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We normally do a blood test for HCG 2 weeks after the embryo transfer to find out if the embryos have implanted and if the cycle has been successful or not.

This can be a very long 2 weeks , and many women will start doing pregnancy tests 5 days after the embryo transfer.

The problem is that even if the embryo has implanted and you are pregnant, the embryo produce such small quantities of HCG for the first few days after it implants ( remember that it's just a microscopic ball of about hundreds of cells or so at this time), that it's not possible to detect this HCG in the blood . To be able to detect the HCG in the urine will take even more time, which is why you need to be patient.

Of course, many patients will cheat :) - and this is an email I got from a patient today. A picture is worth a 1000 words, and this image clearly shows how her pregnancy tests have now become strongly positive ( C stands for Control and T stands for Test). The stripe on C means you have done the test properly. Once the stripe on T shows up ( is positive) , this means you are
pregnant !

She's now ready to start her baby album !

This is a guest post from a very thoughtful patient of mine. I know many IVF patients will be able to identify with her experience . I just wish more doctors would read this as well, so they can provide more support to IVF patients !

When you do ivf as a medical tourist soon you'll find out you have become a traveller between the worlds. Between continents and between medical worlds: "normal" obstetrics and ivf. Unexpectingly it turns out to be much easier finding an ivf doctor in India than finding an obstetric gynecologist in your home town. And once you are lucky enough to get an appointment, you are faced with different treatment concepts: pregnancy in obstetrics and pregnancy in ivf are a world apart it seems.

Unless you are already established with an ob gyn - not so likely; you would not be an ivf patient if you had made it into the normal gyn world - getting an appointment with a gynecologist becomes a real challenge.

After returning from India I called a gyn I had seen once to schedule appointments for the row of betas after the two week wait. She reluctantly ordered one blood test and told me right away that she was not willing to deal with ivf patients in general, much less with ivfers from abroad and that she was not an obstetrician anyway for that matter.

I then contacted other obgyns in my area but they were so fast in telling me that there were no appointments available any time soon that I did not even had the chance to explain the vital importance of the row of betas in ivf and that this was why I needed an appointment much sooner. Since this was my fourth ivf cycle, as a recurrent ivfer I had by now acquired a daunty respect for those fearful beta numbers and their always heart-wrenching doubling time. During the two weeks of wait for the first beta, the tension grows denser and denser and the only thing that can ease your strain, slightly, is a good doubling time. I had to find a beta-willing gyn at any cost.

A certain familiarity with the medical establishment led me to the conclusion that local doctors in private practice might have arbitrary freedom as to wether accept new patients and therefore insisting on small private practice doctors would lead nowhere. I had to find a public structure with more inclusive patience acceptance. I called the medical faculty associates office at a the local university. Among the options at the answering machine : "if you are pregnant ..."That sounded promising.

I pressed the required key and a friendly voice said, he would now check for available appointment dates. I explained right away that I was doing ifv abroad and that I needed two blood tests and a scan done on specific dates. He was listening for a while and after what seemed to me a long stretch of silence he was trying to find out where in his scheduling scheme I could possibly fit in with my outlandish request for a row of betas. "A row of betas ? I don't think the doctor will do that for you". He appeared to want to be helpful, but just could not comprehend my urgency for blood tests. He suggested to do a home test in the meantime.

I did not want to lecture on the difference between qualitative and quantitative bhcg testing for fear this might ruin his sympathetic attitude towards me. I just began to understand myself that timing in ivf was far away from timing in normal obstetrics. The beta frenzy was a thing exquisitely ivf. He was willing to give me an appointment to see a doctor on a day that luckily turned out to be the day my ivf doctor wanted me to have my first scan, in 10 days to come. I gratefully accepted. I had to find another way to find relief from beta hell. There was no way I could wait 10 days without knowing my beta numbers' fate.

When dismissed from Dr. Malpani's clinic, he will ask you to inform him on your beta results. I emailed him that I was not able to obtain blood tests and therefore could not inform him. Within a few minutes he replied sending me a link to a online lab. What a relief. I would have had to pay for the tests privately though. Relief from awful beta-anxiety has no price.

The beta numbers came in, anxiety stayed. Doubts about adequate doubling time and no doctor to talk to. Again I emailed with Dr. Malpani and was reassured.

While my appointment with the obgyn was approaching, I imagined that I would have to go through at least two assistants before I could talk to the doctor. They would both ask me the same questions again ,checking the same checklist. Why was I so hypercritical ? I should be thankful that someone was paying attention to me no matter how formal.
This doctor turned out to have one assistant only and she was indeed simply friendly and asked me where I had my ivf done. "India ? That's pretty far away".
"Only on the map" I replied thinking of how easy it was to get advise from my ivf doctor by email while I hadn't yet seen the local doctor. I was so tense about seeing the doctor and whether he would have me have a scan done, that I made no attempt to explain this apparent contradiction. Whatever her assumption regarding my state of mind that moment , she was surely right.

