The importance of seeing photos of your IVF embryos !

I often see patients who have failed IVF cycles elsewhere. These patients are confused , depressed and despondent because they are not sure what to do next. They come to me for a second opinion , looking for expert guidance.

The first question I ask them is - Can you please show me photographs of your embryos ?

A lot of them look very surprised when I ask them this question and I get lots of answers .

 “ I didn’t know we could see photos of our embryos “ .
 “ I did not know our doctor was supposed to give these to us. “
The commonest response is – “ My doctor didn't give me any “. This can be extremely frustrating.

It's extremely important that IVF clinics routinely document and provide photographs of the embryos they make to their patients. The only tangible an IVF clinic can deliver is an embryo - and in fact the job of a good IVF clinic is to make good quality embryos ! After making the embryo and transferring this into the uterus , whether it will implant and become a baby is outside the doctor’s  control .  However , making good-quality embryos is something which a good IVF clinic can definitely do – and should take pride in doing so ! Some patients answer – “ My doctor told me my embryos were very good – and I trusted my doctor . “  Yes, of course you trust your doctor – and our patients trust us too. Yet we routinely give them photos of their embryos – and this is good for us , and for them as well.

Seeing their own embryos can be an emotional highpoint for patients. They are happy that their reproductive system works well enough to make good-quality embryos. IVF patients are often depressed and unhappy because they're infertile and feel their bodies are defective. Once they see their embryos, their confidence gets a boost. They can now see light at the end of the tunnel – and they understand that it’s then just a matter of time till one of those embryos will implant and become a baby. Equally importantly , it gives patients the confidence that they've received good quality medical care . Even if the cycle fails , the patient does not feel that the treatment wasn't done properly, and it’s easier for them to take the failure in their stride. . They have the maturity to be able to understand that some things are not in the doctors control or in their hands. Even if the cycle fails , they are happy they have received good care, and this gives them invaluable peace of mind . And if the cycle succeeds, these photos are a great way of starting your baby’s album !

Documenting good-quality embryos is very good for the doctor as well. It increases the patient's confidence levels in the doctor’s skills. The patient can see that the doctor is being open , honest and transparent , and is confident of his technical skills, which is why he's giving them photos of embryos, which they can show to other doctors if they want a second opinion.

IVF patients go to an obstetrician when they get pregnant ; or to another IVF clinic , in case the cycle
fails . If the IVF clinic documents the fact that it has made good-quality embryos , other doctors understand that this is a good IVF clinic, which is providing high quality medical care, which is good for the reputation of the clinic within the medical fraternity as well.

If there are no photos , then other doctors ( and the patient herself) will wonder about the competence of the lab ? Do they have anything to hide ? Even if these are poor quality embryos, this should be documented , so that the doctor can use this information to tweak the treatment protocol for the next cycle, so as to improve the patient’s chances of success

Are IVF doctors overusing surrogacy treatment ?

India has the dubious distinction of scoring a number of medical firsts – for example, that  of being the diabetes capital of the world. We also seem to have become the surrogacy capital of the world, and patients from all over the world come to India for surrogacy treatment. This is a welcome sign , which suggests that Indian medical treatment has become world class,  and is great for infertile couples who actually do need surrogacy treatment. However, all this limelight is also causing some unforeseen problems – especially for infertile Indian couples doing IVF treatment.

We are now seeing many patients who are being advised surrogacy by their IVF doctors, because they have failed 2-3 IVF cycles. When the IVF cycles fail, the diagnosis the doctor glibly trots out is “ failed implantation” – and then promptly advises surrogacy. The implication is that if the embryos fail to implant, the “fault” must be with the patient’s uterus;  that her body is faulty and is rejecting the embryos which the doctor has so carefully created in the lab; which is why her best solution would be to use a surrogate !
Actually, this is completely flawed thinking, which benefits only one person – the IVF doctor. For one thing, it gets her off the hook for the IVF failure. After all, if the patient’s body is rejecting the embryos, what can the poor doctor do about this ?

Many doctors will run an extensive series of very expensive, complicated tests to confirm their
“ diagnosis” . These include tests for tumour necrotic factor (TNF)-alpha , interferon (IFN)-gamma levels and natural killer ( NK ) cells. Because these tests are very “ sophisticated” , they have to send the samples to a specific center ( which is usually in a different city – or even a different country !) This just adds to the cost – and the mystique ! Many of these test results will come back as abnormal (the dirty secret is that many fertile women also have abnormal test results !), and the doctor will then use this abnormality as a pretext for doing surrogacy.

Doctors are happy to do surrogacy because it is much more lucrative for them ! It’s also much easier to manipulate the medical records of the surrogate. This is why many surrogates will get pregnant – and then mysteriously miscarry after a few weeks !

There are many reasons why patients fall for this poor quality advise ! For one, patients often do not bother to do any homework on their own. They trust their doctor, and are happy to blindly obey whatever their doctor  advises. Secondly, many infertile women have low self esteem. They believe their bodies are flawed and are quite willing to accept the blame for the failure. Many infertile women feel their uterus is defective. They often mistake the PMS they get every cycle for early signs of pregnancy, which is why they believe that  they must be getting pregnant every month, but that their body is expelling the embryo , because of excessive body heat or immunological incompatibility ( depending upon their level of medical sophistication) ! Also, some are quite fed up of doing IVF, and are quite happy to find a surrogate who can carry the baby for them, so that they do not need to go through the emotional ups and down of an IVF cycle themselves. Surrogacy seems to be the perfect solution for them !

This is especially tragic in the case of the older infertile women. The commonest reason for IVF failure in these women is genetically abnormal embryos , and this is because the eggs of older women have more genetic  abnormalities, because they have “aged”, and these eggs cannot be screened for these abnormalities . They would be much better off using donor eggs . rather than doing surrogacy !

The biggest tragedy is that often the reason for the repeated IVF failure is the fact that the embryos are of poor quality , because the IVF lab is not very competent. Unfortunately, the documentation is very poor – and these labs do not even bother to provide patients with photos of their embryos !

Rather than do surrogacy, many of these patients would be far better of finding a better doctor ,rather than trying to find another uterus !

Providing a second opinion when an IVF cycle fails

As a senior IVF specialist , I'm often asked to give a second opinion on the IVF treatment which patients have taken another IVF clinic. This is a useful exercise for me , because it teaches me a lot. I can study the treatment protocols which other doctors use; and how they modify these , depending  upon the patient's response. I also probe to find out how much the patient has understood about their treatment, because this tells me a lot about good their doctor was. Good doctors take the time and trouble to educate their patients; and if the patient is well-informed, this is a sign that their doctor is a good physician. ,

Sometimes I'm forced to be critical of the treatment which was provided by the clinic . Providing a second opinion can be a difficult task , because you often have to second-guess what the other doctor did. It’s easy to point out flaws , errors and shortcomings with hindsight wisdom . It’s easy to be cleverer than the treating doctor because I am looking through a retrospectoscope ! However, I do not like criticizing professional colleagues,  and try to be respectful, because I always remind myself that I wasn’t there when the actual treatment was being performed, which is why I may not have insight into why the doctor chose to make certain decisions.

