Women Health and Infertility

Swine flu vaccine in pregnancy

2017-08-24T00:48:00.002+05:30

Laser for fibroid removal

2017-08-23T02:24:00.001+05:30

LASER sound fascinating .A laser surgery sounds so exotic and as a MBBS students mention of LASER in the surgery mage it sound really impressive to my ears too.

Recently,my husband Dr Shalabh Mohan started LASER surgery for Piles and fissure and whole lot of general surgical conditions.And that made me curious as usual.Can I use it for my patients in any possible way to make the treatment better?I know vulval warts and skin tags can be removed -but I can it be for something more?

And then came A lady from Punjab.Rather her son got her to me.She had visited PGI Chandigarh and was advised removal of uterus.On examination I found a big cervical fibroid.Question was - Doctor can I avoid Hysterectomy?

I said probably yes with a cervical Myomectomy but with this big Fibroid the bleeding can be quite heavy and suddenly I remembered the friendly Diode Laser sitting next to the study table at home.Oh yes - we can.We surely can.Laser minimises the bleeding and the fibres can reach those nooks and crannies which isn't possible otherwise.So that what she wanted - a laser surgery.Getting an approval from her insurance company was a hassle.Insurance company wasn't willing to pay extra even if it meant less blood loss and early recovery.But still she wished to get the surgery done and I did perform.

With the ease of the LASER the 6cms fibroid was out and away in 1
5 to 20 minutes.The blood loss wasn't even 50 mls and the Lady had left for her home in 4 days.
How did I feel - surely ecstatic...it was a job well done.

IVF and the stimulation story

2017-08-23T01:57:00.000+05:30

I was trying to explain a very old loyal patient of mine today.For an IUI I can't give you FSH in a dose which hyper stimulates you.And she said why?I said - see that can triplets or quadruplets which can complicate the pregnancy besides Ovarian hyper stimulation which can be dangerous for your life.And her response was -whats the harm in having triplets.In my current state I am willing to take all these possible risks.Well....her current state is a secondary sub fertility.Has a cute little child already.

So what it means is that sub fertility a 'disease' which leaves a couple so vulnerable and desperate that one is willing to take all the risks.

I have another lady under my care.Pregnant with an IVF conception.The dose at which she was stimulated was unheard of.And I had asked -so didn't you get OHSS? She said-yes I did.Was even admitted in ICU for few days,but she still had a sense of satisfaction on her face,as if to say,'' doesn't matter ,it was a small price to have baby'.

It becomes a dilemma as an infertility specialist.What is justified?Infertility treatment is nerve wrecking and costly-an emotional roller coaster too.Low dose stimulation means less eggs but then how can one be oblivious to the mothers health and life.But at the same time a low harvesting of egg means a possibility of repetition .

The evidence based and safe answer is still mild stimulation but I just wonder to a couple badly desirous of conception does this makes any sense?

Probably not for most Indian couples.

I am scared Doc!!

2017-06-23T23:56:00.005+05:30

Not uncommonly ,couples visit me with a particular complaint after many years of suffering in silence.Health is a state of physical,mental and emotional well being.And unfortunately these co uples though physically healthy have severe emotional issues.

A typical history is where the male is a considerate person and the woman has a fear of painful sex and they are unable to consummate the marriage despite being in relationship for many years.
Most of the time the Lady doesn't have any problem locally but it is the 'fear' .

If you have tried every possible conservative method in the world and still are unable to overcome the fear,visit a Gynaecologist who has some knowledge of urogynaecology. After examination it can be ruled out if there is a local problem and that can be fixed.If there isn't any anatomical problem,then a vaginal dilatation can be performed under anaesthesia.It works as the lady knows that now the dilation has been performed and that helps them overcome the fear.

Lot many time if there is a local scarring an operation called fentons operation which widens the vagina is useful.It is a kind of vaginal reconstructive surgery .

