Seven frequently asked questions on “Poor Ovarian Reserve”

Poor ovarian reserve is a major cause of reduced fertility among women who delay planning a family. Many of these women remain unaware of this reality and dont know that there was means to preserve their eggs for a delayed child bearing.

Ovarian Reserve is one of the more frequently discussed topic in my infertility practice, especially as many working women plan to defer child bearing while they remain worried about their fertility potential in future. Besides this, I see a lot of women who are not able to conceive and have poor ovarian reserve. Here are seven most frequently asked questions related to “Ovarian Reserve” and my answers to these.

  1. What is ovarian reserve?

Ovarian reserve of a woman is defined as an estimated number of oocytes/ eggs a woman has in her ovaries at a given time. A female fetus has a maximum of 6 to 7 million eggs at 16 to 20 weeks of gestational age. Thereafter, this number keeps on declining and reaches an approximate count of 1 to 2 million eggs at the time of birth, and further falls to approximately  250,000 to 500,000 eggs at puberty. This count further declines to approximately 25,000 at around 37 years of age and to less than 1000 at menopause.

  1. How is ovarian reserve estimated?

There are various tests to assess ovarian reserve. The main tests include –

  1. Serum FSH/LH- done on the 2nd /3rd day of a woman’s menstrual cycle gives an indication of the woman’s egg reserves.
  2. Serum Anti mullerian hormone (AMH) – very sensitive test of testing a woman’s ovarian reserve. It can be done on any day of the menstrual cycle.
  3. Antral Follicle count-  Antral follicle are small follicles present in the ovary that are best seen during the early phases of the menstrual cycle. Transvaginal ultrasound (TVS) of the pelvis is used to count the number of antral follicles, which gives good estimate of the woman’s ovarian reserve.AFC

    3.  Why is testing for ovarian reserve important?

A woman’s ovarian reserve is an indicator of her fertility potential. Women facing difficulty in  conception or planning to delay child bearing should be assessed for their ovarian reserve for timely and appropriate fertility intervention.

  1. What is poor ovarian reserve?

If a woman has a premature decline in her egg quantity due to any reason which reduces her chances of having a mature egg, she is suspected to have “poor ovarian reserve”. It is natural for the number of eggs present in a lady to decline as she ages – both due to ovulation and a natural cell death process called “Apoptosis” – and normally the woman would exhaust her egg reserve by the time she reaches menopause. But, if the decline in egg count happens faster than that and the woman is depleted of her egg reserve before expected menopause, she should be suspected to have “poor ovarian reserve”.

  1. What causes poor ovarian reserve?

Poor ovarian reserve can be caused by a number of reasons-

  1. Genetic defects including chromosomal anomalies such as Turner’s syndrome and gene defects like Fragile X syndrome.
  2. Damage to the ovaries due to any injury, torsion, infection, surgery or due to radiation or chemotherapy.

However in most cases the exact cause of poor ovarian reserve remains unknown.

  1. Does poor ovarian reserve lead to reduced chances of pregnancy?

Poor ovarian reserve is associated with reduced chances of pregnancy both naturally and following fertility treatment. This is because the number of eggs is reduced which corresponds to reduced chances of pregnancy. The goal of ovarian reserve testing is to identify those individuals who are at risk of diminished ovarian reserve so that they can be encouraged to pursue more aggressive treatment to achieve pregnancy.

  1. Is there any treatment to improve the ovarian reserve?

There are no concrete remedies to improve Ovarian reserve however lately some medications have been developed  to improve the egg quality and number. The benefits of these medicines are not yet conclusively proven.

preventing failure

You can read more about management of Poor Ovarian Reserve at

Dr Parul Katiyar 

For more information on poor ovarian reserve and ways to address poor fertility resulting from this, please write to me at


IVF treatment and twins – role of multiple embryo transfer

One of my patients whom I was counselling for IVF treatment for her primary infertility recently asked me a very basic question about the procedure and its outcome. She asked me – “Doctor, can I conceive only twins with IVF?”. This again prompted me to think about this very important aspect of fertility treatment – the risk of multiple pregnancy resulting from multiple embryo transfers. Some big celebrities like Celine Dion, Julia Bradbury and Jennifer Aniston and our own Farah Khan have been in news for conceiving multiple babies with IVF and that somehow makes many women undergoing IVF treatment to think that IVF produces multiple pregnancy only.  In this post, I  will try to explain the reasons for multiple pregnancies resulting from IVF treatment and how can this be avoided.

According to global evidence, approximately 25% of total births resulting from ART treatment are twins, a rate much greater than in the general population (approximately one in 80 births). The incidence of triplets and quadruplets is also high among pregnancies resulting from IVF treatment. However, the majority (approx. 70%) of pregnancies resulting from IVF treatment are singletons. With an ever increasing focus on optimizing treatment outcome and reducing complications associated with IVF treatment, the risk of multiple pregnancies with IVF has become  one of the most important considerations while planning the IVF cycle.