Unfortunately , however, many times the quality of documentation leaves a lot to be desired , and it’s hard not to be critical. Patients are often poorly informed , and are not aware of exactly how many follicles were seen on the ultrasound scans; how many eggs were retrieved; and  what the quality of their embryos was.

Many IVF clinics do not even bother to show patients photographs of their embryos ! Under the circumstances , it becomes very difficult to provide an intelligent second opinion . If I had good-quality documentation , with images of the ultrasound scans of the endometrial thickness and texture ; and images of the embryos, I could tell patients with confidence that they had received good quality medical care. However, when even this basic information is lacking from the medical documentation , then I'm forced to come to some unsavory conclusions . After all , poor quality documentation suggests poor quality medical care. In this situation, I sometimes have to say unkind things about the medical care which was given .

This causes the patient a lot of unhappiness , because they are understandably upset and distressed that their doctor was not transparent , forthright and open with them. Now the point of the exercise is not to cast aspersions on the professional abilities of other doctors; or to play a game of medical one-upmanship. Rather than look backwards , patients need to learn from these mistakes , so that they can move forward confidently and get better medical care for their next IVF cycle, by proactively asking their doctor for better documentation !

Providing good-quality documentation is good for the doctor , because a good doctor is proud of the fact that he's provided high quality medical care and produced good-quality embryos . If he can show these to the patient , he knows he’s done a good job, even though not every good-quality embryo will become a baby , It’s equally important for patients as well , because patients have peace of mind that they've received good quality medical care ; and even if the cycle fails , they are not likely to blame the doctor for providing suboptimal medical care.

Overtreating patients with low AMH levels

AMH is a relatively new blood test which is very useful in checking the ovarian reserve of women. It allows us to estimate the quantity and quality of eggs left in your ovaries, so can get a better idea of how you will respond to superovulation.  Basically, it allows us to check how young your ovaries are – and is much better than the older blood test of checking the FSH level, which was all what was available to us a few years ago.
However, like any other test, it has a lot of limitations. It provides useful information, but as with all biological systems, none of this is in black or white – these are all shades of grey. Like all tests, it needs to be interpreted by a skilled doctor, who uses his judgment to make sense of test result in the right clinical context.

Today, because the test is so easily available, many doctors do AMH level testing in order to counsel infertile women. While a normal AMH level is reassuring, many doctors do not seem to understand what to advise their patients when their AMH level is low. While low AMH levels do suggest poor ovarian reserve, this does not mean that these patients cannot get pregnant with their own eggs. However , there are some IVF specialists who reflexively advise their patients with low AMH levels to use donor eggs as their first treatment choice !

Both doctors and patients need to remember that doctors do not treat lab results – we treat patients. Sadly, it’s so much easier to order lab tests and “fix” these rather than talk to the patient,  that we tend to overtreat abnormal lab results such as low AMH levels.

Please remember that women with low AMH levels do get pregnant in their bedroom as well ! This is especially true for young women with low AMH levels – in these women, a low AMH level does not correlate as well with poor fertility as compared to low AMH levels in older women !

The trouble is that when infertile women find out they have a low AMH level, this is what they start obsessing about – much like the man with a low sperm count who is exclusively focused about his sperm counts !
Please remember that an AMH level is just one piece in a complex jigsaw puzzle ! If you do have a low AMH level, please do not panic. Remember that every problem has a solution – we just need to find the right one for you !

Here are some ground rules which may help.

1.    Please don’t jump to conclusions based on just one report.  Please retest from another lab – remember that not all labs are reliable !
2.    You need to collect additional evidence to confirm the diagnosis of poor ovarian reserve. One of the best ways of doing this is by checking your antral follicle count , using a vaginal ultrasound scan .
3.    It’s worth trying alternative medicines to try to improve your ovarian reserve. While these are untested and unproven, they are unlikely to cause any harm – and will give you peace of mind you did your best. You can use yourself as a personal guinea pig and run a clinical trial on yourself - this is a great way of becoming an expert patient !

It’s important to remember that we do have solutions to this common and frustrating problem, and that a low AMH level does not mean that your dreams of having a baby will never be fulfilled !

It’s a good idea to try IVF to see how your ovaries respond. Using donor eggs should always be Plan B !

Will Clear Passage Therapy take up my challenge ?

Clear Passage uses a wide variety of clever techniques in order to lure patients. They claim to be able to treat lots of conditions , ranging from chronic pelvic pain to adhesions to blocked tubes. ( This is smart, because the more the number of conditions you claim to be able treat, the greater the number of patients will come to you.)

Patients who go to Clear Passage are self-pay , well-heeled patients who are self-referred. These are internet positive patients, who will scour the web to find alternative treatment options, because they are not happy with what their present doctor is offering. Clear Passage does a great job of targeting these patients !

In order to claim legitimacy for their technique , they will get papers published in what they consider to be respected medical journals , and then use these as proof that the techniques work. ( They also use endorsements from a few doctors -  but what weight these carry is difficult to establish. ) Fortunately, they do not need to prove to the FDA that their treatment works ! Sadly, very few patients will bother to read the original paper, the full text of which is not published on their site.

Interestingly, there is no patient they will refuse to treat. Everyone is potentially a paying customer, and they are happy to treat everyone who comes to them , provided they can afford to pay , whether they actually require treatment or not.

For example, it's well known that patients with just one blocked fallopian do not need any treatment at all . One normal tube is enough for normal fertility. However, they will be happy to treat these patients,  and when they get pregnant, they will then take credit for their success. Patients are duped into believing that it was the treatment which help them to get pregnant , without realizing that a number of women with just one blocked tube will get pregnant in their own bedroom , without having to spend US $ 4000 on Clear Passage
Therapy !

Also they will not highlight the limitations of the diagnostic techniques which are used to diagnose blocked tubes. Doctors know that sometimes tubes may appear blocked on a hysterosalpingogram ( HSG ) because of cornual spasm , rather than because the tube is actually blocked. These patients will often get pregnant on their own, but if they happen to have taken Clear Passage therapy before their pregnancy , they will believe that it was the treatment which helped them to clear their blocked tubes ! These are how some of these myths and misconceptions are propagated.

The problem of adhesions is even more complex. Pelvic adhesions can only be diagnosed reliably by doing a laparoscopy. However, it’s very easy for these therapists to diagnose adhesions in all women who come to them with pelvic pain.  It’s well known that adhesions can cause pain – but concluding that every woman with pelvic pain has adhesions is plainly ludicrous ! The great thing is that there’s no way of confirming this diagnosis – or disputing it. Women with pelvic pain are miserable . Doctors have little to offer them , so they are often quite fed up and happy to grasp at straws. Clear Passage promises them relief – based on what seems to be a logical proposition at first blush, so they are happy to give it a trial.