Those who have never faced this issue might find this post surprising but for those it is a real concern,their life is muddled with a problem which they find difficult to share with anyone easily and keep on suffering.

Chronic Vaginitis

2017-06-07T02:37:00.000+05:30

Nothing can be more frustrating that a constantly itchy vagina with a fungal or bacterial infection.What increases the frustration further is one has already visited the best of gynaecologist in the town,has had many courses of anti fungals,antibiotics,many pessaries,potassium permegnate solution and all sort of ph maintaining washes.

By now many sufferers start thinking that their martial life has gone for a toss or they themselves are mentally ill.

Is there anything which still remains to be tried?As a hope of relief comes Boric acid capsules which can be used vaginally for 14 days to get rid to resistant fungal of bacterial infection.Next time you have a similar condition under your Gynaecologist's supervision do try .It should be used as 600 mgs pessary.In India it isn't easily available ,so you can try this product from Amazon which I recently searched online for one of my patients.

Book to read while Pregnant

2017-06-07T02:05:00.002+05:30

Many a times Pregnant women ask we the book or books they should read while pregnant.Those who have been my patients know that I give an elaborate handbook ( What to expect when expecting)to all the moms under my care which answers most of the FAQs.Still if you wish to read further you can read this book available on Amazon.This book is good.Also covers lots of Pregnancy complications which many a pregnant women tend to imagine themselves with all possible complication while reading this book.Avoid that and then it is a nice book to read and understand pregnancy.

Stressed ???

2017-05-29T01:00:00.000+05:30

Stress - It isn't uncommon word or rather it is an extremely common word.
Atleast 50 % of my patients are stressed.It leads to whole load of health problems.It has contribution in infertility,metabolic syndromes like PCOD,irregularity of periods,discordance in sexual and marital life and so on and so forth.

But why are we stressed? Who is responsible?Is it us?Is it our surrounding?Is it multifactorial?
Who can help us?How can one help oneself?

I am writing this post for two reasons.One -this is a very commonly asked question.Second-I think ,I am qualified to write it now.A stage in life where I can say I have learnt to handle situations in life in a way which has reduced the stress levels to a minimum.

Not long back I was a typical type A personality who was driven on adrenaline.Even today I am a type a Personality but I have learnt to tame that type A person in me.I let it be awake when I need it but at other times I make it have good rest.Yes....thats correct you need to take good rest,detach yourself from the mad rush around you to perform more effectively and more productively .

After so many years in my profession and also my life,I realize,events are predestined.Though one should give one's best in whatever one does,nothing is in one's hand.Once I could feel this and make myself believe in this theory 70 % of my stress was relieved.Secondly ,the definition of success has changed for me.It no longer means the biggest player in the market ( number wise).I enjoy what I do.But excess of anything is bad,including enjoyment.The moment one increases one's work load beyond a certain limit the performance and productivity falls down.Recently there was a Lady admitted under surgeons for some general surgery related problem.She had an incidental ovarian cyst as well which she wished to get removed in the same sitting.Now due to whatever reason,it was convenient for the surgeon to operate the Lady late in night around 10 pm.In my opinion elective surgeries are best done in elective hours for best outcome.So what I did was I refused to operate .That lady had not come for me.For her it didn't matter who the treating gynaecologist was and thus I requested the surgeons to call some one else,which they did.

I saved myself from a stressful situation.Previously I would have operated her even at 10 pm in the night against my own wishes and belief and a tired body and mind.It would have given me 12 - 13 k but I would have lost my health and sleep and of course would have been an unsafe tired surgeon.

It is just an example .The situations are varied and you will have to find your ways to minimize your stress levels.

Another change - now when in theatre I am not worried of the waiting list in OPD.Things need to be prioritized.An emergency or on going active surgery takes priority over an OPD patient.If unhappy to wait,there are other consultants available around and am sure they can be taken care of.There is no point trying to be omnipresent. 1300 OPD fees ,isn't worth a complication in OT or a law suit in court.

