Does IVF cause premature menopause ?

Many women worry that going through IVF will deplete their ovarian reserve , as a result of which they will run out of eggs , reduce their long-term fertility, and reach the menopause earlier. Logically, this makes sense  ! We all know that women are born with a certain number of eggs ; and that their ovaries do not produce any new eggs after birth. If the doctor stimulates the ovaries to grow lots of eggs during the IVF treatment by giving hormonal injections, won’t this mean that there’ll be fewer eggs left in the ovaries after the IVF treatment – especially if they are doing many IVF cycles ? When going through IVF , the doctor harvests several eggs at the time of egg retrieval by stimulating the ovaries with hormones (FSH or a combination of FSH and LH). A woman with a menstrual cycle length of 28 days ovulates only 12 eggs per year. But women going through IVF produce 15 or more eggs at a time. Doesn’t  this mean that IVF depletes the egg reserve faster than usual and can lead to earlier menopause ?

Let’s look at the facts.

The ovaries are a pair of organs situated in the pelvic region of women, one on each side. They act as the reservoir for our eggs. Eggs are the cells which carry half of the information (genetic blue print) necessary for creating a baby. Such precious egg cells are stored, nourished and protected within specialized structures in ovaries called follicles.  A female foetus at around 18-22 weeks of gestation contains about 2,000, 000 follicles in its ovaries and each follicle contains one egg. At the time of birth, a girl has only about 3,00,000 egg left in her ovaries – she’s lost over 80% of her eggs even before being born ! The remaining follicles continue to get depleted during her life time ; and when there are only about 1000 follicles left, she reaches menopause . A woman normally ovulates only about  400 eggs during her lifetime , releasing one mature egg each month , from the time of attaining puberty until reaching menopause. An ovary contains several immature follicles (and hence several eggs!) but not all these follicles will become mature enough to release a functional egg. More than 99.99 % of the follicles (and hence the eggs) are simply lost , without serving their biological purpose.  Human reproduction is remarkably inefficient !

During each menstrual cycle , several ovarian follicles start growing in response to the FSH secreted by the pituitary gland. Of these recruited follicles , only one follicle grows to maturity , and this is called the dominant follicle.  It carries the mature egg which will be released during ovulation. The other follicles which fail to reach maturity are lost . They die, and this natural process is called atresia. During IVF treatment our body is supplied with high amounts of FSH (several folds higher than our body naturally produces), in the form of injections. This high amount of FSH helps to rescue more of the follicles which are recruited during that particular menstrual cycle. This is the reason why IVF specialists are able to harvest several eggs during an IVF treatment. This is also the reason why IVF treatment will not deplete your ovarian ( egg) reserve ! The follicles (  and the eggs inside them) which would normally have died during that particular menstrual cycle are being rescued during an IVF cycle. This is why an IVF treatment will not cause you to go through menopause earlier. This is true even if you do many IVF cycles !

However, do remember that many infertile women are at increased risk for having poor ovarian reserve and reaching menopause early , whether they do IVF or not ! This maybe because they have endometriosis, or because they have undergone laparoscopic surgery.  If they reach menopause earlier than expected after having taken IVF treatment , they are quite naturally going to blame the IVF treatment for this – whereas the reality is that they would have reached the menopause early anyway,  even if they had not done IVF !

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
 

Do IVF drugs increase the risk of cancer ?

Infertile women go through lot of emotional turmoil, and to add insult to injury, there are lots of misconception regarding the use of fertility drugs. Some link fertility drugs with gynaecological cancers; while others even believe that children born out of fertility treatment carry an increased risk for developing certain kind of cancers. What is the truth ?

It’s easy to understand why women would have this belief – it sounds quite logical ! We know that breast cancer is a hormonally dependent tumour; and that estrogen levels are high during IVF treatment. Also, a lot of hormonal injections are given during an IVF cycle , in order to help the women grow lots of eggs. If the hormonal stimulation helps them produce a lot of eggs, it’s quite reasonable to conclude that this ovarian overactivity may increase the risk of developing ovarian cancer later on as well ! Husbands are understandably scared about the impact of these drugs on their wives, and don’t want to risk her heath in their quest for a baby.

Please remember that being infertile is itself a significant risk factor for developing certain kind of gynaecological cancers. For example, women who were never pregnant have a higher risk of developing breast cancer. This is because both pregnancy and breast feeding reduces a woman’s exposure to the estrogen hormone produced by her ovaries, which stimulates the growth of the cells lining the mammary glands in the breast. Pregnancy and breast feeding also mature these breast cells into milk-producing cells , and these mature cells are refractory to the transforming effect of hormones. Women who had a full-term pregnancy also have a lower risk of ovarian and endometrial cancers – the higher the number of full-term pregnancies , the lesser is their risk of developing these kinds of gynaecological cancers. You can read more about this at http://www.cancer.gov/cancertopics/factsheet/Risk/reproductive-history.

What do the data show ? To assess whether the risk of cancer after doing IVF increases or not is an extremely complex task , because there are so many other variables which have to be taken into account . Simple examples include: an individual’s life style, family history of cancer and their exposure to carcinogens, all of which are likely to confound the results . This is why these studies are very hard to conduct. One such recent study involving 9175 Finnish women showed that the general risk of cancer or the risk of hormone-related cancer was not increased by IVF (PMID:22343550). Another study in Lancet examined the incidence of breast and ovarian cancer in 10,358 women referred for IVF between 1978 and 1992. They concluded that ovarian stimulation during IVF does not increase a woman’s risk of breast cancer. They also found that there was no significant increase in ovarian cancer after ovarian stimulation for IVF. On the other hand, they concluded that women with unexplained infertility had an increased risk of ovarian cancer ! (PMID:7475593).

This is good news. Remember that IVF hormonal injections are natural hormones, which get excreted promptly from your body, and do not linger on to cause mischief later on. Over 2 million IVF babies have been born worldwide over the last 30 years, and we have not seen an increased prevalence of breast or ovarian cancer, so this is very reassuring. Going through IVF will not increase your chance of having cancer at a later age. Infertile women should try to ensure they have a healthy lifestyle , because infertility by itself is a significant risk factor for certain forms of gynaecological cancers – but this is simple common sense advise , and you don’t need a doctor to tell you this !

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
 

Will my embryo fall out after the embryo transfer ?

A fear which is wide-spread among IVF patients is – will my embryo fall out if I stand up or walk around after the embryo transfer ? This is quite a reasonable worry – after all, if the embryos are transferred through the uterus through the cervix, then why can’t they come out through the same route?  However, if you understand the anatomy of the uterus , these doubts will vanish and you will fell much more confident and comfortable during your 2ww.

Women imagine that when the doctor puts the embryos inside the uterus, they are deposited inside a space within the uterus in which the microscopic embryos can roll freely!  They believe that if they rest, the embryos will settle down and stick to the wall of the cavity. After all, when you stick two pages together with glue, don’t you leave them undisturbed for some time to allow the glue to set ? They are worried that if they walk about, the embryos will be disturbed from their resting place , and may fall out of the cavity.
In reality, the uterus is a muscular organ , about the size of your fist. When people hear the word ‘uterine cavity’, they imagine that there is a real cavity within the uterus ( like a cave, perhaps) , but this is not true. The cavity we talk about is not a true cavity , but just a potential cavity . The walls of the uterus are in contact with each other – after all, there cannot be any empty areas inside the body ! For example, press your palms together. There is no real space between them , since your palms are touching each other. What happens when you insert a small ball in between your palms ? The ball has created a space for itself ! In the same way , a uterus which doesn’t have an embryo inside it carries only a potential space. Only when the embryo grows in size will this space enlarge. Do you know that at 5 weeks of gestation your embryo is just the size of a sesame seed ? Imagine what will happen if you keep a seed between your pressed palms and move your hands in whatever way you might wish to ? There is no way the seed will be dislodged  - it is safe , snug and secure in its resting place. This is exactly what happens to your embryos inside your uterus !  Nothing you do can dislodge an embryo – NOTHING (even jumping or running) ! If the embryo is healthy and if your endometrial layer is receptive , the embryo will stick to the wall and bury itself inside the lining (just like a seed does , when planted in fertile soil). External physical activity cannot influence this natural biological process which occurs in utero.

