Announcement not Advertisement- A call to change the Medical Code of Ethics

The Medical council of Tamil Nadu recently forbade doctors from having websites saying it was ‘unethical and amounts to advertisement’.

As India moves towards becoming Digital India, as Justice Lodha frames new rules for the Medical Council of India, isn’t it time we revisited the principles governing the practice of Medicine in India?

It’s a small world

We’re going global. The world wants to come to India for Medical treatment because Indian doctors are knowledgeable, experienced and healthcare in India is reasonably priced. How can doctors announce themselves to the world without even a website? Patients never go to hospitals. They go to a particular doctor. Websites for doctors are a must in today’s world.

Double role

Doctors are not merely medicine men or women. Or surgeons. They may be owners of a clinic, a nursing home or a hospital. They may have invested in real estate and equipment. They employ other doctors, nursing staff, paramedical workers, receptionists, managers, and even cooks and cleaners. They pay commercial prices in rent, electricity and water supply. They have to maintain everything in pristine condition since it is lives they deal with. They pay insurance and for various permissions. How do they keep all this going without at least announcing their presence and services offered by them in the form of a hoarding, a website, or a ‘yellow page listing’? The moment they do this, they get slapped with notices from their Medical Councils that it’s unethical to advertise. But if a non medico or a non allopathic doctor owns a hospital, [they can advertise because the Medical Councils can only suspend licences of allopathic doctors] that's okay. Many societies where our clinics are located don’t allow even a decent sized board visible from the street. How will people know we are there to look after them? Please give the poor MBBS a break.

Piece of the pie

Another of our PM Modi’s plans for India is to curb the parallel economy. How does a doctor fill his or her hospital if they can’t announce themselves to the community? They resort to malpractices like ‘cuts’ or referral fees to other doctors who refer patients, even to Hospital receptionists, ward boys, cab drivers, ‘agents’ anybody who sends them patients. And from where does this money come? From hiding income and not paying tax. By forbidding websites and announcements in the press, the government is just  fueling the Black economy. Let patients directly find their doctors instead and do away with all middle men. This will also curb unindicated surgeries or tests.   

The privileged clubs

Who benefits from the ‘no advertisement’ clause? Corporate hospitals-because they can advertise. Clinic chains. Old established doctors because the competition gets no mileage-they are the ones on all committees and councils and very keen on this rule. The American Medical association has done away with this rule for this very reason. In today’s world where people settle wherever their job takes them, patients need the digital world to find a good doctor. The good old family doctor cannot advise you on who is best. A corporate hospital or clinic chain may have really young and raw doctors to attend to you or a doctor who knows the owner or is politically connected to get the attachment- not necessarily the best doctor for the job.

Boundaries

We don’t want to make tall claims or quote false results. We just want to be allowed to inform the public at large that here is a doctor with these degrees who can treat you for these conditions at this price. Or who has special expertise in a particular area. Or who offers extras like a weekend clinic or low priced clinic or all women staff or senior consultants or unique procedures. Nobody forces patients to a treatment. We want them to make an informed choice. And maybe talk to other patients of ours for a feedback.

Why me?

Miracle cures are announced by homeopaths, ayurveda practioners, gym owners, dieticians, fitness experts in all newspapers and magazines and on the net all the time. No action is taken against them. Why be so very strict with allopathic doctors who don’t want to make tall claims, just to announce their existence on a street, an area, a city or a country? The Medical councils are welcome to issue strict warnings in case false claims are made or miracle cures announced. But to completely take away our right to put up signages or websites is extreme.

Dog eat dog 

In an intensely competitive world, often it’s the competition that complains about a doctor who has made any kind of announcement thereby threatening the existing kings or queens. News paper interviews are given or such complaints ‘leaked’ to newspapers to demean the doctor and ruin his or her reputation and practice –benefitting the one who complained. By all means take action against offenders but let there be a law against vilification of doctors by other doctors or administrative officials or going to the press before a case is tried in court. Just as there is a law against physical abuse against doctors let there be a law against newspaper statements or cyber abuse.

