A letter to my embryos, with love !

This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.

Dear Blasties, (I wish I could call you children!)

 How are you both? Hope you are feeling fine inside my uterus! Is it warm and comfortable enough? Does my activity disturb you in anyway?  I know that the bedding I have provided you is not so great. Is it difficult to snuggle in because of that? Have you apposed to the endometrium, had a successful cross-talk and started to invade? Did the endometrium welcome you with appropriate adhesion molecules , cytokines, growth factors, proteinases and neoangiogenesis factors? If it doesn’t, please do not give up. Coax it to produce all that you need for successful attachment. You can do it!  When I saw you both on Friday, after the thaw (after defreezing) you both looked perfect - as if you have woken up from a nice sleep (of course, it is a sleep but cold sleep!). You didn’t even show the slightest strain of the vitrification process. I even felt that you both smiled :) I thought how competent you both are! Even the embryologist commented how good you both look! So never ever give up the struggle!

I know it will be hard inside. The place you both were formed in ( the petri dish in the IVF lab) is so different from the environment within my body . For 6 long days you spent your life in an artificial set-up, and then you both were kept metabolically silenced for 7 long months! I do understand it will be scary inside the uterus. You meet so many different molecules and cells you haven’t met before.  But, remember little ones, this is the place you belong to! This is where you can be happy. This is where your real developmental potential is tested.  This is the place which gives you scope for further development. Of course, life in an IVF lab incubator is easy and cozy. There you are fed at appropriate time, supplied with proper nutrients and the embryologist must have pampered you a lot! But, only obstacles and struggle make you stronger , and not the pampering. Without struggle there is no progress in life (both in yours and in fully developed organisms)! That is the norm in this world. This is the first lesson you both have to learn. If you want to come out with flying colours, fight against the obstacles. When you overcome each and every obstacle inside the uterus , you are one step closer to becoming a full-fledged baby.

Are you aware that you became blastocysts from the supernumerary embryos which they wanted to wait and watch in vitro before they could freeze you ? You passed that difficult test and that is why you are inside my uterus today. The other embryos which were with you failed to develop and were discarded. The difference between you and all the other discarded ones are- they gave up the fight, they gave up the struggle to survive!  So, whatever way I look at you both- YOU ARE SPECIAL! You definitely have the potential to develop into beautiful babies! Please do fight hard to come into this world. I will not promise you that life on earth is as easy as pie, but for sure it is very beautiful! You have very good people to protect you and take care of you.

There are lots of people longing to see you as babies. The most important person is your dad. I am gifted to share my life’s journey with him. He is a very calm and composed person. Normally, he doesn’t show any overt emotions in his face or speech (be it happiness or sadness!). When we both saw you through the IVF lab microscope , I could not understand what kind of emotions were playing in his mind. He never talks about it. He didn’t allow me to enter the kitchen until now. Yesterday, I tried to cajole him so that I could gain back my territory (I cook super duper good food!), but he refused my plea and went on to  cook some beans with tomato. Sadly, the dish was horrible, but I ate it quietly without any reaction. When he tasted it, he also ate quietly and after few minutes he said- sorry Manju! :) I could not control my smile but to tell the truth, because of the love he mixed with the food it was very palatable ! Now-a-days, he gives me a foot massage. It is a soothing gentle touch, and I love his hands rubbing the sole of my foot. This is one of the most relaxing moments for me. He knows that very well but he never did it on his own -  I would have to plead for a foot massage every time. But, now-a-days, even if I say no, he takes my feet , keeps it on his lap and rubs it gently. Do you understand why? It is  for you both! He wants you both to snuggle in, attach and become his children. I carry you both in my uterus but he carries you both  in his heart. Are you listening? Does it feel good to hear about him? Please young ones , please attach to me and grow into healthy babies! There are also so many other people who are praying for you and waiting for you too – if I have to tell you about everyone , I will need several more pages!

When I talked about prayer, I remember on the embryo transfer day, Dr.Malpani asked me,  ‘Manju, which God are you praying to?’ To tell the truth I prayed to nobody and I do not want to pray to anybody. I told him the same. I asked him whether he believes in God. He said yes and I asked him why ? He said ‘I do not have a rational explanation and I also think it is ok for the heart and the head not to agree with each other :) When he transferred you both inside my uterus, he again said ‘pray’! But I didn’t! I was so adamant! I am not angry with God and neither am I blaming God for my situation. I simply do not believe that praying will help. I just enjoyed the moment you both went inside me and relaxed. But, little ones, when I think of it now , I wonder whether I should have said a short prayer to some God? What do you both think? Will it have helped you? Have I spoiled your chances of becoming a baby? But, still I believe, if I pray or not,  nothing is going to change. Prayer can bring about a sense of relaxation but on that day I am surrounded by good people and I am actually very happy and relaxed. Even if you both become my babies I am not going to teach you about the concept of God. Being good and being a theist has no connection. I will teach you to be good human beings and you have to decide whether you need God or not when you grow-up! I think, in this way I can safe-guard you from the unnecessary guilty feelings most humans suffer in the name of God.

Today is the 5th day of your stay within me. I sit here wondering what is going on with you both. I wish you could send me some signals so that I could feel your presence all the time. Carrying you both in my uterus is not difficult (even those 9 months won’t be difficult!) but carrying you both in my mind is driving me crazy! I wish the test date never comes! It feels so good to be pregnant , at least in my heart . I have lots to say. But all that can wait. The main message is NEVER EVER GIVE UP! My love to you both! Fight as much as you can. Life is a beautiful struggle and struggle is what makes you HUMAN and keeps you human!

Waiting with lots of love,
Mom


You can email Manju at [email protected]

Her blog is at www.myselfishgenes.blogspot.com

So, why don’t you just adopt a baby?

I stole this title from my Dr’s blog. I selected this title because this is exactly what people ask about adoption (very casually!), without bothering to understand what we are going through.

To tell the truth I haven’t faced this question often. But when some people advise me to adopt in the most uncompassionate way possible , I get hurt. On the other hand, I have friends who really care for me. Recently I got a mail from one such person. She wrote to me explaining why I am special and how I have touched her life. She then asked about adoption in the most compassionate way possible. ‘Manju, I know you for a long time. I understand the struggle you are going through. My mind sometime thinks why should Manju not adopt a baby?'  She also said ‘Manju, I understand that you know better; might be you want to have a little one as a symbol for the wonderful love you share with your husband’. How thoughtful my friend is! When I read such a compassionate mail, the respect I had for her increased several times more and I am not hurt a bit. Love you dear for what you are!

Why can’t you adopt? I want to ! After undergoing this struggle, I will be happier to adopt than to carry a baby in my womb (I really mean it !). Now-a-days I feel getting pregnant and carrying a baby is a Herculean task. My journey to get pregnant is like this - take fertility drugs, wonder whether my ovaries will respond properly to them, obsess about the number of follicles and the amount of eggs that will be collected, continue to panic about how many will fertilize and divide; and wonder how many will be competent enough on day 3 or day 5 to be transferred to the uterus. After transferring, obsess each and every second about the symptoms and wonder whether the embies will implant or not. When the pregnancy test turns out to be negative I break down to pieces emotionally and the psychological impact that cycle created  will take months to heal. If the test becomes positive; again I have to keep wondering whether the baby will cross the 8 week, 12 week mark. If there is no vomiting, I have to panic whether everything is OK.  Oh my God! Women who get pregnant without knowing when and how should appreciate how blessed they are!