Remember that when surgeons and companies such as Johnson & Johnson want to establish that their products ( such as Interceed) help to reduce adhesions, they have to document the severity and extent of adhesions prior to treatment with a laparoscopy ; and then follow up with a second look laparoscopy later on , to see what the effect of their treatment has been on the adhesions . Clear Passage Therapy does not bother to use any documentary evidence to establish the presence of adhesions , or to quantify their severity. Ideally , if they were serious, they would use exactly the same criteria which surgeons do. They would do a laparoscopy prior to starting treatment to assess the grade and severity of the adhesions; and then they would re-check with a second look laparoscopy after a few weeks, to see what has happened to these adhesions.  Fortunately, they do not have to prove the efficacy of their therapy to the FDA. Instead, they prefer using patient testimonials, because these appeal to prospective patients who can identify easily with these.  However, it's well known that simple tender loving care by a sympathetic doctor will also help patients with chronic pelvic pain to get better. How does one prove that Clear Passage is any better than a placebo in helping these women ? Patients with pelvic pain are understandably reluctant to undergo surgery. Not only is this expensive and scary, most good surgeons are honest and explain that the results of surgery are unpredictable as regards pain relief. The Clear Passage people have no qualms in making tall claims , because they can get away with these.

They claim that Clear Passage helps to improve circulation. This is easy to claim – but how can they possibly prove this ? They know they can’t – so they can get away with making these preposterous claims.
I am not being cynical, but I am skeptical, because there is no sound biological sense behind this therapy. A healthy dose of skepticism can be good for health !

I’d like to offer  Clear Passage a challenge. I do hope they will take this up, because if they can convince a sceptic like me, they will have proven their point much more effectively than buying all the google adwords in the world . I would like them to treat 5 patients with documented bilateral hydrosalpinges .( I will be happy to refer five of my patients to them. )  It is my hypothesis that Clear Passage  will not be able to open these tubes, no matter how skilled the therapist.  If they can get even one of these patients pregnant, I’ll be very happy to endorse Clear Passage, free of cost !

It would also be interesting to do a controlled clinical trial . I’d like to compare patients who have spent 25 dollars on a Self Fertility Massage DVD , and learnt to do self fertility massage, versus those who spend US $ 4000 on Clear Passage – and see whether there is any difference in the outcome of the two groups !

Pregnancy after a failed IVF cycle

All of us know of patients who have failed an IVF cycle and then got pregnant in their own bedroom ! This sometimes raises a lot of questions – how did they get pregnant when they failed the IVF cycle ? Was the IVF doctor good enough ? Or did he do a bad job with the IVF treatment ? Doesn’t this suggest that IVF doctors are greedy and tend to over-treat patients, by advising expensive treatments like IVF, even when they that the patient could get pregnant in their own bedroom ?

All these are valid questions ! All of us see treatment independent pregnancies - patients who get pregnant while they're waiting for the IVF treatment ; or have failed the IVF treatment. There are many reasons for this.

For example , some patients with unexplained infertility will become much more aware of their body’s fertility signals after they've done an IVF cycle . They pay more attention to these , which helps them to increase the chance of achieving a natural pregnancy in the bedroom ! Others get so highly motivated because they never want to do another IVF cycle , that they will redouble their energies on trying to achieve a pregnancy in the bedroom !

Interestingly, we have also seen patients with very poor uterine linings in an IVF cycle , as a result of which their IVF cycle fails, who then get pregnant in the natural cycle , presumably because the uterine lining in the natural cycle was better than it was during the IVF treatment.

It's very hard to pinpoint what the particular problem was in these patients - and what caused it to improve after the failed IVF cycle. While lots of IVF doctors are quite happy to take the credit for these IVF independent pregnancies, the common denominator amongst these successes seems to be that these are highly motivated patients , who don't just give up simply because their IVF cycle has failed – they continue trying actively in their own bedroom ! The one thing which differentiates them from the rest is their sexual frequency - and the rule is simple: the more often you have sex the better your chance of getting pregnant. On the other hand, there are other patients who go to pieces after a failed IVF cycle, and assume they are doomed to never having a baby all their life. This is not true !

Free IVF comic book - become an expert patient !

Are you thinking about doing IVF treatment ? 

Confused about what is happening during your IVF cycle ?

If your IVF cycle has failed, what should you do next ?

You can read and download a free 100 page comic book which can help you learn more about IVF ! 

 This comic book actually makes learning about IVF fun !  You'll be able to impress your doctor by how much you know !

Becoming an expert patient will help you get better IVF treatment and improve your chances of getting pregnant !

Non-IVF specialists

We all know that IVF specialists are infertility specialists who offer IVF treatment . Lots of infertile patients flock to them , because they are seen to be the court of last resort . They can offer lots of clever technological solutions to problems which otherwise could not be solved . either by conventional medical therapy or surgery.

Interestingly there is another breed of infertility specialists, which I call the non-IVF specialist ! These are the infertility specialists who specialize in trying to make sure that the infertile patients who come to them do not need to go for IVF treatment.

IVF treatment is expensive , and results are unpredictable . Many patients are quite scared about the side effects of IVF medications, and have a lot of worries and concerns about this. Also, for many patients , IVF is simply unaffordable , which is why there is a lot of scope for non-IVF specialists who offer alternatives to IVF. Just like you have noninvasive cardiologists who specialize in keeping patients with heart disease away from cardiac surgeons , this group of doctors can serve a useful purpose. However, there are some caveats which need to be remembered.

There are two types of non-IVF specialists. One is the alternative medicine specialist, who uses complementary therapy to heal his patients. These are the naturopaths , homeopaths and acupuncturists , will use the wide variety of therapeutic tools within their armamentarium to try to enhance the natural fertility of their patients.

The other group are the conventional gynecologists , who do not offer IVF treatment themselves, and will therefore offer alternative options such as aggressive medical therapy or operative laparoscopy or intrauterine insemination , in order to hold on to their patients, and not have to refer them for IVF treatment.

Both IVF and non-IVF specialists can work in tandem for the good of the patient. They can learn from each other if they have mutual respect . They need to understand that no one has a monopoly on knowledge . Thus. many nonIVF specialists understand their limitations, and appreciate that there are some problems ( such as a zero sperm count or blocked tubes) which are best served by IVF specialists. Similarly, many IVF specialists understand the limits of what IVF can offer, and will encourage their patients to explore alternatives.  A lot of IVF specialists set up productive partnerships with these non-IVF specialists , to ensure that the patients get the best of all possible worlds - this is integrative medicine at its best .

 However, unfortunately sometimes this can become an adversarial relationship , which cause a lot of harm to patients . Some nonIVF specialists will bad mouth IVF ; or will tell patients false stories about the risks and complications of IVF , to scare them away from IVF. Some of them seem to take a perverse pride is ensuring their patients do not go to IVF specialists ! They end up providing their patients with years of nonproductive fruitless treatment , as a result of which patients get fed up and frustrated . Even worse, they have deprived themselves of the opportunity of doing IVF when they were younger, and the chances of success were higher.

It's important to remember that these are not competitive treatment options - these are complementary.  As an IVF specialist. I will often refer my patients to acupuncturists and yoga therapists. I would not try to prescribe these treatments myself , because I understand my limitations , in that I do not understand much about these fields. This is why patients are better off going  to specialists in these areas, who have much more depth of understanding than I do.

Both IVF and non-IVF specialists can learn from each other , and intelligent, educated patients can serve as a very important link between them. They can share the knowledge, and provide a means of pollination, which increases the knowledgebase for both IVF and non-IVF specialists.

Trying to have a baby ? Free 700 page comic book !

Trying to have a baby ? You can read and download a free 700 page comic book which can help you to get pregnant quickly. 

This comic book actually makes learning about infertility treatment and IVF fun ! 

