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Along with watching the video, you can now also read the transcript - it's just below the video !

" What can I do to improve my chances of success ? " As an IVF specialist, this is the commonest question patients ask me.

The following are the 5 key ingredients which you can contribute to the success of your IVF cycle.

1. Faith and trust. It's important that you be able to trust your doctor. Not only should you be confident about your doctor's technical competence, you should also feel secure that he cares for you; respects your desires; listens to your fears and worries; and will be available to give you a shoulder to cry on when you need this . Make sure your chemistry with your doctor is good. Does your doctor encourage you to ask questions ? Takes time to clear your doubts ? This is a tall list, and most doctors are human , so they are likely to fall short. However, in a good clinic, the IVF team should be able to bolster your confidence that you are in good hands.

Remember that your doctor needs to earn your trust . Don't give it away easily ! " Trust - but verify " should be your philosophy !

2. Smiles. Being optimistic helps to improve success rates. It's not that pessimistic patients don't get pregnant - it's just that patients who smile get better care from the medical team - and everything you can do to improve your odds is worth doing !

3. Being well informed ! Do your homework, so you have realistic expectations from your treatment. Ask questions and take a guided tour of the facility. Request your doctor to show your follicles on each scan - and ask to see photos of your embryos. Well informed patients get better medical care because they ask intelligent questions. Insist on a medical treatment summary at the end of the IVF clinic - this is valuable documentation and keeps everyone's interests aligned . Poor documentation suggests you have received poor medical care !

4. Money. It's true that IVF treatment can be expensive, and you need to be prepared for this. Selecting an IVF clinic which offers a shared risk/ refund program can help you reduce your
risk !

5. Good eggs, good sperm and a good uterus. I know this is asking for a lot, but patients who have good protoplasm have a much better chance of success. It's true that if you are 43, there's little you may be able to do to turn back the biological clock. However, simple self-help measures can make a world of a difference ! Stop smoking; make sure you are fit and have a healthy diet; and take supplements to help optimise your egg and sperm quality. Every little bit helps !

If your eggs and sperm are just not up to the mark, keeping an open mind and exploring the possibility of using third part reproduction can help you achieve your goal of having your baby.

The outcome for any IVF cycle is always uncertain - but taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

Being infertile is stressful and going through an IVF cycle can be even more so because so much is riding on the outcome of the treatment. An IVF treatment cycle is much more than just a medical procedure, because there are so many hopes, dreams and desires wrapped up in the treatment.

However, the biggest emotion is often that of fear ! What will I do if the IVF cycle fails ? Is there any hope of my ever having my own baby if even IVF fails ?

I feel it's the unrealistic expectations which cause the most stress . Most patients who start an IVF cycle refuse to even consider the possibility that the treatment may not work. They have been brainwashed into " thinking positive" , so they refuse to remember that the chances of the IVF failing for a given patient in any cycle are more than the chances of success !

Most of them keep on repeating the mantra - It's got to work ! It will work ! There are lots of family-members and friends who are hoping and praying for success as well, so everyone is on an emotional high during the treatment cycle, because they need to keep each other's hopes up. The truth is that no one would ever start an IVF cycle if they did not feel in their heart of hearts that it was going to work for them.

This is why patients arm themselves with prayers and lucky charms before and during the IVF treatment. While the IVF process is straightforward - grow eggs; make embryos; and then transfer these into the uterus , the outcome is always uncertain. This is because implantation - whether the transferred embryo will become a baby or not - is a biological process which no one can influence. Along with medical expertise and good protoplasm, it also requires a large dose of luck - the one intangible no one can control !

The truth is that no one can ever be sure of the outcome of the IVF cycle, which is why you need to keep your expectations realistic ! While you cannot control the final outcome, if you have peace of mind you did your best, you will find it much easier to manage your stress levels during your IVF treatment !

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

IVF, or In Vitro Fertilization (also known as a test tube baby) is a medical treatment that fertilizes the egg cells by the sperm outside the uterus. IVF is currently the most successful treatment option for infertility .

IVF is usually used after other simpler treatments have been unsuccessful. The process requires the woman to begin hormone therapy for superovulation, to help in the production of multiple eggs. These eggs are then removed from the woman’s ovaries , and are combined with sperm in the IVF lab, where the fertilization process occurs. Once the eggs are fertilized, the resulting embryo is transferred to the woman’s uterus , and if it implants, then a pregnancy is established.

When IVF is used for treating male infertility (caused by sperm which are defective and are unable to fertilise the egg, a variant of IVF called intracytoplasmic sperm injection (ICSI) is used. ICSI is the process in which the sperm is inserted directly into the egg cell using a micromanipulator, allowing the sperm to fertilise the egg.

