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One of the most difficult things IVF patients have to deal with is the fact that there are no external symptoms or signs of what’s happening inside their bodies. Are the follicles growing well ? Is the uterine lining maturing properly ? Are you responding well to the medications ? Are the eggs of good quality ? Are the embryos implanting ?

An important marker of the reproductive cycle is bleeding – and this can become a major source of stress during an IVF cycle !

The start of the menstrual period is an event most IVF patients look forward to, because finally the IVF cycle is ready to commence – and you are now ready to take your best shot at having your long desired baby ! You are all pumped up and ready ! You’ve spent a long time waiting for your treatment to begin ( with waiting lists and getting appointments with busy doctors, it can take 2-6 months to actually start the IVF cycle , no matter how ready you are – and this waiting can be very stressful !) Is the period on time ? Early delayed ? Does it look any different ? If it comes too early, does this mean you’ll have to cancel because the doctor is not available ? If it’s delayed, does this mean you doctor will have to postpone your cycle ? When you are 2 days overdue, you wonder if you should ask the doctor to induce a period – or should you just keep on waiting ?

Remember that the day the period starts – or the quality and quantity of flow are completely unimportant ! Day 1 of your cycle is just a marker which informs the doctor that you are ready to start your superovulation, that’s all ! The bleeding is just the shedding of the old uterine lining – and has no impact on the IVF treatment itself.

While a very early or delayed period will not affect the outcome of the IVF treatment , this can be a problem if you are travelling abroad for your IVF treatment; or if your IVF doctor does treatments by batching patients ! This is why many clinics will put patients on birth control pills to regulate their cycle, in order to make scheduling the cycle easier !
You may have some spotting or bleeding after the egg collection. This is because the doctor has stuck a needle through your vaginal wall in order to retrieve your eggs. This is usually minimal, and stops very soon. Excessive bleeding is extremely unusual – and if you do experience this, you should report to your doctor.

Some women may also have some spotting after the embryo transfer. This can be very scary, but can occur if the doctor had technical difficulty during your transfer and had to manipulate your cervix. This is bleeding which comes from the cervix ( the mouth of the uterus); and will not harm your embryos !

What about bleeding during the 2 week wait ? This is not common, because you are taking luteal phase support with estrogen and progesterone to help support your uterine lining. This is why when bleeding occurs, thus can cause panic because you are worried that this represents the start of your period , which means that your IVF cycle has failed ! Your worst nightmare may be coming true ! Women will often obsess over every drop of blood they see – and some will even imagine that they can see their fetus being expelled with the clot. However, remember that the embryos as this stage are microscopic, and cannot be seen with the naked eye !

Also, this bleeding does not always mean that the cycle has failed . In many women, this bleeding is self-limited and stops as suddenly as it started , which means we can never figure out where it came from or why. In others, it is actually a good sign, because it represents an implantation bleed. Unfortunately, there’s no way a doctor can judge what’s happening because ultrasound scanning does not give us any useful information. It may be a good idea to do a blood test to check your progesterone levels ; and if these are low, the doctor can increase your dose of progesterone to provide additional support to the endometrium.

If you get a period in less than 12 days after your embryo transfer inspite of your medications, you should request your doctor to test your progesterone levels 3 days after your embryo transfer in your next IVF cycle . If these are low, then he may want to change the way he is giving you progesterone by using an alternative route ( by switching from vaginal progesterone to IM progesterone or vice versa)

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 !