Question 1

Should we go for hysteroscopy plus laparoscopic chromopertubation, or repeat HSG, for a patient diagnosed with bilateral proximal tubal blockage?

Dr. Shelly Singh · Accepted Answer

HSG is often done without sedation, and the patient tenses up so much that tubal spasm appears as a bilateral proximal tubal blockage. One useful step is to give an antispasmodic before the procedure; doing it under light sedation also helps, since it is a painful procedure. That removes many false positives for proximal tubal blockage. If both tubes still appear blocked proximally, it is better to go directly for a diagnostic hysterolaparoscopy with chromopertubation, because the tubes are then visualised directly. Most patients find repeated HSG very painful.

Question 2

What is the success rate of IVF, and what are the cost implications?

Dr. Shelly Singh · Accepted Answer

Success rates of IVF in good centres here are now around 60%. The cost depends on the kind of IVF procedure: sometimes an ICSI procedure is needed, sometimes donor eggs. A cycle would start at about 3 to 4 lakh rupees.

Question 3

What size of fibroid must be surgically removed?

Dr. Shelly Singh · Accepted Answer

There is no specific size taken as the benchmark. Even small fibroids need removal if they cause a problem, for example a cornual blockage, and submucous fibroids and polyps will definitely need to be removed. Anything approximately equivalent in size to a 12 to 14 week pregnant uterus is a very large fibroid that definitely requires removal.

Question 4

What about the status of the uterine lining, especially after correction of uterine-related infertility, before proceeding to IVF?

Dr. Shelly Singh · Accepted Answer

We need a good, plush endometrial lining, and if it is not good we have medicines that can improve it. We recently treated a woman with intrauterine adhesions after a missed abortion managed by suction evacuation and curettage elsewhere. The cavity was full of adhesions, the endometrium was under 1 mm in places, completely scarred, with the walls stuck together. We did an adhesiolysis and then gave a combination of estrogen and progesterone; the estrogen helps regenerate the endometrium. So there are ways to regenerate the endometrium, but it varies from patient to patient. If the scarring is very bad, we may not be able to regenerate an adequate endometrium.

Question 5

What is the medical management of fibroids that do not need intervention?

Dr. Shelly Singh · Accepted Answer

Elagolix, a GnRH antagonist, is now being given to shrink fibroids, and we use it when required. GnRH analogue injections such as leuprolide can also be given. These reduce the size of the uterus and of most fibroids. However, submucous fibroids, which are the main culprits in infertility, often do not respond to medical management.

Question 6

After a myomectomy, what is the minimum period before conception?

Dr. Shelly Singh · Accepted Answer

We generally advise contraception for at least 3 to 4 months, with no conception in that window. The uterus has been sutured, and although we try hard not to open the cavity when removing fibroids, it sometimes happens when a large fibroid indents the cavity, and after a hysteroscopic myomectomy the cavity has been entered. These areas are weak points on the uterus and need enough time to heal, which is 3 to 4 months after surgery.

Question 7

Advertising often promises IVF success rates of 90% or 100%, while 50% to 60% is considered excellent even at the best facilities. How should doctors manage patient expectations?

Dr. Shelly Singh · Accepted Answer

In very good centres here the success rate is about 60%, at most 70%. We have moved on from the days when it was about 40% to 50%, thanks to more robust protocols and better medication and injections. But nobody can guarantee a 90% or 95% success rate; that is not achieved anywhere in the world, including the West.

Question 8

When influencers and marketing set unrealistic expectations, how should doctors counsel patients on the reality?

Dr. Shelly Singh · Accepted Answer

Google and Instagram influencers tell patients a different story, and people are often more willing to listen to them than to doctors. The answer is consistent counselling. Be the patient's friend, explain all the pros and cons, encourage them to read the literature, and share your own experience. Be patient, but make sure everything you say is fully backed by protocols, RCTs and the guidelines you follow.

Question 9

Agents sometimes misguide patients and sell false hope. Why is a doctor-to-doctor pathway with Indian specialists better than an agent guiding the patient?

Dr. Shelly Singh · Accepted Answer

We face the same challenge here. Agents bring patients who may not need treatment at all, or who need far more extensive treatment, and promise 90% to 100% results. Much of this is driven by money. Every doctor has to earn, but we must practise ethically. Patients come for surgery that may not be needed, and even when one doctor says so, someone else in the same hospital may operate. Anything doctor-driven, where doctors communicate directly and someone builds a conduit between them, leads to more ethical practice and better results. Patients spend a great deal on medical travel, and it is not fair to them if they undergo surgery they do not need or we cannot deliver the results. A doctor-to-doctor approach is more scientific and is not governed by people who are there only to make money.

Question 10

Could you break down the average cost of IVF for the first cycle and for subsequent cycles if the first does not succeed, and the cost of corrective surgery?

Dr. Shelly Singh · Accepted Answer

Surgery costs vary with the type of surgery, how extensive it is and, to a large extent, the hospital. For IVF, subsequent cycles cost less than the first, because often only a transfer of frozen embryos is needed.

Question 11

Is there an age limit for women to go for IVF at your hospital in India?

Dr. Shelly Singh · Accepted Answer

It is not really a hospital decision now, because the Government of India has laid down guidelines. We used to see people of 60 or 65 getting IVF, and then comes the ethical question of who will take care of the children. That is why, going strictly by the government guidelines, the limit is 50 for the woman and 55 for the man.

Question 12

Is surrogacy permitted in India, including for foreign patients, and what are the rules on egg and sperm donors?

Dr. Shelly Singh · Accepted Answer

Commercial surrogacy is not allowed in India. Surrogate mothers and biological parents faced many problems, so it has been made illegal, and foreign nationals cannot use surrogacy in India; only altruistic surrogacy for eligible Indian couples is permitted. Oocyte donors are available. Packages vary with the kind of donor; donors are matched on physical characteristics and screened to make sure there are no medical or genetic problems.

Question 13

Are egg or sperm donors of African ethnicity available in India?

Dr. Shelly Singh · Accepted Answer

Yes. There are sperm banks and various donors available, so patients who need a donor of the same race can find one here.

Question 14

How long does it take for the endometrium to completely regenerate following estrogen and progesterone therapy?

Dr. Shelly Singh · Accepted Answer

After adhesiolysis we give a combination of estrogen throughout the cycle with progesterone added in the last 14 days, and regeneration takes about three months. We do a transvaginal scan for endometrial thickness before treatment and again after those three months to see how well it is regenerating. Most of the time it starts to improve after about a month and a half, where the scarring is not bad and the adhesions have not permanently damaged the endometrium.

Live Discussion with Dr. Shelly Singh