVF cases)