We are making attempts to adopt a baby. But adoption is not as easy as shown in a movie. In movies they will show a woman who is desperate for a baby. Her in-laws will abuse her. The woman will be crying always. Her loving husband will one day decide to give her the gift of her life. They both will go to an orphanage and find a baby who is very affectionate and attractive. They will talk to the head of the orphanage and take the baby home the following day! How sweet and convenient this process is ! But unfortunately this is not true in real life! Adoption is a very complicated process , which can consume all your time and energy.

It is not the inconvenience of adoption process we panic about. When I tried to register myself in CARA I got a mail saying that the registration process is closed and they asked me to e-mail to German adoption agency (Gemeinsame Zentrale Adoptionsstelle- GZA). When I mailed them , a lady replied by saying that the process will take a long time (she wrote international adoption will take several years!) and we have to know German perfectly to succeed in the process because there will be lots of home study. She also warned me repeatedly about the long waiting list!

So, adoption is not as easy as everyone thinks. Babies available for adoption in India have gone down. This is thanks to awareness about birth control, easily available home pregnancy tests and abortion facilities ! I am happy that unwanted children are no more generated and thrown away like stray cats or dogs! Infertility rates have also gone up because of late marriages and adoption is no longer a social stigma.  Hence there is heavy competition for babies which are available for adoption. There is a thriving black market for adoption – but you need to be a VIP to tap into this. When I talk about adopting a baby, people come up with another question. Why don’t you adopt an older child? I am not comfortable doing so for many reasons. When you adopt, the initial bonding which develops between an adopted parent and the baby is very important. Older children, naturally would have started to form opinions about everyone and everything and hence the ability to show and receive unadulterated love which forms the basis of parent-child bonding will be greatly affected. I am worried this may give rise to bitter problems in the future.

Last but not the least - just because a couple is fertile and are able to produce children, it doesn’t mean that they have the special privilege to be judgmental about an infertile couple. Before asking an infertile couple why don’t you adopt a baby; ask yourself ‘Why I didn’t adopt a second baby when I already had one of my own?’ If you have an answer, the same answer applies to infertile couples too. Do not forget we are humans like you with all the fears and uncertainties which you have in your mind. Just because we are infertile it doesn’t mean that we have to be more compassionate and charitable than you are! When you ask an infertile couple 'why don't you just adopt?', it is like asking a terminally ill person 'why don't you just die?'. When a person dies his existence in this world  ceases. When a person fails to reproduce, his gene transmission ends there. We stop being part of our future generation. Every living organism exists just to reproduce and transmit its genes. If the basic reason for our survival is in question, then naturally any human will try their level best to fight for it. That is why infertile couples are ready to move heaven and earth to get their much desired baby. Our genes are as selfish as we are!  Another argument which has no rationale is ‘if you adopt a baby, you will have your own baby out of that happiness’. Nothing can be as hurting as the above sentence. If I adopt I adopt for the sake of love. I will never adopt thinking that this will help me receive my own genetic child.

Actually, an infertile woman is the best mother in the world. Giving birth doesn’t make anyone a mother. Being a mother is an inborn quality. Woman who are kind, loving, caring, empathizing, understanding and ready to sacrifice their happiness for the people whom they care for are all great mothers. An infertile woman learns all these qualities so quickly because of the troubles she undergoes. Even a mother forgets her child sometime , but an infertile woman’s heart always thinks about her prospective child. She learns to look at every child with love and with lots of adoration. For me, every new life I see-from sprouting buds to dividing embryos is something which I respect and look at with wonder. I understand that creating a life, which is perfect in every little aspect  is not easy. A small copying mistake in our genome from ‘A’ to ‘C’ can cause havoc in the life which is being created , which is why anything which is perfect is a great miracle to me. I love every little child as if they are my own and I am sure every infertile woman does so! So next time when you celebrate Mother’s Day never forget to wish me or any other woman who is struggling to have a baby. We deserve that wish as much as every woman who has a child does!

On a lighter note,  my mother gave me the above picture and it suits this topic perfectly. If someone is ready to give me  Krishna , I don't mind being Yashoda :) I get lots of pampering now-a-days. My mom and my DH buys me whatever I desire. I have so many new things now and Mumbai is great for shopping. I get lost within myself when I walk in Colaba Causeway (great shopping area). One of the few joys of being
infertile! :)


This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.

 You can email Manju at [email protected]

Her blog is at www.myselfishgenes.blogspot.com

Is a blastocyst transfer better than a Day 3 transfer ?

The simple answer is Yes !

This is why you should insist that your doctor do only blastocyst transfers for you.

In the past, most embryo transfers were done on day two or day three. However, most good clinics have moved on to doing day five (blastocyst ) transfers routinely. Sadly, in India this is still not the standard option , and lots of IVF clinic continue to transfer embryos on day two or three. This is primarily because they're not very confident about the quality of their laboratory ; and the ability of their embryologist to culture embryos to day five.  This is why they prefer putting back the embryos into the uterus, and justify this by telling the patient that the uterus provides a better environment as compared to an incubator.  However, this has a lot  of disadvantages, and you should insist that your doctor do a blastocyst transfer for you .

For one thing, blastocysts have a better chance of implantation, which means the success rate with blastocyst transfers is higher as compared with Day 2 or 3 transfers. Because they're more highly developed and have more cells, they have a higher chance of  implanting. This also allows the doctor to reduce the number of embryos he transfers, so he can actually transfer just one or two blastocysts, and still have as good a pregnancy rate as compared to transferring three or four Day 3 embryos.

Also, since the doctor is transferring only 1 - 2 blastocysts, you can freeze the extra blastocysts , which means you get a chance to do more cycles . This makes it more cost-effective , because the cumulative pregnancy rate goes up.

Finally, the most important reason you should insist on a Day 5 transfer is because you don't need to put yourself through that horrible 2  week wait (  2ww) of not being sure whether you're going to get pregnant or not if you have poor quality embryos .  Thus, if the IVF cycle fails after transferring Day 3 embryos, you never know whether the problem was because the embryo did not develop any further in vivo , or if there was some other reason for the failed implantation.  Putting the embryo back too early reduces the pressure for the doctor, because he can claim that at least he did the embryo transfer for you; but you pay the price for this,  because you remain in  the dark about whether your embryos were able to grow to Day 5. In case the cycle fails, this means you have wasted a chance to get priceless information which could help you to plan your future cycles.

This is specially true for the older woman who has few eggs. This is the group who's at much higher risk for IVF failure because they are more likely to have embryos which arrest and do not reach the blastocyst stage. Lots of their embryos will have genetic problems, because their eggs  are older , which is why they are less likely to implant successfully.

These are the patients for whom a blastocyst transfer is extremely useful. However, they are often poor ovarian responders, and when the doctor collects only 3-4 eggs and therefore gets very few embryos, he is very reluctant to grow them to the blastocyst stage, because he is scared that if the embryos arrest in vitro in the lab, the patient will blame him for the IVF failure. This is why they'd much rather transfer the embryos back in the uterus, and if the cycle fails, they can blame this on " implantation failure" .