INR

Now my own health is my priority.I insure to take 2 to 3 hours out for me in my 24 hours for my health and exercise.All the joys and pleasures in the world can be felt only till we have a healthy body and mind for which it should be treated as a temple and should be worshipped.

Lastly ,now i don't think any loss is irreparable accept the loss of life .So ,I don't fear the future.There is no question as what next?

These are few of the changes ,which I think has helped me immensely.Try to incorporate in your life and see if that helps an irregular period or a failing marriage or dry sex or endometriosis or makes you conceive .

I have got thyroid dddd !!!!!

2017-05-16T23:48:00.000+05:30

Are you also worried ,you have got thyroid'? If the answer is yes then we need to know a bit more about thyroid.And what do you mean when you reach the doctor to tell'you have got a thyroid"
Thyroid is intact a gland in neck region of all of us unless surgically removed.It is present since birth.Due to various reasons it can under function when Pituitary gland ,a gland in brain starts producing more TSH and you suffer from Hypothyroidism.

On the contrary if Thyroid is overactive and produces more thyroxine,less of TSH is needed and produced by the pituitary.That is called Hyperthyroidism which is less common but more serious issue then Hypothyroidism.

In Pregnancy the cut off for TSH is 2.5 If the concerned Lady has anti thyroid antibody and TSH level is between 2.5 to 10 mu,even then thyroxine supplement is needed to prevent potential complications like mental retardation ,miscarriage ,if Anti thyroid antibody is negative,no supplement is needed between TSH values 2.5 to 10.Any value measuring 10 and above needs thyroxine supplement.

( Based on American Thyroid society guidelines 2017)

Normal Delivery or caesarean ??

2017-05-01T00:54:00.000+05:30

You are Pregnant.Are you ?Most likely you are if you are reading my post or are planning it real soon.Or may be you are not.Pregnancy and delivery are facts of life which most of the women go through with great apprehension,enjoyment ,doubts and at times confusion.

It is a quite frequent question - Doctor ,which one is better -normal or Caesarean section ?Well well,may be few years back my answer would have been 'of course vaginal delivery if you can manage it safely'.Still my answer is more or less the same but my attitude to it has changed slightly.I don't know whether it is right or wrong but it is changed for sure.I will share my thoughts and the reason behind it.

Before I write what I feel,let me tell my interpretation of high Caesarean section rate in corporate hospitals.It isn't certainly not for money making.No doctor is paid more for doing Caesarean vs normal delivery.Hospital probably gains marginally from caesarean section but atlas I haven't been told my anyone and I mean no one in either of the the two hospitals I have worked to perform a single un indicated surgery.The most common reason is a scared doctor,scared of things going wrong during the long process of labour and at times not to wait the long hours of labour and get tied leaving rest of the chores and social life and responsibilities and at times a busy OPD.

Now coming back on track,Vaginal delivery is good.Caesarean is good too.Vaginal birth after caesarean section is no less good.But what is bad then ?Bad is when a procedure is done against the wishes of the Lady and if it is unindicated. Now a caesarean on demand of a lady without any Obstetric indication isn't unindicated. The Lady needs to know pros and cons of all the three methods and after that whatever she decides is a correct decision.

Not many of us give a unbiased we including me.Vaginal delivery is the normal process which nature wanted.But has caesarean got certain advantages over it ? Probably yes.With vaginal delivery there is for sure more chances of weakness of the pelvic floor in long run with an increased chances of urinary leakage,pelvic organ prolapse.It is not to be mistaken with me saying ,women who delivered by caesarean won't or can't have these problems.If the baby size is too big and if it is a traumatic delivery it can have long lasting impact on your pelvic wall as well as the baby.Again i am not saying ,it is rule of thumb but it can happen.

Now caesarean - well it has many disadvantages too.Recovery is longer than vaginal delivery for sure but it isn't a long long process but there is increased risk of adhesions,injury to bowel and bladder,infection,ectopic pregnancy,placenta praaevia and increased possibility of caesarean section in future pregnancy.

