All about IVF - the graphic guide - Part 4

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World's first IVF and infertility SMS channel !

Malpani Infertility Clinic, in partnership with MyToday, is pleased to announce that we have now started publishing the world's first patient education channels on IVF and infertility.

The mobile is a great tool for educating patients - and using SMS we hope to be able to remove a lot of the myths and misconceptions which surround this emotionally sensitive topic !

You can see all our SMS Infertility Channels here.

You can also subscribe free to our IVF channel here !

At present, this service is available in India only.

Why do doctors bad mouth other doctors ?

Many patients find that the doctor you go to for a second opinion will often be very critical of the first doctor. When a new doctor criticises what the old one did, patients feel frustrated, because they feel it reflects badly on their choice of a doctor.

Why are doctors so happy to criticise their colleagues and peers at the drop of a hat ?

Some of this is simply a power game. Doctors do their best to try to look good for their patients, and by demonstrating the errors and shortcomings of the earlier doctors, they are emphasising how much good they are ! The hidden subtext is - You made the right decision when you came to me - I am the best !

Some of this is simple oneupmanship. Doctors are highly competitive and proud of their intellectual prowess and surgical skills. They take delight in highlighting the shortcomings of their peers, because this reinforces their belief that they are the best ! Medical students have always been competitive, and this immature streak persists , no matter how much they age !

Some doctors will do this as a subtle form of marketing, to cater to the patient's desire. When patients come for a second opinion, they want something new, something different ! Smart doctors are happy to comply , because this tactic offers their patients with new hope, and helps them to justify their consultation fees !

Thus, some doctors will order additional tests ( and the more expensive these are the better ! The really smart ones will say that the tests have to be sent abroad to a highly specialised lab , adding to their aura of omniscience ! ). Others will change the prescription ( often writing exactly the same drug, but with a different brand name , so it costs a lot more, or has to be "imported" !)

Unfortunately, this kind of critical approach has a backlash. For one, patients start believing that doctors are incompetent , and cannot be trusted. This will lead to more lawsuits in the future.
Even worse, remember your friend will return the favour when he gets a chance to do so !

Few doctors have the maturity to say - Yes, your doctor has done a good job and you are on the right track. Please go back to him !

Blocked fallopian tubes and infertility

Blocked fallopian tubes are one of the commonest causes of infertility. The fallopian tubes project out from each side of the body of the uterus and form the passages through which the egg is conducted from the ovary into the uterus. The fallopian tubes are about 10 cms long and the outer end of each tube is funnel shaped, ending in long fringes called fimbriae. The fimbriae catch the mature egg and channel it down into the fallopian tube when released by the ovary .

The tube itself is a muscular highly movable structure capable of highly coordinated movement. The egg and sperm meet in the outer half of the fallopian tube, called the ampulla. Fertilization occurs here, after which the embryo continues down the tube toward the uterus. The uterine end of the tube, called the isthmus, acts like a sphincter, and prevents the embryo from being released into the uterus until just the right time for implantation, which is about 4 to 7 days after ovulation.The fallopian tube enters the uterus at its cornual end.

The tube is much more complex than a simple pipe, and the lining of the tube is folded and lined with microscopic hair like projections called cilia which push the egg and embryo along the tube. The tubal lining also produces a fluid that nourishes the egg and embryo during their journey in the tube.

Fig 1. Normal tube and ovary, as seen during laparoscopy

Remember that a doctor cannot judge if your fallopian tubes are open or closed either by an internal examination; or a vaginal ultrasound scan. Unfortunately, this is a very common mistake many patients make, and they assume that if the scan is normal, this means their tubes are open. This is not true. Sadly, many doctors also make the assumption that the fallopian tubes are open, without bothering to test them. Thus, some doctors will assume that a young woman with polycystic ovarian disease must have open tubes, and they start treating her with clomid, without bothering to test the tubal status. This can sometimes be a very expensive mistake ! Just because you have had no symptoms of a pelvic infection does not mean that your tubes cannot get blocked; and if the tubes are blocked, this means the eggs and sperm cannot meet, no matter what medicines you take. This is why it is essential that you ask the doctor to formally test your tubal status before starting any treatment.