However, after the embryo transfer , the patient is deluded into feeling, "Well, maybe this embryo may implant and become a baby" which is why they are very hopeful during the 2ww.

This false hope is harmful.  When the cycle fails, they feel that it was their uterus which rejected the embryo , and then they are advised to go down the surrogacy route. This is bad advice which is completely flawed, because the problem is with the egg and not with the uterus.

Yes, it can be heartbreaking to see your embryos arrest in the laboratory because the doctor tried to grow them to the blastocyst stage. You then have no embryos to transfer at all, and this can be painful. However, the short-term pain is worth it, because of the long-term gain. This gives you a lot of clarity as to what the reason for the failure was, so you can come to terms with it . It's then much easier to explore find alternative treatment options, rather than muddling around in the dark because you're completely confused.

Of course, this option requires a very determined patient and a courageous doctor, both of whom understand the risks and benefits of the path they have chosen to explore.


Read more at http://www.drmalpani.com/articles/blastocyst

You can see what blastocysts look like at
http://www.drmalpani.com/blastocystimagesasttransfer

How can we improve the clinical consultation

The traditional doctor-patient relationship has always relied upon an initial face to face consultation , to initiate the association . This has a lot of advantages, but it has lots of problems as well. Patients have to travel to see their doctor, and this can be very time-consuming with today’s traffic jams. They have to wait in the clinic ; and the doctor may be stuck in an emergency at that time, as a result of which he is running late ; or may not even be able to see the patient as scheduled . This creates a lot of inconvenience for the patient . Also , a face-to-face consultation is not necessarily the best way of exchanging information with the doctor. He may be in a bad mood because he may have run into a complication , as a result of which he may be short tempered . He may end up using a lot of jargon and may not explain things well because he is short of time and has lots of other patients to see. In addition, it’s well documented that patients forget half of what the doctor tells them , because of the stress of the consultation.

However , one major advantage a real life consultation offers is that it allows the patient to actually check out the doctor . He can feel the ambience of the clinic  and see how patient friendly it is. Is the staff
helpful ? Can he trust the doctor ? A face-to-face consultation allows the patient to judge the doctor’s bedside manner firsthand, so he can assess whether the chemistry between the doctor and him is good; and whether they will be able to establish a productive partnership. However, because of the time and expense involved in doing these consultations , we need to start looking for alternative measures.

One way is to do virtual consultations using videoconferencing and these have become increasingly popular. However, consultations serve two different purposes. One is to meet the information needs of the patient, where the doctor makes a diagnosis ; and formulates a treatment plan . An equally important ( but often neglected ) function is to meet the emotional needs of the patient , so he can decide if he is comfortable with the doctor and is happy working with him.

A good consultation addresses both these needs; and while both are equally important , they are slightly different , and are best met with different tools . It’s now possible to use a mix-and-match of tools , so that both doctors and patients are happy with each other. Thus, the information needs can be best met through online patient education using a website or e-mail ; while consultations are best for meeting the emotional needs. These could be done by videoconferencing ; or a face-to-face consultation.

However, some of these services could be misused. For example , patients could send lots of e-mails to doctors without actually intending to take treatment from them ; and lots of doctors may get irritated by this,  because it consumes their time , and is not a service for which they receive any income.

This is a great opportunity for clever entrepreneurs to think of new and more efficient ways of connecting doctors and patients, which doesn't eat into the doctor’s time, but can increase the level of trust and confidence which the patient has in the doctor.

Why don't patients fire their IVF doctor if they are not happy with him ?

I see a number of patients who have undergone multiple failed IVF cycles in a single clinic . While it is true that most IVF cycles will fail , what amazes me is that these patients are very unhappy with the quality of medical care which they have received in their clinic. However, in spite of the fact that they are  dissatisfied with their doctor , they continue to take treatment at the same IVF clinic , even though they have failed multiple times. This always amazes me and I am still trying to make sense of why this happens.
It’s true that some patients don’t have a choice. For example, if your treatment is being funded by the government, then you have to go to the clinic which the  government selects for you. However, most IVF patients pay a fat fee for their IVF treatment, and do have the option to change clinics ! Why don’t they do so ?


Some people feel that once they have chosen a doctor , they need to be faithful to that doctor and continue sticking with them , even if they're not happy. Others feel that now that they've done one IVF cycle with this particular doctor , he knows and understands their case , and will hopefully do a better job the next time around. Others are just not willing to explore other options. Some naively believe that all IVF clinics are created the same , and that there really is no point in looking for an alternative , because most doctors provide exactly the same kind and quality of medical care , so why not continue with the same one? Others will stick with the same clinic purely as a matter of inertia because they're not willing to take the time and trouble to look for an alternative option. They are lazy and poorly informed and prefer sticking with the known devil . Many don't know how to look for alternatives.

Now just because one IVF cycle fails doesn't mean that you need to go looking for a new clinic for your second cycle. However, if you are not happy with the quality of care you have received, I think patients need to learn to vote with their feet !  Not only should they be articulate and express their displeasure , so that their doctor can fix the problem ( if he is willing to do this); or they need to look for alternative solutions if their clinic cannot provide what they need.

IVF treatment is expensive and patients pay for it out of their own pocket. They rightfully have certain expectations , and not only do they expect to receive good high quality medical care, they also expect that the medical team will provide them with personalized attention as well as emotional support. However a lots of patients are dissatisfied because they find that it is difficult for them to talk to their doctor . They often feel abandoned. Their biggest complaint is that they have very little information about the actual medical details of the treatment. There is very little documentation , and they are often poorly informed and clueless as to what happened and why.

Now while I'm not trying to provide excuses for IVF doctors who do not provide good quality medical care , I also think it is the patient's responsibility to work towards getting good medical care. Patients cannot continue to afford to think of themselves as being passive recipients of attention from medical professionals. They need to take an active part in their medical care if they want to make sure they get good quality treatment. This does involve some effort on their part , but this can pay rich dividends !

Before their first IVF cycle, many patients can be quite naïve and poorly informed ; they select a particular clinic simply because they don't know any better. However, after they have experienced one failed IVF cycle , if they continue to put up with such poor quality medical care , I think they are to blame as much as the clinic. After all, if patients are willing to accept poor medical care; and if they continue going back to the same clinic , even though the care was poor, then there is no incentive for a rational IVF doctor to make any changes whatsoever in the care they provide !

It's high time patients stopped complaining about how uncaring doctors are; or how inaccessible they have become. They need to understand that there is a lot which they can do in order to solve the problem , and they cannot afford to leave everything up to the doctor. Patients need to learn to become well-informed and engage actively in their medical care. Not only is this good for them, it’s actually good for their medical care team as well , because well informed patients will ensure that the team is on its toes and will provide high quality treatment , tailored to the patient's needs . This approach also helps to reduce the risk of medical errors and mixups !

How do I select the best IVF doctor ?

One of the greatest difficulties which IVF patients face is - How do I select the best IVF doctor for my IVF treatment. This is a major decision , and is fraught with a lot of uncertainty. Most patients will ask friends and family members for recommendations ;  some will trust their family doctor to refer them to the best specialist ; while others will do Google searches in order to explore all their options , and not lock themselves into clinics within a particular geographic location. This is particularly true if they've already done an IVF cycle at a particular clinic , and not been very happy with their experience , as a result of which they looking for alternatives.

