Help me – I want to be a father !

I received a heartbreaking email from a young man.

My medical history is as follows. I have been treated for testicular cancer in 2003 and one of my testicles is removed with a surgery. Before and after the surgery I have undergone 4 cycles each of chemotherapy. Every 6 months I get the blood tests done and everything seems to be normal for me. Last year April I have undergone testicular biopsy and it resulted in azoospermia. Last month I got the FSH blood tests done and it came out as 23.51.I have consulted many doctors and as my FSH is high one of the doctor has referred us to sperm donor program. Is this my only option ? Is there any way I can have a baby with my own sperm ?

Unfortunately, this man now has complete testicular failure; and his sperm production has been wiped out as a result of the cancer chemotherapy. Ideally, his sperm should have been banked ( cryopreserved in a sperm bank) prior to his starting chemotherapy. Unfortunately, this was not done, as a result of which his only options now are adoption; donor insemination; or child-free living. His ignorance - and the fact that his oncologist and surgeon did not bother to discuss his future reproductive options wiht him) have proven to be very expensive for him.

There is no doubt that cancer can be a life-threatening illness , but the good news is that many young patients are now surviving their disease and its treatment because of recent medical advances. They have their whole lives ahead of them - and having babies is one of the things most young people look forward to doing. Unfortunately, without enough information, they are not aware of the impact of the chemotherapy and radiation on their testicular function; and when they find out they cannot have a baby, will often resent the fact that their doctor did not discuss their treatment options with them at the time the diagnosis was made.

Oncologists are so focussed on saving lives and managing cancer, that they often fail to discuss reproduction with their patients - and the fact that sperm can be safely and easily banked prior to treatment. This failure causes major heartburn in their patients later on !

This man's story is so different from Lance Armstrong, who banked his sperm prior to taking treatment for his cancer. He used his stored sperm to have his children, after conquering his disease. Lance is doing great work in empowering young cancer patients with information about what they can do to preserve their fertility - I just wish more doctors would do so too !

Dr.Malpani - Repeated IVF failure - what's next ?

Image via WikipediaOne of the most difficult things IVF patients and IVF doctors need to learn to live with is the failure rate after IVF. For every patient who gets pregnant , there will be at least one who doesn't - and quite honestly , we can never predicted who will be successful and who will not be. So is it just a game of roulette ? Does a patient just have to keep on gambling until she hits the jackpot ?

Unfortunately , sometimes it does seem like that . Human reproduction is not a very efficient enterprise – whether it's being done in the bedroom or an IVF clinic. While we are very good at making embryos in the IVF lab, embryo implantation is still a complete black hole, and we still don't know why every embryo doesn't become a baby.

When the patient has finished 4 IVF cycles and still has not become pregnant even after the transfer of gorgeous-looking embryos , both she and doctor are faced with difficult questions which we unfortunately still cannot answer. The honest answer is that we often just do not know why the embryos did not implant ! However, what we do know is that even embryos produced by healthy young fertile couples have numerous genetic defects , even though they may look perfectly normal under the microscope. Sometimes patients just need to be patient until they get lucky !
However , patients do not want to hear that their IVF specialist does not have all the answers. After spending so much time , money and energy , they feel the least they are entitled to are answers – and an honest “ we don’t know “ just does not suffice.

Desperate situations call for desperate measures. After a failed IVF cycle, doctors are usually on the defensive because one of the things patients may feel ( but fortunately are polite enough to rarely say outright ) is – Did the cycle fail because the doctor was not good enough ? Did the doctor goof up ? And sometimes, the doctor also feels that he has let the patient down.

This is why some doctors will resort to expensive and experimental treatments such as immune therapy, which have been never been proven to work, but are still used widely , because of the great demand from desperate patients. 

What is our approach ? We try to analyze the problem scientifically . There are 3 possible variables: the embryos ; the endometrium ; and the embryo transfer. If there has been a problem in one of these areas, we try to figure out whether this was a one-off problem ; or if it is a recurrent problem. Some problems are correctable, and we try to fix them, so that the next cycle as a better outcome. Thus if the embryo transfer was technically difficult because of cervical stenosis , we can transfer the embryos directly into the fallopian tube , by doing a ZIFT. However if the problem recurs , we then need to move to Plan B. Options include : changing the eggs ( donor eggs) ; the sperm ( donor sperm) ; the embryos ( donor embryos) ; the uterus ( surrogacy) - or the doctor !