Vaginal birth after caesarean section can be achieved in 60 to 80 % of women who had previous caesarean section.But if any female decides an elective caesarean after a previous caesarean is also not an insane decision.VBAC has a risk (1%) of previous scar giving way during labour and that risk increases if we need to use any drip -syntocinon or Prostaglandin gel either for induction or augmentation.The lady needs to take an informed decision whether is wishes to take the risk of repeat major surgery or the scar giving way.

Now you know,when I see dispassionately which I wasn't able to do before due to my NHS training which then recommended -Normal delivery rate of 80%,I don't think either of the mode of delivery is bad.It is all about choices.But what I do disapprove is ,if the woman wants a vaginal delivery and can achieve one safely to convert it into a caesarean.

If any one of you wish me to write any further posts on this issue or any other please do write back .

Genital Warts

2017-04-29T02:06:00.000+05:30

Genital warts aren't uncommon.I am frequented by Ladies who have developed warts and aren't sure what it is or they have done so much internet surfing that the are too stressed by the time they visit a specialist.
Genital warts are caused by Human Papilloma Virus,the same virus type which causes cervical cancer but having said that Vulvar warts aren't equal to cervical cancer and thus detection of a wart shouldn't be a cause of panic.It is one of the sexually transmitted disease but it doesn't mean that your partner is cheating on you.Actually most of the women develop these warts many months or years after acquiring the HPV infection.HPV can be transmitted by skin to skin contact and need not be through penetrative sex.Condoms are the most effective way of preventing HPV transmission but condoms don't give 100% protection.Even for oral sex it is advisable to put condom over the penis and sharing of sex toys should be avoided.
Warts in general don't cause massive symptoms or cause major damage.They can look unsightly and if not removed can be a source of spreading the infection to your partner.For very small warts some chemicals can be used but it takes a lot of time for them to get cleared with the chemicals .
Surgically it can be removed using electrocautery or laser.It is important to seek specialist help.HPV infection and warts can get cleared off the body completely or it can be recurrent.There is no medicine to prevent the recurrence and depends on the immunity of the lady.If smoker,stopping smoking can be helpful in making the treatment more effective.

Vaginal reconstruction,Vaginal rejuvenation,tightening of Vagina

2017-04-22T00:55:00.001+05:30

Does these name vaginal rejuvenation,Vaginal reconstruction,Vaginal resurfacing,Hymen repair sound familiar.have you heard it recently more often than before

With changing society the current day health requirements are not just about how one feels but also how one looks inside out,top to bottom( literally)

A lot of attention is paid to the genitalia by females as well as males to get aesthetic surgery for private parts.

Though I don't see a compulsion when a lady about to get married comes to me to repair the hymen,but I do understand her judgement and that needs to be respected.A neo hymen needs to be made and yes,it is refreshed and made.

Then comes a Lady with multiple Vaginal births with a vagina and perineum which has naturally gone lax.She feels embarrassed while her husband feels unsatisfied.A minor issue but a major one for the Lady and her husband.Can the vagina be tightened,refreshed where the couple can get for pleasure out of sex to keep a harmonious marital life.Yes surely it can be done. If you feel the need to visit our centre at Clinic nirvana ,I would feel happy to explain you the procedure and how simply it can be done.

At time women have body dimorphism and the go for aesthetic surgeries and private part is no different and have seen many young ladies who didn't like their Labial size or shape.Can we help them.Sure we can

Urinary Leakage ...well mesh surgery as well as minimal incontinence can be dealt with laser surgery too.

Menopausal lady whose vagina is hormone depleted,gone dry and thinned out and has uneasy buning sensation,she can be helped with laser surgery too by generating new collagen

With many years of experience in urogynaecology,I find aesthetic gynaecology an interesting part of health care.With new techniques and modalities it is possible to give as much efficacy in vaginal tightening or rejuvenation as one would do after a big surgery by just a half day or maximum 24 hours or at times 45 minutes of non knife surgery.-Lasers to be precise.