Becoming an expert patient will help you get better medical care and improve your chances of getting pregnant !

Finding the best IVF expert for your treatment

Infertile patients spend a lot of time on finding the right IVF expert for their IVF treatment. Not only do they spend hours scouring the web for the right doctor, the pore over hundreds of bulletin board messages in order to find the doctor who's just right for them. All patients want the perfect doctor - one who is uptodate, runs a well-equipped clinic ; and is kind and empathetic. While a lot of these searches are done online , they will also talk to friends and family members who been through infertility treatment ; and request their family physician for a referral to the best IVF specialist.

While it's true that finding the right IVF doctor can make a world of a difference to your IVF treatment, I feel that sometimes patients waste too much time and energy on this expedition.

One problem is that when they think they found the right IVF doctor , they will stop doing their homework. They then tend to uncritically accept whatever suggestions the IVF doctor makes , even though some of these may not be scientifically very sound or sensible.

Even worse, the fact of the matter is that trying to find the right expert can often become such an obsessive exercise that it consumes a lot of energy, which can be better utilized in other pursuits. I feel rather than spend all the time and energy trying to find the right IVF expert, most infertile patients would be much better off if they spend the same amount of time and energy trying to become expert patients themselves.

Expert patients are able to identify the right IVF expert for themselves - they do not get swayed by brand names , press releases and five star ambience ! They're also able to critically analyze their doctor's advise, so they can craft a treatment plan in partnership with their doctor, which works for them, rather than just blindly doing what the doctor tells them to do

Frugal medicine - what Indian doctors can teach the US healthcare system

America is the world leader in a number of fields - and this is true for medicine and healthcare as well. Doctors all over the world come to institutions such as the Mayo Clinic and Johns Hopkins , in order to learn about the recent advances in medicines. These institutes are considered to be the embodiments of medical perfection.

Most of the leading medical journals are published in the US ; and most of the authors of the authoritative medical textbooks work in US medical schools . If doctors need advanced training in a particular area, they usually travel to the US ; and lots of the newest medical equipment, tools, technology, and drugs come from companies located in the US. Most keynote speakers at international medical conferences come from the US ; and because medical journals are published in the US , a disproportionate amount of papers published in the medical literature originate from medical centers in the US.

This is why most doctors look up to US doctors ; and this is one of the reasons why the American medical system has such a disproportionate impact on the rest of the world.  I can vouch for this from my personal experience as well. When I was a medical student , the medical books we read were all authored by US physicians ; and when I needed to complete my training, I chose to go to the Johns Hopkins and Harvard because they were supposed to be the best medical centers in the world.

While I have a lot of respect and admiration for US doctors, I think the sad truth is that the US healthcare model is broken. While there are still pockets of excellent, the system itself is dysfunctional .

US healthcare is very technology dependent and there is a lot of mindless over testing in the US. There are many reasons for this. Americans have always prided themselves on their technological expertise,  and they put a disproportionate amount of their trust in tools and technology in all parts of their life. It’s therefore hardly surprising that they will do this in healthcare as well.

Since so many of these technological innovations originate in the academic medical centers in the US, medical professors and researchers aggressively promote the use of these devices by giving lectures all over the world. The one thing the US is still the undisputed world leader in is marketing and advertising – and they apply these skills to the healthcare field as well.

Since the “Made in the US “ label is considered to be a prestigious badge, and since these professors actively publish their findings and disseminate them in international conferences, doctors all over the world ate happy to imitate them.

The doctors who author textbooks are those who work in academic medical centers , and they tend to over emphasize uncommon problems, because these are what they find interesting.  When you consider medical journals ( which is what most doctors read in order to remain au courant, the situation is even worse,  because journals only publish case reports about rare and unusual problems. Medical journals are full of zebra – which most doctors will never see in their lifetime . However, doctors who read these journals then start looking for the zebras in their medical practice , because they want to have their paper published in the medical journal as well - this is considered to be a status symbol in the academic world.

The problem with all this testing is that it's very easy to tick off boxes asking for panels of tests , but it's not very easy to think about which tests are required , and when. Because doctors love rare cases , they often order many tests , in order to pick up the unusual patient with the rare abnormality , so that they can brag to their colleagues about the diagnostic acumen. However , they fail to think about how much of the testing is completely inappropriate and uncalled for.  A patient of mine who has had recurrent pregnancy losses, and now lives in the US , wrote about how a nurse automatically collected over 22 test tubes of blood for testing , saying this is part of our routine workup for recurrent pregnancy loss. While this may seem very impressive , and patients can be very impressed by how thorough their doctor is and how painstakingly they hunt for problems, the fact is that most of her test results will come back as normal , and therefore not add any value at all to her medical care . This is the elephant in the room, which no one talks about – the sheer waste in routine US healthcare. To make a bad situation worse, not only are many of these new tests much more expensive , they also much harder to interpret , because they've not been standardized, and no one really knows what abnormal results mean , because we don't have enough experience with them.

Not only do doctors love ordering all these fancy new tests , they get very excited when one of the results come back as abnormal . They pat themselves on the back , because they finally identified the problem and picked up an abnormality which the earlier doctor had missed. Patients are also quite happy , because they feel that their new clever doctor has pinpointed the problem , and therefore will be able to provide an effective solution. However, it is a mathematical certainty that the more the tests your doctor orders, the more the abnormalities he will find – but a lot of these abnormal findings are red herrings , which have no clinical value at all , because they do not affect the clinical care of the patient.


American medicine, like a lot of other areas in America , has become wasteful because it has been supersized. We need to realize that this is not the best way of practicing medicine , and we need to start learning what I call frugal medicine.

Frugal medicine requires a thoughtful talk to intelligent, caring able to listen to the patient is selective about what tests the authors. These are not easy skills to acquire and there are not many role models to follow. Unfortunately, the commercial demands of modern medicine and the aggressive marketing by large multinational, multibillion dollar diagnostic testing industries and device manufacturers will mean that patients will have to do a lot of hard work if you want to find doctors who willing to practice cost-effective sensible medicine

Bigger is better is a broken model. Small is beautiful !

Cryptozoospermia

Cryptospermia or cryptozoospermia is not a very common condition, which is one of the reasons this diagnosis is often missed. The word crypto means hidden , and as the word suggests , patients with cryptospermia have occasional sperm in the semen , but because their numbers are so few , they are very difficult to find, and easy to miss. This is quite a common problem when the semen analysis is done in a general medical laboratory, where the laboratory technicians are not experienced , and don't know how to do the semen analysis properly.  A lot of technicians will do the microscopic analysis of the semen sample quite casually – and will report it is as having a zero sperm count or azoospermia , if they cannot see sperm in the first quick glance.

This can be very misleading , and lead both the doctor and the patient on a wild goose chase. Many of these patients end up with unnecessary surgery , such as a testis biopsy and even a VEA ( vaso epididymal anatomosis),  because the diagnosis was not made correctly.

This is why it's extremely important that before labeling the sample as being azoospermia, the laboratory technician should centrifuge the sperm sample and look at the pellet very carefully for the presence of sperm.