Multi headed hydra 

Okay. Today you forbid websites. And Facebook pages. Tomorrow Whatsapp accounts, yellow pages like Justdial, Practo, Sulekha, then Instagram, Snapchat, apps for doctors, google adverts, use of SEOs , PR firms, advertorials in short, wipe out a doctor's existence in print or the virtual world. For every head you cut, two will spring in its place. We don’t even know what new technology tomorrow will bring. How can Medical Councils keep tabs on everything and everyone? It’s time to get real and allow doctors a level playing field within reasonable boundaries of course. We don’t want to ‘solicit’ patients or ‘advertise’ or claim greatness. We just want to inform the public and announce our presence on the web and on the street where we work.

May the best get their due.

Cost of a Test tube baby

The Times they are changing
With increasing age of marriage in women , stress filled lifestyles and multiple pollutants, the number of both men and women facing fertility issues is rising. The WHO recently revised it's criteria for 'normal' semen parameters to lower sperm counts and motility. Many of these couples would benefit from simple measures. But for those who have extremely low sperm counts or absent sperms[ azoospermia] in semen [ necessitating extraction from the testes-TESA / PESA/ TESE] or for those women whose tubes are blocked or even those couples where all other treatments have failed, a 'test tube baby' is the right if not only option.

What is the real cost of a 'test tube  baby'
The actual process using even the best of internationally available media with the machines the clinical set up and staff salaries costs around 40-50,000 Indian rupees. The injections given to stimulate the ovaries cost from 40,000 to around 2,00,000 based on the woman's age, ovarian reserve and type of stimulation protocol used. Tests cost around 5,000-10,000. So the actual cost is from around 80,000 to 2,50,000.

Can the cost of a test tube baby be brought down?
Using the newer 'soft stimulation' protocols where fewer injections are given to patients, the cost of a cycle- including medications-can be brought down to as low as 80,000 rupees. These protocols suit the needs of most patient-s give excellent results in experienced hands- with very few really needing the conventional long protocols. All patients do not need a scopy  though it does increase chances of a pregnancy. A good sonography is sometimes good enough.

Why do doctors quote high charges for IVF?
Many factors can inflate the cost of a test tube baby treatment- who and where the clinic is located for one. Rents and real estate in a city can add to the cost.

Outsourcing
Many doctors start IVF cycles [ injections] but send patients elsewhere for sonography and the actual IVF to another centre. Some batch patients and take them by the bus load or a team flies down for 4 days when the egg pick ups embrology and embryo transfers are done. This raises the cost since soft stimulation protocols cannot be used in batching patients. And more people are involved hiking costs.Some clinics call embryologists for ICSI -again raising costs. Some doctors call an endoscopic surgeon as they are not experienced in endoscopy. This further raises costs

Part of a whole
If the IVF centre is attached to a large hospital or is a chain of IVF clinics or has multiple owners, the costs of the cycle can go up since a larger staff, marketing teams, paying of specialised doctors and lab staff increases. A single owner can be flexible in charges and charge lower amounts.

Cost of complications
If hyperstimulation occurs- as in PCOS patients freezing embryos and transferring them later is standard practice now. This hikes costs. If too many embryos are formed, freezing them does add to costs.

Old is not gold
Women in their late thirties and forties or who have had surgery done on their ovaries or suffered a severe infection or have endometriosis have fewer eggs and a higher percentage of abnormal eggs giving fewer good quality embryos. They need high doses of the costly gonadotropins to get a reasonable chance of pregnancy. - thus increasing costs. Using soft stimulation , freezing embryos and accumulating and transferring the best ones after thawing is a better option -it costs nearly the same and yields more pregnancies. Using an egg donor is also sometimes better-cost and result wise.

The 'soil' factor
If the inner lining of the uterus doesn't grow, docs add injections or instill drugs to improve it -increasing costs of cycles

What's the good news?
Competition- so many IVF centres and media providers as well as pharma companies making gonadotropins have brought down the cost with many claiming to be 'Budget test tube baby' centres

Experience As doctors and embryologists grow in experience they can give pregnancies with very few eggs, so cost of injections and hence the cycles is getting reduced.

Two for the price of one?
While there are journal articles showing that pregnancy rates increase at the second attempt, you could end up paying double for nothing.

Last words
Think it out. Plan well. Choose well. Be informed. But don't spoil your chances by bargaining with your doctor or dictating your treatment. Sometimes trust is best.

Too posh to push!

With Aishwarya Rai Bacchan recently giving birth to a baby girl, the natural way- no Caesarean, no chosen birth date- of her own birthday or the much sought after 11/11/11 newspapers were abuzz with this 'abnormal' mode of delivering a superstar. After all she would be ‘too posh to push’.