Considering that anything to do with aesthetic surgery or repairs,doesn't come cheap including the Laser machines used.

We also perform hymenectomy in couples who have not been able to consummate marriage due to any reason.

Cervical Cancer and Pap smear

2017-01-27T23:44:00.000+05:30

So, January being cervical cancer awareness month,I thought of getting repetitive and talk about Pap smears and vaccines once again.

Cervical cancer - Cervical cancer is the cancer of mouth of the womb and is the commonest cancer in Indian women.Unlike other cancers cervical cancer doesn't surprise you by it's sudden occurrence.It goes through various stages of cell abnormality before getting pre cancerous or even cancerous.

High Risk Factors-Promiscus behaviour and multiple sexual partners,usage of Oral contraceptive pills,smoking,multiple child birth to mention a few.It is caused by a virus called Human papilloma virus,which is mostly transferred during sexual encounter.

Screening- Pap smear is a preventive test which doesn't take more than 5-7minutes to perform.A brush is used to gently take the cells from the cervix.At worst this test can be called mildly uncomfortable but not painful.A laboratory examination screens out any abnormal cells.

Pap smear should be done every 1 to 3 years till the age of 64years.

What if Pap smear is abnormal-Incase of an abnormal report,another test colposcopy is done where the cervix is visualised under a magnifying lens after applying a vinegar like solution or iodine or both and if any area looks suspicious,small piece s taken and sent for pathological confirmation.Again,this procedure can be done without Anaesthesia.

What if Biopsy also comes abnormal.If it is till precancerous stage,a procedure called LETTZ is performed where the abnormal area of cervix is 'shaved of' using electric current.A cancer obviously would need removing major chunk of cervix if family isn't complete or a hysterectomy if the family is complete.

HPV vaccine- It covers only 4 out of 100 strains of HPV and thus the maximal protection offered is 72 % and not 100 percent.Maximal benefit derived is before the girl became sexually active.Recommended age group is 9 years to 26 years.After that one would get some protection but difficult to say how much protection.

So a few minutes spared every year can save many lives.If you haven't had a screening so far,it is never too late to begin something as beneficial as this.

let it go to the dogs !!

2016-12-29T02:34:00.002+05:30

It is a doggy story from beginning to end.Nothing about women or health or infertility.
Due to multifactorial reasons I got enrolled for my first 10 kms run scheduled for september 2016-Pinkathon ,Delhi.
The person who initially in 2015 had suggested me to try running,by that time had changed priorities.I had thought he would guide me so called training for long runs,never being an athlete or sports person.I was left with the option of trying it myself or run with the local running group,the timing of which was too early for my comfort.Being a late sleeper ,I needed my 8 hours of sleep an 5 am runs were not healthy at all for me.Other option was to quit that 10 kms.By God's grace I haven't quit anything which needed my solo participation.
I started with walks and to my amazement I had run my first 10 Kms in not too bad timings.But that run is a different story all together.I used to train and practice in my condominium myself,all by myself and You tube videos to guide.4 stray Indian dogs have been adopted by our condominium mates and they mutually co exist with us.
When I used to run,mid way around half the circle,4 of these dogs used to come along with me,join ,lick and pounce and play and do all what they could do to show their affection.It was annoying at first and slowly i got used to it.It became the daily routine.Why they liked me,I still don't know as not even once have I played with them or given anything to eat.
And then 20th November was Airtel delhi Half Marathon.My first 21 kms.Again I was alone to train.My friend has his own priorities,other friends who needed help and moral support and training.Anyways again these four guys followed me everyday at the same pace as mine.If I used to run they used to run .My walks made them slow down their pace.They had become my friends ,who derived pleasure of my company.For them no other gain from me mattered and neither I was of any use to them except occasional chats we would have on the running tract.
Now I have a pedigreed Beagle at home.Son of parents who have been show dogs and prize winners-Buddy.A nice little content four years old.Suddenly I was finding a change in his behaviour.He was ignoring me.What was the reason?And then we realised that all the family members used to give him some prize food as soon as they entered the home while I didn't as the deal was not to over feed him to improve his longevity.I felt bad.You can interpret me as a mean person who feels bad of a dog's behaviour or you can classify me as a person who is sensitive enough to feel bad even of a dog's behaviour.And I did rebuke him.
When I came down to run that day,for the first time I realised the unconditionality of the love these stray dogs had for me.Why?I don't know but their friendship had nothing to do except for being with me for those hours as we were together.I was touched and now we are friends.I look forward to meet them when I go running and in their company I did my first 21 kms.I have patched up with the pedigreed Buddy by offering him his goodies off and on but what I value more is the friendship of street dogs ,who made a runner out of me.