A lot women refuse to go to the bathroom for a few hours after the embryo transfer, because they are scared that if they pee, their embryo will fall out of the uterus. They just end up making themselves completely miserable – and I worry that an overdistended bladder can actually cause uterine contractions needlessly ! Others are scared that if they cough or sneeze after the transfer, they will ruin their chances of success. Please do not obsess – remember that nature has designed the body with enough intelligence, that you don’t need to worry at all !

After the transfer, the uterus can contract (for example , during an orgasm, which often occurs while sleeping during  the 2ww ), but the progesterone produced during the luteal phase will prevent these uterine contractions from dislodging the embryo. Intercourse and orgasm cannot cause any harm after the transfer – after all, fertile couples do have sexual intercourse during the 2ww, and they get pregnant all the time.

After an embryo transfer , bed rest is absolutely unnecessary. I have heard from women who have been forced to spend 2 weeks in bed after the embryo transfer – and many of them have done so because of their doctor’s orders ! ( I think the reason some doctors continue to give this outdated advise is a clever way of subtly blaming the patient if the cycle fails ! “ You didn’t get pregnant even though I did such a good job with your IVF treatment , because you did not rest properly “ is their subliminal message) . Even a couple of days in bed can do you harm , physically and emotionally. Bed rest may increase body aches and back pain , and makes your physically uncomfortable.  Resting may actually reduce uterine blood flow by reducing pelvic circulation. Bed rest creates havoc  with your mental well-being as well ! When you lie down in bed all the time and have nothing to do, your mind will start to play all sorts of games with you. The end result is an unhealthy obsession with your body’s symptoms and signs – and this often causes panic , which does not help after a stressful IVF cycle.  The bed rest, rather than resting your mind, often causes more stress !

Please do not restrict your normal day-to-day activities after an embryo transfer.  Use your common sense, and do not do any strenuous activity which might cause you to blame yourself if your cycle fails ! And what happens if your mother in law enforces house arrest ? Remember that she has been brainwashed , and is following well-meaning but misguided advise, based on centuries of myths and misconceptions about bed rest and pregnancy. She is not trying to harass you – she is just trying to help you to have a baby , based on her personal ( but flawed) world view ! Please don’t rock the boat by flatly refusing to listen to her – just give her this article to read , so she understands why bed rest does not help!  And if she is still unconvinced, please share this with her - Bed rest has not been scientifically proven to improve pregnancy rate after embryo transfer(PMID: 19590224).

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
  

The HELP Patient Education Video guide series

We are planning to create a free library of 100 patient education videos on common topics.
Please check these out - feedback is welcome, so we can improve this !

All you wanted to know about embryo transfer

The day when our in-vitro embryos return back to us (to their mama !) is one of the most exciting moments of an IVF cycle. We forget the struggles we went through when we are admiring our microscopic babies under the microscope. Embryo transfer is one of the rate-limiting steps in an IVF cycle and plays a pivotal role in determining IVF success. Since the invention of IVF, major developments have been made in ovarian stimulation protocols; the way oocytes are collected ; and in the IVF lab; but the embryo transfer method remains largely unchanged. Embryo transfer done badly by an inexperienced doctor can change the fate of an IVF cycle –there is a vital intangible “physician factor” involved in determining the outcome of an IVF cycle! When different individuals perform embryo transfer within the same ART programme , the pregnancy rate of each doctor varies widely. This shows the importance of the embryo transfer technique and how it determines IVF outcome. It is estimated that 30% of IVF cycles fail because of shortcomings in this crucial procedure. What actually happens during an embryo transfer ? Is it an easy procedure ? Will it be painful ? Can my embryos fall out of my uterus after the transfer ? As usual there are many questions: come let us find the answers together.

What is an Embryo Transfer ?

Transferring one or more embryos into the uterine cavity of the recipient is called embryo transfer (ET).  It is the final and crucial step of an IVF process. The embryos in the IVF lab are grown usually until day 3 or day 5 in an incubator in a petri dish. The quality of embryos are graded by inspection under a microscope. The top quality embryo(s) are returned back to the uterus , where they belong ! Even though more than 90% of patients who undergo IVF reach the embryo transfer stage , only a small percentage of them actually get pregnant. Unfortunately, not all the embryos which are transferred to the uterus become deeply desired babies !

How is an ET performed ?

During ET, the doctor puts you in the undignified lithotomy position in the OR, and inspects your cervix with the help of a speculum . The sticky cervical mucus is cleared away using a moist cotton swab carefully. Then the cervix is washed with a sterile fluid. The best embryos are then loaded into the transfer catheter ( a long thin hollow soft sterile plastic tube) by the embryologist in the adjoining IVF lab . He does this under the microscope, and sucks up the embryos into the catheter by applying negative pressure with the help of a 1 ml syringe.  He brings the loaded catheter to your doctor , who performs the ET slowly by inserting the catheter into the uterine cavity through the cervix;  and then expelling its contents ( which consist of the embryos floating in a microscopic drop of culture medium)  by gently pushing the barrel of the syringe. This deposits the embryos into the cavity of your uterus. This method of transferring embryo(s) to the uterus is called transcervical  (through the cervix) embryo transfer. After transferring the embryos , the doctor hands over the catheter to the embryologist , who then examines it immediately under the microscope, to see whether there are any embryo(s) retained in the catheter. If this is the case, the retained embryo(s) are transferred back again to the recipient. An embryo transfer procedure is normally painless, and takes only few minutes to perform. You do not need anesthesia for this procedure. Most embryo transfers are easy but some embryo transfers can be difficult too ! Normally your husband is allowed to stay with you during the ET procedure , in order to hold your hand and provide you with emotional support , so that you remain stress-free and relaxed.

Are there any variations in the transcervical embryo transfer method ?

Transcervical embryo transfer is performed in two ways – without ultrasound guidance (traditional ‘clinical touch’ method) and with ultrasound guidance.
In the traditional ‘clinical touch’ method , the catheter is positioned blindly in the “desired position” ( about 1 to 2 cm away from the uterine fundus), by relying on the clinician’s tactile senses. In other words the ‘clinical touch’ embryo transfer method relies on the experience of the person who transfers the embryo ! During ultrasound-guided embryo transfer, the clinician is able to find the appropriate position for placing the catheter and releasing the embryos using the ultrasound scan image. During ultrasound-guided embryo transfer , you need to have a full bladder , so that the uterus can be viewed clearly ! It does create a lot of discomfort for the patient because the embryo transfer procedure can cause pressure on the already full urinary bladder ! The uterus should not be disturbed during the transfer in order to avoid uterine contractions – if the uterus contracts,  there is a danger of the embryo being expelled from the cavity.

Is ultrasound-guided embryo transfer better than ‘clinical touch’ method ?

As usual , this is a hotly debated topic. There are studies which reported that ultrasound-guided embryo transfer significantly enhanced embryo implantation rates ; and there are studies which found no difference if the ET was done by an experienced clinician in the absence of ultrasound guidance. This is a decision which is best made by your doctor , based on what works best for him ! For junior doctors, an ultrasound guided transfer seems better, as they learn how to master this procedure.

What are trial transfers or mock embryo transfer?