Healthy eggs; sperm ; and a normal uterus are the three key elements that must be present for a successful In Vitro Fertilization. In the past few years, pregnancy rates have greatly improved as a result of IVF treatment; and in good clinics, they are as high as 46% pr cycle. The key is to find a reliable clinic which has a high success rate ; and a dedicated and experienced IVF team.

Want to find out if IVF can help you to have a baby ? Ask for a free second opinion from Dr Malpani, a leading IVF expert, at www.drmalpani.com/malpaniform.htm .Taking treatment at a world-class clinic will maximize your chances of success and give you peace of mind you did your best !

Blocked fallopian tubes are one of the commonest causes of infertility. The fallopian tubes project out from each side of the body of the uterus and form the passages through which the egg is conducted from the ovary into the uterus. The fallopian tubes are about 10 cms long and the outer end of each tube is funnel shaped, ending in long fringes called fimbriae. The fimbriae catch the mature egg and channel it down into the fallopian tube when released by the ovary .

The tube itself is a muscular highly movable structure capable of highly coordinated movement. The egg and sperm meet in the outer half of the fallopian tube, called the ampulla. Fertilization occurs here, after which the embryo continues down the tube toward the uterus. The uterine end of the tube, called the isthmus, acts like a sphincter, and prevents the embryo from being released into the uterus until just the right time for implantation, which is about 4 to 7 days after ovulation.The fallopian tube enters the uterus at its cornual end.

The tube is much more complex than a simple pipe, and the lining of the tube is folded and lined with microscopic hair like projections called cilia which push the egg and embryo along the tube. The tubal lining also produces a fluid that nourishes the egg and embryo during their journey in the tube.

Fig 1. Normal tube and ovary, as seen during laparoscopy

Remember that a doctor cannot judge if your fallopian tubes are open or closed either by an internal examination; or a vaginal ultrasound scan. Unfortunately, this is a very common mistake many patients make, and they assume that if the scan is normal, this means their tubes are open. This is not true. Sadly, many doctors also make the assumption that the fallopian tubes are open, without bothering to test them. Thus, some doctors will assume that a young woman with polycystic ovarian disease must have open tubes, and they start treating her with clomid, without bothering to test the tubal status. This can sometimes be a very expensive mistake ! Just because you have had no symptoms of a pelvic infection does not mean that your tubes cannot get blocked; and if the tubes are blocked, this means the eggs and sperm cannot meet, no matter what medicines you take. This is why it is essential that you ask the doctor to formally test your tubal status before starting any treatment.

The only reliable ways of testing if your tubes are open or closed is by doing either a HSG or a laparoscopy. Personally, I prefer a HSG, because it is much less expensive and provides hard copy documentation.

If a tubal block is found, then what are the next steps ?

The first question is - Are both the tubes blocked ? If only one tube is blocked, then there is no need to take any action at all ! One normal tube is enough for normal fertility. If one tube is open and your doctor advises you to have surgery to open the other tube, please do not agree !

The next question is - Where is the block ? The block could be at the terminal ( fimbrial) end of the fallopian tube. This often causes the tube to get swollen with fluid, and form a hydrosalpinx. In the past, doctors would perform tubal surgery to open this kind of blocked tubes. However, the results were very poor. The tube would usually close down again; or would never function properly, because its inner lining was damaged - damage which cannot be repaired by surgery. Some of these patients would then go on to have tubal ( ectopic) pregnancies.

If the tube is blocked at the cornual end, it's sometimes possible to repair these tubes. Sometimes the block is not a real block, but just an apparent block because of tubal spasm . Sometimes the block is because of a mucus plug or debris, and this can sometimes be cleared with the help of FTR ( fluoroscopic tubal recanalisation). This is a bit like doing an " angioplasty " for the fallopian tube ! ?

Remember that it's impossible for a doctor to judge tubal function. While we know that a blocked tube will not work, it does not follow that an open tube ( which may look perfectly normal anatomically on the HSG or the laparoscopy) is in fact capable of functioning normally ! Sometimes the doctor says the spill of dye is "sluggish"; or that "the tubes filled slowly"; or that they have a beaded appearance. These are just descriptive terms, and often cause more confusion rather than clarity !

Finding out your tubes are blocked can be quite a blow. Because tubal disease is often silent, there is no way of suspecting tubal blockade prior to doing the tests. Blocked tubes will not affect your menstrual cycle, your health or your sexual life, but they will prevent you from having a baby !