And then she asked me about the due date. The due date ? WTH ? Heavens, I am doing ivf ! I am not in the usual pregnancy business. In ivf the due date is an almost non-existing concept. In ivf you go from hurdle to hurdle, from beta to beta, from scan to scan, day by day, week by week. The relief of one doubling beta lasts the blink of an eye and you start worrying about your next beta two days from now. And once you made it to the ultra sound level and you are lucky enough to see what could be a a gestational sac, a black little hole, you start getting very nervous when your next appointment approaches: will there be a heartbeat ? You will never forget that flimsy flickering filament and life appears to be so fragile and delicate, a friable thread of silk.

"The due date", I said, "I never got that far". A look at her told me that she considered my situation to be too complex. She did not inquire and I was glad I did not have to go over my ivf history. I handed her my discharge papers. Without having a look at them she said the doctor would be here soon and left.

The doctor stepped in, I explained I was doing ivf abroad. I told him my beta numbers and he decided they were too low. The feeling of desperation took over. I had the impression that maybe he was not used to see beta numbers at such an early stage of pregnancy and that was why he considered them too low. But I had not enough energy to find that out. I would ask Dr. Malpani.

By now I have become an established patient with both the pregnancy worlds. Pregnancy symptoms might be the common interface. I learned to navigate myself through the "normal" obgyn world being aware that I am confronted with a somewhat different obstetric culture. There is no "clash of civilization" in obstetrics, no self-fulfilling prophecy of conflict. After all, a pregnancy is a pregnancy, no matter where.

The newest IVF technology uses a fancy new technique which marries IVF and genetics. This is called PGD ( preimplantation genetic diagnosis) with CGH ( comparative genomic hybridisation) and there are lots of press releases and articles touting this as the newest breakthrough !

Doctors , like all big boys, love to play with new toys - and the newer the better ! This is especially true when they have expensive new technological tools, which no other competitor has. Doctors can be very competitive - and are always trying to be one-up on each other. An easy way of being different is to use the newest technology - but the trouble is that never is not always better ( though newer is always more expensive !)

Because these new tools are so expensive , doctors need to use them extensively, to justify the expense - after all, they need to show the bean counters who pay their salaries and bonuses that the new tool is cost effective !

The key question thoughtful patients need to be asking is - Is it really better ? Or is it a solution looking for a problem ?

I think the truth is we really don't know right now ! It's very likely to be useful for some patients - but to expect it to be useful for everyone across the board is hoping for too much ! While it may seem logical to use PGD, unfortunately, biological systems are not always logical ! What seems to make sense in theory often does not

As a doctor in clinical practise , whose major focus is simply to get as many of my patients pregnant as quickly as possible, I am quite conservative and prefer to wait and watch.

I follow Alexander Pope's dictum,
Be not the first by whom the new are tried,
Nor yet the last to lay the old aside.

Only time will tell how useful PGD-CGH is - but the enormous commercial pressures under which IVF clinics operate - and the constant demand by patients that their doctor use the newest and the latest breakthrough technology they read about in the newspaper means that most IVF clinic will likely end up overusing it !

I always tell me patients to prepare for the fact that their IVF cycle may fail. Many patients dislike this. They feel I am being too negative - and are secretly worried that such negative thoughts are a jinx which will jeopardise the outcome. Most patients want a cheerful optimistic doctor who will promise them a baby.

Intelligent patients appreciate my honesty and frankness - they prefer a doctor who will tell them the unvarnished truth. Others who cannot handle the truth will usually move on to another doctor who is willing to promise them the moon - and who is happy to tell them what they want to hear !

It's very easy to smile; be optimistic - and make false promises. Everyone wants to think positive - and if you believe the book The Secret, then positive thoughts attract success !

While I am personally very optimistic by nature, I feel it's not correct for a doctor to overpromise success ! Patients are emotionally very vulnerable and it's easy to take them for a ride - something which many unscrupulous IVF doctors do all the time, by quoting inflated success rates and promising the moon !

When I tell patients to prepare for the worst , this does not mean that I not hopeful or that I am a defeatist. I am not being negative or being a pessimist - I am just trying to be a realist !

Being prepared does not mean that you are expecting a bad outcome or that your negative thoughts will attract failure - it's just that you are preparing for it. This is something you do in daily life all the time , so why shouldn't you do it during your IVF treatment as well ?

It's always easier to mentally prepare when you do not need to !

Let's assume to decide to be positive, optimistic and upbeat and prepare only for a good outcome. If you do get pregnant, you'll be pleased and happy - and life will move on. However, if you do not get pregnant , you will go to pieces. Bouncing back will be much harder - and you'll find coping with the emotional roller coaster ride much more difficult.

However , if your prepare for a bad outcome and get pregnant, you get double the joy ! And even if you do not get pregnant, while your heart will still break, your mind will help you heal faster because you were mentally prepared for this.

It's harder to deal with a negative outcome when you are not ready for it ! IVF is a scary emotional roller coaster ride and mental preparation gives you some stability.

The trick is to find the right balance - to look for the middle path - what Buddha called the golden mean ! It can be helpful if both partners have different world views because they can balance each other !

However, if the husband is optimistic and the wife is pessimistic, and the cycle fails, he may end up blaming her for the failure because " you are always negative" ! Victim blaming is very common when patients adopt a pessimistic approach in order to protect themselves from heartbreak - and this is just adding insult to injury !