The process of implantation of an embryo in the womb is a complicated one and we still do not know what transpires between the embryo and the uterus when they come in contact with each other, and therefore, we do not completely understand the reasons for a positive or negative pregnancy outcome also. Since there is no test or procedure that can assure pregnancy with IVF – an expensive treatment not generally covered by insurance policies – the physicians naturally want to enhance the probability of pregnancy and consider putting in more than one embryos. The risk of multiple pregnancy in IVF cycle derives from this tendency among treating physicians to transfer more than one embryos inside the uterus in order to increase the odds of pregnancy.

Pregnancy rates with IVF treatment appear to peak with transfer of three or four embryos. However, the risk of multiple pregnancy also increases at the same time. Multiple pregnancy is associated with   a higher rate of maternal, fetal and neonatal complications and is considered as the single biggest risk or complication of fertility treatment.

Good practice in IVF treatment aims to reduce the risk of multiple pregnancy whilst maximizing the overall chances of conception. This is achieved by proper patient selection and counselling.

  1. Young women who have the best chance of conception, also have the highest chance of conceiving multiples. Therefore, I always offer them a single embryo transfer at a time and freeze the rest of the good quality embryos for later use.
  2. An extended culture of embryos up to the day 5, called as blastocyst culture, helps in better embryo selection for transfer into the uterus. I advise blastocyst culture for patients with more than 3 good quality embryos and transfer a single blastocyst in such patients.

I also believe that treating physicians should counsel the patients that only success parameter in any IVF cycle is a healthy baby born to a healthy mother and reducing the number of embryos transferred in a cycle is a significant step to achieve that goal. Patients should be counselled about the risk associated with transferring many embryos and also explained that freezing the spare embryos and transferring them in subsequent cycles if needed  would give them even better cumulative pregnancy outcome than putting back many embryos in one embryos transfer.

Please contact me at for any queries related to IVF or any aspect related to infertility treatment.

Five things to know about Fertility Preservation in women with Cancer

The incidence of cancers among young people is increasing due to changing lifestyles, deteriorating dietary patterns and many other yet unknown factors. And, at the same time newer techniques and technologies allow for early detection and treatment of cancers. A combined effect of these two factors is that more and more women of reproductive age group are now receiving anticancer treatment. While this helps many women lead a longer life, this does not always translate into a high quality reproductive life. Fertility preservation has therefore become very important for such women and they need to know what all options are available for them. This article explains various methods of fertility preservation available for women diagnosed with cancer.

Question 1- What is fertility preservation?

Fertility preservation essentially means preserving the ability of an individual woman or couple to conceive at a later date. These days, women are going for fertility preservation for a number of reasons. These include –

a) Women diagnosed with cancers and being planned for cancer treatment

b) Women undergoing treatment for Rheumatic diseases like Rheumatoid Arthritis and SLE and Myelodysplasia, which require them to take medications which can harm their fertility

c) Social indications – women not wanting to conceive at a young age for reasons such as career aspirations or if they are still looking for a suitable partner

This article discusses fertility preservation for women who are diagnosed with cancers and are going for cancer treatment. Fertility preservation carried out prior to the cancer treatment plays an important role in improving the quality of life of women surviving cancers. We counsel all women of reproductive age group, who are planned for cancer treatment and offer this option to all women who wish to preserve their fertility.

Question 2 – Why should a woman diagnosed with cancer worry about her fertility?

According to the National Cancer Registry of India, the number of newly diagnosed cases of cancer in India will cross the figure of 11 Lakh by year 2020, more than half of whom will likely be women. Of these, approximately two Lakh will be in adult patients within their reproductive years, i.e. up to age of 45 years.

Abdominal surgeries, especially the ones performed for treatment of cancers of reproductive organs – ovaries and uterus can cause permanent damage to the reproductive organs. Similarly, chemo and radiotherapy for cancers also affect the reproductive potential of women, as they have potential to cause genetic and structural damage to the reproductive organs. According to estimates, approximately 40-80% of women receiving cancer treatment are at risk of infertility resulting from cancer treatments in form of chemotherapy, radiation therapy and surgery.

Question 3 – How does cancer chemotherapy affect fertility of a woman?

Chemotherapeutic drugs kill cancer cells by interrupting critical cellular processes and stopping cellular growth and multiplication. But, these drugs can also cause DNA abnormalities and oxidative damage to the normal germ cells (cells which produce eggs) of a woman, leading to death and deformities of developing oocytes. The degree of damage to oocytes depends upon the specific drug that is used and its dose and also on age of the patient receiving this treatment. Older women with relatively lower ovarian reserves are more likely to be affected by the drugs, which can actually lead to premature ovarian failure (POF). The resulting damage to the ovaries can manifest in form of either temporary amenorrhea or premature menopause, both resulting in infertility.

Question 4 – How does radiation therapy affect fertility of a woman?

Radiation therapy can affect both ovary and uterus, thus impacting the fertility potential of the woman. Radiation induced damage to reproductive organs can cause infertility, miscarriage, preterm labor, intrauterine growth retardation and low birth weight. Radiations damage myometrium (inner lining of the uterus), and reduce its blood supply, which cause uterine fibrosis and hormone dependent endometrial insufficiency. The amount of damage caused to the ovaries by radiations depends upon age of the patient and amount of radiation exposure to the ovaries. Over 90% of patients undergoing total body irradiation or total abdominal irradiation eventually end up with ovarian failure.