While the results of tubal surgery to repair blocked tubes is poor, the good news is that it is possible to offer very effective treatment for this problem today, thanks to IVF, which allows us to bypass the problem completely ! In IVF, the test tube in the IVF lab performs the role the fallopian tube would normally perform in the bedroom !

If you have a hydrosalpinx , some doctors will want to surgically remove this prior to performing IVF. I do not think this is a good idea at all !

I saw a patient who was at her wit's end. She had already had two laparoscopies for treating endometriosis. Since she was still not pregnant, she had gone to a third gynecologist. He did an ultrasound scan and found that the chocolate cyst had recurred; and was advising her to undergo a third surgery to "fix" the problem.

We find this is a very common tragedy which plays out frequently. The diagnosis of endometriosis is often done by the first doctor, while doing a diagnostic laparoscopy. He "treats" the problem by burning off the lesions, and dividing the adhesions. When the woman does not get pregnant after this, she gets a second opinion from an expert. This expert often pooh-poohs the surgical skills of the first doctor, and suggests that he needs to do another laparoscopy, in order to do a better job, to fix the problem once and for all ! The patient regrets having allowed the first doctor ( who appears to have not been very competent in hindsight !) to do the laparoscopy. She signs up for the second surgery and is now very hopeful. The doctor does the laparoscopy and "cleans" up everything - and shows her a beautiful video which demonstrates his surgical prowess. He then puts her on medications, and then tells her to "go forth and have babies " in her bedroom ! She is often quite happy for a few months, because her pain has now improved, and her symptoms are much better. However, when she still does not get pregnant, she goes back to him. Unfortunately, he has lost interest in her problem, because he is primarily a surgeon, and when you have a hammer, all you see are nails. He gives her some more medicines, and tells her to relax, go for a holiday and have more sex. When this also fails, she goes to a third doctor, who then finds the endometriosis has recurred; and suggests that he needs to do another laparoscopy, where he will compensate for the surgical shortcomings of the earlier surgeon, by using the " newest and latest " third generation laser and robotic equipment, which are available only in his clinic !

The sad truth is that endometriosis recurs, no matter how good the surgeon. We can never cure it - and even our treatment leaves a lot to be desired, because of our limitations ! This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Let's go back to my patient.

" What do I do now , doctor ? I am completely fed up ! How do I manage my pain ? And what about having a baby ? "

I explained to her that she needed to set her priorities. " Which is more important right now ? managing the pain ? or having a baby ? We can't do both together - we need to do this one step at a time !"

" For me, having a baby is my first priority doctor".

" Fine, then let's focus on getting you pregnant. Let's forget about the pain and the endometriosis for now . The reason you are not getting pregnant is because your eggs and sperm are not meeting in your fallopian tubes. We need to get the eggs and sperm to do so; and we need to use assisted reproductive technology in order to do this."

The next step is to check the AMH level, to determine what the ovarian function . For young patients with a normal AMH level, the next step would be 3 cycles of superovulation with IUI. However, for older women; those with low AMH levels; and if the IUI fails, then the best course of action is IVF. After all, we need to find solutions , not waste time looking for problems !

Is there any need to surgically remove the endometriosis prior to doing IVF ? No ! The endometriosis is outside the uterus and will not affect embryo implantation, so it's best left alone.
If there is a chocolate cyst, we can always aspirate ( puncture) it under ultrasound guidance, when starting the IVF cycle.

The good news is that an additional bonus with this approach is that once you get pregnant, the endometriosis will also automatically improve !

Many infertile couples are very confused about how their treatment. Unfortunately, many gynecologists add to their confusion. Thus, if an infertile woman is found to have endometriosis, they will spend a lot of time, money and energy on "treating " the endometriosis with medicines. Similarly, the woman has irregular periods, they will concentrate on trying to "regularise the cycle" !

Why are these approaches flawed ?

The truth is that we really do not have any effective treatment for endometriosis. This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Similarly, patients with irregular cycles are often very poorly managed. Many patients are unsure about the relationship between their irregular cycles and their fertility, and consider this as a chicken and egg problem. They naively believe that once the cycles are regularised, they will then get pregnant in their own bedroom ! After all, if the reason they are not getting pregnant is the fact that their periods are irregular, then surely fixing the irregularity problem will them to have a baby ! Many doctors also seem to subscribe to this belief, and will regularise the cycles by putting these infertile couples on birth control pills ! While this will regularise the cycle while they are taking the pills, this is hardly helping them to have a baby ! They obviously cannot get pregnant while taking the pill - and once they stop the pill, their cycles continue remaining irregular, because they are still not ovulating !