Trial transfers or dummy transfers are performed before the actual embryo transfer. They can be done just before the ET ; or during the ovum pick-up ; or prior to the start of the IVF cycle. During a trial transfer the doctor inserts an empty catheter into the uterine cavity , to find the easiest passage to the cavity; and to measure the length of the uterus and the cervical canal (uteri and cervixes come in many different shapes and sizes !) This allows him to measure how deep he has to insert the catheter , so that he can place the embryo at the appropriate position inside the uterus , without disturbing the fundus. Most embryo transfers can be performed easily , but there are some women where the doctor finds it technically difficult to negotiate the catheter through the cervix. In such a situation , their cervix has to be dilated to widen the cervical canal , so that the embryo transfer catheter passes easily through the cervix. There are women where the doctor needs to use a tenaculum to straighten the uterine axis (remember that the cervical canal and uterus are at an angle to each other) and sometimes the uterus is so tilted that the passage of the catheter from the internal opening of the cervical canal into the uterus is difficult. Sometimes pulling on the tenaculum alone cannot do the job , especially if the uterus is acutely angulated in relation to the cervical canal. Then it maybe necessary to curve the catheter, so it conforms to the curve of the uterus. In these patients, using specially designed catheter sets allows the doctor more freedom in gently guiding the catheter through the cervix.

What factors play a role in affecting embryo transfer results ?

The embryo transfer should be smooth and trauma-free. Many studies have shown that the pregnancy rate after embryo transfer is better if it is performed by an experienced physician, as compared to a newbie.
1.    Placement of the embryo
Placing the embryo 2 cm from the uterine fundus (the upper rounded extremity of the uterus , above the openings of the fallopian tubes) helps in enhancing embryo implantation. This is the region which is thought to possess maximum implantation capacity.
2.    Uterus contraction
When the cervix is handled roughly or if the catheter touches the uterine fundus , the uterus can contract. This can expel the embryos from the uterine cavity into the fallopian tubes or cervical canal, and compromising IVF success.
3.    Cervical mucus
Carefully removing the cervical mucus without causing trauma to the cervix improves IVF outcome. The cervical mucus can plug the catheter tip , thus preventing the deposition of the embryo in the uterus. It can also be a source of introducing bacterial contamination into the otherwise sterile uterine cavity.
4.    Catheter choice
Soft catheters have a better IVF outcome because they avoid trauma to the uterine wall.
5.    After the doctor has done the transfer, the embryologist checks it under the microscope. The presence of blood in the catheter suggests that the transfer was technically difficult – and this may reduce pregnancy rates.
6.    Trapped embryos. Sometimes the embryos remain trapped with the catheter, even  through the doctor has plunged the barrel of the syringe completely. When the embryologist identifies the trapped embryos in his petri dish, he simple reloads them again into a new catheter, and the doctor can then re-transfer them . This does not seem to affect pregnancy rates.

Why are some embryo transfers difficult to perform ?

Some embryo transfers are difficult to perform because of the following problems in patients :
1.    Cervical stenosis ( narrowing) or anatomical distortion of the cervical canal and uterus
2.    Acute utero-cervical angulations

If a physician has several years of experience in doing IVF, then most embryo transfers are like a cakewalk. But in some women , the embryo transfer can become an arduous adventure because of the difficulty encountered in traversing the cervix. This is commoner in women of Indian and African origin , where pelvic inflammatory disease (PID) and cervical infections are more prevalent. There can also be anatomical distortion of the cervical canal and uterus because of previous surgery.  These conditions might lead to a traumatic embryo transfer (there might be bleeding , and the patient many experience pain) ; or the embryo transfer cannot be performed at all. The presence of an acute curvature between uterus and cervical canal (utero-cervical angulation) can also make the embryo transfer hard to perform.

How to avoid difficult embryo transfers ?

Performing mock transfers before the actual embryo transfer helps in identifying the problem beforehand , and can help the doctor to take precautionary measure. For example patients with cervical stenosis can undergo a process called cervical dilation to widen the cervical canal. This might help in the atraumatic passage of the ET catheter into the uterine cavity.
But there are some patients in which transcervical embryo transfer becomes impossible ! In such rare cases , there are other techniques which could be used to transfer the embryo to the uterus.

What are the methods which bypass the transcervical route for embryo transfer ?

1.    Transmyometrial embryo transfer
2.    ZIFT

Transmyometrial embryo transfer

In this method , using a special Towako set, two needles (one inside of the other) are passed through the vagina into the uterus wall , under ultrasound guidance, until the needle tip reaches the edge of the endometrial lining. The inner needle is then removed and a thin catheter is inserted inside the outer needle, which carries the embryo into the cavity. The embryos are then released in the endometrium. But the success rate with such embryo transfers are less when compared to transcervical embryo transfers.

ZIFT

ZIFT stands for zygote intrafallopian transfer. During ZIFT , cleavage stage embryos are transferred into the fallopian tubes , instead of the uterus , using laparoscopy. ZIFT is a very good option for women who cannot have a transcervical embryo transfer, but who have at least one normal fallopian tube. Since cleavage stage embryos belong to the fallopian tube and not to the uterus , ZIFT has a higher pregnancy rate than conventional ET.

Most clinics are not able to offer the option of doing a ZIFT , because of the lack of surgical skills and anesthesia facilities. If your embryo transfers are difficult, then find a clinic which offers this option !
 
e-SET

Elective single embryo transfer (e-SET) is becoming popular for women who are young and have good ovarian reserve. While transferring multiple embryos improves the pregnancy rate, it also increases the risk of multiple gestation. Children who are a result of multiple pregnancies have an increased risk of health problems, because of the increased risk of preterm delivery and low birth weight . With the advent of better embryo selection strategies such as comprehensive chromosome screening (CCS) , single embryo transfer may become the norm in the future !
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
 

The billion dollar healthcare IT opportunity which the US government wasted

I had a very interesting conversation with a physician who is the chief medical information technology officer for a large hospital chain in the USA. What he revealed was quite eye-opening .

As we all know, the big problem with EMRs ( electronic medical records ) today is that they have not been enthusiastically adopted by doctors. This is not because doctors are luddites – it’s just that EMRs are not doctor-friendly , because they have not been designed by physicians, or for physicians . They have been developed by engineers, and are usually just after- thought add-ons to practice management systems . While they are great for fulfilling the bureaucratic purpose of tracking revenue, doctors dislike them because they disrupt their clinical workflow . The situation is quite a mess – and the government is having to bribe doctors with thousands of dollars in order to get them to adopt EMRs !

It’s going to take a long time before companies get their act together and start responding to physician feedback. Rather than trying to make systems which work for doctors, companies have been trying to retrain doctors to work with their software ! Doctors are smart guys, and are happy to adopt tools which will help them to improve their productivity and efficiency. However, expecting them to unlearn all their clinical skills just because they have to use a badly designed piece of software as commanded by the powers-that-be is wishful thinking,

His point was that for many years the US VA healthcare system has been using an excellent electronic medical record called Vista . The US government should have released Vista as open –source, and made this the de facto standard for all electronic medical records. This would have become the basic platform on which private companies could add bells and whistles, so that physicians could customize it for their own personal needs . This way , the basic electronic medical record would be given away free to everyone who wanted it; and people who then wanted additional features could pay for them. This would combine the best of all possible worlds , because it would ensure that everyone would use a free time-tested working system, which was robust and physician-friendly. It would form a stable backbone , which would also allow tinkering and tweaking as time went by, because the source code would be freely available.

It's such a shame that the US government missed this opportunity . Unfortunately, this is now going to cost doctors and patients billions of dollars and thousands of frustrated wasted man-hours, while we try to make electronic medical records more patient friendly and more physician friendly

Nano IVF

With the mushrooming of IVF clinics all across the country, I hope that the quality of care for IVF patients in India will improve. Unfortunately, the tragedy seems to be that most IVF clinics are just copying each other. They are  competing for the same set of patients and doing exactly the same thing. They aggressively super ovulate their patients with high doses of injections ; and use agonists and antagonists for down regulation . They copy the protocols which are laid down in western textbooks and western journals  , without taking into account the fact that these have been optimized for Western patients - not Indian patients. Sadly , none of them are innovating or trying to address the special needs of Indians !

While it's true that reproductive biological systems are the same for women all over the world, it’s also true that Indian women marry much younger ; and that their ability to be able to pay is much more limited. This is actually a huge opportunity for a clever IVF clinic which wants to differentiate itself and create a mark in the world by addressing the needs of infertile couples at “ the bottom of the pyramid” ! Rather than follow standard aggressive IVF super ovulation protocols , Indian doctors need to develop protocols for indigent patients. Typically these would be low-cost protocols , which would involve either letrozole or clomiphene citrate for super ovulation , so that these patients would grow maybe 2-3 follicles ; and the doctor would transfer 1-2 embryos without having to make the patient spend a lot of money .

