Friday, January 27, 2017

Cervical Cancer and Pap smear

So, January being cervical cancer awareness month,I thought of getting repetitive  and talk about Pap smears and vaccines once again.

Cervical cancer - Cervical cancer is the cancer of mouth of the womb and is the commonest cancer in Indian women.Unlike other cancers cervical cancer doesn't surprise you by it's sudden occurrence.It goes through various stages of cell abnormality before getting pre cancerous or even cancerous.

High Risk Factors-Promiscus behaviour and multiple sexual partners,usage of Oral contraceptive pills,smoking,multiple child birth to mention a few.It is caused by a virus called Human papilloma virus,which is mostly transferred during sexual encounter.

Screening- Pap smear is a preventive test which doesn't  take more than 5-7minutes to perform.A brush is used to gently take the cells from the cervix.At worst this test can be called mildly uncomfortable but not painful.A laboratory examination screens out any abnormal cells.

Pap smear should be done every 1 to 3 years till the age of 64years.

What if Pap smear is abnormal-Incase of an abnormal report,another test colposcopy is done where the cervix is visualised under a magnifying lens after applying a vinegar like solution or iodine or both and if any area looks suspicious,small piece s taken and sent for pathological confirmation.Again,this procedure can be done without Anaesthesia.

What if Biopsy also comes abnormal.If it is till precancerous stage,a procedure called LETTZ is performed where the abnormal area of cervix is 'shaved of' using electric current.A cancer obviously would need removing major chunk of cervix if family isn't complete or a hysterectomy if the family is complete.

HPV vaccine- It covers only 4 out of 100 strains of HPV and thus the maximal protection offered is 72 % and not 100 percent.Maximal benefit derived is before the girl became sexually active.Recommended age group is 9 years to 26 years.After that one would get some protection but difficult to say how much protection.

So a few minutes spared every year can save many lives.If you haven't had a screening so far,it is never too late to begin something as beneficial as this.

Thursday, December 29, 2016

let it go to the dogs !!

It is a doggy story from beginning to end.Nothing about women or health or infertility.
Due to multifactorial reasons I got enrolled for my first 10 kms run scheduled for september 2016-Pinkathon ,Delhi.
The person who initially in 2015 had suggested me to try running,by that time had changed priorities.I had thought he would guide me so called training for long runs,never being an athlete or sports person.I was left with the option of trying it myself or run with the local running group,the timing of which was too early for my comfort.Being a late sleeper ,I needed my 8 hours of sleep an 5 am runs were not healthy at all for me.Other option was to quit that 10 kms.By God's grace I haven't quit anything which needed my solo participation.
I started with walks and to my amazement I had run my first 10 Kms in not too bad timings.But that run is a different story all together.I used to train and practice in my condominium myself,all by myself and You tube videos to guide.4 stray Indian dogs have been adopted by our condominium mates and they mutually co exist with us.
When I used to run,mid way around half the circle,4 of these dogs used to come along with me,join ,lick and pounce and play and do all what they could do to show their affection.It was annoying at first and slowly i got used to it.It became the daily routine.Why they liked me,I still don't know as not even once have I played with them or given anything to eat.
And then 20th November was Airtel delhi Half Marathon.My first 21 kms.Again I was alone to train.My friend has his own priorities,other friends who needed help and moral support and training.Anyways again these four guys followed me everyday at the same pace as mine.If I used to run they used to run .My walks made them slow down their pace.They had become my friends ,who derived pleasure of my company.For them no other gain from me mattered and neither I was of any use to them except occasional chats we would have on the running tract.
Now I have a pedigreed Beagle at home.Son of parents who have been show dogs and prize winners-Buddy.A nice little content four years old.Suddenly I was finding a change in his behaviour.He was ignoring me.What was the reason?And then we realised that all the family members used to give him some prize food as soon as they entered the home while I didn't as the deal was not to over feed him to improve his longevity.I felt bad.You can interpret me as a mean person who feels bad of a dog's behaviour or you can classify me as a person who is sensitive enough to feel bad even of a dog's behaviour.And I did rebuke him.
When I came down to run that  day,for the first time I realised the unconditionality of the love these stray dogs had for me.Why?I don't know but their friendship had nothing to do except for being with me for those hours as we were together.I was touched and now we are friends.I look forward to meet them when I go running and in their company I did my first 21 kms.I have patched up with the pedigreed Buddy by offering him his goodies off and on but what I value more is the friendship of street dogs ,who made a runner out of me.

Monday, December 12, 2016

Power of Positivity

My biggest handicap while writing this blog is my limited Vocabulary ,having studied in a non english medium school and have little what so ever liking or time for non medical books.(Inspirational ones are the only exception)

How many of you trust,what you do gets back to you like a boomerang?All,many or nobody?

Well,I do believe in it.As after all whatever you  will sow,you will reap.I have many personal reasons to believe it and I will share with you guys in due course of time.

