https://youtu.be/pA4bpuSyDpc

Dear friends ,

I have started my YouTube channel Ladies Doctor on women health issues and the first post is on Pre Pregnancy visit. If you like the video do subscribe the channel as I hope to post videos of patient interest in future. Feedback’s, comments and suggestions are all welcome .

Muhurat IVF

This one came as a surprise to me.I am not for or against it but this particular request left me wondering or atlas gave me food for thought.Have encountered the request for muhurat for Embryo transfer but this one was unique.First of it's kind.
Somebody requested me to time the time when retrieved egg was mixed with the Sperm.As per that gentleman this was the correct time based on which the astrological findings were based in a human beings life and not on the time of birth.

Now if thats correct then all our Janam Patri's are incorrect and so the astrological readings.In that case Muhurat Caesarean is a thing of past.More over in  natural conception we don't know the time when actually fertilisation took place.And unless ICSI even in simple IVF we really don't know the exact moment of fertilisation.
Oh God....that's too complicated :) Anyways ,as long as it doesn't do any harm or too cumbersome,I think we can keep guessing the right Muhurat and try best for our Children as well as future children.What's the correct time in case of a FET ??
Interesting is all what I can say :)

Dr Kaushiki Dwivedee,a self feedback

Few years back I gave my own feedback for the patients to understand my working style and thus find it easier to choose or relate with me or not relate with me.It did help them as well as me.

Now I realise that I am a changed person than what I was till 2014 and thus it would be appropriate that I do my self assessment correctly.


Previously I used to go through each and every online report of each of my patients and advise them as well.Now I don't do it at all.As per supreme court of India it is a punishable offence if a doctor trees a patient without making a diagnosis.There are many cases where doctors tried to helped their patients and ended behind the bars as they had treated online without seeing the patient in person.

I was always bad in picking up phone calls as that I found really irritating while you are attending one patient,you ignore her and start talking to some one else but I used to be good in reverting back at text messages.Now I have delegated this duty to my colleagues dr Ankita Mittal and Dr Pooja Marwaha who keep you informed as well as I know what is going on with you.

For your treatment i am always there whether a cold case or an emergency as before.

One more differenceI travel abroad quite a bit.my commonest destination is Australia ,which i have to visit to maintain my FRANZCOG degree as well as to become an Australian citizen as well .So this December and march 2019 I would not be in India to complete my required number of Australia stay.After March 2019 I shall not be going out as frequently.In my absence Dr Ankita and Dr Pooja are in a situation to take care of you at Artemis hospital.

Though I am unable to make every person a happy person,we still try to be ethical and honest with our work.

Infertility Workup - What it involves ?

0. What is an infertility evaluation?
   An infertility evaluation includes exams and tests to try to find the reason why you and your partner have not become pregnant. If a cause is found, treatment may be possible. In many cases, infertility can be successfully treated even if no cause is found.
   When should I consider having an infertility evaluation?
   You should consider having an infertility evaluation if any of the following apply to you:
   
   • You have not become pregnant after 1 year of having regular sexual intercourse without the use of birth control.
     
   • You are older than age 35 years and have not become pregnant after trying for 6 months without using birth control.
     
   • You are older than age 40 years and have not become pregnant within 6 months of trying without using birth control.
     
   • Your menstrual cycle is not regular.
     
   • You or your partner have a known fertility problem.
     

Evaluating Infertility

What type of doctor does an infertility evaluation?
Your obstetrician–gynecologist (ob-gyn) usually will do the first assessment. You also may choose to see a specialist. Infertility specialists are ob-gyns with special training in evaluating and treating infertility in women and men. These specialists are called reproductive endocrinologists. Men also may be evaluated and treated by a urologist. Some urologists have special training in male infertility.
What causes infertility?
The most common cause of female infertility is lack of or irregular ovulation. The most common causes of male infertility are problems in the testes that affect how sperm are made or how they function.
Other factors in women include problems with the reproductive organs or hormones. Scarring or blockages of the fallopian tubes may contribute to infertility. This may be the result of past sexually transmitted infections (STIs) or endometriosis. Problems with the thyroid gland or pituitary gland also may contribute to infertility. In men, blockage of the tubes that carry sperm from the testes may be a cause of infertility.
How does age affect fertility?
For healthy couples in their 20s or early 30s, the chance that a woman will become pregnant is about 25–30% in any single menstrual cycle. This percentage decreases rapidly after age 37 years. By age 40 years, a woman’s chance of getting pregnant drops to less than 10% per menstrual cycle. A man’s fertility also declines with age, but not as predictably.
Can lifestyle affect fertility?
In women, being underweight, being overweight, or exercising too much may be associated with infertility. In both men and women, drinking alcohol at moderate or heavy levels may be a factor in infertility. In men, smoking cigarettes and marijuana can reduce sperm count and movement.
What should I expect during my first visit for infertility?
The first visit with a fertility specialist usually involves a detailed medical history and a physical exam. You will be asked questions about your menstrual period, abnormal bleeding or discharge from the vagina, pelvic pain, and disorders that can affect reproduction such as thyroid disease. You and your partner will be asked about the following health issues:

• Medications (both prescription and over-the-counter) and herbal remedies
  
• Illnesses, including STIs and past surgery
  
• Birth defects in your family
  
• Past pregnancies and their outcomes
  
• Use of tobacco, alcohol, and illegal drugs
  
• Occupation
  You and your partner also will be asked questions about your sexual history:
  

• Methods of birth control
  
• How long you have been trying to become pregnant
  
• How often you have sex and whether you have difficulties
  
• If you use lubricants during sex
  
• Prior sexual relationships
  What tests are done for infertility?
  Tests for infertility include laboratory tests, imaging tests, and certain procedures. Imaging tests and procedures look at the reproductive organs and how they work. Laboratory tests often involve testing samples of blood or semen.
  What does the basic testing for a woman include?
  Laboratory tests may include a urine test, a progesterone test, thyroid function tests, a prolactin level test, and tests of ovarian reserve. Imaging tests and procedures may include an ultrasound exam, hysterosalpingography, sonohysterography, hysteroscopy, and laparoscopy. You may not have all of these tests and procedures. Some are done based on results of previous tests and procedures. You also may track your basal body temperature (BBT) at home.
  What is the purpose of tracking basal body temperature?
  A woman’s temperature increases around the time of ovulation and stays elevated for the rest of her menstrual cycle. To track ovulation, you will need to take your temperature by mouth every morning before you get out of bed. You record your temperature on a chart for two or three menstrual cycles.
  Charting monthly temperature changes can confirm ovulation but it cannot predict it. Some women also monitor their cervical mucus while charting BBT. Just before ovulation, a woman’s cervical mucus becomes thin, slippery, and stretchy. Cervical mucus monitoring is a natural way to help a woman identify her most fertile days.
  

What do results from a urine test determine?
A urine test determines when and if you ovulate by detecting an increase in the levels of luteinizing hormone (LH) in the urine. A surge in the level of LH triggers the release of an egg. If the test result is positive, it suggests that ovulation will occur in the next 24–48 hours. This gives you an idea of the best time to have sex to try to get pregnant.
How is a progesterone test done?
For a progesterone test, a sample of blood is taken about 1 week before you expect your menstrual period. The level of progesterone is measured. An increased level shows that you have ovulated.
Why would a thyroid function test be done?
Problems with the thyroid gland may cause infertility problems. If a thyroid problem is suspected, levels of hormones that control the thyroid gland are measured to see if it is working normally.
What is a prolactin level test?
This test measures the level of the hormone prolactin. A high prolactin level can disrupt ovulation.
What are tests of ovarian reserve?
The term ovarian reserve refers to a woman’s supply of eggs. Blood tests are used to check the remaining number of eggs.
Why are imaging tests and procedures done?
Different imaging tests and procedures are used to look at the uterus, ovaries, and fallopian tubes to find problems. Some procedures also are used to treat certain problems if they are found. The procedures that you may have depend on your symptoms as well as the results of other tests. Common imaging tests for female infertility include the following:

• Ultrasound exam—This test can predict when ovulation will occur by viewing changes in the follicles.
  
• Sonohysterography—This special ultrasound exam looks for scarring or other problems inside the uterus.
  
• Hysterosalpingography—This X-ray procedure shows the inside of the uterus and whether the fallopian tubes are blocked.
  
• Hysteroscopy—The procedure uses a camera with a thin light source that is inserted through the cervix and into the uterus. This can show problems inside the uterus and help guide minor surgery.
  