Indians have a great reputation for innovation and frugality and Indian doctors need to capitalize on this. This actually is a great opportunity to develop new techniques and innovations which can actually help put the IVF doctor who's willing to do this on the world map and become a global leader . He will be able to treat a much larger number of patients , as compared to the other IVF clinics , which charge so much more. This could happen in medical colleges ; or in private clinics set up in smaller towns , which have a captive patient population base of a large number of infertile women who cannot afford standard high-cost IVF, which is what most IVF clinics in the cities offer . This doctor would then be able to tailor his protocol for patients who are likely to be patient ; and are willing to do multiple cycles , because the cycle costs much less
money , and they cannot go anywhere else !

Is a smart Indian IVF entrepreneur doctor listening ?

Another very funny post by Dr Kishore Shah !

KAUN BANEGA MEDICAL CROREPATI

The psychedelic blue whirling lights moved around as the winner of ‘Fastest finger first’ was announced in the deep baritone of Amitabhhchan. Midst the ascending music, he said, “The doctor who answered the last question the fastest is Dr. Kishore Shah.”

I quickly waved to the audience my two fingers and took the hot seat. Amitabh rumbled again, “Congratulations Dr. Shah for getting into the hot seat. Tell me, to what do you attribute your success in reaching here?”

I smiled and said, “Sir, for this Kaun Banega Medical Crorepati, the only doctors who can win are those who use their fingers fast. Proctologists and Gynaecologists are the only two doctors who keep using their fingers. But we Gynaecologists have an edge, as we use two fingers, so we are twice as fast.”

Amitabh started clapping and said, “Very good, now let us start this new game of Kaun Banega Medical Crorepati. The rules are the same as the regular KBC. The only difference is that Docfriend Pharma has sponsored the first five questions. So whatever happens, you have an assured prize of Rs. 20,000. Docfriend Pharma produces Acidkiller, the fastest acting Antacid. So now let’s directly go to question number 6 for Rs. 40,000!”

What is the most important thing that you do in Medical College?
A.    Take part in dramas and debates
B.    Flirt with a girl
C.    Sit in canteens and time-pass with friends
D.    Study hard

I thought for a moment and then smiled. “Sir, this one is easy. The correct option is A.”

“Very good. Your choice is correct. Now could you tell us why taking part in drama and debates is important for a doctor.”
<^> I smiled again and said, “Sir, in my decades of practice, not even one patient has ever asked me how many marks I got in my exams or about the Gold medals that I got. So obviously studying hard is unimportant. Flirting with a girl becomes important only if she becomes your wife. The other two options are very close in importance. By bonding with your friends, you can form a cross referral network, which will help your practice. But this can be developed later on also. So the most important thing to learn in Medical College is how to dramatize things, so that a common cold seems like Pneumonia. A normal delivery seems like a life and d^ situation. This helps you extract more fees from your patient. Talking also helps you get out of sticky consumer litigation situations.”

“Congratulations! You have won 40,000. Now let us move to question number 7, which is:”

While taking the history of a patient, what is the most important question?
A.    How long has he had the illness?
B.    What is his occupation?
C.    What past medications has he taken?
D.    What are the exact signs and symptoms he suffers from?

Again, I gave a small knowing smile. They were asking such simple questions. I said, “The correct option is B.”

“And why do you think so?”

“Well, it is obvious. In this age of Consumer complaints, it is more important to make sure that the patient you are treating is not a lawyer, a police official or a retired judge. Treating and curing the disease is naturally less important.”

Amitabh started clapping. “Very good. You have won yourself Rs. 80,000. Let us go on to question number 8.”

Which is the least important thing to have for a doctor?
A.    A stethoscope
B.    An Apron
C.    A pen
D.    A prescription pad

I was stunned. Such simple questions! I asked Amitabh, “Sir, are all these questions also sponsored by a Pharma company? They are so simple that they seem to be on the level of those asked at the stalls at conferences where you get free bags for correct answers.”

Amitabh looked a bit miffed. He asked, “You think this question is easy? What is the answer then?”

I folded my arms and sneeringly answered, “A stethoscope is the most useless thing that a doctor can have. Pen and prescription pads are essential because you need to send the patient to labs or consultants with your chits, so that you can get cuts. An Apron protects you from the patient’s germs. But which sensible doctor uses the stethoscope nowadays? You suspect heart or lung disease,^ for an X ray or ECG. You want to hear the fetal heart, do a Sonography. A Stethoscope is like a floppy drive for the computer. You have one because the older versions had it. However, there is no modern use for it.”

Amitabh started clapping. “Very nice, Dr. Shah. You have won 1 lakh 60 thousands. Let us go to question number 9.”

When a new specialist visits you, what is most important factor?
A.    How does he talk and present himself?
B.    From where has he passed?
C.    How much experience he has?
D.    How is he dressed?

At this rate, I was confident that 2 crores would soon be in my pocket. I said, “Obviously, how much experience he has is very important.”

“That is the correct option. Now can you tell me why you think so?”

“Its very easy sir. If he is experienced, he will convince the patient to pay more for some more unnecessary procedures. Due to his experience, he will naturally send you a nice big fat cheque of the commission without grumbling. Thus his experience is the most important thing.”

Even Amitabh was impressed. “Hats off to you, Dr. Shah. You seem to have a lot of experience in this. That’s 3 lakhs and twenty thousands in your kitty. The next question is a ‘Padav’ question.”

If your close friend asks you to attend a free medical camp, should you:
A.    Make excuses and run away
B.    See if there are chances of getting referrals from this camp
C.    Tell him bluntly that you need to be paid
D.    Cheerfully agree to do the free camp

Ah! Now things were getting a bit difficult. I mused over the options then said, “I would like to use the Audience poll, sir.”

After a tense 5 minutes, the results were in. 75% wanted to bluntly tell him to pay. 12% wanted to run away and 12% were worried abou^ferrals. Only 1% agreed to do the camp. I pondered over the results and then declared, “Sir, I would like to go against the audience. I will cheerfully agree to do the camp.”

Amitabh looked quizzically at me. “Are you sure you want to go against the audience?”

“Yes Sir. If I agree to go to his camp, he will be obliged to come to my camp, where I get publicity and patients. If I do not go, who will come to my camps? So for a few hours on a Sunday I get a free doctor when I want him for a camp. I will also get to know some other doctors who do free camps and will come to my camp.”

“You are absolutely right. Thank God you did not go with the audience. Now, no matter what happens, you have at least 6 lakhs and 25 thousands in your pocket. You are playing very well. I hope you win the 2 crores. Okay! On to the 11th question.”

When a conference is announced, what is the first thing that you do?
A.    Read if there are any important topics covered
B.    See what fees are applicable
C.    Search for some Pharma company to sponsor your visit
D.    Look at the place where the conference is taking place

I could see that things were getting tougher. This time I decided that a Fifty-Fifty option would be better. Amitabh smiled at my discomfiture and said, “Okay, Computerji, lets do the Fifty-Fifty.”

The only two options remaining were A- Important topics and D- Place of the conference. I scratched my chin and said, “Alright. I’ll go with the place where the conference is taking place.”

“And why do you think that is correct?”

“Well, Sir, Fees for the conference can be got from some Pharma company. And we do not need to search for a sponsor. There are companies rushing to sponsor you for conferences. The topics are hardly important because if you really want to know about them, you had better read a textbook or journaou go to a conference to enjoy the ambience. You go to have good dinners and cocktails. You go to meet old friends. Thus the place of the conference is the most important thing.”

Even Amitabh was impressed. “12 lakhs and fifty thousands! Wow! Dr. Shah, you are on your way. Let’s see the next, that is the 12th question.”