And reporters could no longer flog the story of the greedy and lazy gynaecologist who waits on patients with a knife, ready to do a caesarean on any woman who does not oblige by popping out her babies at a convenient time.

Here is a gyno’s end of the true story – to do or not to do … a Caesarean section.

It’s true the rates of caesarean sections have gone up all over the world. I think this is why:

1]Forewarned is forearmed: Sonography etc

Plenty of investigations like sonographies and blood tests are available to us today that can warn in advance of babies who are  growth restricted, too large, badly positioned or have loops of umbilical cord round their neck and could have problems with a vaginal birth.

2] Bigger is not better

With mothers being given tons of supplements their babies are sometimes too large for their pelvic structure and cannot be delivered ‘normally’

3]The Test-tube baby epidemic

Assisted reproduction [ test tube babies] have made it possible for women who otherwise would never have conceived, to have their own child. These are ‘precious’ babies often twins , conceived after years of trying and with slim chances of having another one and no doctor or patient in their right minds would leave anything to chance.- A planned caesarean with a team of doctors to attend on the baby is what makes the most sense.

4] No prizes just lawsuits

With women working and small family sizes, patients & doctors tend to avoid difficult vaginal births that could damage the baby’s brain causing cerebral palsies [spasticity], weakness in limbs [ paralysis] or mental retardation. Medico legal issues also force us to be liberal with caesareans.

5] Surgery made easy

With modern antibiotics, blood transfusion, good suture materials, and experience, complications from a caesarean section have become rare. It is often the better option in difficult cases. The mother could also suffer incontinence [inability to control urine or stool] or fistulae in badly done vaginal births as well as suffer severe tears, rupture her uterus and have excessive bleeding after wrongly applied forceps or other manuoevres.

6] Short is sweet where labour goes

 It is true to some extent that doctors tend to finish up and go home for the simple reason that baby outcomes are better when labour is shorter-We are taught ‘A labouring mother must not see two sunrises or sunsets’

7] The scarred uterus

With so many surgeries being done on the uterus like caesareans, fibroid removals, unification of two uteri, patients risk their uterus bursting at the scar and we cannot take chances with the life of both the baby and the mother.

So what’s really happening? Are we doing more caesareans than vaginal births?

The answer is a simple NO. Why not?  I just said its best for the baby!

1] The hen that lays golden eggs

 In India gynaecologists treat not just a patient but an entire neighbourhood. 3 generations of women from the extended family are looked after by the same doctor. A scissor happy doctor would be dropped like a hot potato. One unnecessary caesarean means a chunk of patients lost. And yes the competition is cut throat.

2] Because I can

The word ‘Obstetrics’ means to stand by. Or wait patiently while a woman delivers, gently helping her ease her baby out into the world. We are trained to wait. And in India with its huge population, a gynaecologist in training does every kind of difficult delivery multiple times. We are trained to do it. We have to do it to please the family. So really no reason for us not to do it.

3]If it’s good it’s not news

 According to the 4^th estate, women demand caesareans because they don’t want to suffer the pain of childbirth or they don’t want to get ‘loose down there’. This is not true at all. In all these years, I have had only one patient – a doctor who insisted on a caesarean-though to be fair to her, she had conceived with difficulty, her baby threatened to come out early and was growth restricted. She was anxious for the baby’s well being. Most women want a ‘normal’ delivery and start crying as if they have failed in some way, when we tell them we need to do a caesarean. A well done and properly stitched delivery does not make a woman lose perineal muscle tone. And an abdominal surgery will always be more painful with longer recovery times than a vaginal birth.

4] Magic potions

With prostaglandins- a new group of drugs that make the cervix open up and oxytocin- a hormone that makes the uterus contract, deliveries can be timed and labour cut short by several hours. Added to these are excellent analgesia techniques that remove the pain and relax the muscles helping us to carry out deliveries with ease.

5] Self help

Restricting supplements to essentials, controlling a woman’s sugar levels, helping her take an appropriate diet, avoiding excess weight gain and encouraging her to exercise and be active also contributes to better vaginal birth rates. Preparing the breasts for lactation by massaging the nipples releases oxytocin and helps the baby’s head to enter the birth canal and the patient to deliver on time.

6] The art of Obstetrics.