Related articles

• Dr Malpani - Testing for pregnancy after an embryo transfer in an IVF cycle (drmalpani.blog.com)
• Dr Malpani - Testing for pregnancy after an embryo transfer in an IVF cycle (drmalpani.wordpress.com)
• Dr Malpani - What are my chances of getting pregnant with IVF (drmalpani.blog.com)
• Dr Malpani - Why do I have to wait 2 weeks to do a pregnancy test (drmalpani.blog.com)
• Dr. Aniruddha Malpani (drmalpani.wordpress.com)
• Dr Malpani - Patients with poor ovarian reserve - flogging a dead horse ? (drmalpani.wordpress.com)

Dr.Malpani - Gynecologists versus infertility specialists - who should be your first choice ?

Image via WikipediaInfertile couples are often confused whom they should visit when they need medical assistance. Even though infertility always affects a couple , it's usually the woman who takes the initiative in seeking medical care . Most will bypass their family physician , but are unsure whether to go to a gynecologist or an infertility specialist. Both options have advantages and disadvantages , and it’s worth examining these.

The gynecologist is a logical first choice. Most women have a long-standing relationship with their gynecologist , and are comfortable with him. Since gynecologists are specialists in tackling women's health problems , most can competently diagnose the cause of infertility ; and provide basic medical treatment. They are usually quite conservative; and would be the first choice for simple problems . However , they are often poorly equipped to deal with complex infertility problems. 

Since a man with a hammer only sees nails, they will often subject the patient to unnecessary surgical procedures , such as a laparoscopy; or perform intrauterine inseminations for men with low sperm counts , simply because they do not have anything else to offer. They are often extremely poor at handling male infertility problems , and will usually refer these to their friendly urologist. This often means that care gets fragmented; and ends up of being poor quality. 
Most gynecologists are also not aggressive enough when dealing with older women. Since most of their women are fertile, they often forget to remember the impact which aging has on the ovarian reserve of infertile women.
Also since they rarely have a special interest in treating infertility , waiting rooms are often quite infertile-patient unfriendly. There are often full of expectant mothers , and this can cause unnecessary emotional distress. Also some of them are not compassionate or empathetic enough when dealing with the impact which infertility has on the woman's psyche.

Infertility specialists would be the first choice, if you have a complex problem. Not only are they experts at dealing with infertility they have a lot of experience; and are armed with the advanced reproductive technology to solve most problems. However they are often quite expensive ; and some of them will often resort to unnecessary , complex costly treatment, even to tackle simple problems. 
This means the patient has to choose between the risk of wasted time with the gynecologist, versus overtreatment with the infertility specialist. Since the infertile couple doesn't know how simple or complex their medical problem is , this often leaves them in a quandary.

What we do in our clinic ? If I am the first doctor the infertile couple is seeing, I will complete the workup for them , so we have an idea as to what the reason for the infertility is. This takes about 7 days and costs about US $ 200 only. If it's a simple problem , we will suggest that they find a gynecologist for their treatment. This allows us to concentrate on infertile couples who have complex problems , so that we can provide them with a higher quality of service, without diluting our focus.

In the best of all possible worlds , gynecologists with take care of the simple problems ; and if they have failed to achieve a pregnancy within 6 months , they would refer these patients onto an infertility specialist. Unfortunately, since most doctors have a proprietary attitude towards their patients , they are often reluctant to refer these patients to infertility specialists , because they do not want to lose them. This often means that they waste the patient's time , money and energy in pursuing ineffective treatments.

One useful tip is to create a clear plan of action with a well defined timeframe in 
partnership with your doctor , so you have a clear sense of what your treatment options are. This way, you retain control of your medical treatments as well as your life so you have peace of mind you did your best.

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• Dr. Aniruddha Malpani (drmalpani.wordpress.com)
• Dr Malpani - Chocolate cysts - how we manage them at Malpani Infertility Clinic (drmalpani.blog.com)
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• How your doctor can reduce your fertility - a guide from Dr Malpani (drmalpani.blog.com)

How your doctor can reduce your fertility - a guide from Dr Malpani

Infertile patients expect that their doctors will provide them with treatment to improve their chances of having a baby. Tragically, some medical procedures can actually end up reducing your fertility !

Here's a list of the top ten procedures which can actually harm you, rather than help you ! If your doctor advises any of these, please get a second opinion before agreeing !