This is a guest post from Carina Freeman, the Fertility Coach.

I think it's time to take the time and share my story. To help you understand why I am passionate about Hold your Hand fertility coaching.

In 1997 I was able to conceive a son with no problems at all. I had no idea what my future would hold. I have always had very severe menstrual cramps. However, I never went to get them checked out because I thought it was "normal." My mom, her sisters, and their mom also had severe cramps. I always wanted more children after my son was born in 1997, but thought maybe it just wasn't my time yet. So, we kept trying for years with no success. This made me feel like less than a woman. Why could I not give my husband a child? After several years, my husband suggested I go to the doctors to have myself checked out. In 2005 I decided to take the 1st step. This step would lead to my documented fertility journey.

My doctor did a "normal" fertility work up (blood work and exam) which came back "unremarkable". At that time he questioned me about my family history and my severe menstrual cramps. From my family history he came up with a possible diagnosis of Endometriosis. This was something I had never heard of. So, I began to research this subject on the internet. My research gave me different answers with m any poss
Still, wanting to bear another child of my own, my physician said IVF would be my best choice. Of course I had to do my own research so I asked several of my MD friends and they all agreed. I read every book that I could find about IVF and realized that would be my best chance to complete my family. A few months later, my husband went to Iraq for his second tour of duty. I felt alone. I felt like no one understood what I was going through. Depression was starting to set in. The "why me" thought was always present and in front of my thinking. What did I do wrong? I felt like less of a woman for not being able to have another child. Living in a military town, it seemed as if EVERYONE around me was pregnant. I couldn't go to the grocery store without seeing a pregnant woman. Why and how can SHE have so many kids, and why not me? The pressure from my mother for a grandd
That was not the change I needed. In fact it left me feeling even more alone. Not even a trained counselor could help me. Since I love to read, I found lots of great books on positive thinking. I learned the art of meditate and the art of training my thinking. I then realized my negative thinking was indeed harmful! That HAD to change! Having negative thinking for so long, it's was VERY hard to change on my own. Luckily, I found a great friend, she was going through infertility too! Together we began to work on our negative thinking, and began to get our minds and bodies ready for this great adventure! It wasn't an easy change, as change rarely ever is. However, now I know it was extremely necessary. We began to work on our diet, while putting our thoughts on a "diet" as well. Finally my husband came home from war. We began to talk about IVF and how we would pay for With a new way of thinking, and feeling confident that IVF would work for us, I began to research different IVF clinics. I came across lots of great US clinics, but one clinic in Europe for IVF caught my attention. Together my friend and I (and our husbands of course)
took a 2 week trip to Europe.

In 2008, after one IVF treatment, I was PREGNANT! I gave birth to perfect babies; a boy and a girl. My friend also got pregnant on her first IVF attempt with twins!
Through out my pregnancy I kept a IVF diary made very public on you-tube. http://www.youtube.com/user/Medicluvstrauma?feature=mhum

My education continues every single day to help you educate you. Dr. Google has good information but is not always the best. With my dedication, knowledge, and compassion to help others, I will be here for you in every aspect!! My way of coaching is like no other. I help bridge the gap between your mental and physical health by helping you find your true self, teaching you how to train your thinking through meditation and other channels, and getting you ready for a successful pregnancy.

Thank you for listening to my story!

Sincerely,

Carina

Throughout my journey there was on online doctor that went above and beyond with the free information he offers. He deserves to be recognized for all he does for the infertility community. Please check out his website and grab the free information he provides. He also provides an infertility cartoon!! Please take a look.

www.ivfindia.com

Thank you so much Dr. Malpani !!

For older infertile women, AMH ( anti-Mullerian hormone, also known as MIS ( Mullerian inhibiting substance) has become the new FSH . AMH is a very good marker for egg quality - and provides us with a quantitative measure for egg quality and quality.

In the past, we had to depend upon FSH levels. A high FSH level suggests poor ovarian reserve, but FSH levels are not very reliable, because they vary according to which day of the cycle the test is done; and can also be artificially suppressed by a high estradiol level

AMH is a much better marker for ovarian reserve. It does not vary from cycle to cycle; and remains the same throughout the cycle. A low AMH suggests you have poor ovarian reserve - but even if your level is low, this does not mean you should panic !

Remember that it's just a test - and good doctors do not treat tests - we treat patients !

Step number one is to repeat it again - preferably from another lab.
Step number two is to run additional tests to check your ovarian reserve.

You have 2 options: an ultrasound test called the antral follicle count ?
and a blood test called a clomid challenge test.

Even if these are poor, this does not mean you cannot improve it ! While Western medicine does not have much to offer, there are alternative medicine options you can try to improve your ovarian reserve

These include the following:

1. Yoga
2. Acupuncture
3. DHEA, 25mg thrice a day.
4. Wheat germ daily
5. CoQ 10, 100 mg daily
6. Vit D3 ( Calcirol), 60000 IU, once a week for 10 weeks

Read the book, Inconceivable.

Re-test your AMH level after 12 weeks to see if it improves.

Even if it does not improve this does not mean you cannot get pregnant ! Patients with low AMH levels do also get pregnant on their own ( though their chances are reduced). After all, levels provide information about groups of women , and there can be a lot of individual variability !