If a serious accident victim is brought to you in an emergency and death is inevitable, what will you do?
A.    Send the patient immediately to a larger medical center
B.    Try your level best to save the patient and treat him
C.    Give first aid and convince the relatives to take the patient away
D.    Disappear from the clinic and tell the nurse to send him away

The questions were getting more and more tricky. I thought this over for a minute.^n a bit hesitatingly I replied, “Sir, I think I shall go for option B i.e. try my level best to save and treat the patient.”

“That’s very noble of you. And why should you try to save the patient?”

“Well Sir, if death is inevitable, we should at least try to extract whatever fees possible from the patient. So we should put the patient on ventilators, start costly drugs and maintenance regimes. Only then will patients, or in this case, the relatives, pay us.”

“Wonderful. Now you have won an astounding twenty-five lakhs! Lets go to question 13 and see what is in store for you.”

If a patient with HIV infection comes to you, you should:
A.    Make excuses and say his disease is not treatable by you
B.    Tell him that you are sorry, and he can go anywhere else he likes
C.    Refer him directly to a government referral center
D.    Admit the patient for treatment at your hospital

Now the hot seat was really heating up. I deliberated over this one for a while. Then I took the plunge. “Sir, I think I will admit the patient. That way, even if I do not want to personally treat the patient, I can always get some ‘bakras’ who are willing to treat him. Why should I miss out on my fees?”

“FIFTY LAKHS!” Amitabh clapped loudly. “Just two more questions.”

If a patient comes to you asking for an illegal, secret Sex determination test what will you do?
A.    Quietly but firmly show her the door
B.    Quietly but firmly give her the address of your friend who does that test
C.    Shout at her and give her a big lecture on ethics and morality
D.    Inform the police about this patient

This seemed to be a tough nut to crack. I decided to use my Flip option. I asked Amitabh to flip the question. He said, “Okay, Computerji, lets flip the question.”

However, after flipping, the same question came up. Amitabh was stunned. “The computer was supposed to change the question. How come?”

I suddenly had a brain wave. I said, “Let it be, Sir. Maybe the computer wants me to answer that question. Okay, I shall go with option A that is I shall quietly and firmly show her the door.”

Amitabh nearly shouted with joy. “This is astonishing, Dr. Shah. You have won a Crore of Rupees. However, I would like to ask you how you knew the right answer.”

“It is simple sir. In all the other options I do not gain any money. But by quietly showing her the door, where my assistant is waiting to take her to a discreet place, I shall retain the moolah!”

There was a loud applause. The tension now was palpable. I asked for and got a glass of water. Amitabh cleared his throat and said, “Okay, now only one question separates you from the grand prize of five crores. Ready? Here is your question now.”

If your son or daughter cannot make it to the MBBS seat in the Government Medical college, which is the next best option?
A.    A local medical college with 30 lakhs donation
B.    A medical college in China or Russia costing 4 lakhs per year
C.    Opt for parallel streams like Ayurved, Homeopathy or Unani at 2 lakh
D.    Opt for Dentistry with 25 lakhs donation

This final question was a true crackerjack. I had absolutely no idea of the correct answer.

Amitabh prodded me, “In case you are unsure, you have one more lifeline, that is phone a friend. You can use it.”

I agreed with him. The phone connected and soon I was speaking with my friend Rahul. I asked, “Rahul, If your son does not make it to a government medical college MBBS seat, what will you do? Will you pay 25 lakhs for a private seat, or 15 lakhs for Dentistry or 2 lakhs per year for China or will you choose Ayur^ etc. at 1 lakh?”

Rahul answered immediately, “Am I mad? I sent my son to do software engineering.”

This put me back to square one. I thought and thought, but could not come up with any logical answer. Should I take the one Crore of Rupees and quit?

I turned to Amitabh and said, “Only an idiot would want to pay such astronomical sums for a medical seat. None of your options are correct. I would prefer to invest the money lucratively and tell my son to opt for some less expensive alternative.”

Suddenly the balloon on the ceiling burst open and confetti and silver foil descended on me. Amitabh stood up with a broad smile and said, “Exactly. That was a trick question. But you have answered even that correctly. Bravo and congrats for winning the huge sum of FIVE CRORES!”

He crossed over to my side and started patting my back. But in his enthusiasm, he was patting it very hard. It was almost painful. I winced and said, “Not so hard, its hurting me. Pat me slowly.”

“What do you mean pat you slowly? I have been trying to wake you up for half an hour now. Get up right now or you will be late for your clinic.”

I said, “Okay! Okay!” to my wife and reluctantly lumbered out of bed to the bathroom to wash away my expensive dreams.

Kishore Shah MD

From the Heart of my Bottom

This is a guest post from Dr Kishore Shah of Pune - and proves that doctors have a sense of humour too !


-----------
It was a very painful decision, but it had to be taken. Yes! I needed a haemorrhoidectomy. I had reached the ‘bottom’ of the barrel of excuses and could not put it off any longer.

But who was going to get the honour of seeing my bottom? At that time, there were three surgical bosses, Dr. Trivedi, Dr. Narang and Dr. Belokar. All of them were competent and proficient in their own ways. It was a difficult choice.

Dr. Belokar had a very typical way of examining patients. If there was a large hydrocoele, he would caress it lovingly and exclaim, “Wonderful!!!!!” I winced at the imagined picture of him caressing my bottom and saying ‘Wonderful!’

I decided that the best judges would be Anaesthetists. They had seen all and they knew all. They were like Eunuchs in a harem. They knew everything about everything, but could not do a thing.

My friend Murthy, was doing his house job in Anaesthesia. I intruded upon his post prandial siesta and asked him, “Murthy, Sabse achcha kaun katta hai re?”

“What?” Murthy was a bit disoriented.

“Who is the best surgeon here?”

Murthy eyed me warily and said, “For what?”

“What do you mean, for what?”

“Major or Minor Surgery?”

“Fairly major.”

“Some relative of yours?”

“Yeah! Sort of!”

“What Operation?”

“Piles.”

“PILES??!! You call that ‘fairly major’?!!! Any fool can do piles. I can also do piles. Now get out and stop disturbing me.”

This guy Murthy just does not understand the definition of Major, which means any operation about to be done on you. I asked around with equivocal results. No one was ready to commit himself.

I took the decision in my hands. I did a survey, and do you know the deciding factor?
I selected my surgeon on the basis of the diameter of his index finger!! After all, it was my aperture that was at stake.

Dr. Belokar had big sausage shaped fingers. Shudder! Dr. Trivedi had fingers the size of small potatoes. Shudder! Shudder! Dr. Narang had long tapering surgeon’s fingers. My surgeon was chosen by my sphincter.
* * *

The auspicious day of my admission to the surgical wards dawned. I had not dreaded my day of admission to MGIMS as much as this admission day. The first shock that I got was when a cute, fair Sister came inside my private room and closed the door. My heart started palpitating. Then she told me to remove my clothes. I stuttered, “Why… What?”

She removed a razor from her pocket and said, “Shaving karne ka hai!”

I cringed and backed off in a corner. “I’ll, …. I’ll do it! Give me the razor.”

“No Sir. Dr. Narang will shout at me if you are not shaved properly.”

Reluctantly, I unzipped myself and dropped the garments down. I would never be able to meet the eye of this particular sister henceforth in future. I coyly studied the floor. She then told me to bend down over the bed.

I think this was the most embarrassing position that I have ever been in my life. Just imagine, here is this sweet little thing, who you want to impress, staring at your bum and telling you not to be afraid!

I think that she had been giving some patient cold compresses before attending to me.

“Owww! You have cold hands!”

“Heh! Heh!”

Whenever the razor touched my bottom, some involuntary movement would occur. I am sure that this must have reminded the sister of a cow’s bottom, which goes into that idiotic dance after a good voiding.

“Do you have to shave that too?”

“Of course!”

“But I am being operated behind!”

“Chup baitho.”
* * *

Did I say that shaving was the most embarrassing position that I have ever been in? Cancel that. Dr. Shetty, our HOD of Anaesthesia, asked me, “Are you comfortable?”

