Question 1

Can you say more about the injectable medications you mentioned for weight loss and obesity management?

Dr. Hrishikesh Pai · Accepted Answer

Three drug classes now exist: GLP-1 agonists (semaglutide), GLP-1/GIP combinations (tirzepatide, marketed as Mounjaro), and a GLP-1/GIP/glucagon combination about to be released. Injectable semaglutide starts at 0.25 mg subcutaneously, rising gradually to 2.4 mg; an oral form (Rybelsus) is also available but must be taken daily rather than weekly. Mounjaro, launched in the US two years earlier at roughly $1,000 a month, was released in India at about one-sixth of that cost (roughly Rs 15,000 to 20,000 a month) because of the scale of global obesity; with semaglutide's patent expiring in March and around eleven companies preparing to launch competing versions in India by April, prices are expected to fall further.

Question 2

There is a lot of misinformation online about Ozempic and similar drugs. What class of drug is this, and how real are the risks?

Dr. Hrishikesh Pai · Accepted Answer

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.

Question 3

Does the drug create dependency, so that someone who loses weight once and regains it later has to keep using it?

Dr. Hrishikesh Pai · Accepted Answer

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.

Question 4

For IUI stimulation, what is your combination of medication, and when do you start it?

Dr. Hrishikesh Pai · Accepted Answer

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.

Question 5

If genital tuberculosis is diagnosed, what are the clinical findings in the uterus?

Dr. Hrishikesh Pai · Accepted Answer

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.

Question 6

Why should we consider IVF over intrauterine insemination, and what are the complications of IVF?

Dr. Hrishikesh Pai · Accepted Answer

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.

Question 7

What are the factors that reduce the success rate of IVF?

Dr. Hrishikesh Pai · Accepted Answer

Age is the dominant factor. Citing the US SART and UK HFEA registries, Dr. Pai gave approximate success rates by age band: under 35 about 40%, 35 to 37 roughly 35 to 40%, 37 to 39 about 25 to 30%, 39 to 41 about 15%, and over 41 about 5 to 10%, because genetic abnormality rates in eggs rise with age even when embryos form. Low ovarian reserve, with AMH sometimes as low as 0.3 to 0.4 ng/ml, is the other major factor; for patients who decline donor eggs, he tries platelet-rich plasma injected under ultrasound or laparoscopic guidance and, in some cases, stem-cell therapy, using the laparoscopy to also rule out genital tuberculosis, which can itself lower ovarian reserve.

Question 8

Many women presenting with infertility have a white, cheese-like vaginal discharge. Could there be a connection?

Dr. Hrishikesh Pai · Accepted Answer

This is usually a fungal infection, and both partners need treatment, along with lactobacillus supplements. Because a wet mount or culture can miss organisms such as Trichomonas, Chlamydia or Mycoplasma, Dr. Pai often gives combination therapy (an antifungal such as fluconazole plus an antibiotic such as azithromycin) with local clotrimazole cream, and screens for diabetes, since fungal infections are common in patients who are obese or diabetic.

Question 9

A woman with blood group O negative delivered her first child and received anti-D prophylaxis, then had a miscarriage at 16 weeks. How should such couples be managed?

Dr. Hrishikesh Pai · Accepted Answer

If antibody titres are very high, management becomes difficult. Where it is legally available, Dr. Pai suggested surrogacy carried by an Rh-negative surrogate as a way to avoid maternal antibody-mediated complications and repeated interventions such as cord blood transfusion, rather than risking complications like kernicterus in the baby.

Question 10

Is letrozole considered more effective than clomiphene for ovulation stimulation?

Dr. Hrishikesh Pai · Accepted Answer

Not universally. Dr. Pai calls clomiphene his master drug and reserves letrozole specifically for PCOS patients. His practice stratifies by AMH and antral follicle count: normal responders (AMH 2 to 3.5 ng/ml, AFC 7 to 15) receive clomiphene or clomiphene plus HMG; poor responders (AMH under 1.5, AFC under 7) also receive clomiphene plus HMG; hyper-responders with PCOS (AMH over 3.5, AFC over 15) receive letrozole; pure HMG is reserved for IVF cycles.

Question 11

What is the referral process for sending a patient's case in for review?

Dr. Hrishikesh Pai · Accepted Answer

Answered by the Jivo Healthcare coordination team rather than Dr. Pai directly: each referring doctor is assigned a relationship manager who collects and documents the case file, shares it with the Fortis coordinator and Dr. Pai's team, and returns a review with further guidance within 48 to 72 hours.

Diagnosis and Management of Infertile Couple - Latest Guidelines by WHO

Questions Doctors Asked Dr. Hrishikesh Pai