Wednesday, August 17, 2016

Poor Responders in IVF

Few Problems in IVF are more frustrating than a poor responder to Gonadotropin stimulation.
The commonest causes are advanced age and also Ovarian Surgery.Let me inneumrate it for ease of understanding

  • Advanced Fertile age.The fertility goes a steep downhill after the age of 37 years.
  • Previous Ovarian surgery
  • Severe endometriosis
  • endometrioma
  • Obesity
  • Previous pelvic adhesions
  • Previous pelvic infections
  • Smoking
  • Previous chemo/radiotherapy.

Though there are many definitions of poor responders but the most widely accepted one is < 3 Oocytes retrieved despite maximal stimulation.An AMH , 3 Pmol/l or an antral count of < 5.
( One can't stimulate follicles which aren't there).

There are various so called treatment options for Poor responders but only testosterone patches and Letrozole have been used with some success.Unfortunately Letrozole is still not accepted as a fertility medicine in India,once it was withdrawan following the Canadian controversy.DHEAS has also been recently attempted to help the poor responders.

One is tempted to use Gonadotrophins at higher level in such patients as a starting dose 

Wednesday, July 20, 2016

Oh so famous

People ask me how is the settling down back to Gurgaon.And my answer is slow and steady. Well yes, exactly that is what it has been.

When I was about to join Artemis Hospital,there was continous enquiry at our call centre as if every pregnant Lady in Gurgaon just wished to shift over to me.But no...this isn't how things work.That was just initial frenzy.And it has settled down quite a bit.

I do get patients,every day 2 to 3  new ones ,who already have heard something positive about me .But yes it isn't a busy clinic by any standards ,certainly not by the standards I left it in 2014.So the upside is that I get plenty of time to talk to these patients and their families and their kids.All are happy and I enjoy the chats just like I used to do so in 2007 when I started initially in Gurgaon.

But today I was surprised.The patient who visited in my clinic ( she was following my India return ever since she got shifted to Gurgaon) is actually my tower mate and we live just 1 floor apart.And she had no clue.This much for my socializing and advertising.

As if this was not enough for me to feel bad about my anti social nature and lack of PR.another gentleman whom I met in my building lift and on knowing my name asked-Kaushiki,the famous Kaushiki Dwivedee,you live on this floor.Heard so much about you seen for the first time.Now tell me,wasn't it enough to make me feel so bad about my PR skills.

I don't have as many patients as I would like to and their are people who are trying to trace Kaushiki Dwivedee out.Need to do something fast.

Marketing.New paper ads!!Any suggestions?

Friday, July 15, 2016

Miscarriage and Progesterone ( To prescribe or not to prescribe)

This Miscarriage and Progesterone will be as pertinent to me whether I am donning the role of an Obstetrician or of an Infertility specialist.I am sure you know of some one had miscarriage.It is a very common process in pregnancy( as common as 1/4th Pregnancies would end up in termination).Why it happens?99 % as the Pregnancy is unhealthy and nature is trying to save you as a parent and the foetus if it survives undetected from the miseries to follow on birth.So is miscarriage a cause of sorrow or relief?? ( I would come across as ruthless,insensitive person giving such a statement.But this is a fact and how much hard I try to sugarcoat it,facts and statistics still remain the same)

In India ,it is a common practise to get Progesterone levels done,declare that there is a chance of miscarriage and start Progesterone or many times HCG injections.So many times it is done just routinely,randomly to 'prevent a miscarriage'Can miscarriages be really prevented,unless they are recurrent miscarriages where there are some factors in mothers body which isn't allowing a healthy foetus to grow?Or it is a late miscarriage due to incompetent cervix where 'a stitch in time can save nine'.If your gynecologist thinks she can prevent miscarriage by a shot of progesterone,probably she/he can but there isn't a scientific evidence to it.Good part is that Progesterone doesn't harm you or the foetus ,so don't worry even if you are on it.You wish to stop it or continue it,it is up to you.If you are my patient,I will explain you all these details but won't prescribe from my side unless you ask for it.