1. D&C ( dilatation and curettage) . This is a "minor" surgical procedure in which the doctor dilates the mouth of the uterus ( the cervix) and scrapes the uterine lining using a curette

( curettage). This endometrial tissue is then sent for pathological examination. In the past, when doctors had very little to offer to their patients, this used to be the mainstay of the treatment of an infertile couple. In fact, even today, some women will ask the doctor to do a D&C for them because their mother conceived after doing this procedure ! They feel that it helps to "clean the uterus", thus improving their fertility ! While it is true that some women will get pregnant after a D&C ( sometimes this is just a placebo effect; while sometimes the endometrial inflammation induced by the procedure can improve uterine blood flow and fertility), this is an obsolete procedure which should be used in this day and age only for confirming the diagnosis of endometrial tuberculosis.

2. Metroplasty. This has become quite a fashionable procedure in some parts of India, where the doctor "improves" the shape of the uterine cavity to improve fertility. It can actually create uterine scarring and induce fertility. It's only in India that doctors use this technique for "treating" infertility. In all other countries, it is reserved for correcting uterine anomalies or removing intrauterine adhesions.

3. Hydrotubation. This is a procedure in which the doctor flushed the uterus and the tubes with fluid ( which often contains a concoction of chemicals such as steroids and antibiotics) to treat infertility. While it can help some women with cornual blocks, for the vast majority this painful treatment ( which is often repeated many times in one month) is a waste of time and money.

4. Empiric treatment for abnormal sperm . This continues to remain a major time-waster for infertile couples. Tragically, most doctors are still unaware of the recently revised criteria of what a normal sperm count is - and will often reflexively treat men with what they think is an "abnormal sperm report". There are various levels of sophistication to this futile effort. To cloak this with an aura of scientific respectability, high tech labs will now test sperm for DNA fragmentation levels - and doctors are quite happy to "fix" the problems these tests will often pick up. What many patients do not realise that there is very little correlation between these test results and their fertility potential - and that even fertile men have high DNA fragmentation levels ( but are fortunately unaware of this, as they have enough sense not to get their sperm tested in a lab !)

5. Treatment for genital tuberculosis. We are now seeing an "epidemic" of uterine TB in India - especially in north India, where it appears that practically even woman who goes to a gynecologist has TB ! Doctor use dodgy tests called PCR to test the endometrium for the presence of DNA fragments which are supposed to be be specific markers for the tubercle bacilli - without even bothering to determine what the prevalence of this TB PCR positivity is in the fertile population ! Not only do these poor patients end up taking 6 months of toxic and expensive drugs; their husbands will often stop having sex with them ( because they are worried that they will transmit the TB to them); while others are scared that they will give the TB in their uterus to their baby !

6. Treatment for TORCH infections. Women who have been unfortunate enough to have a miscarriage will get routinely ( and mindlessly) tested for the presence of antibodies against the TORCH group of infections. If any of these tests is positive, the doctor then promptly treats this infection with antibiotics ( which are completely useless and uncalled for !). The truth is that pregnancy. You can read about this at www.drmalpani.com/torch.htm

7. IUI ( Intrauterine insemination ) for treating couples men with a low sperm count. Since everyone knows that " you need just one sperm to fertilise an egg", it seems to make a lot of sense to treat infertile couples who have a low sperm count with IUI . After all, IUI is a simple and inexpensive treatment, which every gynecologist can offer - and patients understand the logic as to why it should help. The truth is that the problem with men with low sperm counts is not just that their sperm count is low - its often that the sperm are functionally incompetent - and no amount of concentrating the good sperm or washing them is going to help !

8. Diagnostic laparoscopy. Once upon a time, a laparoscopy was a major advance in evaluating the infertile woman, because it actually allowed the doctor to visualise the ovaries and fallopian tubes without having to cut open the patient ! Minimally invasive surgery was a major advance then , but now it's being overused. Many doctors still routinely perform a laparoscopy for all infertile women, which is completely unnecessary surgery, as is does not change the therapeutic options for these patients. The status of the fallopian tubes can as easily be checked with a simple HSG, which is much less expensive ! It's true that a laparoscopy allows the doctor to also "find" adhesions and endometriosis, but making the diagnosis of this ( or "treating" them ) does not really improve the patient's fertility at all !