I reached my OPD Chamber and there was a middle aged couple chatting with my Assistant Ankita.Ankita told in her typical way the medical history where she weighs every word she speaks carefully, weighing each and every word . After all I am the boss.Ok so this 46 years old Lady wanted a Hysterectomy today.Period!!We will call this lady K hence forth for the sake of convenience.

K is a govt teacher ,travels everyday 128 kms towards Rajasthan and comes back.She had not taken a single leave in her career of many years ,she told me proudly.I was impressed ,no doubt.For her 46 years ,she looked younger.It would have been easier to accept her asA 35 year old.A chatty female,who was in rush not just to get a surgery done but also to tell a lot of related stories.Her husband was the scared  and quite one.Scared ,if he would be able to run this show all by himself i.e getting his wife operated and manage the home too.

K had been diagnosed with a big fibroid which in my opinion she could have lived further.But she was,surgery and surgery as that too ASAP.Advised to get endometrial biopsy done preoperatively and she said 'no'.Okay so the next day she was taken for removal of uterus and we decided ( what me...all decisions were of K and I was just executing it)to preserve the ovaries as everyone in her family gets menopause after 60 years of age only.

Do You know me or my professional profile?No came the answer pat.And you are in urgency to get a major surgery from me?Doctor,a neighbour told go to Artemis and in Artemis we liked your name best .I do loved my name before,and I love it more now.Thanks Mom and Dad for the same.I thanked her but said my name kind be the only thing.She said,it gives me positivity.Then came the bouncer.

She said,'Even God has to show his face to us and not just vice versa) .As I have not harmed /hurt or professionally did any misdeed/I don't think a reason to be in  wrong hands.What face will he show to me?Her word were even re assuring for me.It always helps the doctor to treat her patient better if the patient shows so much confidence in the doctor.
It was a complicated case with adherent bowl and bladder due to previous multiple abdomen Surgeries.The surgery went well and uneventful.She visited me again in OPD.So full of praises for all of us but mostly her husband who according to her had graduated to being husband rather than a scared companion of past.

While leaving she again said.God had to show his face to me.That's why I met your team.I didn't do any online search and once I had talked to you the vibes told me-Go for it under her and no where else.

The theory of The secret says,what ever you you wish with full heart the universe conspires to make it happen.I have seen it happens.You are guided rightly by your circumstances.A believer is better than someone who has done mega research on the doctor on internet and still isn't able to trust the person in whose hands has put her life.

Being working in a ECS empanelled hospital,I do get wives of senior level Army officers off and on.It is a huge concession for them.Now this lady , say R,needed a surgery which went smooth again.She came in follow up and just notice the difference in K and R's behaviour.She is a non believer,it sounded.She said doctor I have to say everything went well.I am not even sure you did any surgery on me,as I feel really comfortable.And yes...this is exactly she meant.
In my personal life I have seen power of positivity.It works.In each and every sphere of life.Only-Trust,believe and when things go against you still have Gratitude for a while.And you will realise....everything is back on tract once again.Usko bhi to much dekhana hai !! :) :) 

Wednesday, August 17, 2016

Poor Responders in IVF

Few Problems in IVF are more frustrating than a poor responder to Gonadotropin stimulation.
The commonest causes are advanced age and also Ovarian Surgery.Let me inneumrate it for ease of understanding

  • Advanced Fertile age.The fertility goes a steep downhill after the age of 37 years.
  • Previous Ovarian surgery
  • Severe endometriosis
  • endometrioma
  • Obesity
  • Previous pelvic adhesions
  • Previous pelvic infections
  • Smoking
  • Previous chemo/radiotherapy.

Though there are many definitions of poor responders but the most widely accepted one is < 3 Oocytes retrieved despite maximal stimulation.An AMH , 3 Pmol/l or an antral count of < 5.
( One can't stimulate follicles which aren't there).

There are various so called treatment options for Poor responders but only testosterone patches and Letrozole have been used with some success.Unfortunately Letrozole is still not accepted as a fertility medicine in India,once it was withdrawan following the Canadian controversy.DHEAS has also been recently attempted to help the poor responders.

One is tempted to use Gonadotrophins at higher level in such patients as a starting dose 

Wednesday, July 20, 2016

Oh so famous

People ask me how is the settling down back to Gurgaon.And my answer is slow and steady. Well yes, exactly that is what it has been.

When I was about to join Artemis Hospital,there was continous enquiry at our call centre as if every pregnant Lady in Gurgaon just wished to shift over to me.But no...this isn't how things work.That was just initial frenzy.And it has settled down quite a bit.

I do get patients,every day 2 to 3  new ones ,who already have heard something positive about me .But yes it isn't a busy clinic by any standards ,certainly not by the standards I left it in 2014.So the upside is that I get plenty of time to talk to these patients and their families and their kids.All are happy and I enjoy the chats just like I used to do so in 2007 when I started initially in Gurgaon.

