Thursday, March 13, 2008

Intelligent patients make being a doctor so much fun !

I answer a lot of queries from patients all over the world by email. Here's one I received recently.

I am writing to apply for a Gestational Surrogacy Treatment of your clinic. I heard Malpani Infertility Clinic is the Best hospital in India. My name is SK. I am a 40 years old Japanese female. We (I and husband) have been married for 10 years, trying to conceive and having intercourse around the days of ovulation but failed again and again.

Causes of our infertility is never identified after extensive investigations, but a doctor said there may be an immune problem because we have HLA Agreements (Parental HLA Sharing) and Lymph Mixture Reaction Negative. I have regularly ovulating, viable eggs, open fallopian tubes with no adhesions or endometriosis, no structural abnormalities of the uterine cavity fallopian tubes; my husband has normal sperm production (but sometimes low sperm count); and the postcoital test is positive.

As below, we have failed repeated IVF attempts as fertiled eggs cannot implant and continue to grow in uterus; implantation dysfunction with unexplained reasons;

In-Vitro Fertilization (IVF),

Frozen Embryo Transfer (FET),

2-step (Consecutive) EmbryoTransfer

(Assisted Hatching, at the natural cycle, still keeping a frozen embryo)

Now we are considering to hire an experienced surrogate mother for Gestational Surrogacy in India.

I replied saying,

Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem.

I think you have occult PCOD (

Repeating the ICSI cycle in our clinic with better superovulation and careful monitoring and transferring more embryos would be your best treatment option as it would maximise your chances of conceiving. You can read more about our approach at

Time is now at a premium for you - please don't waste it ! When you are 50 years old and looking back at your life, you should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment. While the outcome of any treatment is always uncertain, taking treatment at a world-class clinic can give you peace of mind you tried your best, which can be priceless !

She then emailed me back, saying

If I have PCOD, I expect from my Japanese doctors way of talking, it's not so serious. A doctor said I possibly had slight tendency of Luteal dysfunction, but my menstrual periods and ovulating are regularly every month, I've never taken hormonal tablets (progestins) to induce a period, BBT (Basal Body Temperature) is normal between 35.98C (low) - 36.76 (high), now I gain weight but ususally at 60kg-64kg, I am a rather muscular than fat, no-hirsutism, I have vaginal ultrasound examinations but my ovaries are not so enlarged except when strongly stimulated with HMG...

It's said that I have not PCOD under the Japanese diagnosis criteria; because of no androgen excess, ovulating every month, and no polycystic ovaries by gynecologic ultrasound. But the doctor admitted the immaturity of eggs ovulated or retrieved on Day 12. Usually on D12 I have follicle grown over 20mm which looks like nearly ovulating.

I replied saying,

This is exactly why it's called occult PCOD - it's easy to overlook ! The eye only sees what the mind knows !

She emailed me back,

Thank you very much for your replying soon, and I always deeply appreciate your deliberate and thoughtful advice.

Yesterday I went to see the doctor, confirmed my medical problems and I found some misunderstandings; my blastocysts Day5 had only 20%-30% possibility to be successfully implanted. I completely mistook it "70%-80%"of success rate instead of failure. I found I ovulated with rather poor quality egg for fertility.

I learned a great deal with reading this site, and I'm deeply impressed with the noble philosophy of Dr.Malpani. I must study more and think again. Even if I can hire a gestational surrogacy, my poor quality egg leads to only miscarriage and fatal risks of a surrogate woman. I should adopt the idea of donor eggs. However sorry to be insistent on saying such things but indeed I 'd like to have a baby of genetically myself and my husband. I may be too desperate to think reasonably.

I'm very interested in IVF treatment of your hospital, but still now I can't get out of the idea of a surrogacy; Obsession! Could you give me some more time for reconsideration? I'll study again.

I'm really appreciating your graciousness and always highly intelligence.

Even though this is a patient I have never seen and may never meet, I still feel we've established a doctor-patient relationship. I hope she has has become more knowledgeable about her treatment options by listening to a point of view which is different from her doctors in Japan; I have certainly become wiser by being allowed to see things from a patient's point of view !

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