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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 !

A chocolate cyst of the ovary ( also known as an endometrioma, endometrioid cyst, or endometrial cyst) is found in some infertile women who have endometriosis. In this disease, the inner lining of the uterus ( called the endometrium ) grows in various abnormal locations within the pelvis . One of the commonest sites this aberrant endometrial tissue can be found in is the ovary. With every menstrual period, this tissue grows, enlarges , bleeds, and sloughs off . Here it forms a cyst; and because the contents of this cyst are black, tarry and thick, they resemble dark chocolate , hence the name ! ( I feel that sometimes doctors can have a perverse sense of humor . For most women, the word chocolate produces happy feelings, because chocolates are a woman’s favourite treat. To label a disease condition after a dessert is something which only an unfeeling man would do ! )

How is the diagnosis made ? While an alert doctor will often suspect the diagnosis in infertile women with progressively painful periods, often women with chocolate cysts may have no symptoms at all. This means this diagnosis is made during a regular infertility workup ; or even during a routine pelvic examination. While some cysts are large enough to be felt on pelvic examination, many are small and cannot be detected on clinical examination.

Ultrasound scanning is an excellent way of diagnosing chocolate cysts and can pick up cysts which are very small. On scanning, chocolate cysts are complex masses ( which have both solid and cystic components); and are often tender. They have a typical ground glass appearance because they contain old blood. They can vary in size from a few mm to over 10 cm; and can be bilateral. However, it’s not possible to make a definitive diagnosis of endometriosis on ultrasound scanning, as many other conditions can also produce cysts in the ovary. The diagnosis can be confirmed either by aspirating the cyst under ultrasound guidance ( and finding the typical dark old blood which is diagnostic of endometriosis); or by doing a laparoscopy.

In the past, a laparoscopy was the gold standard for making the diagnosis of endometriosis, as this allowed the doctor to actually inspect the pelvic contents. However, because it involves surgery, many infertility specialists no longer do a laparoscopy for their patients.

There are 3 key factors which doctors need to evaluate when making a decision as to how to treat chocolate cysts in infertile women.

1. Whether the patient has any symptoms
2. The size of the cyst
3. The AMH level

Thus, when a small chocolate cyst is picked up when doing a routine vaginal ultrasound scan in a young asymptomatic infertile woman , the best course of action maybe masterly inactivity. This is because this is an incidental finding which is best documented and left alone. Remember that doctors do not treat ultrasound images - we treat patients ! Many fertile young women also have endometriotic cysts which they live with happily for all their lives ( and because they have enough sense not to go to a doctor, they often do not even know that they have a chocolate cyst !) Unfortunately, many doctors tend to be trigger-happy, and when they find a cyst on a pelvic ultrasound scan, they reflexly perform laparoscopic surgery – both to confirm the diagnosis; and to treat the cyst ! The danger is that this unnecessary surgery can actually reduce your fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.


Small cysts ( less than 3 cm in size) can be happily left alone . If they are larger, they can be monitored by serial scans, before making a decision as to what the definitive treatment should be.

As regards treatment choices, the options include medical therapy or surgery. Medical therapy consists of medicines such as danazol or GnRH analogs to suppress the endometriosis; and while this is very effective in providing temporary symptom relief , it is not very effective in treating the cyst, which tends to remain inspite of the treatment.

The definitive solution is surgical; and this usually consists of operative laparoscopy . Very few doctors will now do open surgery ( laparotomy) to treat a cyst, no matter how large it is.
There are many controversies regarding the optimal surgical management of chocolate cyst s in an infertile woman, which is why it is important that you go to an expert. In the past , doctors would try to excise ( completely remove) the entire cyst , to reduce the risk of its recurring . However, because this meant that they needed to also sacrifice normal ovarian tissue during this process, they often ended up pushing infertile patients from the frying pan into the fire by reducing their ovarian reserve and worsening their infertility ! This is why most doctors today prefer to be far more conservative in infertile women with chocolate cysts ; and will usually just create an opening in the cyst wall ( marsupialisation) to drain the contents. This often provides dramatic temporary relief. During the operative laparoscopy, the doctor also has an opportunity to remove the adhesions (scar tissue) and the other endometrial implants which are often found in women with chocolate cysts and treating these can also help to enhance their fertility for a few months. The chances of achieving a pregnancy are maximal within a few months after the surgery. However, if a patient has failed to conceive within one year of the surgery, then the chances of success with repeat surgery are quite poor; and it’s better to consider assisted reproduction.