Power of Positivity

2016-12-12T03:12:00.001+05:30

My biggest handicap while writing this blog is my limited Vocabulary ,having studied in a non english medium school and have little what so ever liking or time for non medical books.(Inspirational ones are the only exception)

How many of you trust,what you do gets back to you like a boomerang?All,many or nobody?

Well,I do believe in it.As after all whatever you will sow,you will reap.I have many personal reasons to believe it and I will share with you guys in due course of time.

I reached my OPD Chamber and there was a middle aged couple chatting with my Assistant Ankita.Ankita told in her typical way the medical history where she weighs every word she speaks carefully, weighing each and every word . After all I am the boss.Ok so this 46 years old Lady wanted a Hysterectomy today.Period!!We will call this lady K hence forth for the sake of convenience.

K is a govt teacher ,travels everyday 128 kms towards Rajasthan and comes back.She had not taken a single leave in her career of many years ,she told me proudly.I was impressed ,no doubt.For her 46 years ,she looked younger.It would have been easier to accept her asA 35 year old.A chatty female,who was in rush not just to get a surgery done but also to tell a lot of related stories.Her husband was the scared and quite one.Scared ,if he would be able to run this show all by himself i.e getting his wife operated and manage the home too.

K had been diagnosed with a big fibroid which in my opinion she could have lived further.But she was determined...surgery,surgery and surgery as that too ASAP.Advised to get endometrial biopsy done preoperatively and she said 'no'.Okay so the next day she was taken for removal of uterus and we decided ( what me...all decisions were of K and I was just executing it)to preserve the ovaries as everyone in her family gets menopause after 60 years of age only.

Do You know me or my professional profile?No came the answer pat.And you are in urgency to get a major surgery from me?Doctor,a neighbour told go to Artemis and in Artemis we liked your name best .I do loved my name before,and I love it more now.Thanks Mom and Dad for the same.I thanked her but said my name kind be the only thing.She said,it gives me positivity.Then came the bouncer.

She said,'Even God has to show his face to us and not just vice versa) .As I have not harmed /hurt or professionally did any misdeed/I don't think a reason to be in wrong hands.What face will he show to me?Her word were even re assuring for me.It always helps the doctor to treat her patient better if the patient shows so much confidence in the doctor.
It was a complicated case with adherent bowl and bladder due to previous multiple abdomen Surgeries.The surgery went well and uneventful.She visited me again in OPD.So full of praises for all of us but mostly her husband who according to her had graduated to being husband rather than a scared companion of past.

While leaving she again said.God had to show his face to me.That's why I met your team.I didn't do any online search and once I had talked to you the vibes told me-Go for it under her and no where else.

The theory of The secret says,what ever you you wish with full heart the universe conspires to make it happen.I have seen it happens.You are guided rightly by your circumstances.A believer is better than someone who has done mega research on the doctor on internet and still isn't able to trust the person in whose hands has put her life.