• Laparoscopy—This procedure uses a camera with a thin light source that is inserted through the abdomen. This can show the fallopian tubes, ovaries, and the outside of the uterus.
  What does the basic testing for a man include?
  Testing for a man often involves a semen analysis. This analysis is done to assess the amount of sperm, the shape of the sperm, and the way that the sperm move. Blood tests for men measure levels of male reproductive hormones. Too much or too little of these hormones can cause problems with making sperm or with having sex. In some cases, an ultrasound exam of the scrotum may be done to look for problems in the testes.
  How long does it take to complete an infertility evaluation?
  An infertility evaluation can be finished within a few menstrual cycles in most cases. Some insurance companies may cover the cost of an infertility evaluation. It is a good idea to call your insurance company to find out before you start your evaluation.
  

Why do IVF Cycles fail ?

A question which is often asked by my patients after a failed cycle despite my pre IVF cycle priming and counselling.It is frustrating for Patient and doctor alike when an IVF cycle fails.I don't make any claims of having a fantabulous IVF success rate.Till date any one quoting it anything more than 35 - 40 percent isn't telling you the complete truth.

Let us first understand the reason that why is IVF such a wasteful process.Every month around 300 follicles undergo degeneration as they are unhealthy.By giving gonadotrophin we are forcing them to grow and mature but that doesn't necessarily means a successful implantation or conception or live birth.

Let me discuss a case scenario.A 35 years old Lady with PCOD in whom I retrieved 12 embryos.7 became blastocysts.And can you imagine how many of them were actually healthy? It is shocking .We got Pre implantation genetic testing done .And there were just 2 which were not having any chromosomal anomaly.Which means 10 of these embryos would have either not got implanted or would have miscarried or we would have needed to terminate the pregnancy.

So it is unhealthy eggs and thus embryos which are the reason of the disappointing results that IVF provides.It is no one's fault.Not of your IVF specialist and not of you who can blame inadequate rest for failed cycle of hers. Relax.Plan early.Plan your pregnancy in time.And if you don't have a partner at right time ,Freeze your eggs,If you have a partner ,Freeze your embryos as we have got more experience of freezing embryos than freezing eggs.

How Much does IVF costs

How much will it cost me?This is the most common question asked by Couples who come for IVF.
I will try to be as clear as possible in answering this question.

First of all it is important to know what all an IVF cycle involves and then it will be easier for you to understand it.

Here I have not included the cost of investigations.

The first process is controlled ovarian Hyperstimulation which involves medicines which are costly.The cost of the medicine would depend on the need of your body.Some women need less medicine and some need more medicine to get similar degree of stimulation.But if you keep an estimate of INR 75,000 plus minus INR 10,000 it would be quite close to what you would eventually spend.

IVF involves Ovum pick up and embryo transfer.Both these procedures need IVF lab and OT.It also involves skills of embryologists apart for the infertility specialist.This amount varies from IVF centre to IVF centre.A good IVF lab needs good quality control and that has big role in determining the success of an IVF programme.A decent IVF lab would charge you around a Lakh.

If you decide to freeze the embryo,it would be another 30-40 thousand INR and you should find it out at the IVF lab .

If you decide to get a PGT done it comes quite costly as not many centres perform this procedure currently.The one I am associated with and provides this facility ,they charge 1.85 Lakhs ( over and above the 1.75 lakhs for the medicine and the procedural charges for IVF))

If it involves Ovum donors the ovum donating agency usually charge 80000 to 1.2 lakhs for a decent educated and pleasant donor.

Semen donors charge less.

This isn't a comprehensive list but just rough estimate of what you need to be ready with when planning an IVF cycle.The costs can be less or more depending upon the IVF centre you choose.

Surrogates can cost around 8- 10 Lakhs apart for the delivery expenses.

I have blocked Fallopian Tubes

Blockage of tubes.Does it sound familiar.Well you might have come across the term on one of the so many infertility help groups or blogs or Google in general where a female might have mentioned it as her cause of infertility.

What tubes do? They carry the egg released from the ovary in the tube where it gets fertilised by the sperm and moves into the uterus.If tubes are blocked this essential step won’t happen normally in the body.Why tubes get blocked.Most of the time we don’t find a reason but the common ones are previous pelvic infections.In India pelvic Tuberculosis is a common condition but still not as common as suspected by the IVF specialists.Other infections can be chlamydia or other sexually transmitted infections and the disease called endometriosis.

There are many such stories to talk about but I will choose one such case history randomly to make you understand more about tubal factor in Infertility.

A couple came to me for infertility investigations.What I found on Sonosalpingography i.e passing the saline through the tubes while observing it with an ultrasound machine that the tubes were bilaterally blocked.So now if there is a block ,what do you do?