We all have our egos. And take pride in doing a difficult job well. So delivering a baby vaginally is an art as well as a science that most of us are happy to practice-though not at the cost of the patient’s well being. This is just another reason why a doctor would prefer a vaginal delivery.

To sum it up, most Gynaecologists or rather Obstetricians will try to give a woman a natural birth, but where needed, they will not be tardy in doing a caesarean. Trust your doctor to do his or her best. No doctor would like to give you treatment that’s worse than your disease. No patient is too posh to push and no doctor too lazy to pull.

Quality control of Conferences

'Whatever you do, do it well.'
This is the principle I and my friends were taught-by parents, grand parents and teachers.
The recent Common wealth games sadly brought to the notice of India and the world that Indians believe problems will sort themselves out. And embarrassed a young nation with shabby construction and toilets. And corruption and poor hygiene standards.
The west used to laugh at Japanese goods, till the Japanese took care of quality-in their cars, electronics and everything.
In the movie 127 hrs, the hero uses a Chinese knife to cut stone and then curses it for being Chinese and regrets leaving his Swiss knife at home-as if the Swiss knife would cut the boulder! Western nations never miss an opportunity to criticise Chinese goods.
India escapes this criticism because we don't make that many finished goods.
But the quality of what we produce, would even make the Chinese laugh.
A recent decree by the Medical Council of India has made it mandatory for Indian doctors to attend conferences and get credit points to renew their licence to practice.
There is hence a mad rush to attend all conferences.
But the MCI would do well to evaluate conferences that they are forcing us to attend.
Most speakers are chosen from among the elected committee members of the body organising the conferences or their friends.
The topic the speaker speaks on is sometimes not of their core competency, or a field where the speaker has researched. Occasionally, the entire talk is downloaded from the Net or books or Journals or prepared by the company whose product the speaker uses. As a result the audience gets no information about the actual practical issues in a topic or can well read up the topic themselves without attending the conference!
Most speakers have a set of prepared subjects that they keep repeating all the time. So we hear the same things at various conferences for years on the end.
The same thing is seen with panel discussions/workshops/debates-tremendous repetition of inconsequential data.
To all the Presidents and managing committee members of various medical organisations-past, present and future, may I offer the following suggestions to make the conference worth our while when we leave our patients, families and leisure to come and listen to you?
1. Choose the topics  and the sub topics for the conference well-let it be approved by atleast 2 more members so as to be relevant and practical to an average gynaecologist while highlighting newer fields and problem areas.e.g High Intensity Focussed Ultrasound with MRI guidance. Pelvic floor repair. The latest in Ovulation Induction.
2. Get Surgeons, Physicians, Anaesthetists, Urologists, Embryologists-all the people from allied fields to talk and let this be followed up by a talk by a Gynaecologist who has extensive experience in the same field. e.g. Cholecystectomy/ Appendectomy/  Multi drug resistant TB/ Malaria in pregnancy
3. Instead of saving up money for the organisation, spend it to get good international speakers who are actually doing path breaking research in their fields. Members fees come from their tax-they won't mind paying a bit more. Pharma companies are more than happy to help. Organise for more people instead of closing limited registrations.
4. For all the time and energy spent by managing committee members, don't give them meaningless lectures but let them get extra credit points for organising a conference. They can also be given preference for a lecture if they are doing work in the area.
5. Invite talks from all ordinary gynaecologists-let them present the jist of their talk beforehand and let it be approved by the managing committee before the person is given the opportunity e.g. removal of large fibroids through a minilaparotomy incision using a tonsillar knife to core out the fibroid.
6. Have a feedback form for the audience-speakers who get very adverse comments should not be repeated. e.g. a speaker who showed several different incisions for a caesarean section but had no explanation for choosing those incisions. Overseas speakers who are incomprehensible. Speakers who quote fake statistics, exceed their time and repeat their talk too often.
7. Introducing some standards like ISO 9000 towards conferences will help improve the level of the conferences.
 In today's information age where all lead journals are available at the click of a button, conferences will be relevant only if they highlight actual work and practical problems faced.
Conferences are for the benefit of the audience and not for the speakers or organisers.