Not only is it important for technicians to be aware of this condition, it's equally important for patients to be vigilant. Thus, if your semen analysis is reported as showing azoospermia, these are the two things you need to do.
1.    You should provide a sequential ejaculate , where you provide 2 samples for analysis . You need to give the second semen sample 1-2 hours after the first. This will often contain a few sperm, even when the first does not, because it is “fresher”.
2.    Explicitly request the lab to centrifuge the semen sample and check the pellet for sperm. Good labs will do this routinely, but unfortunately, some fail to do so.
This is especially true if you have had occasional sperm found in your semen analysis report on one or two occasions.

The reason this makes such a big difference is because if there are a few sperm in your semen sample , then your best treatment option would be ICSI; and there is no need to waste time and money on medical treatment or ineffective surgical therapy.

Why are girls being abandoned and battered ?

It's heartbreaking to read newspaper stories of girl children who have been battered to death by their parents or abandoned to die.

Thanks to the PNDT Act, everyone is aware about the skewed sex ratio in our country and the need to ban female feticide. However, even the word feticide itself is so highly emotionally charged that we sometimes forget that it has been used to frame the debate in such a way that it prevents us from clearly thinking about the issues involved objectively.

When we refer to sex selective abortions, we talk about female feticide. Then why don't we refer to all abortions as feticides ? All abortions involve killing the fetus , and not just the sex selective ones ! However, when the woman finds herself with an unwanted pregnancy, we give her the right to terminate this pregnancy because we respect her right to choose for herself. We believe that she has the freedom to choose what is right for herself, and our laws protect this freedom.  However, the word feticide is so highly emotionally charged , that we refuse to use this when we talk about medical abortions for unwanted pregnancies. This is why we all implicitly conspire to use double standards and refer to these pregnancy terminations using the much more neutral term , MTP or medical termination of pregnancy.  This is not something which is localized to India , and you see the same kind of debate in the US as well. Here , both the camps are equally strong , and while the antiabortion camp will talk about pro-life , the pro-abortion camp does not call themselves anti-life - they call themselves pro-choice !

It's all very well to talk about why society and the government need to lay down policies in order to protect the female fetus.  However, a truly enlightened policy would simply ensure that every child is a wanted child. If we can do this , then parents will naturally love and nurture their children because parental  love is one of the strongest biological urges humans have .

While we are tom-tomming our efforts to protect the female fetus in utero, what kind of protection are we offering these baby girls after birth ? Will we end up improving the sex ratio at birth – and then make the problem of neglected girls from 0 - 6 even worse ? The irony is that when Amartya Sen wrote his landmark paper about missing women 20 years ago, he was referring to the premature death of girls and women because of their neglect by their family and society – not to female feticide !

Why do you want a baby ? Genes , Pregnancy and Parenting

Fertile couples find it easy to make a baby in their bedrooms. Most of us take our reproductive ability for granted , and expect to be able to have babies when we are ready to grow our families.  The urge to procreate is extremely strong and as Sir Osler said, there are two primal desires for humans - to get and to beget !

Why do most of us want to have babies in the first place ?  Very few of us bother to analyze our motives, because babies are often the happy results of our pleasurable bedroom pursuits.  Many couples are just following their basic biological urges , as commanded by their selfish genes. For others , babies are a welcome byproduct of their sexual activity , and they are quite pleased to grow their families. Many others will blindly obey the social pressure to have children , simply because this is what is expected of them.
What about the minority who actually thinks about why they want have a baby ? There could be multiple reasons.

Some simply want to propagate their family name , because this is what their religion commands them to do . Others possess a lot of ancestral property , which is why they want to have heirs to whom they can hand over their assets . Some have extremely high self-esteem and believe that their genes are so special  that they would be doing posterity a favor by having children who have their unique talents, as encoded in their genes . For these people the major desire is their urge to propagate their DNA.

In primitive societies, the major role of the woman was to have babies , and childless women were often treated as outcasts. It was only when the woman gave birth to a child that she was given the honor of being considered to be a productive member of society. While this attitude was extremely common in the past, some of these primitive beliefs die hard , and are still true today in many parts of the world. For these women , the major desire to have a child is so that they are no longer considered to be second-class citizens , and can become respected members of society.  Just as a mother gives birth to a child , remember that a child too gives birth to a mother !

For a thoughtful minority , the major reason to have a baby would be to become a parent.  These are people who love children and want to have the pleasure of bringing up their own child , so they can share their experiences and wisdom with the next generation. They understand that just as they hope to teach their child , they will also learn a lot by becoming a parent , because a child will often teach as much to a parent as he learns from her.

Fortunately for most couples , having a baby in the bedroom allows us to package all these desires into one joyful package ! When babies are made in the bedroom , this natural biological process allows us to propagate our genes ; experience pregnancy and birth , so we can claim our place as adults in society ; and also bring up our children , so that we can both teach them and learn from them.

However, this desire gets thwarted for infertile couples ; and then they need to make some hard decisions as to what their priorities are, when they want have a child. Some couples are adamant that the child has have to have their own genes. This means they want to use only their only own eggs and sperm, and will not countenance the use of donor gametes.  This is why a number of older women are then misled into doing surrogacy treatment by IVF doctors, even though this will not help them at all  ( because the problem is not with their uterus, but with their eggs).

There are other couples who are not so fixated on their personal DNA ; and simply want to experience the pleasure of having a baby. They are willing to consider the use of donor eggs , donor sperm and donor embryos to fulfill their desires. The more the options you are open to, the better the chances of your achieving success !

Finally, there are couples who simply want to have a child so they can rear the child and shower him with their love and affection. In the past, adoption was an excellent solution for a lot of these couples . Today thanks to assisted reproductive technology, they have even more choices, such as surrogacy. You can read a great first person account on how one couple made up their mind at the article, Meet the Twiblings .

If you are infertile and are not sure how to proceed,  you need to step back and discuss with each other what your primary goals and motives are in having a baby.  Is it biological ? personal ? social ? cultural ? This can become quite a sore issue, especially when you and your partner do not see eye to eye.  The lust and craving to have a baby can be much stronger in women than it is in men , especially when their biological clock goes off – and this can create a lot of angst !

When less is more – or is it ? The pros and cons of mini IVF

Patients with poor ovarian reserve can be extremely challenging. Because we know that not every egg becomes an embryo and not every embryo becomes a baby , doctors will do their best to get IVF patients to grow lots of eggs to maximize their chances of getting pregnant.

However, it can be very hard to super ovulate patients with diminished ovarian reserve. It seems that no matter what we try, these ovaries just do not respond well to our medications. This can be very frustrating both for doctor and patient , which is why doctors have come up with lots of strategies to deal with these patients.

The standard approach is to be more aggressive with super ovulation and use a higher dose of gonadotropin injections to help coax the ovaries to grow more eggs. Doctors have also tried to tweak the super ovulation protocol by using a mix-and-match of various drugs, which is supposed to help the ovaries to perform better during the IVF cycle. These include androgens such as DHEA; injections of growth hormone which can be extremely expensive; and supplements such as Royal jelly and wheat germ. Many clinics will also combine the super ovulation with acupuncture and yoga.

However, the results with a lot of these protocols have been mixed and while some patients do well, the vast majority still end up growing only a few eggs no matter what we do.

This is why some clinics will use the mini IVF or a gentle IVF protocols for these patients. The logis is simple - since we cannot get them to grow lots of eggs , then why not just make the best possible use of the few eggs which do grow , without making them spend a fortune on expensive drugs which don't seem to do much good.