Being working in a ECS empanelled hospital,I do get wives of senior level Army officers off and on.It is a huge concession for them.Now this lady , say R,needed a surgery which went smooth again.She came in follow up and just notice the difference in K and R's behaviour.She is a non believer,it sounded.She said doctor I have to say everything went well.I am not even sure you did any surgery on me,as I feel really comfortable.And yes...this is exactly she meant.
In my personal life I have seen power of positivity.It works.In each and every sphere of life.Only-Trust,believe and when things go against you still have Gratitude for a while.And you will realise....everything is back on tract once again.Usko bhi to much dekhana hai !! :) :)

Poor Responders in IVF

2016-08-17T00:39:00.001+05:30

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

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

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

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

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

Oh so famous

2016-07-20T00:56:00.001+05:30

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

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

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

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

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

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

Marketing.New paper ads!!Any suggestions?

Miscarriage and Progesterone ( To prescribe or not to prescribe)

2016-07-15T01:58:00.000+05:30

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

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

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

For those who wish to read further please follow this link
http://www.miscarriageassociation.org.uk/information/research/the-promise-trial/

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

2016-07-15T01:26:00.002+05:30

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

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

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

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

And then is when I thought,if I wish to have my sleep and at the same time not increase my Caesarean section rates and sleep with a clear conscience.When I know that I didn't use early decelerations as and excuse of foetal distress,when I know that a high head of baby is genuinely a high head of baby when I call it a caesarean, when a thin meconium at 8 cms is no indication for a caesarean

section,I need to reduce the Obstetrics component of my private practise.Very Honestly it wasn't just the love of IVF,treating infertility and the money involved but most importantly ,trying to switch over from a totally unplanned life of obstetrician to a more routine life of 9 am to 5 pm.

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

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

2016-06-28T18:53:00.001+05:30

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

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

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

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

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

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

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

2016-06-23T01:30:00.000+05:30

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

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

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

And I know...no bariatric surgery.I need a personal trainer and not a Bariatric surgeon myself :) :)

Freeze the future !! ( All about IVF)

2016-06-22T01:37:00.001+05:30

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

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

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

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

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

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

then(of course by donor egg).

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

How Much Time Have I got Doctor?

2016-06-19T09:47:00.000+05:30

It is not an uncommon question encountered by a routine Gynaecologist by Women in her 30s who wants to balance between a career and a family.Do we have an answer?Up to an extent yes but not certainly with a hundred percent certainty.

There is a hormone called AMH -Anti mystery hormone :) .Well this anti mystery hormone is actually called anti Mullerian Hormone.This AMH gives an idea of your ovarian reserve.It would not give any idea of the quality of hormone remaining but will comment on the quantity of ovarian follicles remaining at that particular time.Higher the AMH more is your ovarian reserve and probably you can wait few more years and vice verse.

AMH has other uses too.It is measured by Infertility specialist world over as the baseline which helps us in deciding the starting dose for Gonadotrophins for stimulating an IVF cycle or for that matter even IUI cycle.

Some interesting facts about AMH
AMH can be tested on any day of the cycle unlike FSH
It is higher in women who have PCOS simply because women with PCOS have at least 6 times more antral follicle than non PCOS women(even PCOS has something to cheer up about :) That is why in PCOS the risk of OHSS is more and your infertility professional is super careful about the dose of medication if needed for your ovulation induction.

But remember it the only mystery it clears is the amount of follicles not the QUALITY OF FOLLICLES,which deteriorates with increasing age.

Love,stress and Dhoka (LSD)

2016-06-17T23:10:00.001+05:30

Somebody asked me the other day.Doctor,why this sudden rise in abnormal children,Complicated pregnancies and increased conception with IVF?

Well the answer isn't too complex or complicated.Very straight forward.Even you can answer even if you are not a Medico.