If you have poor ovarian reserve, IVF is often your best option as it maximises the chances of a pregnancy. IVF allows you to make the best use of the few eggs which are left, by telescoping time.

Plan B would be to use donor eggs, if you are willing to consider this option. This has a much higher success rate

“What can you possibly learn from your doctor that is not available on the Internet?” We suspect we'll hear such radical sentiments increasingly in the future. Knowledge is said to be power, and some of the past imbalance of power between patient and doctor may be equalized. But information and knowledge do not equal wisdom, and it is too easy for nonexperts to take at face value statements made confidently by voices of authority. Physicians are in the best position to weigh information and advise patients, drawing on their understanding of available evidence as well as their training and experience. If anything, the wealth of information on the Internet will make such expertise and experience more essential. The doctor, in our view, will never be optional."

Actually, there are some things which the internet can teach patients far better than the doctor
can ! Youtube videos ( on how to take your IVF injections for example) can be played and replayed - and websites don't lose their patience with patients ! Also, many doctors are often not very good at teaching because they cannot stop using medical jargon.

Websites and doctors are all tools which a smart patient should have in their medical tool box. The real mark of a wise patient is that she knows which tool to use at which time !

Hi, We are from Canada and this is our short story that we would like to share as noted below:

First of all, would like to extend our warm gratitude to Dr.Aniruddha & Dr.Anjali Malpani, and your staff making our IVF treatment a SUCCESS !!!
I am on the eleventh week of pregnancy now and hoping and always pray it will be a SUCCESS until the baby is born.

Planning/deciding to undergo IVF is not a joke/easy. There are a lot of things to consider.

1. Financial - IVF involves a huge amount of money like travelling expenses, hotel,food,medicine and might affect the job as well
2. Stress - Need to manage your stress - IVF involves a lot of stress.
3. Taking the risk

a. Job - Ready to quit the job to have full rest if required according to case to case basis before and after the treatment until the baby is born
b. Effort - Regardless how much effort you exerted expect that sometimes it doesn't succeed at one time treatment only.
c. Time - Ready to accept that in first/second try did not go thru.
d. Budget - It might be very tight at times especially if income is limited.

4. Health - It is very important to remain healthy like balance diet, avoiding caffeine,/alcohol/smoking and have a daily exercise with the doctor's guidance according to health conditions.

I am now in my first pregnancy which is my third IVF treatment with Dr.Malpani coming from Canada to India 3 times. It was really hard to travel and adjustments to another country and lot of stress and finance involved. We cannot fight with God's creations or the nature but the doctors can help to make it happen.

We are really lucky to find the right clinic with experienced doctors who are always there to help, and taking extra steps to make the IVF treatment a success and its so fantastic to have a doctor who responding to all our inquiries promptly all the time additionally his staffs are all helpful and very co-operative treating us like a family and clinic has an excellent facilities everything is done in the clinic itself no need to go somewhere else which is very convenient for us, being a patient for 3 times there we know everything. and enjoyed as well. There are lots of good things to tell but there is no words to express...

However, just to let you know that there are still lot of trauma during my pregnancy on 6th to seventh week had 3 times heavy bleeding but this did not lost our hope I have to deal with and relax thank god did not happen again and very soon I am going to finish my first trimester by April 16,2011.

Thank God !!! There is really nothing impossible. First of all trust in God, trust your doctors, trust yourselves, take a risk and go for it!!!

crpp1@hotmail.com

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)

For many patients, the emotional stress of going through an IVF cycle is far more than the physical stress ! The overriding fear is that of failure – what will I do if the cycle fails ? Will life be worth living ? They understand that IVF is the one treatment option which maximizes their chances of having a baby and have pinned all their hopes and dreams on the cycle succeeding. They dread to entertain the possibility of failure , as a result of which they are emotionally very vulnerable.

Even before starting the IVF cycle, they spend a lot of time and energy doing their homework. Some will do their research and become an expert on IVF; others will doctor shop; while some will go to a temple to make sure God is on their side !

While there are quite a few ups and downs during the moments of truth during an IVF cycle, the fact that there is so much action ( are the follicles growing ? do we have enough eggs ? are the embryos of good quality ?) , the mind is extremely hard to manage during the 2ww , and plays havoc during this time.

While your head knows you should be detached, and that the final outcome is now out of your hands, your heart finds it hard to do this ! You look for omens and signs all the time ! Everyone ( especially your husband ) tells you not to “ stress “ , but how can you possibly not stress about this – after all, so much rides on this ! While your friends are sympathetic and caring, they just cannot understand what you are going through. Every minute seems to take an hour to pass – and you are never sure whether to be hopeful ( because you’ve read somewhere that being positive increases the chances of success ?); or to be prepared for failure ( so that it’s easy to deal with the emotional roller coaster ride). Unfortunately, many doctors make a bad situation worse by forcing their patients on “bed rest” after the embryo transfer. When you lying in bed all day long, it’s hard to stop your mind from imagining the worst !