If you are infertile, how can you make sure your doctor is providing you with the most effective treatment ? The answer is surprisingly simple ! Remember, that the reason you are infertile ( no matter what your actual diagnosis is !) is the fact that your eggs and sperm are not being able to meet. The question you need to ask is - what is the doctor doing to increase the chances of the eggs and sperm meeting ?

Thus, if he is simply suppressing your endometriosis with drugs; or regularising your cycles with birth control pills, he is wasting your time and not doing a good job ! We need to look for solutions - not waste time in finding problems which maybe irrelevant . Fortunately, our technology for bypassing problems ( even without identifying them precisely ) is better than our technology for identifying problems !

Remember, the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby ! The quality of a doctor’s answers depend upon the quality of the patient’s questions !

Not sure if you are on the right track ? I'll be happy to provide a free second opinion ! Send me your medical details by filling in the second opinion form, and I'll be happy to help !

Being infertile is stressful - and going through an IVF cycle can be even more stressful, because so much is riding on the outcome of the treatment. While the actual medical treatment in an IVF cycle ( shots, scans , pickup and transfer) is not physically taxing, the emotional demands ( because of the hopes, dreams, desires, fears which are such an integral part of all infertility treatment ) can exact a huge toll.

The one factor which causes the most stress is having unrealistic expectations . Every patient feels in their heart of hearts that " this is the cycle when it's going to work !" - and I do not think any one would ever start an IVF cycle if they did not feel it was going to work. Unfortunately, the only thing which is in your hands is the process. You can make sure you have a competent and caring doctor; and your doctor can make sure he provides you with high quality medical care. Sadly, no matter how good your prognosis; how good your doctor; and how perfect your IVF cycle, the outcome is always uncertain.

While we are good at growing eggs; making embryos; and then transferring them into the uterus, whether the embryo will become a baby or not is a biological process no one can influence. Implantation still requires a bit of luck ( for lack of a better word !)

This is why, when you can never be sure of the outcome , you should still be able to ensure you have peace of mind you did your best. This is why you need to reframe how you judge the "success" of the IVF cycle. For most people, the answer is easy - did I get pregnant or not ? However, from a medical point of view, this is too simplistic. Was the process performed properly or not is a better yardstick for judging the outcome.

Unfortunately, very few patients have the maturity to prepare for failure when they start an IVF cycle. This is why IVF treatment can be such an emotional roller coaster ride !

" It's got to work ! It's going to work ! I've said my prayers ! Everyone is rooting for me ! I have my lucky charm on ! My period is 1 day late ! I'm feeling some heaviness in my breasts..."

All these mind games just add to your stress levels when the cycle fails - and what's worse, you ( or your loved ones) will then start blaming this stress for the failure. " The cycle failed because you are too tense. If you just relax, I'm sure you'll get pregnant. I know this friend who..."

We find that along with encouraging patients to learn meditation and yoga, offering a guaranteed pregnancy option is very effective in helping them to manage their stress levels. Not only does it signal the fact that we are very confident that we will be able to give them a baby ( after all, I am putting my money where my mouth is !); it also helps them to keep their expectations realistic . When they select this option, they are helping themselves to prepare for possible failure ; and equally importantly, they are making a commitment that they will put in the time and energy needed to help them to reach their final goal.Each failed cycle helps us to tweak our protocol, so we can fine tune it based on your response, until we can finally give you a baby !

A vaginal ultrasound scan has now become a routine part of the work of an infertile woman, because it provide so much useful information. Unfortunately, many IVF specialists misuse this simple technique.

I have seen patients who have been advised donor eggs by IVF doctors, because their "ovaries looked small" on the vaginal scan done at the time of the consultation . Even worse, is the fact that some doctors advise surrogacy because " the uterine lining is thin".

They do not bother to provide any documentation of their scans - or to explain options and alternatives to their patients. Most patients are quite easily initimidated; and since the IVF doctor is seen to be the "court of last resort", many follow the doctor's advise blindly or get disheartened and give up.In fact, some clueless patients are very impressed by how skillful the doctor must be, that he ( or she) could come to the correct diagnosis so quickly - a diagnosis which had eluded all their earlier doctors ( because it is wrong !)

There is no question about the fact that IVF is a competitive business. IVF clinics are usually run by doctors in private practise, who do their best to attract lots of patients to maximise their revenue.

This competition can be good for patients because it enforces doctors to keep their prices competitive; and they also need to ensure that their technology is updated, so that they do not fall behind.