But today I was surprised.The patient who visited in my clinic ( she was following my India return ever since she got shifted to Gurgaon) is actually my tower mate and we live just 1 floor apart.And she had no clue.This much for my socializing and advertising.

As if this was not enough for me to feel bad about my anti social nature and lack of PR.another gentleman whom I met in my building lift and on knowing my name asked-Kaushiki,the famous Kaushiki Dwivedee,you live on this floor.Heard so much about you seen for the first time.Now tell me,wasn't it enough to make me feel so bad about my PR skills.

I don't have as many patients as I would like to and their are people who are trying to trace Kaushiki Dwivedee out.Need to do something fast.

Marketing.New paper ads!!Any suggestions?

Friday, July 15, 2016

Miscarriage and Progesterone ( To prescribe or not to prescribe)

This Miscarriage and Progesterone will be as pertinent to me whether I am donning the role of an Obstetrician or of an Infertility specialist.I am sure you know of some one had miscarriage.It is a very common process in pregnancy( as common as 1/4th Pregnancies would end up in termination).Why it happens?99 % as the Pregnancy is unhealthy and nature is trying to save you as a parent and the foetus if it survives undetected from the miseries to follow on birth.So is miscarriage a cause of sorrow or relief?? ( I would come across as ruthless,insensitive person giving such a statement.But this is a fact and how much hard I try to sugarcoat it,facts and statistics still remain the same)

In India ,it is a common practise to get Progesterone levels done,declare that there is a chance of miscarriage and start Progesterone or many times HCG injections.So many times it is done just routinely,randomly to 'prevent a miscarriage'Can miscarriages be really prevented,unless they are recurrent miscarriages where there are some factors in mothers body which isn't allowing a healthy foetus to grow?Or it is a late miscarriage due to incompetent cervix where 'a stitch in time can save nine'.If your gynecologist thinks she can prevent miscarriage by a shot of progesterone,probably she/he can but there isn't a scientific evidence to it.Good part is that Progesterone doesn't harm you or the foetus ,so don't worry even if you are on it.You wish to stop it or continue it,it is up to you.If you are my patient,I will explain you all these details but won't prescribe from my side unless you ask for it.

So is progesterone helpful.Yes it is in IVF conceived Pregnancies where Ovary has been suppressed by medications and there isn't proper formation of corpus luteum due to artificial intervention in the process of conception and after cerclage of cervix.I will write about usefulness of progesterone in one of the posts.

For those who wish to read further please follow this link

IVF Specialist-When you got to sleep ,you got to sleep!

Many a times I have been asked this question-What made you leave your flourishing practice and leave for Australia.And every time I come out with an answer which I feel was the probable reason.But I think the most important reason was deprivation of sleep.Yes,that is true.Readers ,I am sure you all are aware that medicine is a demanding profession.Without going in the data collection of which study shows what about in which country how many hours do the doctors sleep,it is a known fact that a doctor practising Obstetrics is sleep deprived.

In 2007 when I started my private practice ,totally new to Gurgaon and for that matter even Delhi,I had a zero patient base and then it improved.The numbers of emergencies( mostly deliveries) were limited.And conducting a vaginal delivery be it Normal,Vaccum or forceps used to give me an ultimate kick(More techniqualy difficult,more was the kick).......much more that elective gynaecology surgeries including Laparoscopy surgeries as well as uro gynaecology surgery which I was quite comfortable with even then - with what Dr Plemming and Dr Klazinga had taught in United Kingdom.

Slowly by God's Grace the practise improved and so did the number of deliveries.By 2014 ,I was awake almost every night with routine OPDs and OTs as scheduled.There were times I would reach delayed for OPD,with not so happy patients who had their appointments delayed by an hour or more already as I was stuck in Labour ward trying a vaginal delivery.7 years of Obstetrics was taking it's toll.I was still maintain the WHO approved 80 % vaginal delivery rate but that Kick was gone.It was a job ,no more a passion.And when I don't enjoy something just like any other human being I loose interest.It was making me cranky,irritable and bored.Increasing Number of patients didn't excite me any more.It wasn't healthy for me.

And then was the Option to take a break.Move to Australia.Have more regulated hours of work.The famous Work life balance.It was enthralling and rejuvenating. 2 years break helped me a lot.

And then is when I thought,if I wish to have my sleep and at the same time not increase my Caesarean section rates and sleep with a clear conscience.When I know that I didn't use early decelerations as and excuse of foetal distress,when I know that a high head of baby is genuinely a high head of baby when I call it a caesarean, when a thin meconium at 8 cms is no indication for a caesarean
section,I need to reduce the Obstetrics component of my private practise.Very Honestly it wasn't just the love of IVF,treating infertility and the money involved but most importantly ,trying to switch over from a totally unplanned life of obstetrician to a more routine life of 9 am to 5 pm.

Now after reading this post,if you have a question,why did I return back,I am not surprised by your query :) :) Perhaps 2 years from hence I will tell the real reason of my return too ;-) ;-)