Unfortunately, there are no reliable symptoms or signs which can predict what the outcome will be. The symptoms are exactly the same, whether or not you are pregnant or not. This is hardly surprising, given the fact that the symptoms of PMS are exactly the same as those of early pregnancy – and that all the hormones you are taking for luteal phase support are the same hormones your body produces during pregnancy !

You need to find ways to cope constructively ! Think of this as a learning opportunity which can test your emotional resilience. Tap into your inner strengths and remember you have dealt with waiting in the past as well – waiting for exam results; or waiting for your boyfriend to call ! The waiting game is exactly the same and learning mind management skills such as yoga and meditation can help ! Keeping yourself gainfully occupied and continuing to work is very useful – this keeps you distracted and allows you to channel your energies constructively !

I always tell my patients to prepare for the fact that their IVF cycle may fail. Many patients dislike this. They feel I am being too negative and are secretly worried that such negative thoughts are a jinx which will jeopardise the outcome. Most patients want a cheerful optimistic doctor who will promise them a baby.

It's very easy to smile and to make false promises. Everyone wants to think positive - and if you believe the The Secret, then you also believe that positive thoughts attract success !

While I am personally very optimistic by nature, I feel it's not correct for a doctor to overpromise success ! Patients are emotionally very vulnerable and it's easy to take them for a ride - something which many unscrupulous IVF doctors do all the time, by quoting inflated success rates and promising the moon !

When I tell patients to prepare for the worst , this does not mean that I not hopeful or that I am a defeatist. I am not being negative or being a pessimist - I am just trying to be a realist.

Being prepared does not mean that you are expecting a bad outcome - it's just that you are prepared for the eventuality. This is something we do in daily life all the time - which is why we buy an insurance policy - not because we want to die, but because we need to be prepared for death !

It's much easier to prepare for a negative result before you get the actual beta HCG result. For one, this is just a theoretical exercise, because the hope that the result will be positive is always there. For another, you have time to think about options and Plan B, so you can think rationally and calmly.

If you prepare for a good outcome and get a good outcome, you can pat yourself on your back , send your doctor a box of chocolates, and move on. However, if you prepare for a good outcome and get a negative result, you are likely to find it very difficult to bounce back or think straight for a long time ! It's much harder to deal with a negative outcome when you are not ready for it.

Conversely, if you prepare for a bad outcome and get a bad outcome, at least you know what your next action steps are and you can move on with life. And if you prepare for a bad outcome and get a positive result, then you have twice as much reason to celebrate !

IVF can be an emotional roller coaster ride; and mental preparation gives you some stability to cope with the ups and downs. It's helpful if both partners have different world views, so they can balance each other !

Intelligent patients appreciate my honesty and frankness - they prefer a doctor who will tell them the unvarnished truth. Others , who cannot handle the truth , will usually move on to another doctor who is willing to promise them the moon - and who is happy to tell them what they want to hear !

I see many patients who have failed IVF cycles in other clinics. In order to improve their chances of success, I ask them basic questions about their earlier cycle: How many follicles did you grow ? How many eggs were retrieved ? What was your embryo quality ? Surprisingly, many are quite clueless , and know very little about the medical details of their treatment cycle, because " my doctor did not tell me anything " ! They are often upset and angry- and resentful that their doctor did not share more information with them.

After realising how much their doctor has kept them in the dark, they conclude that they made a mistake in the doctor they selected. They feel cheated and start believing that they can no longer trust any doctor.

One of the reasons for their bad choice is because they did not do any research or homework before starting their IVF treatment. Many people just go to the nearest IVF clinic - or just blindly follow their family doctor's advise.

This is not a happy situation, and ends up hurting both good doctors and patients. It's especially tragic when IVF patients who have had a bad experience refuse to try another doctor, because they then lose the opportunity to take treatment with a good doctor !

When you make a mistake, you should learn from it; forgive yourself; and move on. I tell all my patients - It's OK to make a mistake once - just make sure you don't make it again !

Many IVF patients get very confused about how the doctor calculates the age of their pregnancy
( = gestational age, in medical jargon). Logically, shouldn't it be from the day of the embryo transfer ? After all, it's only after the embryos are transferred that a woman can be considered to be pregnant !

However, doctors are not always logical, and we usually use the menstrual age when talking about the length of the pregnancy. This is because obstetricians usually see women who have got pregnant after having sex in their bedroom. Very few of them will know the exact date they ovulated , which is why we use the menstrual age in clinical practise. This does not change just because you have had an IVF pregnancy - the clinical rules remain the same !

This creates a lot of confusion in patient's minds - especially when they are trying to make sense of their ultrasound scan results or their HCG levels.

Remember that your OB is always talking about the menstrual age - not the age of the
embryo ! This is purely for clinical convenience and is a well-accepted universal convention.

So how do you convert the date of embryo transfer to menstrual age. This is very simple ! The key reproductive event you need to focus on is ovulation ! It makes much more sense to talk about the pregnancy in terms of DPO ( days post ovulation), rather than the menstrual age or the day of the embryo transfer. This is because we can use this landmark for all situations
( including IUI pregnancies; and for Day 3 embryo transfers and Day 5 embryo transfers as
well !)