Open the tubes or proceed for IVF where you bypass the need of tubes by fertilising the eggs outside the body.Of course I got her tested for genital tuberculosis as well as gave her azithromycin tablet just incase she had Chlamydia( After all a tablet of Azee comes cheaper than the test for Chlamydia).So there was no evidence of genital tuberculosis .

In modern day infertility treatment tubal surgery unless very minimal has got no role.Opening of tube doesn’t mean that the doctor has been able to restore the normal functioning as well as structure of the fallopian tube.Which would simply mean that you are not sure even if the doctor has opened the tube still you will get pregnant or not.There is also an increased chance of Tubal or ectopic pregnancy.So no doctor who follows evidence based medicine will give you an option of ‘opening the tube’.

The more realistic and cost effective treatment is IVF.Only 35 % but still it is a realistic option of conception per cycle.Even in IVF there is 4% increased chance of ectopic pregnancy that spontaneous conception but still it is better option than a tubal surgery any day.

Now this couple insisted upon tubal surgery and I did perform a hysteroscopic cannulation and laparoscopic fimbrioplasty.It opened one side of the tube.But was it the correct treatment.No it wasn’t. At least it isn’t the evidence based option.If I think in terms of my monitory benefit it is all good but probably that wasn’t the idea.the idea was to help them conceive.But who knows whats in store for her.miracles happen and if by chance the sperm sneaks in through that tube it was the wisest decision on part of the couple.If they failed or if she has an ectopic pregnancy,few more years would be wasted.Eggs would be little more old.More chance of having aneuploidy and chromosomal defect.Poor IVF response and if she conceives more chance of miscarriage.

Fingers crossed and let me hope she conceives.

Safe Age to get pregnant

It has been a long gap when I am trying once again to revive this blog.It was writers block or some fear or sudden maturity about the big bad world of social media or unwarranted trolling (trolling is always unwarranted) which prevented me from writing this blog.Previously I used to write what I used to feel,uninhibited and suddenly there was this apprehension.I was uncomfortable to bare my inner self to the whole world.I can't pretend and at the sometime I wasn't being able to be me.

I think I need one more chance and probably this time I shall be lucky.

Those who know me I was a general Obstetrician and Gynaecologist who extended my self to IVF and infertility treatment as well after a formal training in Australia.After more than 4 years I feel more attached to infertility management than delivering babies.Not that my skills are lost as I have been practising Obstetrics as heavily as before but it doesn't excite me as much as a professional as it used to before.

I shall start covering Infertility related topics one by one in a story line format to maintain the information quotient as well as to keep it interesting.

I live in a Metro called GURGAON or GURUGRAM. It is a modern Indian city,very polluted but still modern.The women of this city are smart ,fit and healthy.They take care of themselves,exercise,take vitamin supplements.Practice yoga and medication.Eat quinoa,Sushi and Chia ( All exotic and organic).All good ...isn't it.But something is going wrong terribly.In order to achieve this and more they are deferring there first pregnancy till late age.

It is true you have a toned body of a 25 years old at 35 years old.You look damn good and exotic.You are a Gurgaonmom and entrepreneur and successful.But have you been able to fool the time? No you haven't been.Your Ovaries are ageing.The best time to get pregnant is 20s.In 30 s your fertility starts to decrease and after 35 years the decline in fertility is fast.

The incidence of Aneuploidy meaning increase or decrease in the chromosome number in your egg increases.Leading to unhealthy eggs and embryos.You will face increased risk of miscarriage and will have decreased chance of pregnancy.

If you are in your early 30s ,try for conception for 12 months and if still unsuccessful meet an Infertility specialist.If you are between 30 years to 35 years ,are known to have irregular periods or scanty periods or endometriosis or any other health concern,meet the infertility specialist after 6 months of failed trail of conception.

if you are 35 years or  more , you might look 22 years old.But still don't fool yourself.Your ovaries look like that of a 35 years old.Devoid of follicles with decreasing egg quality.Meet the infertility specialist within 6 months of failed trial.

You might conceive spontaneously or with the help of IUI or might need IVF.Let your Infertility specialist decide.

For males also fertility decreases with increasing age but the decline isn't as fast as in women and males can father children even in their 60s and 70s while a women can ovulate after menopause.

https://www.reproductivefacts.org/globalassets/rf/news-and-publications/bookletsfact-sheets/english-fact-sheets-and-info-booklets/Age_and_Fertility.pdf