The only reliable ways of testing if your tubes are open or closed is by doing either a HSG or a laparoscopy. Personally, I prefer a HSG, because it is much less expensive and provides hard copy documentation.

If a tubal block is found, then what are the next steps ?

The first question is - Are both the tubes blocked ? If only one tube is blocked, then there is no need to take any action at all ! One normal tube is enough for normal fertility. If one tube is open and your doctor advises you to have surgery to open the other tube, please do not agree !

The next question is - Where is the block ? The block could be at the terminal ( fimbrial) end of the fallopian tube. This often causes the tube to get swollen with fluid, and form a hydrosalpinx. In the past, doctors would perform tubal surgery to open this kind of blocked tubes. However, the results were very poor. The tube would usually close down again; or would never function properly, because its inner lining was damaged - damage which cannot be repaired by surgery. Some of these patients would then go on to have tubal ( ectopic) pregnancies.

If the tube is blocked at the cornual end, it's sometimes possible to repair these tubes. Sometimes the block is not a real block, but just an apparent block because of tubal spasm . Sometimes the block is because of a mucus plug or debris, and this can sometimes be cleared with the help of FTR ( fluoroscopic tubal recanalisation). This is a bit like doing an " angioplasty " for the fallopian tube ! ?

Remember that it's impossible for a doctor to judge tubal function. While we know that a blocked tube will not work, it does not follow that an open tube ( which may look perfectly normal anatomically on the HSG or the laparoscopy) is in fact capable of functioning normally ! Sometimes the doctor says the spill of dye is "sluggish"; or that "the tubes filled slowly"; or that they have a beaded appearance. These are just descriptive terms, and often cause more confusion rather than clarity !

Finding out your tubes are blocked can be quite a blow. Because tubal disease is often silent, there is no way of suspecting tubal blockade prior to doing the tests. Blocked tubes will not affect your menstrual cycle, your health or your sexual life, but they will prevent you from having a baby !

While the results of tubal surgery to repair blocked tubes is poor, the good news is that it is possible to offer very effective treatment for this problem today, thanks to IVF, which allows us to bypass the problem completely ! In IVF, the test tube in the IVF lab performs the role the fallopian tube would normally perform in the bedroom !

If you have a hydrosalpinx , some doctors will want to surgically remove this prior to performing IVF. I do not think this is a good idea at all !

Treating endometriosis in an infertile woman

I saw a patient who was at her wit's end. She had already had two laparoscopies for treating endometriosis. Since she was still not pregnant, she had gone to a third gynecologist. He did an ultrasound scan and found that the chocolate cyst had recurred; and was advising her to undergo a third surgery to "fix" the problem.

We find this is a very common tragedy which plays out frequently. The diagnosis of endometriosis is often done by the first doctor, while doing a diagnostic laparoscopy. He "treats" the problem by burning off the lesions, and dividing the adhesions. When the woman does not get pregnant after this, she gets a second opinion from an expert. This expert often pooh-poohs the surgical skills of the first doctor, and suggests that he needs to do another laparoscopy, in order to do a better job, to fix the problem once and for all ! The patient regrets having allowed the first doctor ( who appears to have not been very competent in hindsight !) to do the laparoscopy. She signs up for the second surgery and is now very hopeful. The doctor does the laparoscopy and "cleans" up everything - and shows her a beautiful video which demonstrates his surgical prowess. He then puts her on medications, and then tells her to "go forth and have babies " in her bedroom ! She is often quite happy for a few months, because her pain has now improved, and her symptoms are much better. However, when she still does not get pregnant, she goes back to him. Unfortunately, he has lost interest in her problem, because he is primarily a surgeon, and when you have a hammer, all you see are nails. He gives her some more medicines, and tells her to relax, go for a holiday and have more sex. When this also fails, she goes to a third doctor, who then finds the endometriosis has recurred; and suggests that he needs to do another laparoscopy, where he will compensate for the surgical shortcomings of the earlier surgeon, by using the " newest and latest " third generation laser and robotic equipment, which are available only in his clinic !