So is progesterone helpful.Yes it is in IVF conceived Pregnancies where Ovary has been suppressed by medications and there isn't proper formation of corpus luteum due to artificial intervention in the process of conception and after cerclage of cervix.I will write about usefulness of progesterone in one of the posts.

For those who wish to read further please follow this link

IVF Specialist-When you got to sleep ,you got to sleep!

Many a times I have been asked this question-What made you leave your flourishing practice and leave for Australia.And every time I come out with an answer which I feel was the probable reason.But I think the most important reason was deprivation of sleep.Yes,that is true.Readers ,I am sure you all are aware that medicine is a demanding profession.Without going in the data collection of which study shows what about in which country how many hours do the doctors sleep,it is a known fact that a doctor practising Obstetrics is sleep deprived.

In 2007 when I started my private practice ,totally new to Gurgaon and for that matter even Delhi,I had a zero patient base and then it improved.The numbers of emergencies( mostly deliveries) were limited.And conducting a vaginal delivery be it Normal,Vaccum or forceps used to give me an ultimate kick(More techniqualy difficult,more was the kick).......much more that elective gynaecology surgeries including Laparoscopy surgeries as well as uro gynaecology surgery which I was quite comfortable with even then - with what Dr Plemming and Dr Klazinga had taught in United Kingdom.

Slowly by God's Grace the practise improved and so did the number of deliveries.By 2014 ,I was awake almost every night with routine OPDs and OTs as scheduled.There were times I would reach delayed for OPD,with not so happy patients who had their appointments delayed by an hour or more already as I was stuck in Labour ward trying a vaginal delivery.7 years of Obstetrics was taking it's toll.I was still maintain the WHO approved 80 % vaginal delivery rate but that Kick was gone.It was a job ,no more a passion.And when I don't enjoy something just like any other human being I loose interest.It was making me cranky,irritable and bored.Increasing Number of patients didn't excite me any more.It wasn't healthy for me.

And then was the Option to take a break.Move to Australia.Have more regulated hours of work.The famous Work life balance.It was enthralling and rejuvenating. 2 years break helped me a lot.

And then is when I thought,if I wish to have my sleep and at the same time not increase my Caesarean section rates and sleep with a clear conscience.When I know that I didn't use early decelerations as and excuse of foetal distress,when I know that a high head of baby is genuinely a high head of baby when I call it a caesarean, when a thin meconium at 8 cms is no indication for a caesarean
section,I need to reduce the Obstetrics component of my private practise.Very Honestly it wasn't just the love of IVF,treating infertility and the money involved but most importantly ,trying to switch over from a totally unplanned life of obstetrician to a more routine life of 9 am to 5 pm.

Now after reading this post,if you have a question,why did I return back,I am not surprised by your query :) :) Perhaps 2 years from hence I will tell the real reason of my return too ;-) ;-)

Tuesday, June 28, 2016

Tushar Kapoor-single parent Surrogacy (What do you say) ?

#Tushar Kapoor becomes a dad , came as a surprise to many.First of all congratulations to him and his whole family.And as I clicked on the net to find some juicy gossip about a possible clandestine affair,it turned out to be interesting,informative,bold,unconventional and thought provoking piece of news.Single parent surrogacy!!

Not long back some one wanted to know the rights of single males to opt as an option for surrogacy#.The Indian Law allows an Indian female or male to opt for surrogacy legally.If you are a foreign national ,then you can't get it done in India legally.

The legalities associated with surrogacy is complex world over with no uniform law.India is one such country which allows the intended parents the legal rights by virtue of the contract signed by the surrogate mother.

Those who are curious about how can a male be a single parent..A male can have a Ovum donor,a surrogate mother and his sperm and take help of an # ICMR certified centre to go ahead with a surrogacy.