Since every IVF patient knows the date they ovulated ( = the day of egg collection), it's easy to calculate your menstrual age. Just subtract 14 from your date of ovulation. This is your
" corrected LMP" ( last menstrual period) .

( Corrected) LMP = Date of egg collection minus 14

The reason we do this is simple - it's because text books assume the follicular phase is exactly 14 days ! Once you know your corrected LMP, it's then easy to use this as the anchor, based on which your OB can calculate your gestational age.

This means that the menstrual age will always be 14 days more than the actual age of the embryo.

Confused ? Let's look at an example.

Let's suppose your LMP was 5 Jan; and your egg collection was done on 24 Jan ( let's assume you took a long time to grow eggs); and your embryo transfer was done on 29 Jan ( Day 5 transfer). The HCG pregnancy test will be usually done about 14 days post ovulation ( DPO), which is 7 Feb. If it's positive - say 120 mIU/ml, the doctor will confirm you are pregnant ! This means that even though you are only 14 DPO ( and your embryo's age is only 14 days ) , he will calculate your corrected LMP as 10 Jan ( date of ovulation , 24 Jan, minus 14 days) - which means your clinical gestational age ( or menstrual age) will become 4 weeks ( 28 days) ! Once you understand this " 2 week gap" and the rationale behind it , you'll find it much easier to date your pregnancy !

We were a happy carefree couple, enjoying our freedom to do things that we liked, for the first four years of our marriage. And then when we finally thought of starting a family…. It didn’t happen for another year and we were happy childfree couple. Couldn’t figure out initially what can go wrong, but when we decided to do a reality check, we landed up at a neighborhood Obs&G’s clinic. She ran a few preliminary tests which didn’t point to anything in particular, prescribed few medicines for me. Six months later, the same tests were repeated again, and again. And then I was referred to a urologist for surgery for a suspected varicocele. That’s when it dawned upon us that may be we are knocking on the wrong door!

After a couple of months & a million clicks on the net, we decided to go to a specialist. The research on the net had classified us suffering from “unexplained infertility”. We landed up at Dr Malpani’s in search of explanation. Few new tests were prescribed for my wife and same old ones for me. Everything looked normal to the doc, which was a source of confidence that it would happen sooner or later. We were suggested to try IUI at our local gynec for 3 cycles. There was a hint of sadness creeping up after every unsuccessful IUI. Doubts started cropping up… Did we leave it for too late to start the family? We were back to the drawing board. Dr Malpani assured that everything was ok and he suggested IVF and we decided to go ahead. It’s to the clinic’s credit that the entire process is handled so systematically & in such an organized way that it gives you the confidence that every thing possible will be done, without going overboard,
to make it a success. The entire IVF process went as planned by the doctors and bingo…now we have graduated from being TTC couple to 12 weeks pregnant!

A BIG thanks to both Dr Aniruddha & Dr Anjali and their team!

mum.pgs@gmail.com

All infertile couples know that the sperm plays a vitally important role in fertility. However, there's still a lot of confusion ! If we need only one sperm to fertilise an egg during ICSI, does the sperm count and motility really matter ? And if it does, how and why ?

The fact that the WHO has kept on changing the definition of what a normal sperm count just testifies to the fact that experts are as confused as patients are. This is especially true when we consider 3 contentious areas. While it's true that the sperm provides 50% of the child's DNA, can it be responsible for:
failed fertilisation after ICSI ?
poor qualty embryos ?
miscarriages ?

In order to drill down further into when the sperm can be responsible for reproductive problems, researchers have developed sophisticated tests to analyse whether the sperm are "normal " or not. In the past, the only tests we had available were the sperm count, motility and morphology. These are admittedly crude tests, and the hope was that newer tests which could directly check the functional status of the sperm's DNA would give us more useful information. Logically, since the man's DNA contributes half of the offspring’s genetic material , it is reasonable to assume that abnormal DNA in the form of fragmented DNA ( when excessive strand breaks are present ) may lead to derangements in the reproductive process.

Let's look at some of these tests.

The tests used for the assessment of sperm DNA integrity can be distinguished into direct and indirect. Direct assays try to detect the actual DNA breaks, while indirect assays quantify the susceptibility of sperm DNA to break after an external insult, such as acid treatment. The most commonly used direct assays are; Terminal Deoxynucleotidyl Transferase-mediated Nick End Labeling (TUNEL), Single Cell Gel Electrophoresis (COMET) and In-Situ Nick Translation (NT) assay. The most common indirect assays are; Flow flow cytometric acridine orange assay, Acridine Orange test (AO), DNA Break Detection-Fluorescence In Situ Hybridization (DBD-FISH) and Sperm Chromatin Dispertion test (SCD).

The very fact that it's such a long list is a testimony to the fact that we really do not understand what the results signify in real life. For example, breaks affecting genes in “silent” areas of the genome are unlikely to have any clinical importance, but no assay can evaluate this factor yet.

The truth is that for the present, there is no differentiation between clinically significant and insignificant fragmentation. While it's true that many studies using a variety of assays have shown statistically significant differences in sperm DNA fragmentation between fertile and infertile men, remember that these refer only to the mean or median . In reality, there is extensive overlap between the values found in fertile and infertile men.