The lifestyle has changed a lot in last 10-15 years.People fall in love and then get out of love and then again fall in love and get out of it , till a women has reached in her 30s.Suddenly you realise the body clock is ticking away and you need to be in long term love and marriage too.(Indian community still is quite conservative.Partners aren't still so much in vogue as are the husbands).What ticks away are your ovarian follicles meant to be the eggs for ovulation and conception and baby.

You can exercise hard,you can get plastic surgery done,you can get office time shots of Botox and look half your age.But remember,you can't fool your ovaries which is loosing hundreds of follicle every month since your birth.And comes a point the quality of eggs remaining isn't of best possible quality,which increases
INFERTILITY,difficulty in conception,structurally and genetically malformed babies and increased rate of IVF Pregnancy or even failed IVF cycles.And that leads to stress,which anyways is no less already with all the approaching deadlines,pending assessments and probable promotions.A dream of moving to foreign land,decreased frequency of sex as it is anyways hampered by the hectic life of deadlines which both partners are living

And suddenly you feel cheated ( Dhoka) by the nature.While you were busy building your career ,Nature was busy stealing your oocytes or deteriorating it's quality.

Isn't the answer very simple and logical?

So do we stop building carriers?Absolutely not !! Do we have answers to deteriorating oocytes or depleting oocytes,a late age possible conception and still get good outcomes?Yes there is .Promise ....will try to give the answers in next post.But goes without saying....Natural way is the best without intervention of an IVF doctor like me.

Women Health: Patience is a Virtue -Ovulation Induction for IUI

2016-06-12T02:54:00.001+05:30

Women Health: Patience is a Virtue -Ovulation Induction for IUI

Patience is a Virtue -Ovulation Induction for IUI

2016-06-12T02:34:00.003+05:30

There is a friend of mine,who insists patience is a virtue,has compelled me to be patient and leave my quick fix ways.And I am inculcating the habit.Patience is a virtue in personal life,professional life and life of even the patients we treat.

As always my posts are all motivated by real life posts.In last one month I came across 4 prescriptions showed to me by patients who had come to me for a second opinion regarding their subfertility treatment.Except for one,all three had 8-9 follicles > 16 mms ,were already given 10.000 IU of HCG and were ready for a spontaneous conception or IUI.It can be dangerous.Really dangerous.Multiple pregnancies are no fun neither is OHSS.

In this post I wish to talk of how much is too much for stimulation in cycle meant to be an IUI(Intrauterine Insemination)?I won't site specific cases as I realise that way the patients reading the posts can identify themselves and might not feel too comfortable.

IUI is known treatment for
Mild Male factor infertility
Unexplained infertility

For Mild factor Infertility(I will disscuss what is mild factor in next post) with no female factors even an unstimulated cycle is good enough and there is no advantage of using clomiphene citrate or Gonadotrophins

For Unexplained Infertility stimulation with Gonadotrophin + IUI gives maximal percentage of success.(more than Gonadotrophin alone or CC + IUI).If treating unexplained infertility my first line of treatment would Gonadotrophin + IUI but one needs to be cautious about the dose.
AMH levels give a fair idea about the initiating dose for IUI as well as IVF stimulation cycle.
THE AIM SHOULD BE TO DEVELOP NO MORE THAN ONE BUT MAXIMUM TWO LARGE FOLLICLES.Any thing more than that increases the level of multiple pregnancy and it's complication significantly.One way of acheiving it is by giving low dose FSH for 14 days straight(Now you know why I remembered my friend?He has made me understand the virtue of patience) and if need be increase the dose another 37.5 for a week and give trigger when we have a nice follicle ready for it and plan IUI.

If bychance you have give gonadotrophin in a dose higher than needed....well recognise the problem.Either ask the patient to abondon the cycle.Or talk with the couple if they are willing to get it converted to an IVF cycle.with 6-7 > 15 mm follicles and a trigger of 10000IU HCG,she would be definitely safter with an IVF than an IUI.One can control the number of embryo transfer as well as prevent OHSS by sucking out the follicle and follicle fluid.