While the internet allows patients a lot more flexibility in their ability to search for the doctor who is right for them, this also creates more complications ! After all, how does the patient judge the competence of a doctor based on his website ? After all, anyone can publish a good website ! Does having a good web designer mean the doctor is a good IVF specialist ?

Read more at http://www.drmalpani.com/how-do-i-select-best-ivf-doctor.htm

The Expert Patient's Guide to IVF - Why did my IVF cycle fail ?

This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.

The first question that arises in a patient’s mind after an IVF failure is ‘Why did my cycle fail ?’ A failed IVF cycle is heart-wrenching. It is painful because your dreams are shattered, your hard-earned money has gone down the tube and you do not know what to do next ! As humans we all need an answer for the failures we encounter. Why did a particular endeavor fail ? If we get an answer for this , then we tend to have peace of mind , because we believe that we can achieve success the next time around if we can rectify what went wrong in the previous attempt. But when an IVF cycle fails unfortunately no one has an answer for the same – not even your doctor ! You might have had a perfect cycle – lots of eggs, good fertilization rate, good quality embryos, excellent endometrium, easy embryo transfer – but no positive pregnancy test !

Read more at http://www.drmalpani.com/expert-patient-guide-to-ivf.htm

How CSR can boost patient education in India

The amendments of the Indian Companies Act which have been recently passed now make it compulsory for companies to invest two percent of their net profits in CSR or corporate social responsibility . For many observers in the financial sector, this seems to be a retrogressive step . They believe companies are in the business of making money , and their main goal is to be profitable. Once they've made their profits , what they choose to do with this money is a decision which should be left up to the management . They can use the surplus for paying dividends to their shareholders ; or for growing the company , so that it becomes even more profitable . They do not approve of the fact that the government is now mandating that companies invest part of their profits into CSR , because they believe that CSR is not part of a company’s core competence. Doing social good should be best left to people who understand that particular sector, and it's not fair to mix the two together. There are also obvious concerns that companies will then choose to invest in CSR activities which are run by NGOs in which the wife of the CEO is the Trustee ! This could then become another method of providing gratification for people the Board chooses to favour.

While this is a valid criticism , another school of thought is that this is an extremely progressive step. One of the criticisms about capitalism is that it's very market-oriented ; and that because they are so focused on making profits , companies sometimes tend to lose sight of the fact that they are a part of society and social responsibilities . By forcing companies to invest in CSR, we are helping them to become enlightened citizens. Not only is this good for their public image, it’s also good for society as a whole  because successful profitable companies, are presumably better at investing money in socially responsible activities , as compared to the government, which is notoriously inefficient.

For example, rather than have the government invest in activities which promote healthcare for the poor, if healthcare companies ( such as pharmaceutical manufacturers) were forced to invest in nonprofits ( such as HELP, the world's largest free patient education library) which are active in the healthcare space, this would create synergy . These win-win partnerships are likely to be beneficial both for the company , as well as the NGO , and it would be the end user who would benefit as a result of this multiplicative effect.

As usual there will be some companies will use this as a way off siphoning off some of the profits back to the pockets of an NGO which the CEO favors because it is run by a family member. However, just because a particular provision can be misused, this does not mean that it should not be explored at all !  I am quite optimistic that some good will come of this !

Doctors, one-upmanship and medical ethics

Some doctors do their best to be No 1 , as a matter of professional prestige. However, sometimes they carry this to ridiculous extremes, in their desire for their 15 minutes of media fame !

What's even worse is that they are blatantly flouting the Code of Medical Ethics as laid down by the Medical Council of India. Regulation 6.8.1 (h)  ( amended in 2009) states - " A medical practitioner shall not endorse any drug or product of the industry publicly ! Any study conducted on the efficacy or otherwise of such products shall be presented to and through appropriate scientific bodies or published in appropriate scientific journals in a proper way."

Why free medical camps can be bad for your health !

I have observed that many hospitals are starting to offer free specialty medical camps. For example , IVF clinics offer fertility camps for women who are trying to have a baby ; while urology hospitals offer camps to screen for prostate cancer.

Medical camps have always been very popular in India, especially for conditions such as cataract surgery and for performing family planning operations. Originally , the purpose of the camps was to provide medical services to poor patients who lived in remote areas where medical facilities were not available. Rather than forcing patients to travel to cities in order to get medical care, it made more sense for teams of doctors to travel to villages , where medical services could be provided to these patients at their doorstep. This was a very cost-effective way of delivering medical care, and allowed thousands of  patients to be treated effectively. A lot of these camps were paid for by philanthropists and charitable organizations , who were happy they were doing good by providing free medical services to the poor.

Today, however, hospitals seem to use these medical camps more as a method for marketing and promotion !  Providing these free camps provides them with a lot of publicity , and helps them to highlight what a useful community service they perform. However, a lot of these camps have a hidden agenda which many patients are completely unaware of. Not only do the camps allow hospitals to collect a database of potential patients to whom they can market to , they create a vicious cycle of over diagnosis and overtreatment of many patients , who would actually be much better off by having been left alone.

In a camp , multiple examinations and tests are performed for anyone who walks in through the door. It is a simple rule that the more the tests you do , the more the abnormalities you are likely to pick up. Unfortunately there is very little correlation between finding an abnormality on a medical test, and the patient's clinical condition. However patients do not have the sophistication to understand this , and whenever the doctor finds a problem on a test , the patient automatically assumes that he then requires treatment for this so-called diagnosis / condition.

We need to remember that doctors do not treat lab tests - they treat patients. Doing lots of tests does not help the patient at all, but just helps the hospital. If the test results are abnormal , you have effectively created a patient from a person who was healthy before he came to you ! The probability of this patient then coming to you for treatment is very high , because the patient feels obligated to you , since you “ diagnosed “ his problem.

Both doctors and patients are very excited when they find an abnormality on the test result. They pat themselves on the back , believing that they have now diagnosed and picked up a problem which would otherwise not have been diagnosed in time. The naïve belief is that early diagnosis of these abnormalities will help in early treatment , which in turn will help patients to live longer and have a better quality of life. Unfortunately, these beliefs are completely false and unfounded !

The significance of an abnormal test result in an asymptomatic patient ( with no complaints ) is completely different from the significance of exactly the same abnormal test results in a patient who has medical complaints for which he needs medical attention . Unfortunately, because both doctors and patients do not understand this , when they do a battery of tests for asymptomatic patients, they end up finding a lot of abnormalities , which they then feel obliged to investigate further, and treat. While this obviously increases the volume of business for the hospital and increases its profitability , it doesn't help the patient at all.
While it may be very tempting to get a consultation and medical tests free of cost in a medical camp,  sensible people will stay away from these camps, which are effectively designed to fill empty hospital beds !

Why is the Indian government creating obstacles for IVF tourism ?

India is supposed to be a leading medical center for reproductive tourism. Patients come from all over the world to India for IVF treatment , especially for procedures such as surrogacy.

One would expect the Indian government to actively promote medical tourism . Not only is this an excellent source of revenue for the country, it also helps to position India as a country which offers world-class medical facilities , at a fraction of the cost of what is available in the West. However, rather than promote medical tourism , the Indian government seems to take perverse pride in creating difficulties for IVF clinics.

