Dear Friends,
The idea of starting this forum was to form a link not only between you and me but also between all of you. However while I did manage to write to you a bit I could not forge a link between all of you. I had to wait a long time but FINALLY I have managed to start a discussion forum on my website www.careivfkolkata.com http://www.aimpl.com/approval/care-ivf/infertility-clinic/index.php ). We can now have members, discussion forums, chat sessions and many more experts sharing their valuable expertise. From now on I will be writing solely there and hope to have all of you, who took valuable time out to visit this site, come there as well and make that site even better. Best of luck to you and me.
07 February 2010
27 January 2008
AM BACK
Hi folks. At the outset I must apologise for the disappearing act. The blog was started in earnest but I guess I had not accounted for the time taken by my regular professional work. I must admit that once the initial excitement died down, I would keep putting off the writing on one pretext or the other although the guilt would haunt me every now and then. Even armed with a new year resolution, it took me a good 25 days to get back to writing. I hope I shall be more regular with my writings. Please help by making the site more interactive and write in with as many questions and comments as possible.
13 September 2007
Fallopian Tubes and testing for its patency
Fallopian tubes arise from the womb (uterus) and curve around the ovaries on either side. The ends of the tubes sweep over the ovaries and collect the eggs once the follicles rupture. This egg is then swept along the inside of the tube, towards the womb, by fine hairs (called cilia). At a point called the ampulla of the tube, the egg is met by the sperms, rising up the womb and swimming into the tubes. This is where the fertilization occurs. The fertilized egg or embryo stays in the tube for another 4 days, matures, grows and then enters the womb and attaches it self to the wall of the womb and grows there. Voila !!! pregnancy is thus positive.
The fallopian tubes are very sensitive structures which can be easily damaged. The tubes can get blocked, damaged by infection, kinked due to adhesions or simply, the small hairs inside could be damaged. This prevents the egg from meeting the sperms, thus creating Infertility.
Tubal testing can be done by HSG (Hysterosalpingogram) or Laparoscopy. The former has the advantage of being cheap, quick and not requiring hospitalisation but has the disadvantage of being painful and sometimes giving inaccurate and sometimes limited information. Laparoscopy on the other hand gives a complete picture and tells us not only if the tubes are open or closed but also whether the tubes are healthy or not. A condition called Endometriosis can be best diagnosed by laparoscoy. Any small defects can be corrected in the same sitting. If Polycystic ovaries are present, ovarian drilling can be done. However laparoscopy can be an expensive procedure and requires hospitalisation and is not covered by insurance.
The decision whether to do HSG or Laparoscopy and when cannot be a black and white answer. It depends on several factors like age, duration of infertility, other associated problems, economic factors and also sometimes on the patience levels of the couple. An HSG is good as an initial investigation for a couple who is just starting treatment and for a couple who is willing to be patient as treatment progresses systematically. Another useful test to do is testing for Chlamydia as it is the most common infection which is silent but causes blocked tubes. If the results are positive, one should go in for a Laparoscopy rather than HSG.
The fallopian tubes are very sensitive structures which can be easily damaged. The tubes can get blocked, damaged by infection, kinked due to adhesions or simply, the small hairs inside could be damaged. This prevents the egg from meeting the sperms, thus creating Infertility.
Tubal testing can be done by HSG (Hysterosalpingogram) or Laparoscopy. The former has the advantage of being cheap, quick and not requiring hospitalisation but has the disadvantage of being painful and sometimes giving inaccurate and sometimes limited information. Laparoscopy on the other hand gives a complete picture and tells us not only if the tubes are open or closed but also whether the tubes are healthy or not. A condition called Endometriosis can be best diagnosed by laparoscoy. Any small defects can be corrected in the same sitting. If Polycystic ovaries are present, ovarian drilling can be done. However laparoscopy can be an expensive procedure and requires hospitalisation and is not covered by insurance.
The decision whether to do HSG or Laparoscopy and when cannot be a black and white answer. It depends on several factors like age, duration of infertility, other associated problems, economic factors and also sometimes on the patience levels of the couple. An HSG is good as an initial investigation for a couple who is just starting treatment and for a couple who is willing to be patient as treatment progresses systematically. Another useful test to do is testing for Chlamydia as it is the most common infection which is silent but causes blocked tubes. If the results are positive, one should go in for a Laparoscopy rather than HSG.