Because these tests are so new, they've not been standardised. Clear reference values have still not been established, just adding to the confusion. Just like conventional semen parameters have been proven to be disappointing at predicting the outcome of IVF, sperm DNA fragmentation has been equally disappointing in predicting pregnancy rates after standard IVF and ICSI.

If you have poor quality embryos and your test shows you have increased sperm DNA fragmentation , it's very tempting to conclude that it's the sperm DNA fragmentation which is responsible for the fragmented embryos. However, this has never been proven ; and please remember this is not necessarily cause and effect. Men with higher sperm DNA fragmentation have had completely healthy and normal babies in their bedroom !

DNA fragmentation is a new parameter for the evaluation of male factor infertility . However, just because it is new does not automatically mean it is better ! In fact, at present it just seems to add to the confusion, rather than clarify it !

Many older infertile women are very unsure as to whether they need to do IVF; and if they do need IVF, if they should use their own eggs or to use donor eggs. While they understand with their heads that using donor eggs would maximise their chances of getting pregnant, it's hard for their heart to accept this decision, because most of us want a genetic link with our child !

This is especially true for older women who have regular cycles; grow follicles on ultrasound scans ; or have had a miscarriage in the last 2-3 years. If my cycles are regular and I can get pregnant in my own bedroom, doesn't this prove my eggs are fine ?

Gynecologists ( who do not specialise in infertility treatment) will often add to this confusion. Because they see 42 year old women who get pregnant in their own bedroom, they fail to understand there is a big difference in the biology of a fertile 42 year old and an infertile 42 year old. They will often "treat" these older women with clomiphene and follicular monitoring - causing them to waste valuable time !

The more sophisticated doctors will get their patient's FSH levels tested - and if these are normal, this will lull them into a false sense of security ! Not only are FSH levels very poor markers of ovarian reserve, they also vary from month to month; and if they are checked without also testing the estradiol ( E2) level at the same time, you may get an apparently normal FSH level, even if the ovarian reserve is very poor. ( A high E2 level can suppress a high FSH level into the normal range, and fool both doctor and patient !)

Unfortunately, most older women do not want to hear bad news. They are often in a state of denial and are not happy to listen to an IVF specialist who tells them that their "eggs are bad" ! They confuse calendar age with ovarian age - and are even more perplexed when they go online and read success stories of older women with high FSH levels who have got pregnant in their own bedroom !

Who should they trust ? Is the IVF doctor pushing IVF because he wants to make more money ?
Or is he providing medically sound advise ? Will you regret not doing IVF ? Or do you have an equally good chance of making a baby in your own bedroom ? And what if the IVF cycle fails ? Then what ?

While it's true that we do have better tests today for checking ovarian reserve, such as the AMH level and the antral follicle count , it's hard to make such an emotionally charged decision based purely on the results of medical tests. How reliable are these tests ? Can the results improve with alternative medicine ? herbal supplements ? acupuncture ?

If you are unsure what to do , and are emotionally detached enough to make a decision based purely on medical testing, then please ask your doctor to do a clomiphene citrate challenge test ( CCT) for you. This is a simple , inexpensive test, which provides very valuable information; and has stood the test of time. When it's hard to make a decision and you are confused, sometimes basing your decision on an objective test result can help you overcome your paralysis and move on with your life !

How does one do this test ?

Day 1 = day the bleeding of the period starts

On Day 3 , you need to do a blood test to measure your levels of FSH,LH,PRL and TSH; and AMH ( anti-mullerian hormone). Do this from a reliable lab please !

Take 100 mg clomiphene citrate from Day 5 - Day 9.

Repeat the blood test for FSH again on Day 10.

If the Day 3 plus Day 10 FSH levels are less than 25, then we can try to do IVF with your own eggs.

If the Day 3 plus Day 10 FSH levels are more than 25, this suggests you have ovarian failure,
and that donor egg IVF would be your best treatment option, if you are willing to consider this. A low AMH level will help to confirm this diagnosis.

If you are not sure how to interpret your results , you can ask me for a free second opinion !

For the older woman, time is now at a premium for you - please don't waste it ! When you are 60 years old and looking back at your life, you should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment. Treatment can be expensive, but a baby is priceless !

Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

This is an email a patient from Nigeria sent me today.

" I have set aside this morning to commend you and your beautiful wife on the good work you are doing for humanity. You give hope to the hopeless, healing our wounds of years by showing commitment and concern, even when the situation looks gloomy. You are ready to even pray for mercy and help for your patients! I am impressed.

I have discovered that IVF is a journey. The travellers are the patients, but all of us will have to travel by different means of transportation, The luckiest by air, some by sea, others by road. It means there will be travellers by jet, speedboat, canoe, ships, cars, bikes, rail or even trucks and cartwheels! I am happy you guys are the drivers and my prayer is that the Almighty Creator will always grant you the wisdom to choose the right means of transportation, and the patience/perseverance to convey your travellers to their desired destination.

Please keep up the good work. I love you both and appreciate you."

An IVF cycle is full of uncertainty and suspense , like any other biological system. However, being prepared for these can help you cope better !

Think of an IVF cycle as being a series of hurdles - and you need to cross all these to reach the finish line ! While most patients will cross these hurdles with ease in a good IVF clinic, each of these is a " moment of truth ".