A lot of patients who want surrogacy treatment have frozen embryos which they created and stored for themselves in IVF clinics all over the world. When they want surrogacy treatment , they need to transport these frozen embryos to India , so that the IVF clinic can then transfer these embryos into the surrogate’s uterus. Shipping frozen embryos is a very simple medical procedure , which IVF clinics do routinely all the time. However, the Indian customs department no longer allows Indian IVF clinics to import embryos ! They have stopped this for many months , by claiming that the ICMR has still not authorized which IVF clinics are permitted to import embryos.

While I understand that it's important to regulate IVF clinics to ensure that infertile patients get a high quality of service , the problem is that the ICMR seems to be in no hurry to actually implement any of their decisions. They have not even started to inspect IVF clinics in order to register them. Just like these frozen embryos are in a state of suspended animation, it appears that the regulating authorities are also in a state of suspended animation , because they have not taken any action in this regard for many months, inspite of numerous reminders. While they may not consider this to be a matter of urgency, this failure to act creates a lot of heartburn and angst for infertile patients who are very keen to get on with their treatment , so that they can have a baby and showered their love and affection on their child.  However, if they cannot ship their embryos to India, they will not be able to pursue surrogacy treatment here. Not only is this a major loss for them, it is also a major loss for Indian IVF clinics who can then no longer provide this service to their patients. Even worse , these patients then end up going to other countries such as Thailand , who are much more progressive and liberal in their attitudes. If the government continues to take this kind of obstructionist stand , the future for Indian medical tourism seems to be very bleak. While it is too much to expect the government to actually support private medical clinics , even though they are foreign exchange earners for the country. It's very heartbreaking and disappointing when they actually create obstacles for doctors and medical service providers.

Decoding Medical Gobbledygook - read the book free online !

Open publication - Free publishing - More patients

One of my friends asked me , Who is this book intended for ? Is it meant for doctors ? or is it meant for patients ?

I found this question interesting. Health literacy is considered to be a fairly dry topic and most of the books which have been written about it so far have been fairly academic . They are designed for health professionals , to help them communicate better with their patients. There are also quite a few bestsellers which are written for patients , to help them to be able to communicate properly with their doctor. However, most books address either the doctor, or the patient, not both.

I feel this is a very artificial distinction. After all , communication is a two-way street and any book which talks about health literacy has to address both the parties in the communication process - doctor and patient.  This is true for multiple reasons.
For one , it's important for doctors to be able to look at life from the patient's perspective. It helps to improve their empathy , and if patients are confident that the doctor understands what they're going through when they are ill, they are more likely to be able to form a happy partnership with their doctor. This is why doctors should read the sections which are written for patients.

Patients should also read not only the chapters which are addressed to them, but also the sections which are addressed to doctors. If you want to communicate properly with someone , you need to understand their worldview and their thought processes.

Even more importantly, we need to remember that decision makers in the healthcare industry - CEOs of hospitals ;  CEOs of pharmaceutical companies ; and policymakers are usually laypeople. All of them have been patients at some point , and reading this book will help them understand some of the challenges which doctors encounter when trying to talk to patients.

Finally, it is my hope that enlightened patients will consider requesting their doctor to read this book, so that he can improve their his communication skills , and take better care of them !

Is IMSI better than ICSI ?

Human sperm stained for semen quality testing in the clinical laboratory. 

Myth :  IMSI is better than ICSI
Fact :  This is another unproven claim in the field of ART , another logical fallacy !

A sperm is the smallest cell in a human body and an egg the largest. The union of the sperm and the egg brings the genetic material from the male and female together , to allow the creation of a new life.  A normal human semen sample consists of anywhere between 20 – 150 million sperms and not all sperms look alike ! Human sperms are very heterogeneous in their appearance and they have many different shapes. This is in sharp contrast to animals, most of whom have perfect looking sperm.  When we test a sperm sample in the lab, we check the shape ( morphology) of the sperm by staining them and examining them under high magnification. When studying male fertility , researchers were very interested to understand whether the shape of the sperm is in any way connected to the man’s fertility potential. This led to lots of studies aimed at determining what normal human sperm morphology is !

What does a normal (fertile man’s ) sperm look like ?

Actually, no one knows the answer ! A human semen sample consists of sperms which exhibit significant intra (within a single ejaculate) and inter variability (when ejaculates from different fertile men; and even ejaculates from the same fertile man at different times, are compared) in their morphology. Hence , determining the criteria to say whether a sperm is normal in its morphology is very difficult.  In the animal world, fertile animals have sperm which look identical , and this  makes it easy to determine what an abnormally shaped sperm looks like . Infertile animals have sperm which are abnormally shaped. On the other hand , when you compare the ejaculates of two fertile human males , their semen sample contains sperm of widely varying shapes, even though they are both fertile. As a result of this , it is hard to find a benchmark as to whether a particular sperm shape is normal or abnormal ! Hence characterizing the fertility potential of men based on sperm morphology became a hard task.

In earlier times , researchers observed human sperms under the microscope carefully. When they felt that a particular sperm looked very different from the rest,  they considered such a sperm as being abnormally shaped  and recorded such sperm shapes in the form of schematic representation and drawings (which lacked accurate details). By using such an approach , sperms which are not considered to be abnormal are considered as normal ; and normal sperms are thus identified as being normal by default , because of the absence of any gross defect. This method , which is used to classify sperms as being morphologically normal, is called the liberal approach.

Then came the method of identifying sperm morphology using strict criteria or Tygerberg criteria (Kruger’s strict criteria). According to this approach , the morphology of sperms which are found at the internal cervical os (the part of the cervix closest to the uterus) and the sperms which are found attached to the zona pellucida (egg coat) of the human egg are considered to be the gold standards for labeling a sperm as normal. The sperm present in the above places are found to be homogenous in their morphology , although they still exhibited differences in their head shapes. This method of sperm morphology evaluation also included the functional capability of the sperm , because sperms which are able to reach the egg are used as a benchmark for determining what normal sperm morphology is. This means that studying sperm morphology is still not perfect , and there are still several arguments as to the right approach!
Ref :PMID: 20111081

What is the cut-off value for evaluating normal sperm morphology in a semen sample?

The standard textbook for evaluating sperm is the WHO laboratory manual for the examination and processing of human semen. In the first World Health Organization (WHO) manual published in 1980 , the cut-off value for mean normal sperm morphology was 80.5%, with a range of 48.0%–98.0%. In the second WHO manual published in 1987 the cut-off was lowered to 50%. Both the cut-off values were determined based on the liberal approach for sperm morphology evaluation. In the third edition, the value for normal sperm morphology was changed to ≥ 30% morphologically normal spermatozoa , based on strict criteria for sperm morphology evaluation.  In the fourth  edition of the WHO manual , no cut-off value was provided but it stated that 'Multicentre population-based studies utilising the methods of morphology assessment in this manual are now in progress. Data from assisted reproductive technology programmes suggest that, as sperm morphology falls below 15% normal forms using the methods and definitions described in this manual, the fertilisation rate in vitro decreases.' And in the newest ( fifth ) edition the proposed cut-off value for normal sperm morphology is just 4% based on strict criteria for sperm evaluation!