The major bugbear with chocolate cysts is that they tend to recur. This is why doctors will often combine medical suppression with surgical treatment. However, all these are temporizing measures, which help to buy the patient time – we really do not have any way of curing this enigmatic disease !

If the chocolate cyst recurs, patients are understandably upset, and feel that the doctor was incompetent and did not do a good job with the surgery. This is not always true, because endometriosis can be quite an aggressive disease in some women, and can recur even if the surgeon was very skilled. It’s important to ask for DVD documentation of all surgical intervention, so that the video can be reviewed later on, if needed.

If the cyst recurs, patients will often go to another surgeon ( who they feel is more expert) to try to correct the problem. The pelvis in some of these patients starts resembling a battle field, because they often end up having many laparoscopies done by many different surgeons, each of whom claims to be the best ! The surgery can be extremely challenging in these patients . The scarring , adhesions and previous surgery tend to distort the anatomy and the pelvis sometimes is completely frozen. Operative complications in these cases ( for example, inadvertently opening the bladder or rectum) are not uncommon.

The AMH level is a very important factor which many doctors tend to overlook in treating infertile women with endometriosis. The major danger with endometriosis is that the chocolate cyst replaces normal ovarian tissue, as a result of which many of these patients have little normal ovarian tissue and poor ovarian reserve as a result of their disease. This is why it’s important to assess your ovarian reserve by checking your AMH level and your antral follicle count before doing anything further ! If your AMH level is low, then it’s best to avoid surgery and to move on to IVF to maximize your chances of having a baby quickly ( before the disease becomes worse and eats away more of your precious reserve).

For young women with normal ovarian reserve, open fallopian tubes ( as proven on HSG) and small chocolate cysts who have no symptoms, it’s worth trying IUI before doing anything more aggressive. However , if the patient is symptomatic and the endometriosis is causing pain, then this become a trickier issue ! You need to set your priorities – is pain control more important ? Or is having a baby more important ? This is often a difficult decision to make, but you need to decide. It’s best to make a list of all your options so you can think through these logically.
If having a baby is key, then it’s best to manage your pain symptomatically and concentrate your energies on getting pregnant quickly. IVF is very effective , as it maximizes your chances of getting pregnant quickly . The beauty with IVF is that it allows you to kill 2 birds with one stone – not only do you get your deeply desired baby, you also have dramatic pain relief for at least 1 year ( because your periods will stop during your pregnancy and your postpartum period ). As an added bonus, the endometriosis will also get better as a result of the pregnancy in some women ! This is why many doctors advise that the best treatment for a young woman with endometriosis is a pregnancy. Of course, this is easier said than done, because endometriosis does affect your fertility !

Do you have a chocolate cyst and are unsure what to do ? Send me your medical details by filling in the free second opinion form and I'll be happy to help !

There are major disadvantages to the cut system. For one, this system increases the cost to the patient. It also promotes malpractice, because family physicians often pressurise specialists to do surgery in order to maximise their revenue, which means that procedures are done, which are not always in the patient's best interests. Because this practice is hidden, it's never discussed openly, and this creates a lot of resentment amongst patients.

The fact that doctors indulge in giving kickbacks is an open secret - and hiding this reality creates a lot of suspicion in the patient's mind. “This is one of the major reasons patients do not trust their doctors, and why the reputation of entire medical profession has taken such a beating in recent years,” says Dr. Malpani.

One thing I like about the web is that it forces doctors and hospitals to be transparent. This empowers patients with information.

Patients often find it hard to find out how much medical procedures and surgery cost - and they have to doctor shop to find a hospital which they can afford. Also, many doctors are very reluctant to discuss costs - and some are very creative about their billing practises !

It's very helpful for patients to have a benchmark so they know what the "market rates" are. This way they do not suffer from "sticker shock" - or get taken for a ride by an unscrupulous doctor.

It's good to see that hospitals are now publishing their charges for the various medical procedures they offer online !

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Today I saw a 28 year old woman who was worried because a 1.0 cm size uterine polyp
had been diagnosed on a vaginal ultrasound scan, and two gynecologists had advised that she needed to have surgery to remove this . She wanted a third opinion, because she was understandably reluctant to go through this surgery. A polyp is a benign finger-shaped outgrowth of the uterine lining, and is quite commonly found in young women.

The patient had no complaints . The polyp had been detected while doing a routine vaginal ultrasound scan during her annual health checkup ! This was an incidental finding, which was not causing her any problems, but when most doctors are confronted with an " abnormality " the "knee-jerk" reflex response is - "fix it ! After all, if you have a hammer, you are likely to see nails everywhere !