30 August 2007
Ovarian Reserve Testing
The term 'Ovarian Reserve' refers to a woman's reproductive potential with respect to the number of eggs in the ovary and the quality of those eggs.
Once the eggs are outside the body and under the microscope its obviously easier to speak about its quality but the whole idea is to be able to predict the outcome even without handling the eggs. The following are used:
Age: Age as discussed earlier is in itself a predictor of the outcome. The chances of getting good number and quality of eggs after the age of 40 are quite remote. Although even spontaneous pregnancies do happen they cannot be used as a yardstick to treat women at higher age groups.
Antral Follicle Count: As I have said before, women recruit about 15 to 20 eggs just before the beginning of each menstrual cycle. Of these, depending on the stimulation given, one or many will eventually grow to mature size. This baseline pool of eggs can be counted on Day 2 or 3 of the periods by Trans Vaginal Ultrasound. If more than 5 are present then the woman stands a good chance to produce eggs with stimulation.
Baseline FSH and Estradiol (E2) levels: As normal values(done on Day 2 or 3 of periods), the FSH levels should be less than 10 and E2 levels between 20 and 80pg/ml. FSH levels are one of the earliest parameters to rise, long before the eggs actually finish. To give you an idea, you can imagine FSH to be the whip which stimulates the ovary to produce eggs. Under normal circumstances, less whipping is required and the levels of FSH are thus low. When the ovary is failing, the whipping required is far greater resulting in high FSH levels. Sometimes the FSH levels tend to fluctuate between abnormal (high) and normal (low) levels. However one must remember that even a single FSH level above 10 means that the eggs may not be of very good quality, even though the levels may come down later.
Clomiphene Challenge Test: In this test the baseline FSH is tested on Day 3. Thereafter Clomiphene Citrate 100mg tablets are given orally from Day 5 to Day 9 of the periods. Fsh values are again tested on Day 10 of periods. A normal value would be to have both Day 3 and Day 10 FSH values to be below 10.
Inhibin levels: While FSH tends to rise in ageing women, the Inhibin levels tend to fall. Infact it has been suggested that Inhibin levels are more sensitive and detect more subtle changes than baseline FSH levels. However as the test is still experimental, not widely available and quite expensive, it is not used in routine practise.
Thse are the common parameters used by us in day to day practise but like they say "nothing prepares you for life' similarly nothing can predict how the ovary will ultimately behave once we start to stimulate it. Well either as doctors we dont yet know the whole story or as we commonly say' maybe there is someone else above us all who controls everything'.
Once the eggs are outside the body and under the microscope its obviously easier to speak about its quality but the whole idea is to be able to predict the outcome even without handling the eggs. The following are used:
Age: Age as discussed earlier is in itself a predictor of the outcome. The chances of getting good number and quality of eggs after the age of 40 are quite remote. Although even spontaneous pregnancies do happen they cannot be used as a yardstick to treat women at higher age groups.
Antral Follicle Count: As I have said before, women recruit about 15 to 20 eggs just before the beginning of each menstrual cycle. Of these, depending on the stimulation given, one or many will eventually grow to mature size. This baseline pool of eggs can be counted on Day 2 or 3 of the periods by Trans Vaginal Ultrasound. If more than 5 are present then the woman stands a good chance to produce eggs with stimulation.
Baseline FSH and Estradiol (E2) levels: As normal values(done on Day 2 or 3 of periods), the FSH levels should be less than 10 and E2 levels between 20 and 80pg/ml. FSH levels are one of the earliest parameters to rise, long before the eggs actually finish. To give you an idea, you can imagine FSH to be the whip which stimulates the ovary to produce eggs. Under normal circumstances, less whipping is required and the levels of FSH are thus low. When the ovary is failing, the whipping required is far greater resulting in high FSH levels. Sometimes the FSH levels tend to fluctuate between abnormal (high) and normal (low) levels. However one must remember that even a single FSH level above 10 means that the eggs may not be of very good quality, even though the levels may come down later.
Clomiphene Challenge Test: In this test the baseline FSH is tested on Day 3. Thereafter Clomiphene Citrate 100mg tablets are given orally from Day 5 to Day 9 of the periods. Fsh values are again tested on Day 10 of periods. A normal value would be to have both Day 3 and Day 10 FSH values to be below 10.