This means a man needs only 4% of normal shaped sperms in his semen to achieve a pregnancy(PMID: 1550422). This evolution of cut-off value for evaluating normal sperm morphology clearly shows the confusion which exists in determining what a normal looking sperm is ; and with the strict criteria which are used now for sperm evaluation , more and more sperms are classified as being abnormal. Actually the decline in the cut-off value for morphologically normal sperm doesn’t mean that the semen quality is declining, it just means that the sperm morphology evaluation criteria have changed ! Sperms which were considered normal in the 1980s are considered abnormal now ( the field of sperm morphology evaluation is very confusing !)

Can a sperm shape predict the quality of DNA it is carrying?

It is tempting to assume that an ugly sperm (morphologically abnormal sperm) carries defective DNA , which is not competent enough to create a beautiful baby. But looks can be deceiving as always. A high amount of morphologically abnormal sperm might indicate poor sperm function but it doesn’t automatically mean that a morphologically normal sperm  is functionally competent , or that the DNA it carries is normal. It also doesn’t mean that sperms with abnormal morphology carry chromosomal defects.
With this background in mind, let’s see what IMSI is !

What is IMSI ?

Intracytoplasmic morphologically selected sperm injection (IMSI) is a new technique which is also called as ‘super ICSI’.  In IMSI technique,  the sperms are magnified 7000X (whereas in ICSI the sperms are magnified only 400X).  Evaluation of sperm morphology at this high magnification enables the embryologist to select sperms which are devoid of any obvious morphological defects. For example any defect in (DNA compaction) is visible in the form of vacuoles in the sperm’s head , and the IMSI technique identifies such ‘defective’ sperm (those are the sperms which are supposed to carry a defect in their DNA !) . Such sperms are excluded from being used for fertilizing the egg. Selecting a sperm which is morphologically perfect from a semen sample high contains a high number of abnormal sperms is thought to help in achieving and maintaining pregnancy via ART technique. This is what the IMSI technique promises us.
Isn’t it logical to use IMSI in place of ICSI ?

Theoretically , it appears logical to use IMSI , but this is not true in real life for a variety of reasons :

1)    Just because a sperm is morphologically normal doesn’t guarantee that its DNA is normal. Similarly, just because the sperm is morphologically abnormal doesn’t mean that its DNA integrity is compromised and that it will fail to give rise to a healthy baby. You can’t judge a book by its cover !

2)    Sperm DNA integrity is not as important as we think. It is a well-established fact that sperm contribute only 10% to embryo aneuploidy ( abnormal chromosomal content) ; and that 90% of aneuploidy defects in embryos arise as a result of abnormal eggs. It has also been proven that the sperm’s DNA is extensively repaired (any defects in sperm DNA integrity is set right) and remodeled by the egg’s ‘error correction’ machinery after fertilization(PMID: 21546611)(PMID: 22541549)(PMID: 17978187). Although it is surprising to know that such a mechanism exists , it is very logical from nature’s point of view. Nature provide an egg with much more power to control the embryo’s development ! A woman is the one who is going to carry the baby to term and take care of the baby until it becomes independent. This is perhaps why nature has given the egg an upper hand in deciding a baby’s developmental fate ! An egg from a young woman can efficiently repair damaged DNA of a sperm ! So when the egg is young , even poor sperms can give rise to healthy babies.

3)    There is no solid scientific proof to say IMSI is better than ICSI! There are no well-controlled randomized studies to prove this claim.

IMSI is not a magical solution for couples with multiple IVF failures, with poor sperm morphology or with recurrent pregnancy loss. In fact, abnormal sperm morphology cannot even be the only indication for performing ICSI because men labeled as having abnormal sperm morphology are able to father a child without any medical help many a time ! Today, a man who has 96% abnormal sperms and only 4% normal sperms is still considered to be fertile . If your husband has only 2% normal sperm morphology ,then should he be labeled as infertile ? My logical answer will be a ‘NO’. Can 96% abnormal sperm and 98% abnormal sperm really make a difference ?


 You can email Manju at [email protected]


Her blog is at www.myselfishgenes.blogspot.com

Our Early Christmas Present !

Wow we we have received the most amazing gift we could ever have wished for.

It has been a bit over 2 yrs since I first contacted Dr Malpani desperate to make a family, he was so helpful and supportive it was not long before we took steps to making it happen.

It did not happen first time but after fourth transfer we became pregnant, it did feel like a long 9 months being so far away, but Dr Malpani and his staff were always there to answer questions and offer support.

So jumping to the good stuff, 3 and half weeks ago on the 22 November we finally held our most precious beautiful baby boy we could ever have imagined. He is perfect healthy happy and the love of our lives, we cannot believe it, we still pinch ourselves to make sure not dreaming .

We cannot thank Dr Malpani his staff and associates enough for the joy they have bought into our lives. It has been more amazing than we could ever have imagined.

The surrogate we had was amazing such a lovely relaxed friendly woman who obviously was relaxed and enjoyed the pregnancy as this shows with our son as he is so calm and peaceful, for this we are great full.

Any one who is feeling that void in their life we cannot recommend highly enough the expertise and professionalism of Dr Malpani and his staff.

If you have any questions or concerns please feel free to contact me.

[email protected]

Thank you Dr Malpani

Brian Jeffreys

Try, try again until you succeed - IVF success story !

We got married in the year 2003, ours being a love marriage. Initially we thought that making a baby would come to us naturally – after all, when couples spend time together, most will have a baby on their own without any help. However, as years were passing by, we were not able to have a baby in spite of all our systems being normal.

In year 2005 end we went to G Hospital,  Bangalore and after basic tests we came to know I had  polycystic ovaries, for which weight reduction was suggested as I was 72 Kgs. We underwent IUI with no result. In end 2006 we went to an infertility center at Bangalore for another check up. The doctor suggested for another IUI cycle , but this also failed.As my husband was traveling a lot due to his nature of work , we were unable to fallow up continuously. Mean time we were trying naturally, yet no result.

In year 2008 end , we went to Chennai . Again we under went all tests,  including laparoscopy , and everything was found to be normal. Doctor suggested for another IUI yet no success. After going there , we decided we will not go for IVF as we saw the couples who had undergone IVF were not enjoying their pregnancy as they were forced to have complete bed rest for 7 -8 months in the hospital.
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As we were getting older , we were desperate to have a baby , so we decided to go to Dr. Aniruddha Malpani , who was suggested by my husband’s  friend who had a success story at his clinic.

In year 2011 March , we went to Dr.Malpani clinic two days before my cycle was to start. After meeting and talking to doctor who suggested in view of age it was best we go for IVF directly. We felt like we are in safe hands He told us the IVF treatment is like  a normal process and you can enjoy pregnancy and motherhood just like other women do. Dr.Anjali picked up 11 eggs out of which 9 embryos fertilized. Three embryos of day three 8-cell Grade A were transferred. We took it for granted that we will have our baby so we were hesitant to freeze the remaining embryos but doctor advised for freezing the remaining six 8-cell Grade A embryos. We distributed cakes to Dr.Malpani and Team and came back home after the 6th day of ET , very cautiously , avoiding bumpy roads. We waited for the remaining days with anxiety but the Beta HCG Blood Report was negative. We were shattered and shocked to see the result.

We called up doctor and informed him the result . He advised us not to get disheartened; to take two months of break ; and then go for the frozen cycle.

