Cross-Border Fertility Care: Treating Fibroids, Adenomyosis and Long-Distance Patients

Ozempic is semaglutide. Untreated obesity itself carries heart, kidney, liver, joint and psychological risks that dwarf the drug's own side effects, which Dr. Pai compared to the rare risk of a plane crash or of liver failure from paracetamol, neither of which stops those products being used. He attributed the outsized scrutiny to how much public attention weight-loss drugs attract, not to an unusual risk profile compared with other common medications such as blood pressure drugs.

These drugs are not used during pregnancy. Dr. Pai's protocol is to bring the patient's weight down, stop the drug, wait about a month for it to wash out, then begin ovarian stimulation, retrieve eggs, freeze embryos, and transfer roughly a month later. He noted that around 50,000 unplanned pregnancies occurred among women on Ozempic in the US with no reported harm, and drew a parallel to metformin, once considered risky in pregnancy and now used throughout it.

Clomiphene 50 mg twice daily from day 2 to day 6, plus HMG 150 IU on days 7 and 9. HMG is avoided in PCOS patients because of hyperstimulation risk; PCOS is diagnosed by an antral follicle count above 15 with a necklace pattern on ultrasound and a high AMH, which Dr. Pai called their gold-standard test. He also recommends AMH testing for daughters to check ovarian reserve, with egg freezing considered before age 35 if a woman is not yet married.

Most commonly amenorrhoea or very scanty periods, occasionally heavy bleeding. Diagnosis relies on TB-PCR and D&C with histopathology, but because PCR can be falsely negative, Dr. Pai prefers laparoscopy for direct visual confirmation, alongside a chest X-ray, palpation of cervical and groin lymph nodes, family history, sputum AFB testing on three consecutive days where indicated, interferon-gamma release assays and a Mantoux test. Treatment is AKT-4 for two months followed by AKT-2 continuation therapy, nine months in total, which must be completed fully to avoid multidrug-resistant TB; laparoscopy and hysteroscopy are repeated afterward before trying IUI, and IVF only if that fails.

WHO's pathway is stepwise: rule out anovulation with day-21 progesterone above 10 ng/ml, rule out tubal block with an HSG, rule out uterine factors with 2D or 3D ultrasound, and test semen; if all are normal, try timed intercourse with clomiphene for 3 to 6 months, then 2 to 3 cycles of IUI (up to 6 if needed), which Dr. Pai's practice sees succeed in about 30% of cases, before moving to IVF. He named failure to conceive as IVF's biggest drawback, though across three attempts roughly 80 to 90% of patients achieve pregnancy, and frozen-embryo banking means most repeat cycles no longer require re-stimulation. In his estimate, about 80% of patients never need IVF at all if laparoscopy, hysteroscopy, ultrasound and a competent IUI lab are available; only 20% require it.

Fibroids and adenomyosis are significantly more common drivers of infertility among African patients, and both are surgical problems handled routinely by laparoscopy, often removing large or multiple fibroids within 5 to 10 days.

For patients needing extensive fibroid removal, stimulation and embryo freezing happen first, then surgery, then three months at home to heal before the transfer. For smaller fibroids, the order can reverse: IVF and embryo freezing first, fibroid removal in the same visit, then a trial of natural conception for three to four months before returning to use the frozen embryos if needed.

IUI, lifestyle management and lower-complexity cases should be handled in-country, both to spare patients the cost and disruption of travel and because roughly 80 percent of infertile couples do not need IVF at all. Azoospermia, complex tubal disease or repeated IVF failure remain cases better referred to India.

Egg count and quality decline with every year of delay, so earlier referral produces better outcomes than a patient exhausting local options first before finally seeking specialist care.