Both my legs were tied to stirrups. I surveyed the entire OT from between my undraped legs, exposed to the whole world. I saw a giggling nurse. I saw my smirking class mate posted in Surgery. I saw my female class mate, then house officer in Anaesthesia, trying to keep a straight face.

I turned to Dr. Shetty and said, “Yes Sir! I am very comfortable.”

What else could I say?
* * *

I woke up feeling sore at all the funny places. Dr. Narang came in and asked me, “How are you feeling, Kishore?”

“Not too bad , Sir. But did you remove my tonsils by mistake?”

“No! Why?”

“Because my jaw and neck are aching!”

“Oh! Ha Ha! That is because of the intubation. But how’s the .. ahem.. rest?”

“I feel down in the dumps!”
* * *

The best part of being laid down in the hospital is that the college queen comes to visit you.

“How are you feeling, Kishore? What’s the bottom line?”

“Ha ha!”

“Let’s see the operated part.”

Her jokes had touched ROCK BOTTOM!
* * *

Day Three: I could hobble along in the ward. But my shuffling gait was not due to the pain in the you-know-where, it was due to a thick 4 inch x 10 inch thick wad of cotton stuffed between my legs.

I waddled up to the nurse’s station in my lungi, luxuriating in the power of strolling the wards in casual clothes. You couldn’t get more casual than a lungi.

While returning back to my room, surprisingly, I could walk more easily. Maybe I was improving rapidly.

“Hey you!”

I turned around. The staff nurse was calling me.

“Yeah”, I said grandly, “Can I help you?”

“You dropped something.”

I looked at the floor where she was pointing. That wad of cotton seemed to have worked its way down and out. I became a deflated balloon. Quickly retrieving my property, I slunk back to my room to make the necessary adjustments. No wonder I was able to walk easily.

* * *
At the Silver jubilee function of our batch, I stood up to say a few words. I said with gratitude, “When I left Sevagram, after passing, a part of me remained here.”

Dr. Narang looked at me and smiled. Only he knew that I meant it literally.

* * *
Dr Kishore Shah MD

How to delight your patients !

How to delight your patients ! from Aniruddha Malpani

3 free books for caring doctors !

You can read the following 3 books, online free at www.thebestmedicalcare.com!

Dr Jaya Bajaj reviews our book Decoding Medical Gobbledygook

Dr Jaya Bajaj reviewed our book, on her website, www.healthradii.com
Here's her review

Medical care has become complex in last few decades and there is growing mistrust in healthcare. The “Care” seems to be disappearing from health care and not just patients but also health care professionals feel lost in the plethora of information. Most Medical Schools focus on teaching the “science” of medicine and as a result there are very few health care providers who can practice the “Art” of Medicine along with science.
In “Decoding Medical Gobbledygook” authors layout a matrix of Health Literacy covering basic information on what health literacy is and why it is important to addressing health literacy from the point of view of various stakeholders. “Health Literacy in India, where Health Literacy is not the most talked about subject by any of the stakeholders, this book offers a fairly comprehensive review of the problem. As Dr. Malpani mentions in the book “This is a huge challenge as well as a great opportunity”
Who should read this book?
I recommend this book to be read not just by doctors, medical students and all healthcare stakeholders but also by patients and caregivers. The book has been published under creative common’s license and is free to be viewed online here.
What is Health Literacy and why we should care?
One of the definitions of Health Literacy used in the book (Canadian Expert Panel) is- “The ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life course. Thus, Health Literacy demands not just the ability to read, but also the skills of listening, analyzing and decision making, and the ability to apply these skills in the health context”. The authors clarify in the very first chapter that it is important to distinguish health literacy from health education and health communication. Health literacy empowers patients and helps them navigate better through the health care system with better outcomes.
In Chapters 3 and 4, the authors go on to explain how low health literacy can be detrimental to not just patients but health care professVls as well. The next few chapters cover information on assessing health literacy and strategies to iVve it at multiple levels. Health literacy is a complex problem and there is a need to sensitize various stakeholders in healthcare. “It takes a village” to solve a problem of this magnitude and chapters 10 and 11 explain this beautifully. Instead of blaming each other and expecting someone else to come solve the problem of health literacy, we all have to recognize our roles and empower us with information on how we can become health literate as well help the community improve the health literacy.
Health literacy in India:
India is a very diverse country with multiple cultures, languages, as well as belief systems. While we can learn and adapt the things that have worked in western societies, we have to find local solutions. Chapter 13 sheds light on the barriers and issues but also brings some inspirational stories from India and shares the “bright spots” in the system that we all can learn from.
With technological advances happening in urban as well rural India, technology can be used efficiently to promote health literacy. The book gives an extensive listing of  technology resources that can be used
My two cents:
I wish the book gets published in few Indian languages- atleast in Hindi since we have a major patient readership in India using Hindi.
Health Literacy is a globV challenging issue and highly neglected. It’s inspiring to see books like Decoding Medical Gobbledygook to move the cause of Health Literacy forward. I like the way the book has been structured. This book offers a 360 degree view of health literacy problem as well as a comprehensive list of resources available (at the end of the book).
I agree with Dr. Malpani that there we have to improve health literacy one person at a time. Health literacy gives doctors an opportunity to CARE where CARE stands for (as mentioned in the book)
C-Compassion
A-Acceptance
R- Respect
E- Effective care
The book has been published under creative common’s license and is free to be viewed online here.

My opinion about the change in rules for surrogacy for gay foreigners

The Times of India carried this story today. " In a first-of-its-kind step towards regulating the practice of surrogacy in India, the Union home ministry has issued stringent guidelines for visas being issued to foreigners seeking to rent a womb in India. The diktat indicates that gay couples and single foreigners will no longer be eligible to have an Indian surrogate bear their child as only a foreign "man and woman" who have been married for a period of two years will be granted visas.
http://timesofindia.indiatimes.com/india/No-surrogacy-visa-for-gay-foreigners/articleshow/18066771.cms"

While I understand the need to prevent the birth of stateless children; and the importance of ensuring that the child born after a surrogacy treatment will be able to travel back to their country with their intended parents, I feel this rule is discriminatory.

If the ICMR rules allow surrogacy for Indian gay couples and Indian single men, then why should it not allow foreigners to take advantage of this treatment facility in India as well ?

Also, if the adoption laws allow foreign single men and foreign gay couples to adopt from India, why should they logically not be allowed to do surrogacy as well ?

Ten Commandments for medical clinic staff

I. The patient is never an interruption - the patient is your work. Everything else can wait !
II. Greet every patient with a friendly smile.
III. Call patients by their name.
  IV.  For patients, all staff members are as important as the doctor !
V. Never argue with a patient. Be a good listener.
VI.Never say, "I don't know."  Say – “ I will find out”.
VII. The patient pays your salary - treat him like your boss !
VIII. Choose positive words when speaking to a patient
IX. Brighten every patient's day.  This will make your own life happier.
X. Always go the extra mile. Exceeding patient expectations is the best way of keeping your patients loyal for life !

The HELP Video Guide to Ovarian Cysts

The HELP Video Guide to Ovarian Cysts

Please provide feedback !

Why me ? A guide for the infertile couple searching for answers !

Why do bad things happen to good people ? Why do good people suffer ?  This question arises in our mind many a time , but most frequently when we are suffering ourselves. Most infertile couples ask themselves - ‘Why is this happening to me?’ I am a good person. I haven’t done any harm to anyone. I am fond of children. When everyone around me has children so easily, why am I doomed to suffer physically, financially , socially and emotionally ? Did I do something wrong ? Is it a punishment from God ? Why is the natural happiness of having children denied to me ?”  Most of the time , there are no answers to why , but the pain becomes much easier to handle when we start thinking how to deal with it ! After all, what happens to us doesn’t matter , but how we look at it and deal with it matters a lot !