9. Medications for treating endometriosis. Endometriosis is an enigmatic and frustrating disease; and mot doctors will still reflexively "treat " this with medications, such as GnRH analogs. While these medications are great at suppressing the endometriosis (and will provide dramatic pain relief), this suppression is only temporary - and does not improve the patient's fertility at all (since they also suppress ovulation at the same time !) Once the meds are stopped, the endo recurs ! Even worse, "treating" the endo with meds just wastes the patient's time - something which most infertile patients cannot really afford to fritter away !

10. Operative laparoscopy for myomectomy and cystectomy. One problem with today's high tech diagnostic tools ( such as vaginal ultrasound scans) is that it allows the doctor to "diagnose" small 1 cm size ovarian cysts and fibroids. Now while cysts and fibroids are very common in fertile women as well; and small cysts and fibroids do not affect fertility, once the sonographer has "reported" his "diagnosis", the patient often panics ! The doctor is happy to point out these abnormalities - and convinces the patients that it is these abnormalities which are the cause of her infertility - and that once these are "treated", she'll get a baby quickly ! What's worse is that it's easy to do the surgery with a laparoscopy ( which is just "minor surgery"), that patients are quite happy to sign on the dotted line without realising that these are incidental findings of no clinical importance; and that the surgery will not help them. What's worse, is that this unnecessary surgery can reduce your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

I sometimes think we are seeing an epidemic of overtesting and overtreatment. Doctors seem to like doing tests - and patients like being tested ! Unfortunately, patients are still not sophisticated enough to differentiate between useful tests and useless tests - and the truth is that some tests can actually be harmful !

The hidden danger with a lot of these unnecessary testing is that patients get fed up; lose confidence in doctors; and refuse to pursue more effective treatment options, because they do not trust doctors any more !

The message is simple - if you have a medical problem, remember that Information Therapy is invaluable ! Please get a second opinion if you are unsure and confused. Send me your medical details by filling in the free second opinion form at www.drmalpani.com/malpaniform.htm and I'll be happy to help !

Dr. Aniruddha Malpani

Dr. Aniruddha Malpani is one of the best Infertility Specialists in India. He completed his MBBS from Seth GS Medical College, Bombay, in 1982. He took his DGO and MD degrees from Bombay University. He passed his D.N.B. appearing for the National Board of Examinations. Dr. Malpani has been the recipient of a glittering array of prizes, awards and scholarships through his academic years. Currently, he and his wife Dr. Anjali Malpani, both infertility specialists, are in private practice. Dr. Aniruddha and Dr. Anjali Malpani have started India's first Sperm Bank in Bombay, for therapeutic insemination by using donor cryopreserved sperm The Bank has a full-fledged infertility unit, which provides comprehensive services, including IVF, GIFT and micromanipulation. The doctors have achieved the first pregnancy in India using the sophisticated technique of PGD (preimplantation genetic diagnosis), which allows a screening of embryos for genetic abnormalities. They have also started India's first support group for infertile couples, a registered charitable trust, called Infertility Friends. Dr. Malpani believes in empowering the public with health awareness, as a means of promoting its health, and helping itself prevent and treat ailments in partnership with doctors. He has founded the Health Education Library for People, India's first Consumer Health Education Resource Centre with reading, browsing and other library facilities. It has a collection of books, magazines, journals, CD ROMs, and videotapes covering all aspects of health explained in terms, which the lay person can understand. Dr. Aniruddha has, with Dr. Anjali Malpani, authored two books: Getting Pregnant - a Guide for the Infertile Couple, and Best Medical Care - A Guide for the Intelligent Patient. He has published articles in several national and international journals. Memberships: He is a member of the European Society for Human Reproduction and Embryology, Brussels, Belgium.

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• Dr Malpani - Testing for pregnancy after an embryo transfer in an IVF cycle (drmalpani.wordpress.com)
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Dr Malpani - Why do I have to wait 2 weeks to do a pregnancy test

Most patients find that one of the most difficult things to manage during an IVF cycle is the dreaded 2 week wait ( 2ww) after the embryo transfer. Time seems to come to a halt and you live in a state of suspended animation - a bit like Schroedinger's cat ! Am I pregnant ? Am I not pregnant ? Every ache and twinge sends you scurrying to the bathroom to check if your periods have started - and you over-interpret every signal your body sends you. Am I feeling nauseous ? Is this a good sign ? Do my breasts feel fuller than usual ? Is this just PMS ? You try to prevent your mind from playing games with you, but this is surprisingly hard to do. Every hour seems to stretch on like a day ! You obsessively compare notes with all your online IVF friends - and drive your husband batty with your interpretations and wild imaginings ! Every time he drives the car through a pot-hole, you go bonkers with the anxiety that the jolt has jarred your embryos out of their safe uterine haven and caused them to fall out !