Whites-Do's and dont's

‘Doc, I wish I had come to you earlier. I just didn’t know who to talk to this about’-is a common refrain of many women to their Gynaecologist.
 Most of my patients come to me after suffering a while, because they are too shy to talk about their illnesses even to their mothers or daughters.
A common ailment across age groups is white discharge from the vagina. The medical term used is 'Leucorrhoea' but commonly referred to as Whites.
Excessive discharge is normal during the middle part of the menstrual cycle-when a sticky strand may stretch even outside the vagina-this disappears soon after the egg bursts from your ovary.
It is also normal to have discharge at time of sexual arousal and in pregnancy.
In late pregnancy, excess vaginal discharge may be a sign of onset of labour or may be a break in the 'bag of waters' that surrounds your baby-warranting a visit to the hospital.
In young girls prior to onset of periods, excessive discharge may be due to a foreign body-beads, toy parts or grains in the vagina-this needs to be checked out by a doctor who can telescopically remove the same.
In women of reproductive age group, the commonest cause of whites is a vaginal infection.
Three types of usual infections are – fungal, trichomonal or bacterial.
Thrush/yeast/fungal/ candidiasis/moniliasis is the commonest.
This occurs when the normal bacteria in the vagina which maintain acidic environment die out -as following antibiotic therapy. This also occurs if  vaginal acids are neutralised by alkaine semen [after frequent sexual intercourse] or taking alkalinisers for urinary infections. Yeast thrives in a moist, sugary environment that happens after exercise, in summer or the monsoons or after binging on sweets or in diabetics. Tight clothes, synthetic materials & excessive pubic hair, trap moisture, create friction, damage skin and encourage fungal growth.
Thrush is seen a curd like discharge that doesn't smell too much and is accompanied by itching and soreness and burning while urinating.
Trichomoniasis is sexually transmitted, accompanied by profuse greenish, frothy discharge and dyspareunia-pain during sexual intercourse.[though this can occur in any vaginal infection-its severity isgreater in Trichomoniasis.] Partner treatment is important here else chances of a recurrence are high.
Bacterial vaginitis may cause a foul smelling, greyish or yellowish discharge and needs local and/or oral antibiotics.
The cervix which is the mouth of the uterus may have an ulcer, a growth or an erosion[ overgrowth of mucus producing inner lining] which causes the discharge or may be elongated and herniated-this needs to be thoroughly checked and surgically treated .
Sometimes a fibroid in the uterus or a swollen fluid filled fallopian tube may also cause vaginal discharge and would show up on sonography.The treatment options for these would be put before you by your gynaecologist.
To reduce the spread of HIV, which either partner is more likely to get, if there is unprotected intercourse in the presence vaginal infection, doctors or sometimes nurses adopt a 'syndromic approach' to treatment-they treat all three types of infection with a combined vaginal tablet or a kit of oral medicines.
Worms migrate from the bowel to the vagina, carrying with them germs that may cause an infection. This is common in India and sometimes, deworming helps relieve the infection. It also helps improve your nutrition and resistance in general.
Other sexually transmitted diseases like gonorrhoea, herpes or syphilis may also present as a white discharge. Your doctor may order tests before starting treatment.
Older women who lose hormonal support and hence have thin vaginal skin, may need short term or local hormonal therapy besides treating their infection.
 Even a mild vaginal infection can spread to the uterus, pelvis and blood and have serious consequences especially in pregnancy or after a surgery. Vaginitis also makes you prone to other infections. Hence it needs to be treated quickly, and completely.
Some simple things you can do to avoid repeated infections are:
Cut the sugars from your diet
Trim your nails-fungal spores and worms eggs get caught under long nails, and reinfect you by an itch-scratch cycle.
Keep you hair trimmed down there for hygiene-to avoid trapping moisture and germs
Use cotton inners-natural fibres breathe and keep you dry avoiding frequent infections.
Use tissues to gently dab yourself dry after passing urine, instead of washing with water.
Wash after intercourse if you are not trying for a baby and dab yourself dry.
Loose clothes like skirts, Parallels, or Salwars or Sarees are better than tightly fitted trousers or Churidars. Jeans, Jeggings and Tights are totally unsuited to Indian weather-put them away till you’re fine.
If possible, sleep without a panty so that your parts stay aerated and you avoid infection.
Douching your vagina is not a good idea. Let your natural defense mechanism take over.
Eating yoghurt and pro-biotics colonises your bowel with friendly bacteria which migrate to the skin and vagina and protect you from future infection.
Use a mild soap or a special pH controlled perineal wash for your privates-that keeps the natural resistance mechanisms going.
Using condoms protects against infections –so insist on it.
Some panty liners contain chemicals that may causes irritation and allergies-avoid these.
Sterilise your panties by soaking them in half a bucket of water into which a cap full of dettol or similar antiseptic solution is added, for a couple of hours. Wash thoroughly with detergent before use. You need to do this only once, not daily.
During your periods, change sanitary pads every few hours and wash atleast thrice a day. The glue from some makes of pads and panty liners doesn’t wash off. It traps germs and re infects you. Change the make or keep a separate set to use only during your periods[with a pad]
Above all, your vaginal discharge may just be the symptom of something more serious-see your doctor and get things cleared.
Asking your partner to go for a check and maybe adopt some of the measures mentioned above-might help both of you.
Severe Infections may need long term oral treatment -follow your doc’s advice and try not to give up half way.
Let there be White no more!