Infertile couples are as  anxious and depressed as patients with other chronic illnesses such as cancer or heart disease. Why is infertility so hard to handle? Most infertility treatments demand lots of blood tests; frequent vaginal ultrasounds where your most private parts are poked and prodded by strangers ; and the use of hormones , which are pumped into our body in the form of injections, tablets and pessaries. As a result of all this , we feel we no longer have any control over our body !Infertility treatments are costly and can empty our bank balance in no time , leaving us panicking about the future. In many societies, infertile women are treated as unfortunate, pitiable creatures who are considered to be second-class citizens. This damages our self-esteem and our confidence vanishes. Many women leave their much sought-after job,  fearing that their ‘job stress’ makes them incapable of conceiving , only to realize later that this decision causes even more havoc financially and emotionally(no career, no money, no baby and lots of spare time in which to obsess fruitlessly !)  Infertility can disrupt friendships as well. An infertile woman recount, ‘ I had a friend with whom I used to share my pain and suffering , but when she got pregnant , she didn’t even inform me until very late into her pregnancy. I felt betrayed and was totally crushed ‘ .

This physical and emotional ordeal , coupled with the social stigma of being infertile and being subjected to a barrage of ‘advice’ from ‘well-meaning’ people can make the infertility journey more hazardous than walking through a minefield ! How can you endure such suffering and yet remain sane ? Can we find a purpose and meaning in life during this crazy struggle ?

Is suffering bad ? Before answering this question let me ask another  - Is  physical pain bad ?  What will happen if we lose the ability to feel pain ? It appears on first thought that if we do not feel physical pain , everything will be well and good – no need for painkillers, no need for a doctor, and because the body always feels good , there is no fear of physical suffering. But, if you stop to think clearly , you will understand that if you stop feeling pain , our body is in danger all the time.  For example, what happens when you step on a sharp object ? The pain you feel immediately alerts you; you remove your leg from that sharp object and you take care not to step on it again. In this way, your body is protected from the danger of being wounded deeply. Pain also alerts you to seek medical help at the proper time , so that further damage to your body is alleviated. In short, pain teaches you to avoid dangerous situations and to seek help when necessary, by acting as a protective shield. A person who is unable to feel physical pain is physically handicapped – and a living example of this is patients with leprosy, who are at risk of progressively losing their fingers and toes because they cannot sense pain anymore . Just like physical pain is good for our body , emotional suffering is definitely good for our soul ! Emotional hardship makes us sensitive to other’s pain; it teaches us to respect life; it helps us to appreciate the goodness in our own life; and makes us stronger and humble at the same time . Suffering teaches us a lot of life lessons – and most of us learn much more by experiencing hard times .  Suffering helps us to grow spiritually; and shapes us into mature human-beings.  A human without suffering is emotionally handicapped , because he cannot relate to what others are going through , nor can he know what real happiness feels like !

It is true that suffering teaches us many valuable lessons in life which happiness cannot, but if we are not resilient  , this suffering can tear us apart emotionally, rob us of our natural goodness and can leave us bitter and full of fear and cynicism. But there are humans who blossom gracefully amidst the pain they endure – like a dazzling flower in a desert ! How can some people manage to become better human beings inspite of all the suffering they have had to experience ?Why do others become bitter, resentful and downhearted ?How can we use this experience of infertility to become better human beings ? How can we find the strength to cope ?  I have listed some strategies which help me to stay strong , and I hope they help you too !

Compare yourself with the less fortunate !

When you compare yourself with someone who is worse off than you, it will help you to accept your suffering gracefully. Gratitude for the blessings you do have in your life ( as compared to those who do not have these)  helps you look at the glass as being half full, rather than half empty. Being empathetic and experiencing another’s pain makes managing your pain a lot easier .‘Look at people who are less fortunate than you are and be contented with what you have ’- this is the lesson which my parents taught me at a very young age - and it has helped me to tackle one of the worst crises in my life very effectively. As the saying goes – I felt sorry because I had no shoes – until I saw a man with no feet .

I agree infertility is very hard , but if you decide to live a life filled with anger, resentment and hopelessness , won’t this just make it much worse ?  I have a friend who was full of happiness and energy. Her favorite pastime was to read books. She completed her PhD with flying colors. She stood first throughout her studies; got married to the love of her life and gave birth to a beautiful daughter within a year of her marriage. A year later, she fainted and slipped into coma. The doctors , after a lot of struggle , diagnosed her as having TB of the brain. In the course of her treatment , she lost her eye sight. She turned from a beautiful woman to a person who is just skin and bones. Her daughter was separated from her for three years. She spent this time all alone , sorely missing her daughter. Now she is getting better after years of struggle. She is someone whom I respect and worship wholeheartedly. I believe the suffering she has endured has raised her above all of us.  When I talk to her I learn a lot about life. Even if she is depressed sometimes , she fills me with positive energy. I have never seen her cry for herself but she broke into tears when she heard about my IVF attempts and the failures I went through. She has given me many gifts, but the best one is a book (I hope you understand the importance of getting a book from her – she gave me something which she cannot enjoy anymore - her unfairly denied pleasure !); and a cute pink frock for my prospective daughter. She is the most beautiful human being I have ever met and her suffering has transmuted her into a woman full of strength and compassion. When she was in hospital , she wrote the following verses from the Bhagavad Gita and stuck it in her room (in her present childish scribbling).

It read :
“Whatever happened, happened for the best . Whatever is happening, is happening for good . Whatever will happen, will also happen well. For what are you crying? What did you bring with you, for you to lose? What did you create, for it to be wasted or destroyed? Whatever you took, it was taken from here. Whatever you gave, it was given from here. Whatever is yours today, will belong to someone else tomorrow. On another day, it will belong to yet another”. I understood the profound wisdom in those words; and if I hadn’t been infertile , I don’t think I would have been able to do so !

Is infertility a greater suffering than what many other people endure ? I have come across people who get very angry when I say - Look at the suffering which others go through in order to console yourself. Their argument is, isn’t every suffering unique ? Is my pain worthless ? Don’t I have the right to feel my pain ? Like happiness, suffering is relative. Comparing yourself with persons who are less fortunate than you, will turn you into a compassionate and grateful human. When you feel their pain,  your pain will automatically appear a lot lesser , and this protects you from many negative emotions and depression. It stops you from complaining , and helps you to appreciate life. If you spend most of your life feeling sorry for yourself because you are infertile, learning to shed tears for others will help your own life to appear worthy and precious !

Be happy !

Isn’t the purpose of life to be happy? What will you achieve by being sorry for yourself, carrying a ton of guilt, being resentful and angry and by becoming bitter everyday , just because you are infertile ? Aren’t your hurting your spouse too by being sorry for yourself all the time?

How can you be happy when you are struggling with infertility? The truth is our circumstances don’t have anything to do with our happiness – it is the way you look at your circumstances that either robs you of your bliss or helps you to stay strong. Look at infertility as an interesting challenge rather than a mere struggle. You have something to hope for, to wish for, something to be excited about (a baby!) most of the time – is there anything else needed to keep someone happy ? Of course there are very hurtful and sad times during infertility struggle, but doesn’t that sadness make the happiness in our life taste better ? The best way to be happy is to make someone else happy– try it and you will understand! Give happiness priority in your life. It will make all the suffering appear a lot less and you will gain enormous strength to cope with infertility ! Below is the serenity prayer by Reinhold Niebuhr which helps me to remain serene amidst my infertility journey :
God, grant me the serenity
To accept the things I cannot change,
Courage to change the things I can,
And wisdom to know the difference.

Hope it helps you too ! Stop worrying about things which are beyond your control and appreciate the blessing which you do you have.

Do not equate happiness with a baby

The mistake many infertile couples do is equate happiness with a baby. They wait and wait for a baby -  and for happiness too. All through their journey to have a baby , they remain sad and bitter. When you are sad and bitter , you turn the people around you off . Happy souls tend to make others happy and hence attract happiness ! During your infertility journey, you need support from your friends and dear ones; leading a lonely life only adds to emotional suffering. Many infertile couples live an isolated life. People do not move away from you just because you are infertile – rather, you move away from them because you are sad and depressed. I have heard many women say – “ If only I had a baby , how happy I would be!” Do you think having a baby will solve all your problems and bring you everlasting joy ?  Of course having a baby is one of the sources of happiness , but a baby is not the only source of happiness. The time to be happy is now; you never know what the future has in store for you ! Only when you are contended with what you have do you get the ability to enjoy happiness ! If you make your happiness conditional to getting something  you don’t have , life becomes miserable. If you learn to be happy , you learn to tackle life’s ups and downs with equanimity !