Single parent surrogacy has many ethical issues.There can't be a right or a wrong answer to them.Here we are taking care of an individuals right  and instinct to have child but at the same time it is also pertinent question.....what about the child?Is it in the larger interest of that child.I am no one to judge and would invite the readers to pour in their comments.

Same sex couples can't have children through surrogacy but if single parents can then obviously there can be loop holes which same sex couples can use to satisfy their parental instincts.And moreover it doesn't make sense either to deprive them of that instinct(but then in India same sex couples will have to wait to get it done legally till it is approved by our judiciary.

Thursday, June 23, 2016

Doctor : Please give me a twin.( Can I...May Be I can)

I am an attractive looking female in early 40s.Look younger than my age :)
Still I keep on asking my husband to perform a weight loss surgery on me when he shows me the pictures of people who were Obese and lost many kgs following a Bariatric surgery.I get annoyed and depressed at times or mostly.Being skinny was never my lives aim but to have toned body,6 packs ab and sun kissed skin was.And for a while I think he is giving unfair advantage to his patients. They are more uncontrolled and thus they can have surgery while I am thinner...I have to work hard to get my dream body.

And then comes a lady to me or rather two.Both have one prior baby and they ask me to perform an IVF on them to give them twins.They have got pots of money at home and they wish to have children who can enjoy.Fair enough.Demand is valid.Isn't it?Both these women are my ex patients and I am myself amazed how i managed to conduct so many vaginal deliveries in past.I am impressed by myself.

And I sit down thinking but fertility isn't an issue,how can I perform an IVF with desire to  have twin Pregnancy as an indication?And she cajoles me.Doctor it will be a great help and you know money is no issue for me.Ask whatever you want to.I trust you.And here I am ...she trusts me and how can I perform an un indicated IVF and how do I promise her a twin.The embryos might get implanted or they might not.I can't be so unethical as to put 4 or 5 embryos anyways and then performing the guillotine of reaming 2 or 3 with KCL.Even the Lady got horrified with this thought.Well she was justified in asking.I even got swayed for a while with her authentic demand and then the guidelines and ethics.So a NO.

And I bariatric surgery.I need a personal trainer and not a Bariatric surgeon myself :) :) 

Wednesday, June 22, 2016

Freeze the future !! ( All about IVF)

Though there are many moments of my past which I want to vitrify and keep it frozen for ever,take it out once in a while thaw it,feel it and keep it back safely frozen.We all know freezing prevents early decaying or rotting.But this whole paragraph was just a weird imagination of freezing the moments.

Another scenario.A young woman visited for consult and told how young men aren't willing for commitment these days.And being human one ends up having sex with people who don't even commit long term.I could relate what she said with a similar condition in Sydney,where wealthy qualified Ladies in 30s couldn't find a partner to have child with as these 40 plus boys were interested in skate boards,cycling,maintain a physique and a half age trophy wife.

So what?So a very big social dilemma.What happens of women who want children and can't have as they don't have a committed partner or husband?or still further she has either but wants to defer pregnancy for a career she always dreamt of?

There comes the role of oocyte freezing.There are techniques by which the stimulate ovary is used as a site of oocyte retrieval and then the eggs are frozen for ages.Suppose a lady decides to get it frozen at the age of 30 years her egg
will remain 30 year old when she turns 40 years.And thus her  chances of conception by using that stored egg is same as that for a 30 year old lady and not 40 year old lady .Amazing...isn't it.

So if career is important or till you find a proper partner,you can cryopreserve your eggs and make baby when you really want.

And most important is the age of egg for conception.Implantation failures are really a rare cause,otherwise 72 years old won't be getting pregnant with IVF with menopausal uterus
then(of course by donor egg).

This whole process is a reality.I would advise all the young women stuck in a dilemma like this to come and meet me at my clinic and I can enlighten you further.I can even come to your companies to talk about this rather sensitive and important issue.