The Lowly Gynaecologist

“ A Physician works at cerebral level, a Surgeon at spinal level and a Gynaecologist at Lumbrical level”

This was the sneering statement made by a Physician while we were in training.
For the non medical people, it implies that a Physician [post graduate in internal medicine] uses his brain, a surgeon his inherent skill, while a gynaecologist merely uses her hands without thinking or talent- the Lumbricals being muscles in the hand.
This patronising attitude towards us gynaecologists continues through our working lives.

With the Nobel prize for medicine being awarded this year to Professor Robert Edwards, the originator of the test tube baby and the first gynaecologist to win the award, all of us gynaecologists feel vindicated. It was balm on our bruised egos.
Thinking back, Gynaecologists have given several firsts to the world of medicine-

Professor Ian Donald, first thought of holding an ultrasound probe over the adbdomen of a pregnant woman and got images of the baby, thus starting the whole new field of sonography-which is indispensable in  diagnosis in almost every branch of medicine and even used in therapy.

Professor Kurt Semm also a gynaecologist, removed an appendix laparoscopically and then started doing hysterectomies setting the trend for endoscopic surgery. The surgeons followed with Laparoscopic cholecystectomies etc.

Prof. Camran Nezhat again a gynaecologist first used an endovision camera and monitor to do laparoscopic surgery while looking at a screen and not peeping through the telescope with one eye shut. Today extensive cancer surgeries are possible because of this one small step /giant leap.

Then there was the test tube baby- Louise Brown the brain child of Sir Robert Edwards and Patrick Steptoe. Gynaecologists all over the world adopted their methods successfully –leading to a whole new field of assisted reproduction. With this came advances in culture media, incubators, operative microscopes, sterile environments and led to development of stem cell research, tissue preservation and even cloning.

Prof Charles Koh, started doing endoscopic tuboplasty [for repair of the fallopian tubes] and opened up the field endoscopic microsurgery –useful even to cardio-vascular surgeons.

Besides these landmark developments by Gynaecologists, I feel a 'Doctor for Ladies' is different from other consultants in many ways-She has to be both Physician to treat various diseases in pregnancy, taking into account the effects on the mother and the baby; and Surgeon to operate on various pathologies of women. Besides gynaecologists need to have a fair knowledge of endocrinology, oncology and breast diseases. Plus she has to know about and use psychotherapy and also step in to sort out the social problems of her patients. Women she has delivered look to her for baby care tips and a basic knowledge of paediatrics is also in her domain. She also has to educate- girls starting puberty, women getting married, or trying to have a baby, sort out physical marital problems and help women age in comfort.

Gynaecologists are often primary care physicians for pregnant women and for those who are too embarrassed to see a male family doctor for an ailment of a personal nature.

To all derisive statements made towards us by doctors of other specialities, I would like to say we are not only your equal, we are first among equals.

Congratulations to Sir Robert Edwards for getting the highest honour for his work. Sir, you do us all proud.

Treatment by halves

" Sonny, send your worst cases to your enemy"-An old Gynaecology Professor to his assistant.