I am a conservative doctor, and I told her that no action needed to be taken at this time. The best course of action would be - masterly inactivity or watchful waiting. Now I am a senior doctor, and am comfortable advising patients that they do not need "treatment" for everything which a scan picks up, but I seem to be in the minority these days !

I feel the problem is that doctors only see patients with problems ! They do not see healthy people at all, and sometimes I feel most doctors would not be able to diagnose a healthy person if they saw one ! Infertility specialists only see infertile women, which means that they unthinkingly assume that every problem they find during their diagnostic testing is the cause of the patient's infertility and needs to be " fixed" . However, this is flawed thinking. The truth is that we we do not know the natural history of many of these conditions. Thus, we do not know how many fertile women have polyps - after all, most normal women have enough sense not to go to a doctor !

This means that we tend to over-diagnose and over-treat. Sadly, taking a second opinion does not solve the problem because most doctors will give the same advise - treat it ! After all, it's much more more profitable to treat it than to leave it alone. Incidentally, this is perfectly acceptable medical practise, and would not be considered to be unnecessary surgery, because most textbooks do advise that polyps need to be removed and most doctors are quite happy following these textbook recommendations ! For one, they can just follow the protocol blindly, which means they do not have to apply their mind or individualise their advise for the patient's unique circumstances - something which takes time and energy ! Modern medicine believes in protocols and guidelines, which leaves individual doctors with very little freedom to make decisions for special cases. Everyone has to be squeezed into the protocol, no matter what ! It's much safer for doctors to do this, as they cannot be criticised for following accepted guidelines. Sadly, there is no incentive for doctor to not do anything !

I think we need to remember that we do not treat ultrasound images - we treat humans ! The exact same polyp seen on an ultrasound scan in a 34 year old infertile woman needs to be managed completely differently as compared to a 29 year old asymptomatic woman !

Aggressive over treatment can have a downside , because it can end up creating more problems ( for example, operative hysteroscopy for polyp removal can result in infection or bleeding). The trouble is that our machines for making a diagnosis have become much better , and because the technology is so good, it's very easy to pick up normal variants and label them as an abnormality ! It's also easy to offer to treat, because modern treatment is minimally invasive , and does not involve scars or hospitalisations , which means that doctors are more willing to intervene !

However, remember that no surgery is minor for the patient which means patients are often confused. They are fine, so they are reluctant to do under the knife. However, their mind starts playing games with them; and when two different doctors advise surgery, most are happy to toe the line. They often feel - thank God the doctor diagnosed the " problem " early , before it became a major issue - let's fix it now when it's small !

Sometimes it's best to leave well alone - but it requires a mature doctor - and a mature patient - to be able to do so !

We all know that prevention is better than cure, and this is one of the reasons that executive health checkups have become so popular. They promise to help your doctor to pickup medical problems early , so they can be treated more effectively.

Unfortunately, even though the logic is very appealing, the sad truth is that in real life, health checkups are good for hospitals and diagnostic centers, but not for patients ! In fact, most doctors never do a health checkup for themselves , because they know how useless they are !

So what is your doctor not telling you ?

Let's look at why hospitals promote health checkups so aggressively. The checkup is great way of converting well people into patients; and creates a constant stream of customers for the healthcare system.

How ?

It's a mathematical certainty that if you run a sufficient number of tests , you are bound to find abnormalities. Once you find an abnormality, then the person is snared into the healthcare system, and the vicious cycle starts.

Abnormality = more tests = more consultations = more treatment - more surgery, often unnecessary

Let's consider a 40 year old asymptomatic woman who goes for a deluxe super-duper health checkup at a local 5-star hospital. Because she has opted for the Platinum scheme, the doctors does a vaginal ultrasound scan to check her uterus. She finds a 4 cm fibroid and then advises the patient to undergo surgery to remove it. Since most patients are ( understandably !) reluctant to undergo surgery, the soft-sell is that this is going to be " minimally invasive" surgery done through a laparoscope, so that there is no cut and this can be done on a day-care basis. Also, the insurance will pick up the tab !

It's very common to do this for ovarian cysts as well. Cysts are very common in women; and most are functional and will resolve on their own. However , the doctor scares the patient into doing surgery, using a number of fear-inducing techniques, such as : it may increase in size; it
may burst; or, it may become cancerous. The sonographer is also a part of this scam, and magnifies the findings by highlighting them and by reporting the size in mm, instead of cm ( a 4 cm cyst is reported as a 40 mm cyst , to make it seem bigger !)