• You should grow many follicles
  
• These follicles should mature
• Your uterine lining should also mature in synch with your follicles
• Ovulation should not occur before the eggs can be collected
• Mature eggs must be retrieved by the doctor during the "pick-up"
• Your sperm must fertilize the eggs ( with IVF or ICSI)
• The embryos must divide and grow healthily in the IVF lab
• Your embryos should be transferred by the doctor smoothly into your uterus
• Your embryos should implant

Think of it as a series of hurdles, all of which have to be cleared , in order to win the race !

As you can see, how well you negotiate these hurdles will depend to some extent on your biology ( how good your ovarian reserve is , for example); while others will depend upon the skill of the doctor !

A good clinic will guide you through these moments of truth, and share information with you, so that you can rejoice when things are going well - and be prepared in case things do not go as planned. Unfortunately, as with any biological system, IVF is also full of ups and downs - and the more you know about what is happening - and what is going to happen next, the more easily you'll be able to go through your IVF treatment !

Everyone knows IVF has a limited success rate and that there are no guarantees in medicine. If that's the case, then why do we offer an IVF guaranteed pregnancy program ?

Is this just a marketing gimmick ?

No ! There are lots of benefits to this option, both for our patients and for us.

For one thing, this option bolsters the patient's confidence levels ! Patients who have failed IVF cycles elsewhere have lost confidence in doctors - and in themselves. Before starting the IVF cycle, most clinics promise the moon. However, when the cycle fails, the patient becomes a leper and the doctor becomes inaccessible ! Finding a doctor who is is willing to put his money where his mouth is helps them to rebuild confidence in the medical system !

This option also helps patients to have realistic expectations of the IVF treatment. For many patients, IVF is their last resort. They are fed up and frustrated and do IVF with a lot of hope that this high-tech expensive method with such a high success rate will finally give them the baby they have longed for for such a long time ! When the IVF cycle fails, this is often the last straw which breaks the camel's back, and they are shattered, disheartened and dis-spirited. This is why the drop out rate with IVF treatment is so high - very few patients have the emotional stamina to do more than 2 cycles. It's true that IVF can be an emotional roller coaster ride, but when patients think of IVF in terms of a single cycle "sure shot" technique, they are setting themselves up for unhappiness. Even worse, by not repeating the cycle, they are depriving themselves of their best chance of having a baby !

The guaranteed pregnancy option is very useful as it helps them to reframe their perspective . They look at the treatment more realistically and realise it's not always a 100 meter sprint. The are willing to work with the doctor - and give the technology enough time and opportunity to maximise their chances of success.

It also helps them to regain control of their life. This option helps them to establish a timeline , so they have a clear road map of what they will do ; when they will do it ; and when they will move on to Plan B. Otherwise, when an IVF cycle fails, many patients are paralysed into inactivity - and they do not have the heart or the stomach to try again ! When they make a 4-cycle commitment upfront, they realise they are in it for as long as it takes , which is far more
realistic !

This option also helps them to move on with their life. Even if they do not get a baby at the end of it, at least they have peace of mind they did their best, in a systematic and well-organised fashion, so they do not have any regrets when they are looking back at the age of 50 !

It also helps to reduce disputes between husbands and wives. Men are from Mars and think only with their heads. Women , on the other hand, think with their heads and their hearts, and this just ends up confusing their husbands. This option ensures both are on the same page - and that they will remain there, even if the cycle fails ! This makes it easier for the husband to console his wife if the cycle fails, because they have something positive to look forward to !

Everyone knows that IVF success rates improve with repeated attempts - and the cumulative conception rate in our clinic after 4 cycles is 87% ! I usually tell my patients - I am very sure we will be able to give you a baby - it's just that I don't know when this will happen, as I am not a fortune teller !

This option is very helpful from a medical point of view as well. It allows us us to learn how the patient responds to the treatment, so that we can continually improve and fine-tune the treatment protocol until we achieve success ! After all, every woman is different, and we need to tailor or protocol to her response - a process which can take time ! This option allows us to learn from each cycle, so we can move closer to the desired goal !

Can we offer this option to all patients ? Sadly, no. We restrict it to patients with a good prognosis, allowing us to create a win-win situation.

Does this make any financial sense for us ? In case the 4 cycles fail, where does the money to pay back the patient come from ? Do we lose money ? No, we don't. In what I think is a way of sharing risk amongst patients by pooling them together, the patients who get pregnant ( and " overpay" us) end up subsidising the treatment of those who fail !

Does this make financial sense for the patient ? Yes, definitely ! For one, it protects you against a future price rise, as you can do your 4 cycles any time you want over a 2 year period. Also, there is no additional cost for freezing your embryos and transferring them. This means that if you have frozen embryos, you get a number of additional free "bonus" cycles - at no extra cost to
you !


We do sign a legal binding contract before we start the treatment, so the patient is protected and secure. While the actual medical protocols we use are the same for all patients, whether they use the standard single cycle pay as you go option, or the guaranteed pregnancy option, over the years we have observed that patients who select this guaranteed pregnancy option have a much higher success rate !