Again we went to Dr.Malpani in September 2011 for ET, Three embryos of day three 8-cell Grade A were transferred out of six. We came home with lots of hope this time as it was a frozen cycle; we waited for the Beta HCG Blood Report and the count was 21.2 mIU/ml,we called up doctor who informed us it might be chemical pregnancy , but to keep our fingers crossed . The doctor asked us to repeat the test after three days. After three days we repeated the test, and the result was Negative. Again we went to Dr.Malpani, on 24th November 2011 . ET was done; we repeated the pregnancy test and it was negative yet again.

We went for the fresh IVF cycle in Jan 2012.  Dr.Anjali picked up 11 eggs out of which 7 embryos cleaved. This time four embryos of day three 8-cell Grade A were transferred. The remaining three embryos did not survive for freezing. We came home with lots of hope this time as well, we waited for the Beta HCG Blood Report with lot of prayers and keeping our fingers crossed and repeat the test, but the result was negative again.

We decided that we will take few month breaks during which I went for ayurvedic detoxification of the system and reduce my weight. Dr.Malpani suggested we will try ZIFT this time so he advised to carry out HSG test. The report was Normal, so Doctor said we can go-ahead with ZIFT.

Every time after the result was negative , we used to sit and read all the success stories of Dr.Malpani clinic and boost our confidence and build faith and trust in doctor and think positive always and keep questioning GOD why its not happening to us. Even Dr.Malpani and team were confused as all embryos were good, endometrial thickness were good ,procedure was going good but it was not happing to us.

We went for fresh ZIFT cycle in the month of September 2012, Dr.Anjali picked up 11 eggs out of which 9 embryos fertilized, and three embryos were transferred by ZIFT procedure, out of remaining six embryos three were frozen on day five. Other three did not survive. As usual we came home with lots of hope this time as well, we waited for the Beta HCG blood report with lot of prayers and keeping our fingers crossed, but the result was negative again.

We called up doctor and asked him why is not happening to us. He gave us five options:  1. Transfer the frozen embryos, 2. egg adoption, 3.embryo adoption, 4.surrogacy, 5.change the doctor.

We had never lost our hope, faith and trust in Dr.Aniruddha Malpani and started our next frozen cycle in November 2012 , deciding that this is our last attempt of IVF as we had only three frozen embryos to be transferred. Finally the ET was done on 12th November 2012 with three embryos. As usual we came home with lots of hope this time, we waited for the Beta HCG Blood Report with lot of prayers and keeping our fingers crossed and finally at last the result was positive with reading 394.0 mIU/ml. When we saw the result we were completely out of this world and so happy which words can’t define. This was possible only because of Dr. Aniruddha Malpani and team’s sincere effort and hard work and of course by the grace of Almighty GOD ( every time we use to go to Siddhi Vinayak temple at Dadar) and numerous prayers and blessing of the elders. The HCG level rose well, and the day we went for a scan to see how many embryos had implanted, we came home happily with the news that we had a singleton pregnancy. Later in the  evening there was some discharge , which made us shocked and disturbed , till we got the reply from our doctor that there was nothing to worry - it is quite common during pregnancy. We would every time contact him over e-mail and he would respond at the earliest. Whenever I have doubt, I would mail him and his response would be there within 24 hours. On 10th Dec 2012 we went for scan to see the heart beat of our little baby angel.

We are very very happy and thankful to Dr. Aniruddha Malpani and Team from bottom of our heart. When we had gone to other clinics for check up or consultation , we were been treated  like we have some disease, but in Dr.Malpani Clinic we never felt that we have come here for treatment as Dr.Malpani and Team are very friendly and co-operative. We pray GOD bless Dr. Aniruddha Malpani and Team in their great work of bringing smiles to the childless couples from across the world.

To our dear readers - never give up, have faith and trust in doctor and Almighty God and positive results will follow for sure. We wish and pray Almighty God for all the childless couples to be blessed with child and bring big smile on their face.

Decoding Medical Gobbledygook

Open publication - Free publishing - More patients

When making babies becomes a challenge !

This is a guest post from our expert patient, Manju.

All of us want our life to be perfect. For most of us , a perfect life consists of growing up comfortably, earning well, getting married to the love of our life, having children and dying peacefully at a ripe, old age. Since we are so used to viewing life through rose-colored glasses, it is hard for us to accept life’s bitter realities. As a result, any deviation from a so-called ‘perfect’ life is viewed as a time of crisis. The inability to have a baby is one such life crisis which can have enormous emotional impact on the individuals concerned.

The sweetest dream of many married couples is to have a baby - a baby who will be proof of their love and oneness, a baby who will make their life a celebration by making it interesting and worthwhile, a baby on whom they can shower all their love and affection, a baby from whom they can get lots of unconditional love and a baby who will propagate their genes and make them immortals. For most married couples,  their ‘baby dream’ comes true even though they are not aware of the scientific details of the reproductive process. They get married; enjoy physical intimacy; and one fine day , the woman misses her menstrual cycle followed by a positive pregnancy test. The moment a couple learns that they are going to be parents is one of the happiest and most exciting periods of their life. It gives them immense satisfaction because one of their main goals in life is fulfilled – to procreate! For many couples reproduction is a pleasurable pursuit, which brings a lot of happiness and celebration in their lives. But for some, it becomes a Herculean task , filled with desperation and heart-breaks. What happens when this basic life goal is threatened? 

Infertility is one of the most difficult emotional crisis one can go through and is hard to cope with for many reasons. Infertility is a challenge which you face during the prime of your life. Shouldn’t it be easier to fight it as you have the necessary power and vigour to do so? A logical answer should be yes,  but the time we have to tackle infertility is also the period during which we come out of our safe cocoon, get married, accept responsibilities and try to build a family. That is the time period during which our sense of superiority is highest. Everything in life seems to be achievable. Life appears rosy. During that time infertility comes as a big blow to all the optimism you posses about life. When people around you seem to achieve their reproductive goal so easily, you are dismayed when you realise that this is going to be an uphill task for you. Your pride dies and humility sets in ! Infertility gives a hard blow to our ego and to face such harshness during our salad days makes life’s journey appear extremely strenuous !

For many women , including me , having a baby is a long cherished dream. Have you ever watched a girl play with her dolls ? I have eagerly watched them and most of the time the little ones like to role play as mothers. The love for nurturing young ones is very much inherent in a female’s psyche , even from a very young age (even from the age of 3 or so). I am sure many of us were a loving and caring mom to our pretty dolls (and I am sure many of us are still so !) and the longing for experiencing motherhood is deep-seated in a female’s mind, heart and genes. I grew up in an Indian setting where motherhood is looked upon with awe, respect and admiration. The air of secrecy surrounding a pregnant woman, the sudden attention she gets, the amount of pampering given to her,  the delight she takes in her growing tummy, the way her face glows day by day, the ceremonies performed to highlight her motherhood and all the celebrations associated with pregnancy and child-birth made me dream of motherhood from a very young age. For example, in my hometown they conduct a ceremony at the 7th or 9th month of pregnancy (just like a baby shower) to welcome the young one and to honour the mother-to-be. It is a very colourful ceremony attended by ladies and the best part of the ceremony is that they decorate the arms of pregnant woman with so many colourful glass bangles (it is believed that the clinging sound from the bangles will make the baby happy). The expectant mother with her growing baby bump, glowing face and with the soft sounds arising from her bangles is such a pleasure to look at. I still remember the days where I longed to become a mother just to wear so many bangles in my arms. That beautiful, unfulfilled dream is still alive within me, deeply rooted in my heart. It hurts when that day never seem to come true !