Inhibin levels: While FSH tends to rise in ageing women, the Inhibin levels tend to fall. Infact it has been suggested that Inhibin levels are more sensitive and detect more subtle changes than baseline FSH levels. However as the test is still experimental, not widely available and quite expensive, it is not used in routine practise.
Thse are the common parameters used by us in day to day practise but like they say "nothing prepares you for life' similarly nothing can predict how the ovary will ultimately behave once we start to stimulate it. Well either as doctors we dont yet know the whole story or as we commonly say' maybe there is someone else above us all who controls everything'.
Life Begins at 40 ?
Most women around the age of 30, whom I have seen do show apprehension regarding that particular age as if one fine day at age 30 they would suddenly find themselves less fertile.
I think the problem needs to be better understood. Unlike men who produce sperms throughout their whole life, women are born with a definite number of eggs. It is from this pool that they select 15 or 20 of them every month to grow of which again only one grows to maturity under unstimulated conditions. As she keeps using her reserves, one day the pool of eggs finish and this coincides with Menopause. However much before this event actually happens, the fertilizing ability of the eggs starts to diminsh even though the woman might still have normal regular periods. Contrary to popular belief, while this usually happens around age 40 and above, it can even happen below the age of 35, a term called Premature Ovarian Failure.
There are many problems related to the age of the woman as far as fertility is concerned. If at age 25 the chances of being Infertile is around 6%, then the chances around the age of 40 is about 40%. there are several factors which are associated:
Poor Response to Ovarian Stimulation:Drug doses required to produce eggs are usually very high and may yet be incapable of stimulate the growth of good eggs.
Poor Egg Quality: The fertilizing ability of the eggs is poor and this can be only established if Assisted Reproduction is being done when we get the chance to see the eggs under the microscope.
Lower Implatation rates: Women above 40 do not have lesser chances of embryos attaching to their wombs, not because the defect lies in the wombs but because their own embryos may be incapable of doing so.
Genetic Abnormalities: The eggs recovered from elderly women may have higher percentage of genetic abnormalities which make them either incapable of fertilizing or lower chances of implanting or once implanted the chances of having a miscarriage are higher.
Having said this I would like to reiterate that it is not my objective to strike the fear of god in every woman over the age of 30. It only means that when you are approaching 30 or have crossed so, you must be aware of the problems asociated, take a deeper interest in your treatment and ensure that it is aggressive.
To save myself from the wrath of feminists, I must add that although men dont have the kind of problems with fertility (with age) that women have, it has been found that there is a decline in semen volume, sperm motility and structure of the sperms although their counts remain normal.
My next post will deal with testing for the effects of age on female fertility and few pointers about treatment.
I think the problem needs to be better understood. Unlike men who produce sperms throughout their whole life, women are born with a definite number of eggs. It is from this pool that they select 15 or 20 of them every month to grow of which again only one grows to maturity under unstimulated conditions. As she keeps using her reserves, one day the pool of eggs finish and this coincides with Menopause. However much before this event actually happens, the fertilizing ability of the eggs starts to diminsh even though the woman might still have normal regular periods. Contrary to popular belief, while this usually happens around age 40 and above, it can even happen below the age of 35, a term called Premature Ovarian Failure.
There are many problems related to the age of the woman as far as fertility is concerned. If at age 25 the chances of being Infertile is around 6%, then the chances around the age of 40 is about 40%. there are several factors which are associated:
Poor Response to Ovarian Stimulation:Drug doses required to produce eggs are usually very high and may yet be incapable of stimulate the growth of good eggs.
Poor Egg Quality: The fertilizing ability of the eggs is poor and this can be only established if Assisted Reproduction is being done when we get the chance to see the eggs under the microscope.
Lower Implatation rates: Women above 40 do not have lesser chances of embryos attaching to their wombs, not because the defect lies in the wombs but because their own embryos may be incapable of doing so.
Genetic Abnormalities: The eggs recovered from elderly women may have higher percentage of genetic abnormalities which make them either incapable of fertilizing or lower chances of implanting or once implanted the chances of having a miscarriage are higher.