However, this can be a mixed blessing. One effective way of getting patients is to get an interview published in the press. This is why many doctors now employ PR agents, to ensure that they get a lot of press coverage. While this has its pros ( it creates a lot of awareness about the newer medical options which are available for treating infertility) , some of the downsides are that health journalists are often not sophisticated enough to differentiate between hype and reality - and they may end up misleading patints by providing inaccurate information supplied by the IVF doctor who wants to promote his clinic as being the best.

Along with competing with other IVF clinics for press coverage, many IVF doctors also play a more subtle game of oneupmanship within the clinic !

When a patient comes to you for a consultation, how do you show her that you are better than all the other IVF doctors ? What makes you their best choice ?

Let's take the case of the patient who has failed one IVF cycle, and is now looking for a second opinion. This patient has already lost confidence in IVF doctors and is now "looking for the best" !

There are many subtle ( and not so subtle) techniques doctors use to influence the way the patient perceives them.

1. Give appointments after many weeks , to show how busy they are !

2. Give the patient an appointment, and then make them wait for ever and ever, in order to see the doctor. ( It's easy to do this if you have poor time management skills, and overbook lots of patients for the same slot ) Patients are very impressed by how busy the doctor is ! As Prof Cialdini's book, Influence showed, social proof is a powerful way of influencing others !

3. Order lots of tests - and the more expensive and esoteric they are, the better ! This long list of tests shows how thorough this doctor is ( in comparison with the earlier doctor, who missed out on doing all these basic tests - another testimony to his incompetence !)

4. Use new ( unproven and untested) tests and treatments ( such as IMSI)

5. Use lots of jargon to confound the patient. Any one who uses so many polysyllabic words must truly be an expert !

6. Criticise the earlier doctor, for not doing a good job ! ( for example, if the doctor did a Day 3 transfer, even if this is standard medial treatment, say they should have done a Day 5 transfer). It's very easy to be wise in hindsight, but you do not improve your standing by pulling someone else down !

The truth is that you can fool some of the people some of the time - and it's especially easy to fool infertile patients , most of whom are very vulnerable and desperate. However, this approach can also often backfire. Badmouthing other doctors can end up hurting all doctors ! You cannot build up a patient's confidence in your medical skills by undermining her confidence in other doctors ! Also, what goes around comes around - and the other doctor will be happy to badmouth you when your failures go to him ! Doctors need to take a more mature approach - if you are good, you are good , and you don't need to be any better than anyone else !

Doctors love coining new terms , and this seems to be especially true for IVF specialists. Infertile couples have to learn a whole alphabetic potpourri of medical terms - ranging from IVF to GIFT to ICSI to ZIFT. It's easy to get lost and confused; and most patients can't seem to make sense of any of these !

To add insult to injury, many IVF doctors claim to use "the new and latest" technique to improve pregnancy rates. Obviously, every "new" technique needs a new name - so the confusion gets compounded. It's a competitive business, and IVF doctors always try to keep one step ahead of other doctors ! While this is good because it allows patients access to the newest technology, the downside is that many doctors will then promote a particular technique – not because it is better, but simply because it is new !

It’s easy to get a lot of press coverage for a lot of these “new” advances, because reporters are often not medically sophisticated, and most are quite happy to oblige their doctor friends. Poor patients get even more confused – and will often flock to the doctor featured in the latest article, in the hope that this new technique will give them a baby ! This then sets up a vicious cycle, where doctors compete with each other, in order to be featured in the press. It often becomes a game of one-upmanship, where the doctor with the best PR firm wins !

The newest kid on the block is a term called IMSI ! This stands for Intracytoplasmic Morphology Selected sperm Injection – quite a mouthful ! This is simply a modification of the standard ICSI technique, in which the sperm are magnified even further. The rationale is very logically appealing – let’s use higher powered magnification, so we can select the “best “ sperm for ICSI ! One would therefore expect that this technique would result in higher pregnancy rates after ICSI.

Unfortunately, this is not true in real life. Not only does IMSI not improve pregnancy rates as compared to ICSI, it can actually decrease them. The reason is simple - IMSI takes longer to perform than ICSI because it's much harder to identify sperm when using such high magnification. At such a high power, the field of view is obviously very limited, which means that the embryologist has to scan for much longer to pick up the selected sperm. This means that the embryologist has to keep the fragile eggs ( into which the sperm have to be injected ) on the micromanipulator for longer while doing IMSI, and since eggs are very sensitive, and do not like being kept outside the incubator, this extra exposure can cause them to get damaged.

However, it's very easy to take patients for a ride, and many clinics are now pushing patients who have failed ICSI cycles in other clinics to do IMSI, claiming that the success rates are higher with IMSI.

Caveat emptor - let the patient beware ! More is not always better - and often established techniques are much better than newer ones !