The joy of motherhood becomes complete when a little one arrives. Who wouldn’t love a new born baby ?  Even the most hard-hearted person will melt at the look of a young one. I remember the days where I spent my time with little babies - looking and wondering at their perfect features, the beauty of their sudden flashing smile which travels across their lips when they are asleep (my elders used to say that God is showing a bunch of flowers to the young one and playing with her,  and that is the reason for that smile), their warmth and their milky smell ! Those were the days during which my passion for having a young one for myself grew steadily. A baby is a wonderful gift which God leaves by your side when you are asleep - that is what I was taught when I was a child and asked where did the baby come from !

My love for young ones did not develop solely by looking at human babies ! We always had pets at home, mostly cats-sometimes several of them. None of our male cats were neutered and female cats spayed. So you can imagine the amount of (re)productive activity that goes on. At least twice a year our female cat gave birth to kittens. The mother cat and her kittens are such a pleasure to watch-the way the mother cat feeds the young ones, the struggle it undergoes to protect them, the happiness with which it plays with them, the effort it puts in to teach them the much needed life skills (like hunting and self-protection) ! Once I even saw my cat give birth and that was a breath-taking moment for me! More than the birth of the kittens, the birth of a mother amazed me ! Our playful cat suddenly became a responsible mom! I have sat nearby a new born calf for hours just to touch it and watch it; ignoring my parents pleas to return home ! All these experiences taught me the happiness of motherhood.  I understood that the joy of having young ones is manifold and I naturally craved for it. I felt happy to be a female, I felt happy to be a potential mother-to-be !

I am sure most women, like me, are proud of their womanhood. Many have beautiful baby dreams. What happens when such delicate dreams are threatened? After marriage the only thought I had in mind was to get pregnant as early as possible. When every month passed without anything happening,  there was more and more panic. Every menstrual cycle became emotionally painful. I started dreading the arrival of AF. Can buying sanitary napkins become this hurtful ?! Sex became a joyless act which was performed solely to get pregnant. When I was told that without fertility treatment it is impossible for me to get pregnant , I broke down. I stepped into the world of infertility, no, no infertility stepped into my beautiful world and the first thing infertility did was to shatter my beautiful dream - a dream of decorating my arms with many colourful glass bangles !

In the beginning the most difficult thing for me to accept was the word ‘infertile’. This word carries lots of stigma with it. The dictionary gives many meanings for this word like ‘barren - sterile - fruitless - unfruitful – unproductive’. I am sure none of it seems to fit the image I have for myself. Am I barren and fruitless? I remember the day when a papaya tree was planted in my home when I was young. I and my dad planted it. I saw it grow in front of my eyes. We are eagerly expecting the fruits from it. But unfortunately nothing happened. It flowered but no fruits. My grandfather brought some men one day and took away its life ! I was upset and asked my granddad for an explanation and I still remember the words he said ‘what use is a barren tree which cannot produce fruits ? It is just occupying the space.’ Am I barren? Am I just like that papaya tree? Don’t I have a fertile heart and a fertile mind ? How could someone label me as ‘infertile’? I despised infertility and the word ‘infertile’. As time went by I started to accept reality and tried to look for ways to escape from infertility’s grip. But unfortunately infertility loved me so dearly, it did embrace me very strongly !

After infertility set in, my whole world changed completely. Life started to revolve around only one thought - ‘a baby’. Doctor appointments became the norm. Injections don’t cause anxiety anymore. 99 % of internet searches are about infertility treatments. My body suddenly become an object of experimentation  (several vials of blood taken, several novel tests are conducted, different drugs are tried on me and what not !)  My private parts are poked and prodded by the infertility specialists – ‘do I really feel feminine enough now-a-days’ ?  Conversation with my in-laws became very uneasy. The pleasure associated with eating favourite foods are gone, food is divided mainly into two category-foods that help with fertility and foods that harm fertility ! Love-making became a chore – the fruitlessness of the act brought in a sense of guilt. Making love with a baby in mind is the most absurd side-effect of infertility- I wish no one should ever go through it !

Money suddenly became the utmost priority in life. No job - no money - no baby; there is a baby connection to everything in life. Life started to appear very insecure. When everyone around us is striving hard to earn money in order to secure their future, buy a car, and buy a home , we are stuck in a costly ‘baby-making’ process !  Life is no longer under our control and everything has become uncertain. The smooth flow of life is suddenly interrupted and only a baby seems to be a solution for all the craziness infertility has planted in our life.

Babies are gifts from God – this is the thought with which I grew up. That is what the culture in which I am brought up taught me. When baby making became a challenge , the question that naturally came to my mind is– why is God denying me the gift which he gives to everyone around me ? What did I do wrong? Am I a sinner ? Most religions preach that if you do wrong you will be punished by God. Hinduism talks about how your past life ‘bad karma’ could affect your present life. Religion instilled only one thought in my mind - you are a sinner ! Suddenly all my present life wrong-doings (thank God I am not aware of my past life !) became magnified out of proportion. Is there anything else which could damage your self-esteem so badly ?

Infertility did rob me and my dear one’s of many of life’s natural happiness. What will someone do when they hear that their little sibling is pregnant ? That is one of the happiest news to be shared and celebrated,  right? For me it brought tears to my eyes ! Even now I feel guilty for how I reacted at that moment ! I was not as mature as I am now.  I was not jealous - I just didn’t know how to react. A sudden attack of happiness and sadness at the same time made me cry. I felt toppled from my ‘big sister’ position suddenly. My own misfortune came as a hindrance for the happiness I felt for my sister. I could also sense how difficult it is for her to share life’s very important and very happy news with me – after all, she is my little one who is naturally worried about my emotional safety ! It didn’t end there, and throughout her pregnancy I couldn’t ask her many of the questions a ‘big sister’ would ask. I didn’t have any wisdom about pregnancy to share with her. She didn’t know what to ask me or what to share with me. Throughout her entire pregnancy there was an ‘iron curtain’ between her and me which both of us were very reluctant to lift. But the day I saw her little one , my heart just melted away - haven’t I become a mom too ! Aren’t they my children too?

Infertility is very, very hard to deal with - both physically and emotionally. It can shatter your routine, so-called ‘perfect’ life beyond belief. If you are not careful enough , it can leave you bitter and full of scars at a very young age. It can play havoc with your relationships. Is infertility bad ? Of course it is , when you don’t have the right attitude towards it ! As Khalil Gibran said ‘Your living is determined not so much by what life brings to you as by the attitude you bring to life; not so much by what happens to you as by the way your mind looks at what happens’.

I am a good person. I love children. Why am I doomed to go through the pain of infertility ? Why do bad things happen to good people ? There are many different answers for this question and hopefully my next post will be on this – ‘WHEN BAD THINGS HAPPEN TO GOOD PEOPLE – HOW INFERTILE COUPLES CAN FIND THE STRENGTH TO COPE’!

Manju's blog is at www.myselfishgenes.blogspot.com