The truth is that you cannot make an asymptomatic patient happier - and if she has no complaints to start with, she most probably does not need any intervention at all ! The right advise would be masterly inactivity. However, few doctors have the maturity to advise this.

In fact, they tell the patient that thanks to this checkup, they have picked up a problem which could have snow-balled in the future. The amazing thing is that patients are happy when an abnormality is picked up ( they can justify the money they spent on the health checkup !). Most patients are very pleased that the problem was spotted before it became a major issue.

The truth is that most of these so-called abnormalities are not really problems at all - they are just incidental red herrings discovered with modern medical technology, which the patient would have happily carried to her grave if she had been unaware of them.

All this overtesting is leading to an epidemic of overtreatment. Is this going to change ?

No - it will just become worse as time goes by. Thanks to better technology , it's becoming easier and cheaper to produce high quality images of practically any nook and corner of the human body. However, better pictures does not equal better clinical outcome. A lot of these images will pickup problems, which are just anatomical variants, but which will be "treated" by over-enthusiastic doctors. There is too much money at stake !

Also, remember that if an "abnormality" is detected, it requires a very courageous doctor to advise against treating it with surgery ! In reality, it's s much easier for the doctor to advise surgery and "fix" the problem. After all, if he does the surgery, no one will object ( whether the surgery was needed or not is never discussed). Find a problem - fix the problem, is a common knee jerk response. It's also much more profitable for him !

However , if he advises against surgery and the problem worsens over time ( as it will in a very small minority of patients), the patient is quite likely to sue the doctor for not taking care of it when it was first pointed out ! Even good doctors will advise surgery to protect themselves, even when they know in their heart of hearts that this surgery is not in the patient's best interests !

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Many women with blocked tubes go in for IVF treatment . Some of them have a hydrosalpinx, in which the blocked tube is filled with fluid. It has now become standard advise to remove the hydrosalpinx or to clip the blocked tube prior to IVF. This needs to be done by performing an operative laparoscopy ; and this procedure is supposed to improve IVF pregnancy rates ( because the hydrosalpinx fluid is toxic and can prevent the embryos from implanting.)

Most gynecologists are happy to advise this surgery before referring the patient for IVF, because this is an additional surgical procedure for which they can charge the patient. In reality, however, this unnecessary surgery can actually end up causing harm.

For one, it leads to overtreatment. In many IVF clinics, all blocked tubes are surgically removed prior to IVF, even if the hydrosapinx is very small ! This has never been proven to be of any benefit ( the original study only selected patients with a large hydrosalpinx) , but sadly patients are not well informed enough to ask questions and most are quite happy to sign on the dotted line. However , as is true of all surgical procedures, even this "minimally invasive surgery" carries a risk. This surgery can impair ovarian blood flow and reduce ovarian reserve.

In reality, there is a much easier way of ensuring that the hydrosalpinx fluid will not affect the embryos when they are being transferred . At the time of egg collection, the hydrosalpinx can be aspirated under vaginal ultrasound guidance. This means that when the embryos are being transferred into the uterus 3-5 days later, there is no toxic fluid in the hydrosalpinx to harm the embryos . This is a simple, zero-cost, non-surgical solution which ensures that the hydrosalpinx fluid will not affect embryo implantation or IVF success rates !

Today, very few Indian doctors have their own website and I find this quite surprising ! Indians are meant to be leaders in IT, and Indian doctors are usually quite smart and entrepreneurial! Let's look at some of the reasons as to why the internet presence for Indian doctors is so low.

Why do most Indian doctors not see any value in having their own website ?

* I have practised successfully for many years without one, so why should I bother ? * Why should I take the trouble of having a website when most of my colleagues
don't have one either ?
* It's an unnecessary expense and will not add any value to my practise
* Isn't it unethical ? Isn't it the same as advertising ?
* It may be fine for some fancy doctors, but most of my patients do not use the computer, so why should I bother about a website ?
* I do not understand all this high tech computer business and email, so I'd rather not get involved in something which is beyond me.

I feel this is a big mistake.

Most successful doctors in India today do have their own websites . This is especially true for high end high profile medical services, such as IVF , cosmetic surgery and dentistry.

Websites serve many useful purposes.