Helping others is the best way of helping yourself !

We all need help sometimes ! When going through infertility we definitely need help; I am not talking about monetary help, I am talking about emotional help. We need kind words to keep us strong ; we need a shoulder to lean on when we are tired; we need an understanding heart who empathizes with us ; and we need to know that we are not alone ! But how do you get this much needed help ?I have learned a very important lesson in my life by going through this infertility struggle – “ helping others is the best way of helping yourself”. My blog helps me to help others by sharing the knowledge I have acquired. When I do this , I gain more knowledge too , because I have to keep myself updated !After all, teaching others is the best way to learn something. So by gathering knowledge , I am helping myself first so that I can help others ! Nothing gives me more satisfaction than when I can help other infertile couples. By supporting them , I am supporting myself; by helping them I am helping myself ! I get a feeling of self-worth and I am proud to be a patient ! My self-esteem grows daily because I  get so many comforting words and emotional support from my virtual friends. So if you think you need help, learn to help others first. Infertile couples often feel that they are alone – that no one understands them , and they crave for comfort. In such a situation , the best way to get support is to support others who are in a similar situation as you are. Online infertility communities and forums are the best way to reach out to someone who is going through what you have gone through. Helping them and supporting them can bring a sense of goodness in your life. Having an online journal can help you emotionally and help others too !There are always people around you who need help , and you can help them in many different ways - providing monetary help; sharing your knowledge; supporting them with your kind words and deeds -  anything which you do is fine, when it’s done without any vested interest ! Spending your precious time and resources for others will help you to have a positive attitude.When you taste the happiness which is inherent in the help you extend to others, you will never feel tired or sorry for yourself. It is not only about the appreciation you receive, it is about the genuine intrinsic spiritual happiness inherent in such activities which keeps you strong and resilient. Helping others provides enormous emotional gratification and protection and I will always be thankful to Dr. Malpani for teaching me this valuable lesson – thank you very much Dr !

Out of suffering have emerged the strongest souls !

Kahlil Gibran said “Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.”The more suffering you face the stronger you become. When I had my last IVF failure and was struggling with depression Dr.Malpani quoted  Nietzsche “  What doesn't kill you makes you stronger ! Grappling with infertility can help to make you more empathetic and emotionally much more resilient, so you can deal with all the hard knocks life can (and will) deliver in the future as well !” So, never look at your suffering as punishment – it is a blessing in disguise. It helps you appreciate how strong you really are !It will prepare you to face other difficult situations in your life with a strong heart and a clear mind. Once you have successfully weathered the storm of infertility, anything else life chooses to throw at you will be child’s play to deal with. Infertile couples suffer for what we deeply crave for – a baby – can there be a sweeter pleasure than such suffering ? The way you react to struggles determines who you are. A person who is in his comfort zone may be good – but only one who is pushed by challenges can grow to his true potential.  If you grow better every day without becoming bitter amidst your struggles , that is the greatest achievement you can aim for in your life. Accept your sufferings gracefully and allow it to shape you into a beautiful human being. Suffering is a brutal teacher , yet it teaches you the best lessons in life ! Make sure you learn the lessons without yielding to self-pity and depression !

Life is a succession of lessons – learn from them!

Life is a continuous learning process - when you stop learning, you stop growing too ! Many infertile couples avoid social gatherings because they are afraid of facing awkward situations and unkind thoughtless comments. They try hard to isolate themselves , and as a result they stop learning the valuable lessons life was designed to teach them ! There are many unreasonable people around , and they might hurt you with their words or  deeds. But remember that no one can hurt you without your permission – and their unkindness reflects on them , rather than on you. By meeting them , you can learn how not to behave ! Tackling hurtful situations and comments helps you to grow spiritually and emotionally. We all build resilience by tackling difficulties in life. Remember, life is a learning experience and it’s the experiences you need to struggle with which will teach you the most precious lessons. If you refuse to tackle your pain, you will never grow emotionally. Stunted emotional growth makes you vulnerable to pain and depression. If you want to be emotionally hardy , treat life as a continuous learning experience and be willing to learn from it !
“Life is a series of experiences, each one of which makes us bigger, even though sometimes it is hard to realize this. For the world was built to develop character, and we must learn that the setbacks and grieves which we endure help us in our marching onward.”
-    Henry Ford

Keep yourself occupied !

The best antidote for depression is being occupied with something you like doing. Anything you are good at will bring you happiness. An idle brain is the devil’s workshop and being idle exposes you to all sorts of unreasonable thoughts and fears. So always engage yourself in some work which keeps you busy. If that work becomes your passion you will naturally excel in it.  If you are a working woman who is trying hard to have a baby, please do not quit your job for the sake of a baby. The stress you experience in your job will not prevent you from conceiving – this is just an old wife’s tale ! In fact, being busy will help your emotional well-being ! If you are mentally unoccupied you will find lots of time to obX, and the more you obsess, the more likely you will sink into depression. The best way to cope with infertility is to engage yourself in activities you like– be it a hobby, your job, some charity work and so on. If the work you do gives you a sense of satisfaction and self-worth , you will be able to cope better with the times when you feel sorry for yourself, and you’ll be able to snap out of the infertility blues more quickly.

Turn a deaf ear to hurtful opinions and comments

Many women say “I try hard to be strong and happy amidst my infertility struggle , but the people around me hurt me with their words and deeds. This turns me into a coward , and I am unable to face them . How do I cope with this? “ One of my friends told me “I got a call from one of my relatives who recently had a baby, and she went on and on about how good it feels to be a mother  ! To add insult to injury, she also gave me her opinion on how infertility treatments can actually prevent one from conceiving  ! “   One of my friend’s in-laws made the cruel comment  - “What use is a fertilizer if the soil itself is inherently bad ? “ How is possible to remain strong when such unreasonable people are around ?

I agree it hurts to have to deal with these emotional assaults all the time. It can make us weak and fearful. But if you observe people who get happiness by poking their nose into other’s misfortunes,  you will find that they are unhappy themselves.  Rather than get angry, you should feel sorry for them. If someone hurts me unreasonably, my first thought is “ What has this person gone through which has made him this bitter “. Remember, a happy human will not hurt others. Only people who lead a miserable life filled with anger, hatred, guilt and suspicion will have the time and energy to find happiness in other’s troubles. So the best thing you can do to safeguard your peace of mind is to pity  these nosey-parkers - being compassionate will give you a sense of superiority, and will allow you to forgive them more easily ! You cannot control someone else’s actions – but you can control your response to them ! Just turn a deaf ear to their hurtful opinions and comments , and ignore them. When you give undue importance to such comments and worry about them, you unconsciously give them power over you. Your brain starts believing that what they said is right - and this can actually make you more emotionally susceptible. Remember that what they say and how they behave shows who they are - and not what we are . Anyone who deliberately chooses to hurt you deserves your pity !

Seek therapy !

Last , but not the least, please seek psychotherapy if you find it hard to deal with infertility. Infertility can play havoc with your  emotional-wellbeing. If you are someone who is constantly tearful and fearful; if you are overwhelmed with negative thoughts all the time; if you cannot take your mind off the thought of infertility;  if you cannot sleep well; and if your work and personal life are affected because of the crisis of infertility, please seek medical attention. Not everyone is blessed with the ability to be strong and resilient during all major life crises. We all can benefit from professional help during a crisis in our life – and a good therapist will teach you tools to tackle stressful situations in a more constructive fashion. Seeking medical help doesn’t  mean you are weak. Actually,reaching out for help shows that you are wise enough to understand something is wrong and can take bold steps to overcome it. There are many different forms of psychotherapy available , which will help you to bounce back !

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