This is a perfectly reasonable alternative treatment option, provided patients have realistic expectations of what this approach can achieve . Unfortunately, the proponents of mini IVF tend to over promise too much in order to convince patients and doctors that this is a better approach. They highlight the successes without explaining the limitations and the downsides.

The fact remains that with the mini IVF approach , the cancellation rates of IVF cycles is extremely high and patients need to be prepared for this. The mini IVF approach is a sensible approach, provided the patient is well informed and who has realistic expectations. As the patient your best option is to find the clinic, which is flexible enough to use all the possible options and alternatives so that you can maximize your chances of having a baby and achieve peace of mind that you gave it your best. However, this may involve doing repeated cycles , in order to find out what works best for you.

Masturbation, sperm counts and fertility

Misconceptions are very prevalent about sensitive , personal and private topics such as sexuality. Masturbation is still an area about which myths abound. This is especially true in conservative societies, which will consider this to be a taboo subject, as a result of which young men are completely clueless as to what the impact of masturbation is on their health and fertility.

A number of men with a low sperm count ( and a zero sperm count ) believe that the result for this is the fact that they used to masturbate as teenagers. They believe that masturbation has drained all the sperm from their body , as a result of which they are now sexually weak , and cannot produce good quality sperm any more. A lot of these men do not understand the difference between sperm and semen ; and are often misled as a result of advertisements and billboards put up by quacks. A lot of these quacks are now online as well , where they prey on the ignorance of these young men.

Since masturbation is something which young men do on the sly in the privacy of their own room behind locked doors, it’s an activity about which they are often ashamed. Also, because of our puritanical attitudes , we still believe that anything which is so pleasurable cannot possibly be good for us ! This is why when these young men find out that they have a low or zero sperm count , they are emotionally very vulnerable and often believe that it is their excessive indulgence in this “ bad habit” which is responsible for their problem.

From a purely logical point , this actually makes sense , because they do not know the scientific facts. They have heard a lot of people talking about how it takes 40 drops of blood to produce one drop of semen ; and that excessive masturbation is bad , because it leads to a depletion of energy. Many Indians still believe that brahmacharya  ( sexual abstinence) can actually help to improve physical and intellectual vigour. Men know from first hand experience that after an orgasm, they feel sleepy and tired . This is why they are quite willing to buy into the belief that masturbation causes “ sexual weakness “ – this makes a lot of intuitive sense.  Also, many have  a flawed belief that each person has a limited amount of sperm ; and that every time they masturbate , they use up part of this precious reservoir. ( They confuse sperm with semen, and because they have observed that the volume of the semen they ejaculate increases considerably when they abstain for many days, this misconception makes perfect sense to them). Based on this incorrect perspective, it’s easy to understand why they believe that excessive masturbation can cause them to become infertile.

The truth is that masturbation is a completely normal, harmless activity which everyone indulges in. It is a useful and safe outlet for sexual energies , and has no harmful effects. In fact, masturbation can actually be useful , because it allows people to explore their own sexuality and understand their own erogenous zones.
However , because there is very little sexuality education for teenagers in our country, it’s very hard to get rid of some of these false beliefs ; and once they are implanted, it’s very hard to extract them. Even today, the commonest questions which medical advice columnists have to answer are those regarding masturbation.

Unlike ovaries, which have only a limited number of eggs which get depleted as the woman reaches menopause, men's testes are remarkable in that they will continue producing billions of sperm daily, no matter how old he gets. The sperm will finally need to get ejaculated from the body in order to make way for new sperm. This ejaculation could occur during sexual intercourse , or during masturbation. If it does not, the body will still expel these sperm during a wet dream (nocturnal ejaculation).

Men need to understand that they cannot “store up their sperm” and that they cannot “run out of sperm” ! We need to educate and reassure young men that masturbation will not affect either their sexual performance , or their fertility !

Empty Follicle Syndrome ( EFS) - a guide for IVF doctors

A vaginal egg collection is a very routine procedure in an IVF clinic. The procedure is over in about 20 minutes , and good doctors will usually get one egg from each mature follicle.

However, one of the dreaded complications which can mar a vaginal egg collection is called the empty follicle syndrome. The doctor starts puncturing the follicles , and is dismayed when the embryologist does not getting any eggs whatsoever in the follicles. The procedure  in the OR seems to be technically straightforward. The follicles collapse well when aspirated and thee is free flow of follicular fluid into the test tubes. However, when the embryologist scans the follicular fluid under his microscope, he does not find any eggs as all !
This is unexpected and uncommon; and many doctors are completely stumped as to what to do when this happens, because they have not dealt with this condition earlier. This is actually a medical emergency, but is often managed badly.

Because many doctors don’t know how to deal with this problem, they tend to just continue with the procedure blindly, and suck out the follicular fluid from all the follicles. After completing the procedure, they then leave the theater. When the embryologist then reports that he cannot find any eggs, they tell the patient – Sorry, we did not get any eggs  at all . Patients are stunned into disbelief and don’t know how to respond. The doctor may offer the use of donor eggs at this time - and often patients are bulldozed into agreeing, in order to salvage a bad situation.

Actually , this is a sign of poor medical management. So how should a doctor manage this crisis ?

Remember that 99 percent of the time , empty follicle syndrome occurs because the patient has not taken the hCG injection properly . This could occur for multiple reasons.  The patient may have forgotten to dissolve the powder in the solvent while taking the trigger shot, and taken only the inert solvent; or she may have taken an HMG injection instead of the hCG ; or may have mis-timed it; or may have spilled the drug, and was too scared to tell the doctor what happened.

How do we manage empty follicle syndrome in our clinic ? Firstly, we use a double lumen needle for the egg collection, and flush each and every follicle at least 4 times, with the expectation of finding one egg in each follicle . However, if the embryologist does not get any eggs after we have flushed three mature follicles , we stop the procedure .

We do a detailed analysis , in order to ensure that the patient has taken the trigger injection at the right time. In order to make diagnosis of empty follicle syndrome we use a rapid home pregnancy test kit in order to check the urine ( obtained by catherisation) for the presence of hCG. ( Instead of urine, it's also possible to do the test on the aspirated follicular fluid. ) If the patient has taken her hCG properly , we would expect to find a positive pregnancy test. This rules out the diagnosis of empty follicle syndrome , and we can then continue with the egg collection. However, if the pregnancy test is negative,  the diagnosis of empty follicle syndrome is confirmed.

At this point we stop the procedure , leaving the rest of the follicles intact, and wheel the patient out of the OR . We give the patient an additional HMG injection to  support follicular growth ; and do a blood test to measure estrogen and hCG levels.  ( Remember that we will get the results of the blood tests only after a few hours. ) We then give the patient another hCG injection , and reschedule the egg collection 36 hours after this second hCG shot. If we are worried about the quality of the hCG injection, we may use recombinant hCG ( such as Ovitrelle) to trigger ovulation ; and we may also increase the dose of hCG to 20000 IU ( instead of the  standard 10000 IU we use routinely) .

The next day, we review the blood test results. We would expect the estradiol levels to be high; and the hCG level to be less than 100 mIU/ml, thus confirming the diagnosis of EFS. An ultrasound scan at this time confirms that the follicles are still intact.