Why do I have to wait 12 days after the embryo transfer to do a pregnancy test ? Can't I do it earlier ? After all, if I am pregnant, won't the test show this ? Aren't the new tests very sensitive ? Aren't they supposed to show a positive result even before the period is missed ?

You cheat and start doing pregnancy tests anyways - how can it hurt ? And every time it's negative, you still hope against hope ! Maybe I did it too early ? Maybe it will show up as positive if I wait another 2 days ? How can God be so unfair ? After all the shots I have taken and the pain I have suffered, I am sure he will not let me down and will give me my baby !

Remember that your embryos are safe in your uterus and that nothing you do can harm them ! If they are going to implant, they will and there's precious little you can do to influence the inefficient biological process of embryo implantation either way.

Continue taking all your medicines; leading a normal life; and please remember the Serenity Prayer.

God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

Dr Malpani - Testing for pregnancy after an embryo transfer in an IVF cycle

While all IVF patients understand with their heads that not every IVF cycle results in success, in their heart of hearts, every patient expects to get pregnant every time they do IVF ! This is why the 2ww after the embryo transfer can be so nerve-wracking ! Am I pregnant or not ? Have the embryos implanted or not ? The suspense during the 2ww can be even worse than the pain of the IVF injections !

Most patients would love to have a test which will allow them to find out if they are pregnant immediately after the embryo transfer ! Have the embryos stuck or not ? Why can’t we do a pregnancy test and find out right now ? Even if I am not pregnant, at least it’s better to know than to be unsure.

To understand why patients ( and their doctors ) still have to suffer through a 2 week wait to find out the outcome of an IVF cycle, let’s look at the biological basis of pregnancy tests and how they work.

A pregnancy test measures the amount of beta hCG ( human chorionic gonadotropin) that is in your body. HCG is a hormone which is produced by the trophectoderm cells of the embryo. It is produced in detectable quantities only after the embryo implants. Since implantation occurs 3 - 8 days after the embryo transfer ( depending upon whether you have had a Day 3 transfer or a blastocyst transfer), this means that the HCG produced by your embryo will be first detectable in your bloodstream only after this time.

As your pregnancy progresses, the amount of hCG in your system will increase. At 10 days past ovulation ( DPO) , for example, the average woman has an hCG measurement of around 25 mIU. This amount doubles to 50 mIU at 12 days past ovulation, and then doubles again to 100 mIU at around two weeks past ovulation. Every woman’s body is different, and there’s a lot of variation in HCG levels from woman to woman !

Home pregnancy tests measure the level of HCG in urine. Different pregnancy tests have different levels of sensitivity which means if you use a home pregnancy test that is sensitive to 100 mIU, it will not tell you that you are pregnant if your level of hCG is only 75 mIU. These tests cannot measure a level lower than 25, so they do not become accurate until a few days after embryo implantation. A negative result before then is meaningless, since there would not be a high enough level of HCG to detect even if you were pregnant. If your test is negative, you should retest after 2 days. This is why taking a pregnancy test too early can lead to inaccurate results. I know it’s hard to wait those extra days and you may want to try much earlier. It’s fine to do this, but please don’t assume that a negative results means that you are not pregnant.
This is also why blood tests for HCG are much better than urine tests. Not only are they more reliable, accurate and sensitive, they also give the doctor a number which he can measure and monitor.

If blood tests are so sensitive, then why not do a blood test for HCG 1 week after the embryo transfer ? Unfortunately, doing a blood test for HCG so soon does not make any sense. This is because there will still be some HCG in your body as a result of the HCG trigger shot ( Choragon or Ovidrel) which the doctor gave you to trigger off ovulation 36 hours prior to egg collection. If you test too early, the test will always be positive, as this HCG will show up in the test and give rise to false hopes ! This is why the doctor needs to repeat the blood test for HCG after 48-72 hours. In a healthy pregnancy, the HCG levels will continue to rise. If they do not do so, this means this is not a viable pregnancy.

Finally, remember that you should do the test even if you bleed. Bleeding can sometimes occur during pregnancy as well – and just because you have had bleeding or spotting does not mean you are not pregnant !