At the Wadia Maternity and Gynaecological Hospital in Mumbai that is exactly what we get. Women who have undergone multiple surgeries that have failed, multiple cycles for infertility treatment and have exhausted their resources but not hope, have lost a number of babies and are taking that one final chance, mothers carrying babies with severe growth restriction or anomalies where the gynaecologist doesn't want to break the bad news, ART practitioners who want their patients to undergo laparoscopy cheaply and save money for IVF and so on.
I speak from hind sight and a review of cases that I have managed and here are some of my observations-
ART practitioners, seem to jump too soon into IUI and then IVF cycles and further ICSI if all fails.
Several patients have a simple problem like lack of knowledge of fertile period, insufficient frequency of coitus, use of lubricants or douches, washing off the ejaculate, pain during intercourse from infection or inadequate relaxation and just advising couples on these basic techniques works for them.

The cervical factor is another neglected area. Most IVF clinics do a transvaginal scan and a simple per speculum or per vaginal check is skipped. Cervical erosions, ulcers, small polyps chronic cervicitis contributing to her infertility are missed. The first time the cervix is looked at is during an IUI by which time its too late to treat and the doctor proceeds with the procedure-which is likely to fail if the infection has tracked into the uterus or results in an abortion should a pregnancy occur. A simple procedure like a cryo or thermo cauterisation cure the erosion and several patients conceive spontaneously after.

Sometimes the cervical canal is tortuous or stenosed or there are large cysts [Nabothian]-obstructing passage of sperms and causing infertility. A generous dilatation, rupturing the cysts, removing the polyps and lysing the adhesions cures the infertility or makes the IUI or Embryo transfer much smoother and bloodless and hence more likely to be successful.

Uterine polyps are treated by most gynaecologists by simply pulling it or curetting it out-increasing chances of recurrence. If done at hysteroscopy taking care to cut the base, the polyp is unlikely to recurr and the patient has better chances of pregnancy -spontaneously or assisted.

Fibroids not only distend the uterine cavity, make the endometrium inflamed and hostile to implantation, they may mechanically obstruct passage of sperm if they are close to the cervix or the fallopian tubes. They also make an IUI / ET a bit more difficult. With modern laparoscopic techniques, it is possible to have few or no adhesions after myomectomy and often patients conceive after the myomectomy.

Poly cystic ovaries or indeed any ovarian cyst needs to be diagnosed and ovarian drilling removes large unruptured follicles that mechanically obstruct newer ones, changes the hormonal environment, and these patients come back pregnant much to their surprise. If they are on treatment, ovarian drilling makes them sensitive to drugs like clomiphene to which they were hitherto resistant, reduces their requirement of gonadotropins and chances of Ovarian Hyperstimulation. However one needs to do just 4-5 punctures, with a minimum current for just a few seconds and copiously irrigate the ovary to avoid thermal damage to other eggs.

Endometriotic cysts are often punctured and left to nature by gynos not sufficiently confident of endoscopy-removing the cyst wall is essential to prevent recurrence of these cysts.

Tiny patches of endometriosis are also left untouched-these release several factors that inhibit ovulation, alter tubal and uterine peristalsis and interfere with conception. Removal of all endometriosis, makes a patient better responsive to ovulation induction and increases her chances of pregnancy.

If there is a problem in sperm count or motility, the male partner is sent to an andrologist who may rule out hernias, hydrocoeles, varicocoeles and undescended testes but rarely bothers to do his sugars, thyroid function tests and take a history of exposure to high temperature or stress, do a semen culture and treat the infection. An exhorbitant nutritional supplement is prescribed that most men stop after a month because of the cost. It is so easy and cost effective to test and take a history to get at the real problem before jumping to do an IUI where the few poorly motile sperms will also be lost and then to ICSI. The chances of successful ART  are also increased by taking care of these other common problems.

Finally, many women have multiple cervical dilatations for various procedures and often have an incompetent os on top of a multiple gestation. Good idea to look out for this prior to infertility treatment and continue to look for it from 3 months onwards with a sonography[ most sonologists never comment on the cervix] and take a stitch if required, preventing a precious pregnancy aborting.

Male gynaecologists avoid proper exam of the patients breasts which is left to nurses. they often miss galactorrhoea and though the prolactin levels are normal, correction of the galactorrhoea does often restore normal cycles and fertility.

Thyroid disorders are missed if the tests are not done at a good laboratory-so looking for signs of thyroid disturbance and sending these patients blood to a good [although expensive] lab may be worth it.

So lets 'Look at the patient not just the disease'. Lets not be in a hurry to start an ART cycle. Lets take care of everything we possibly can-this would help our infertile patients get pregnant at minimum cost and carry their babies to term which is the final aim of both the patient and the doctor.