At the time of the second egg retrieval , which is planned 36 hours after the second hCG shot , we expect to see intact follicles ; and expect to retrieve eggs  from each of these follicles. In order to document the diagnosis , we repeat the blood hCG level again , and expect this to be more than 100 mIU/ml.

Using this protocol , it is possible to salvage the situation, and give the patient a very good chance at getting pregnant !

Before you start your IVF cycle - Advise from an expert patient !

Starting IVF treatment can be quite scary. There are so many myths and misconceptions, and it's hard to separate fact from fiction. Will the hormones make you fat ? Are the injections painful ? Will they increase your risk of breast cancer ? Is your IVF doctor the best ?

While your doctor will provide you with guidance, it's much better to get advise from the horse's mouth - someone who's " been there and done that" ! This is a guest post from our expert patient, Manju !

1)     Learn !

If you have decided to embark on an IVF cycle, the first thing you must do is to learn about the entire process scientifically. I agree that this may be challenging if you are an arts or commerce graduate,  but please do not underestimate your abilities-  the learning process can be be very interesting ! It’s always a good idea to exercise your grey matter  !  Learning doesn’t mean that you have to read complicated scientific papers – just start with the basics. All our reproductive organs have a name and a particular function. Educate yourself about,  your ovaries, follicles, egg, fallopian tubes, uterus, endometrium, cervix, sperm, embryo etc., and their functions. If you have understood this, half your job is done !  There are many audiovisual resources to help you learn at www.ivfndiacom. Next, you need to learn about the medicines used in the IVF process. Learn their names use the search box on www.drmalpani.com and google to findout more about what they do and their side-effects. . When you understand this basic information , you will start to understand what your doctor is talking about. Many doctors do not have the time or patience to teach the patient all these basic information. The more you know about the IVF process the better you feel in the clinic. Otherwise, when you are poked and prodded , you will end up with a feeling as if you are treated as an experimental animal! The more you feel alienated from what is happening in your body, the more you will hate the process. It is not only embarrassing to lie down with your legs high up in the stirrups ,  when your private parts are being manipulated, it is also scary! The more you know; the better you feel. Knowing will also boost your confidence and you will be able to ask intelligent questions to your doctors and nurses.

In short, try to cultivate a passion for knowing things. You are undergoing a very important process in your life , which is not only costly but also emotionally very demanding. Educating yourself about the process will prepare you to face the twists and turn inherent in an IVF cycle. This will save you from lot of heartaches!

2)     Select a competent IVF clinic

When I say competent clinic, it should have skilled, experienced physicians; compassionate staff; and full-time embryologists. From my experience, I have learned that an empathetic doctor is as important as a skilled physician. You should have a doctor who can hear your concerns and answer your questions with patience. He should have the minimal courtesy of saying or writing a few comforting word if your IVF cycle fails. Emotionally, you depend on your doctor for support during the process. When the process fails, naturally you turn to him/her . I heard from one of my friends that when she informs her doctor about the negative outcome of the cycle, she gets back a mail which asks her to plan for the next IVF cycle. Only when people undergo an IVF cycle will they understand how devastating such an experience can be! If you do not get any reply at all, then it is evenworse . So, find a humane, skilled doctor who owns a competent clinic.

How will I know which clinic is competent enough and which doctor is good? The only way to find this is to use multiple sources of information. The usual way people decide which clinic to select is through the information they get from their neighbours, relatives and friends. Actually, this method is easy and convenient. There will be people who have attended a particular clinic , and if they are successful in their endeavour and have a baby, they will recommend that particular clinic. Internet search is another good option. Most clinics have websites today Many websites are very colourful (with beautiful baby pictures) and attractive; with many positive patient stories. But, neither method is fool-proof. So how will you decide which clinic is best? Here are a few points to ponder:

1)     How experienced are they in the field of ART?

2)     Do they have a full-time embryologist?

3)     How easy is it to approach the doctor?

4)     Do they answer all your questions sincerely and promptly?

5)     Are the staff warm and compassionate?

6)     Are all the facilities (from routine hormone tests to egg collection facility) situated within the clinic? (You obviously do not want to run here and there for every procedure!)

7)     How transparent are they in their functioning?

8)     If they own a website, look for how informative it is , rather than how attractive it is!

This is the basic information you should look for. But, the final proof is in the pudding! Only when you enter a particular clinic and work with them you will be able to judge for yourself. The field of ART is becoming very competitive and this means most clinics are striving hard to give their best in order to survive the competition. This is compelling them to be more patient-centered and patient-friendly, which is very good news for IVF patients!

3)     How will I identify a good IVF doctor?

1)     A good IVF doctor will not promise you a baby but will promise you quality service.

2)     A good IVF doctor should not be like God-always invisible! You must be able to meet him in his clinic, without any mediators in-between!

3)     A good IVF doctor is friendly and easily approachable.

4)     A good IVF doctor knows what he is speaking about. He is knowledgeable!

5)     A good IVF doctor discusses the various treatment options with you before taking any decision. He must treat you as an intelligent partner in the treatment process, rather than an ignorant patient.

6)     A good IVF doctor will be honest and transparent in his approach.

7)     A good IVF doctor will be patient enough to answer all your questions.

8)     A good IVF doctor will not raise your hopes too high , but at the same times builds your confidence!

9)     A good IVF doctor functions keeping your best interest in mind rather than his monetary benefits. He will not order unnecessary tests and insist that you use costly medicines when cheaper alternatives are available

10)  A good IVF doctor will not talk using medical jargon. He should use  simple language so that you can follow what he is talking about.

11)  A good IVF doctor remembers you as a person.

12)  Last but not the least-he should be empathetic, humane and respectful.

4)     Treat the hospital staff with compassion

Always remember this golden rule ‘Treat others as you wanted to be treated’. When you enter the clinic, the first faces you see are the staff. They are the connecting bridge between you and the doctors. Actually, they are the people who take care of your personal needs in the clinic (from providing you with proper medicines, injections etc., to offering a few comforting words and positive stories when you are down!). They work long hours and their work is more hectic than that of a physician. When you enter the clinic , never carry all your anger  pain and frustration with you. Learn to smile and be caring and compassionate. Do not complain about petty things. Even though you pay for the service you get, you can’t make everyone smile and behave compassionately just for money. If you find a chance, get to know them a bit and behave in a way that they treat you with love and affection. Most importantly, learn to say ‘THANK YOU’. I am not asking you to put up an act. Of course, these things should come from within you. When you are friendly with them and if they get comfortable with you, the service you receive from them will be far better. This makes your stay in the clinic pleasant - for you and also for them!

5)     It is OK to be inquisitive!

When your treatment starts, be inquisitive! There are no stupid questions except the ones you did not ask. Asking appropriate questions about your treatment and medicines will help you to acquire knowledge and will also keep the doctors and hospital staff on their toes ( which is good for them as well !) . The more the questions you ask about your treatment, the more careful they will be about what medicines they are giving you and how they treat you . Never take any medicine without asking : what it is, why it is used and what are its side-effects. Remember, there are lots of patients and your physician sees many everyday. There are chances that the staff may confuse your details with another patient. So The involved you are in your treatment, the more protection you get from unintentional errors. The more knowledge you gain, the more questions you will able to ask, and the more attention you will get!