Having said this I would like to reiterate that it is not my objective to strike the fear of god in every woman over the age of 30. It only means that when you are approaching 30 or have crossed so, you must be aware of the problems asociated, take a deeper interest in your treatment and ensure that it is aggressive.
To save myself from the wrath of feminists, I must add that although men dont have the kind of problems with fertility (with age) that women have, it has been found that there is a decline in semen volume, sperm motility and structure of the sperms although their counts remain normal.
My next post will deal with testing for the effects of age on female fertility and few pointers about treatment.
22 August 2007
The First Meeting
I had a patient today who apologised atleast 4 times for taking my time, a similar number for boring me with her tales of sorrow and a zillion times for asking so many questions. It made me wonder why one is so scared to discuss with the doctor. I dont know if this is because of the high pedestal people usually put doctor's on and you feel criminal to disturb his valuable space or whether its us doctor's who scare you to death and kill the sacred relationship between a doctor and his patient, even before its begun.
I always feel my job is a blend between that of Ram Jethmalani's and Sherlock Holmes. Just as a lawyer would, I need to know my patients well. I need to understand not only their medical problems but also understand their social pressures, their economic status and guage their desperation in order to correctly devise the right treatment. I need to make sure they are comfortable with me and trust me with their innermost feelings and secrets. This is why I like to spend atleast an hour with new consults. I actually look forward to them. Maybe I like meeting new people. Maybe its my hidden desire to be Sherlock Holmes that fuels it :)
Going through endless past prescriptions and reports, its quite thrilling to be able to piece together a past in synopsis. I frequently tell patients that my job is to find dirt where earlier you thought there was none. To be able to put forward a list of probable reasons for the problem, devise a possible solution and act upon it to see it one day bear fruits, I think, is one of the greatest joys that this profession or for that matter any profession could give me. As an Obstetrician I experience joy only when I help a mother give birth but as an Infertility Specialist, I enjoy this moment twice over. Believe me there's nothing like a phone call early in the morning saying 'Doc, its positive !'
Moving back to my topic, my advise to all couples walking this painful path, do not hesitate to discuss EVERYTHING with your doctor at the first visit. Remember if you feel you cant open up for any reason or fear, you're probably in the wrong hands.
I always feel my job is a blend between that of Ram Jethmalani's and Sherlock Holmes. Just as a lawyer would, I need to know my patients well. I need to understand not only their medical problems but also understand their social pressures, their economic status and guage their desperation in order to correctly devise the right treatment. I need to make sure they are comfortable with me and trust me with their innermost feelings and secrets. This is why I like to spend atleast an hour with new consults. I actually look forward to them. Maybe I like meeting new people. Maybe its my hidden desire to be Sherlock Holmes that fuels it :)
Going through endless past prescriptions and reports, its quite thrilling to be able to piece together a past in synopsis. I frequently tell patients that my job is to find dirt where earlier you thought there was none. To be able to put forward a list of probable reasons for the problem, devise a possible solution and act upon it to see it one day bear fruits, I think, is one of the greatest joys that this profession or for that matter any profession could give me. As an Obstetrician I experience joy only when I help a mother give birth but as an Infertility Specialist, I enjoy this moment twice over. Believe me there's nothing like a phone call early in the morning saying 'Doc, its positive !'
Moving back to my topic, my advise to all couples walking this painful path, do not hesitate to discuss EVERYTHING with your doctor at the first visit. Remember if you feel you cant open up for any reason or fear, you're probably in the wrong hands.
19 August 2007
Letrozole is Safe
I am writing this article because Letrozole is a very commonly used drug by Infertility Specialists the world over, but unfortunately it has also attarcted a lot of controversy and negative publicity. Would like to clear the air on some of the issues involved.
Ovulatory dysfunction is one of the most common causes of reproductive failure in sub fertile and infertile couples. Since the first clinical trial was published in 1961, Clomiphene Citrate (CC) has been the front-line therapy for ovulation induction. Its use quickly expanded to other empiric indications, such as luteal phase defect and the enhancement of fecundity in unexplained infertility. While CC is able to make eggs in 80% of patients, only half that number, or 40% will conceive. This is because CC has certain negative effects on the lining of the womb which hamper the implantation of the fertilized embryo. Failure to respond to CC occurs in up to 20% of cases, which may then require the use of injectable gonadotropins. Clearly, an inexpensive yet equally efficacious oral alternative would be ideal.