* They are an important way of acquiring new patients. These patients are usually the best kind of patients to have because they are well-off and can afford to pay. Even more importantly, you do not have to pay a referral fee or kickback to the referring doctor !
* A website is very cost effective. If you are a cardiac surgeon and your website gets you even one more additional new patient, you have recovered the cost of your site !
* It's a great way of providing additional services to your patients. You can educate them; offer them a personal health record ( PHR); and send them reminders when their followup visits are due, by SMS and email
* Today, even if most patients do not have a PC, practically all of them have a mobile ! It's possible to reach out to them through their mobile using your website !

Times are changing - and those doctors who get left behind will have a very hard time catching up !

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I saw a patient who wanted a third opinion. She was completely confused. As part of her infertility workup, she had had a HSG ( hysterosalpingogram) done. The X-ray showed that her uterine cavity was normal; the dye filled the fallopian tubes , but the spill into the abdominal cavity was loculated.

When she saw her doctor with the report, he told her that this suggested that there were adhesions around the tubes, and she needed an operative laparoscopy to treat this. Another doctor, to whom she had gone for a second opinion advised her against the laparoscopy. He felt that since the tubes were open, her best option would be to do an IUI, to improves the chances of the eggs and sperm meeting. This patient then sought a third opinion, which is why she came to me !

The first thing I did was to ignore the earlier opinions, and asked to see a copy of the original HSG X-ray films, so I could make up my own mind . Unfortunately, there was only one film, and this was of poor quality . The radiologist had done a sub-optimal study, because he had not taken any delayed films ( perhaps to save some money ?), as a result of which it was hard to draw a firm conclusion based on the HSG films. This meant were now back to square one.

The choices were; repeat the HSG; do a laparoscopy; or assume the tubes were fine and proceed with treatment. Each has advantages and disadvantages, and patients need to think their way carefully through their choices, so they can make the right decision. Unfortunately, most patients are not used to making choices regarding their medical treatment. Even worse, most doctors are not comfortable offering these choices to their patients. "The doctor knows best" is the model most patients ( and doctors) are happy to adopt - which means that often the wrong decision is made ( and usually for the wrong reasons).

We could repeat the HSG in a better clinic and make sure that it was done under fluoroscopic guidance and that delayed films were taken. While this option would give a much better X-ray image of the tubes, she was understandably reluctant to repeat the HSG. This is quite a painful procedure - and few women have the courage to do it again !

Laparoscopy is a surgical procedure, which means it costs more; however, the quality of the documentation is much better, because the surgeon can take videos of the pelvic anatomy. However, it cannot provide information on tubal function - which is really the only thing the patient wants to know - are my tubes working properly or not ?

Doing a laparoscopy was an option - but this is an expensive surgical procedure - and while it provides useful diagnostic information, it often does not change treatment options , which is why we are very reluctant to perform this in our clinic. What's the point of doing a test if it does not impact treatment alternatives ?

So what are patients supposed to do when their doctors disagree ? Some of them get very angry and upset when doctors do not see eye to eye ! I actually feel it's good for patients when doctors disagree. Each doctor will present his point of view and justify why this is better than the alternative proposed by the other doctor . The patient gets to see the pros and cons of both options, so she can make a better-informed decision !

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Endometriosis is one of the commoner problem infertility specialists see. It is common in young women, so this is hardly surprising - but what is amazing is the amount of confusion and controversy it causes amongst infertility specialists.

There are many treatment options, but for treating endo in an infertile woman, doctors have to choose between endoscopic surgery; or IVF.

Most gynecologists like operating. They feel that it's obvious that the mechanism by which endo causes infertility is anatomical; and that surgically removing the lesions and the adhesions should fix the problem and restore fertility. Surgery is often less expensive than IVF - and if normal function is in fact restored after surgery, than you can make a baby in your own bedroom ! This is a common approach but is flawed because it is not an accurate representation of reality. After all, surgical correction can restore anatomy , but not function !

IVF specialists see many patients with endo who have had repeated surgeries, but have never been able to get pregnant. Because an operative laparoscopy is "minimally invasive" surgery and so easy to repeat, many surgeons just keep on doing it again and again ! Patients will often move from surgeon to surgeon, each of whom will promise to " fix the problem " by using the latest gizmo or toy they have just purchased , whether this is a laser , a bipolar cautery or a harmonic scalpel. Surgeons are nortoriously macho, and often believe they can do a much better job than the earlier surgeon ! The poor patient is subjected to surgery after surgery, until her belly resembles a battle field - but with nary a single positive HCG in sight !