6)     Insist on seeing your embryos

Seeing your embryos created in an IVF lab is a wonderful experience. It makes the whole process appear real and worthwhile! Every good clinic will be ready to show you the embryos. Ask the embryologist to explain the different stages of an embryo and how they look at each stage. You can also learn a lot about embryo development and how they are graded. Looking at your embryos and understanding their quality will help you to learn a lot , and is the best marker for how competent your clinic is in creating good quality embryos!

7)     Demand your medical records

I did not say you should ask for your medical records or request your medical records – demand them! Your medical records are your property. They carry all the vital information about your IVF cycle. If you decide to switch clinics, the information you carry with you in the form of medical record will save you from repeating many expensive tests. It will also give your present doctor a clue about the further course of action. A good clinic, acting in a transparent manner will provide you with your medical record without asking for it. If they do not provide this, then you have a legal right to demand a copy !  If you make this request in writing, no clinic will dare to ignore this.

8)     Be cautiously optimistic

You have crossed the various stages of treatment involved in an IVF cycle and your embryos have been transferred into your uterus – what next ? What should you expect?

The 2ww is the most draining phase of an IVF cycle. You will be excited and at the same time fearful of the outcome. The people around you will start treating you like a pregnant woman. You will be happy and at the same time you will be unsure how to react? You know that you can’t be pregnant until the embryos attach and start producing HCG. When you tell them the fact they will look at you very seriously and say ‘BE POSITIVE’. You wonder within yourself what it means to be positive - ‘Should I decide that I am pregnant?’ Your husband wants you to be careful all the time and will not allow you to do anything which will make you feel normal. Your doctor will say bed rest doesn’t matter. Your friends will ask you to eat pineapple core to make the embryo stick! Your mother-in-law will ask you to avoid all the heat generating foods (whatever it is!). Your mother will be praying to all the Gods in the world and she will be insisting that you pray too! You will for sure be confused. You do not know how to calm their excitement. Even the simple question, ‘How are you ? ’ triggers frustration within you. People do not realise that they are instilling lots of fears in you and putting all the responsibility on you by their kind actions. They want you not to think about the embryo transfer and be stress free, but each and every action of theirs will remind you of your prescious embryos within you. You worry what will happen to their expectations if the cycle doesn’t work and how you will be able to face them if the result is negative . You will be also wondering about your embryos-what are they doing inside me? You suddenly become aware of your body all the time, you will be sensitive enough to note even the minute changes that happen. Every pain, every cramp will make you wonder whether it is a pregnancy symptom. When you read about early pregnancy symptoms on the internet , you feel that you have all of them - or you will get all of them the next day itself (your mind is so strong, it has enormous control on your body!). It is hard, very hard!

The only wise advise I can give you is – Be cautiously optimistic! IVF is a process which has its own limitations. There is only 40% chance of success if you are below 35 years. So, theoretically the chance of failure is more than the chance of success! Not every embryo transfer will result in a pregnancy. But there are also woman who succeed in their first attempt! Try to have a realistic expectation. Even before starting a cycle prepare yourself to undergo at least 3 IVF cycles. This is the average number of cycle most women will undergo before finding success. It is very natural to expect things to turn out for the best but in an IVF cycle there can be many unexpected twist and turns that could stop things from happening as you expected. There is a lot of uncertainty involved because we are dealing with a biological system. If you are fully aware of this, you will learn to expect the best and prepare yourself for the worst! Being blindly positive will not help you and for sure will not help your embryo to stick. Being too positive might break you into pieces if the cycle fails and will cause you to carry a grudge about everyone and everything involved in your IVF cycle. If you want to protect your sanity; learn to expect the unexpected!

9)     Be kind to your physician

A good physician has your best interest in his mind and works for you. A doctor is a human too and he expects proper recognition for the work he does. I do not know how many people take time to say thank you and appreciate a doctor’s work when the cycle succeeds. But the first person whom most people blame when an IVF cycle fails is their doctor! It is human nature to blame someone or something else for their failure. The blaming nature becomes worse when the person is naive about the IVF process. ‘My friend did her IVF cycle in another clinic, she is pregnant now. Since I did not get pregnant it should be the fault of the clinic’. This appears to be a logical argument when people do not understand the limitations of a biological process. The more ignorant they are, the more likely you are to carry grudge about your doctor for the failure. Remember, you selected the clinic and you are going through the entire process by choice . When you are not satisfied with the quality of service you receive, you should talk to the doctor then and there and solve the problem. A good doctor, like a good teacher, will address all your concerns and try to clear all your doubts , whether they are logical or not. If you do not clarify your doubts and carry them with you all the time, they will be magnified 1000 times if your cycle fails.Whether your doubt is logical or not depends on how knowledgeable you are about the IVF process.

Another reason to hate and blame a doctorwhen your cycle fails is the huge amount of money you have spent on the process. Today, a doctor-patient relationship is solely materialistic. The patient sees doctor as a businessman who is waiting to grab all his money. A doctor just sees a patient as his source of income. Trust is the main ingredient which is necessary for a good doctor-patient relationship and in today’s materialistic world , it is completely lacking! Only when you trust your doctor will you feel good while working with him, especially, when doing IVF. We must accept the fact thata doctor will charge for the knowledge he has , and for the services he provides. Does anyone of us work for free ? Will anyone of us compromise on our salary? It is not wise to see a doctoras a personwho works just for the money you provide.  Be kind to them and appreciate their work! Respect them as you would like to be respected. A doctor travels with you through your IVF journey. He will be happy when you succeed and when you fail to conceive , it is his failure too! Be kind to your doctor when the cycle fails. Do not allow money to play the spoil game. After all, your attitude will often determine whether a doctor works just for what he is paid , or whether he is ready to go the extra mile for you! A good relationship with your doctor will make you feel as if you are cared for in your mother’s home , and not like in your mother-in-law’s place ; )

10)  My IVF cycle failed - should I change the IVF clinic?

If you are comfortable in your present clinic; if you are satisfied with their service; if you trust your doctors and their expertise; then I would say it is not advisable to change a clinic after a single failed cycle. Your doctor needs time to study how your body reacts to the drug. He may design a better stimulation protocol the next time around ; or he may have a better idea which will improve your chances of success . Remember that your doctor has limited powers . Even if a cycle goes perfectly,  he has no control over what happens inside your body. So, be patient! There is no guarantee that you will end up getting pregnant in a new clinic. But, if you could find a clinic which boasts of a 60% success rate (like CCRM in USA) instead of a 40% success rate in your present clinic, then I would definitely give it a second thought.

11)  When should I give up the IVF process?

If you are someone who is blessed with all that you need for doing an IVF cycle, never give up! That would be my personal advice. But there are many factors which could decide how many IVF cycles you can go through before you taste success , or before you decide to quit. Financial status, your ability to bear stress, your relationship with your partner etc., are some of the most important factors which will determine how many IVF cycles you can go through. I would say stop the process when both your heart and mind says enough! I sincerely wish every woman going through this process finds success as quickly as possible, so that they never have to think about quitting. It is wise to have a back-up plan so that you know what to do when IVF doesn’t work!