Recent research has focused on the successful use of aromatase inhibitors, mainly letrozole, for ovulation induction. We have been incorporating letrozole into treatment plans for appropriately selected patients for quite some time now. In India it is sold as Letroz, Letoval etc. Letrozole is a drug which has conventionally been used for Breast cancer treatment. This is only because Breast cancer requires the female hormone Estrogen for its sustenance and Letrozole is an anti oestrogen drug. It is because of this property that Letrozole can also be used to make eggs grow as in the absence of Estrogen, the hormones FSH and LH start to increase and stimulate the ovaries to make eggs bigger. Letrozole is commonly used in a dosage of 2.5mg twice daily from Day 2 to day 6. Several research papers have even used single day dosage of 20mg with good results. Single doses as high as 60mg have been administered without negative results. Letrozole has several advantages:
1. Letrozole has a very short half-life (~45 hours) and, therefore, is quickly cleared from the body. For this reason, it is less likely to adversely affect the endometrium and cervical mucus.
2. The results of several studies show that Letrozole and Letrozole + FSH cycles had the highest pregnancy rates.
There has been a lot of controversy that Letrozole use causes deformed babies, or that Indians have been made Guinea pigs for its trials. On the contrary, Letrozole is cleared faster from the blood than CC and therefore has lesser chances of affecting the conception, when it happens. CC in known to stay in the blood for upto six months after intake. Much before Letrozole came to India, hundreds of research papers were written all over the world and every paper only found benefits in its use. And lastly, before I rest my case, after all that media hype, Letrozole has been quietly given FDA approval by the government, for use in Fertility. Here is a link to a relevant artcile published in a reputed Journal, Fertility and Sterility in 2006 : http://dx.doi.org/10.1016/j.fertnstert.2006.03.014
Ovulatory dysfunction is one of the most common causes of reproductive failure in sub fertile and infertile couples. Since the first clinical trial was published in 1961, Clomiphene Citrate (CC) has been the front-line therapy for ovulation induction. Its use quickly expanded to other empiric indications, such as luteal phase defect and the enhancement of fecundity in unexplained infertility. While CC is able to make eggs in 80% of patients, only half that number, or 40% will conceive. This is because CC has certain negative effects on the lining of the womb which hamper the implantation of the fertilized embryo. Failure to respond to CC occurs in up to 20% of cases, which may then require the use of injectable gonadotropins. Clearly, an inexpensive yet equally efficacious oral alternative would be ideal.
Recent research has focused on the successful use of aromatase inhibitors, mainly letrozole, for ovulation induction. We have been incorporating letrozole into treatment plans for appropriately selected patients for quite some time now. In India it is sold as Letroz, Letoval etc. Letrozole is a drug which has conventionally been used for Breast cancer treatment. This is only because Breast cancer requires the female hormone Estrogen for its sustenance and Letrozole is an anti oestrogen drug. It is because of this property that Letrozole can also be used to make eggs grow as in the absence of Estrogen, the hormones FSH and LH start to increase and stimulate the ovaries to make eggs bigger. Letrozole is commonly used in a dosage of 2.5mg twice daily from Day 2 to day 6. Several research papers have even used single day dosage of 20mg with good results. Single doses as high as 60mg have been administered without negative results. Letrozole has several advantages:
1. Letrozole has a very short half-life (~45 hours) and, therefore, is quickly cleared from the body. For this reason, it is less likely to adversely affect the endometrium and cervical mucus.
2. The results of several studies show that Letrozole and Letrozole + FSH cycles had the highest pregnancy rates.
There has been a lot of controversy that Letrozole use causes deformed babies, or that Indians have been made Guinea pigs for its trials. On the contrary, Letrozole is cleared faster from the blood than CC and therefore has lesser chances of affecting the conception, when it happens. CC in known to stay in the blood for upto six months after intake. Much before Letrozole came to India, hundreds of research papers were written all over the world and every paper only found benefits in its use. And lastly, before I rest my case, after all that media hype, Letrozole has been quietly given FDA approval by the government, for use in Fertility. Here is a link to a relevant artcile published in a reputed Journal, Fertility and Sterility in 2006 : http://dx.doi.org/10.1016/j.fertnstert.2006.03.014
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