So does that mean all patients with endo should be referred to IVF specialists for IVF treatment ? Of course not ! This would be overkill , as many patients with minimal endo can be treated with simpler treatment options.

If you go to a gynecologist or endoscopic surgeon, the odds are he will advise surgery. And if you go to an IVF specialist, he will advise IVF ! After all, if you have a hammer in your hand, all you see are nails !

So how is the patient to decide which is the best option for her ? Some will take an opinion from multiple doctors - and end up getting thoroughly confused, upset and frustrated !

The trick to finding out what your best plan of action is actually quite surprising - you need know what your ovarian reserve is ! Unfortunately, this is something very few patients know about - and very few doctors bother to check !

Your ovarian reserve is a marker of your fertility and gives us an indication of how many eggs you have left. It declines with age; is negatively impacted by endometrisis; as well as the surgery which is done to treat the endometriosis ! Unnecessary surgery reduces your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your impaired ovarian reserve even further .

The best test for your ovarian reserve is a blood test to check your AMH levels.

If you are older and/or have low AMH levels, then it's far better to not waste time with surgery, and move on to IVF directly . This is also true if your husband has a low sperm count.

However, if you are young and have normal AMH levels, it is quite reasonable to attempt reconstructive surgery to treat the endometriosis before considering IVF, which is usually much more expensive than surgery ! If you do choose to have surgery, make sure your doctor checks your AMH levels before and after the surgery ! Many doctors do not bother to do this - and this can reduce your chances of having a baby !

Medical Flying squads were created in order to handle medical emergencies . They were first developed by obstetricians, and a team of medical personnel was rushed to help women with complicated labours and childbirths. They were very useful and were responsible for saving many lives .

While flying squads are no longer very common, the Ahmedabad Medical Association has created a new concept of medical flying squads to help doctors who are faced with unexpected complications or emergencies.

One of the nightmares for any doctor in practise is an intraoperative emergency or complication. Unfortunately, no matter how careful and competent the doctor, it is a sad fact of life that complications will occur. For example, a patient may have a cardiac arrest during a minor surgical procedure; or a patient may die because of uncontrolled bleeding during a caesarean section.

When this happens, angry relatives and friends ( often goaded by goons ) will take matters in their own hands. There are now many instances where doctors have been beaten up and hospitals have been damaged, when these kinds of incidents occur. Doctors feel vulnerable and defenceless - and this has led to a rift between doctors and patients. Doctors will often turn away emergency cases because they do not want to take a risk in case the patient does not do well.

Unfortunately, the police are of little help in such emergencies. They will often fail to turn up - or even when they do, they often refuse to intervene or protect the doctor.

Even more significant than the physical damage these incidents cause, it is the irreparable harm they do to the doctor's psyche and his reputation which are especially worrisome. The doctor's broken bones will heal - but a good reputation created over a lifetime of providing good medical care goes down the drain in a few minutes. The media is quite happy to add fuel to fire, by reporting on the " doctor's gross medical negligence", without ever bothering to find the facts.

These incidents have an impact on other doctors as well, who then develop an patient-unfriendly attitude. Rather than treat each patient encounter as an opportunity to serve and heal, each patient is seen to be a potential adversary !

On a recent visit to Ahmedabad, I was very impressed to learn about a very clever initiative which the Ahmedabad Medical Association, an organisation which is now over 108 years old, has developed. Rather than depend upon the police to help them in their time of need, doctors have banded together to help each other.

The Association is remarkable for the sense of unity and camaraderie which exists amongst its members ! Practically all doctors in Ahmedabad are members - both family physicians and specialists. They have set up a medical flying squad, which consists of a group of senior doctors, who will rush to the aid of any doctor, no matter what time it is, whenever they receive a distress call.

An intraoperative emergency or complication is every doctor's nightmare - especially when this occurs in a small private nursing home. With this kind of backup service available, doctors in private practise can rest assured that help is just a phone call away !

Not only does the squad provide valuable medical assistance and a useful second opinion in handling the emergency, they provide a cool head to assist the doctor, who is often scared witless when the patient has a complication. This group of doctors provides reassurance to the relatives, that their patient is getting the best possible medical care from the leading specialists. They help to maintain peace and order - and can also organise police support if needed, as they are respected citizens who are held in high regard.

I think this is a great service and this is a model all Medical Associations all over the country can learn from. Senior doctors - including those who have retired, can offer to serve on these Flying Squads. Not only will this help them to keep gainfully occupied, it will also help them to earn a lot of respect and goodwill. After all, if doctors do not help each other, then who will ?