The sad truth is that endometriosis recurs, no matter how good the surgeon. We can never cure it - and even our treatment leaves a lot to be desired, because of our limitations ! This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Let's go back to my patient.

" What do I do now , doctor ? I am completely fed up ! How do I manage my pain ? And what about having a baby ? "

I explained to her that she needed to set her priorities. " Which is more important right now ? managing the pain ? or having a baby ? We can't do both together - we need to do this one step at a time !"

" For me, having a baby is my first priority doctor".

" Fine, then let's focus on getting you pregnant. Let's forget about the pain and the endometriosis for now . The reason you are not getting pregnant is because your eggs and sperm are not meeting in your fallopian tubes. We need to get the eggs and sperm to do so; and we need to use assisted reproductive technology in order to do this."

The next step is to check the AMH level, to determine what the ovarian function . For young patients with a normal AMH level, the next step would be 3 cycles of superovulation with IUI. However, for older women; those with low AMH levels; and if the IUI fails, then the best course of action is IVF. After all, we need to find solutions , not waste time looking for problems !

Is there any need to surgically remove the endometriosis prior to doing IVF ? No ! The endometriosis is outside the uterus and will not affect embryo implantation, so it's best left alone.
If there is a chocolate cyst, we can always aspirate ( puncture) it under ultrasound guidance, when starting the IVF cycle.

The good news is that an additional bonus with this approach is that once you get pregnant, the endometriosis will also automatically improve !

Why infertile couples need to look for solutions - and not worry about problems !!

Many infertile couples are very confused about how their treatment. Unfortunately, many gynecologists add to their confusion. Thus, if an infertile woman is found to have endometriosis, they will spend a lot of time, money and energy on "treating " the endometriosis with medicines. Similarly, the woman has irregular periods, they will concentrate on trying to "regularise the cycle" !

Why are these approaches flawed ?

The truth is that we really do not have any effective treatment for endometriosis. This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Similarly, patients with irregular cycles are often very poorly managed. Many patients are unsure about the relationship between their irregular cycles and their fertility, and consider this as a chicken and egg problem. They naively believe that once the cycles are regularised, they will then get pregnant in their own bedroom ! After all, if the reason they are not getting pregnant is the fact that their periods are irregular, then surely fixing the irregularity problem will them to have a baby ! Many doctors also seem to subscribe to this belief, and will regularise the cycles by putting these infertile couples on birth control pills ! While this will regularise the cycle while they are taking the pills, this is hardly helping them to have a baby ! They obviously cannot get pregnant while taking the pill - and once they stop the pill, their cycles continue remaining irregular, because they are still not ovulating !

If you are infertile, how can you make sure your doctor is providing you with the most effective treatment ? The answer is surprisingly simple ! Remember, that the reason you are infertile ( no matter what your actual diagnosis is !) is the fact that your eggs and sperm are not being able to meet. The question you need to ask is - what is the doctor doing to increase the chances of the eggs and sperm meeting ?

Thus, if he is simply suppressing your endometriosis with drugs; or regularising your cycles with birth control pills, he is wasting your time and not doing a good job ! We need to look for solutions - not waste time in finding problems which maybe irrelevant . Fortunately, our technology for bypassing problems ( even without identifying them precisely ) is better than our technology for identifying problems !

Remember, the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby ! The quality of a doctor’s answers depend upon the quality of the patient’s questions !

Not sure if you are on the right track ? I'll be happy to provide a free second opinion ! Send me your medical details by filling in the second opinion form, and I'll be happy to help !

Google books and social media

Google books is a great concept and I love the idea that the content of these books is available for anyone to browse.

A simple way to add value to Google books would be to allow users to highlight selected portions of the text; and then annotate them and share them with others. This would make the book come "alive" and would add much more value to the online book.

An e-book can be far more than just a digital version on a print book and allowing readers to
" mark up " books and discuss them will create much more traffic on the site ( which I am sure google will be happy to monetise !) and add more value for both authors and readers.