Question 5 – What are various methods of preserving fertility among women?

There are multiple techniques, which can help women preserve their fertile potential for future and there are some other techniques, which are still emerging. The five main fertility preservation methods are explained below.

1. Embryo cryopreservation

Embryo cryopreservation means freezing embryos for implantation at a later (more suitable) occasion. This requires the patient to undergo IVF before starting the treatment for cancer. The embryos thus formed are then frozen. Embryo freezing is a proven and established technique and offers good results, which of course depend on the number and quality of embryos frozen.

Limitations of embryo cryopreservation:

a) Controlled ovarian stimulation in order to procure the eggs can take between 2-4 weeks’ time, depending on when the patient consults for fertility preservation. This means that the treatment for cancer has to be delayed by that many days, which may not always be in the best interest of the patient.

b) High Serum E2 levels resulting from hormonal stimulation of ovaries may have a negative effect on estrogen-sensitive tumors. We always seek an expert opinion from an oncologist before starting the stimulation.

c) IVF may not be possible in/ preferred by unmarried women, as it required sperms at the time of the procedure, and some women may not want to limit their reproductive autonomy in the future.

d) There are serious ethical and legal implications regarding disposal of the embryos, in case patient dies before she can use the embryos.

e) IVF cannot be used a fertility preservation technique for pre-pubertal girls undergoing treatment for cancers.

2. Mature oocyte cryopreservation

Oocyte cryopreservation (commonly referred to as Egg Freezing) is a preferred method of preserving fertility, especially among unmarried women as it allows the women to maintain their reproductive autonomy in future. However, egg freezing also required the patient to undergo controlled ovarian stimulation and, therefore, suffers from some of the same disadvantages as embryo freezing.

Just like embryo cryopreservation, egg cryopreservation can also not be used to preserve fertility potential among pre-pubertal girls. Also, since only a limited number of eggs/ embryos can be frozen is one cycle, the patient can take only as many attempts at pregnancy in future.

We recommend only one single attempt at stimulation and egg retrieval in order not to delay start of cancer treatment. We also take extreme care during stimulation so as to minimize the chance of ovarian hyper stimulation. The patients undergoing stimulation for fertility preservation are monitored very closely for ovarian response and dose of stimulation is titrated accordingly.

3. Ovarian tissue cryopreservation (OTC)

Ovarian tissue cryopreservation or tissue freezing is the process of harvesting ovarian cortical tissue (containing primordial follicles), dissecting the tissue into small pieces and freezing them for use later on. In most of the cases, this procedure can be performed laparoscopically (key hole surgery) and is done before starting any treatment for cancer. The frozen ovarian tissue can be re-transplanted into the patient on completion of cancer treatment, either into the pelvis (called orthotopic transplant) or in abdominal wall or forearm (called heterotopic transplant).

There is possibility of natural conception with orthotopic pelvic transplant of the ovarian tissue, but the patient definitely needs IVF treatment to conceive after heterotopic transplant of ovarian tissue. We always suggest orthotopic transplantation as a preferred method, as it is more biological and has better success rates.

Indications of Ovarian tissue cryopreservation-

a) Patient age less than 37 years

b) Good ovarian function – S FSH, AFC, AMH

c) Pre-pubertal girls where egg/ embryo freezing is ruled out

d) High risk for Permanent ovarian failure as a result of cancer treatment

Advantages of OTC over egg/ embryo freezing-

a) There is no need to delay cancer treatment in order to do OTC

b) There is no risk of ovarian hyper-stimulation and negative effect of progesterone on cancer

c) Partner or donor sperm is not required at the time of performing OTC, thus woman’s reproductive autonomy is maintained.

d) OTC helps preserve a larger number of follicles and technically allows for the resumption of ovarian function, which may last then many years.

However, OTC is still not a common fertility preserving method, especially for systemic cancers like leukemia, wherein cancer cells may be present in the frozen ovarian tissue. We consider OTC as a fertility preservation technique only in cases where egg/ embryo freezing is not indicated, namely when delaying start of cancer treatment not an option acceptable or controlled ovarian stimulation using hormones is contraindicated or IVF is not possible. OTC does not work for women over 40 years of age, as their ovarian reserve is relatively poor.

4. Fertility-sparing surgery – Ovarian transposition

Patients needing radiation treatment can benefit by fertility sparing surgeries. But, ovarian transposition is not an option for patients needing combined radiation- chemotherapy, which is a case in majority of patients. This procedure involves surgically moving the ovaries away from the field of radiation. For example-

a) Lateral fixation of ovaries in patients needing craniospinal irradiation

b) Moving ovaries out of the pelvis or into the anterior abdominal wall in patients who require radiation therapy to the pelvis

Disadvantages of ovarian transposition-

a) Risk of cyst formation in ovary and postoperative adhesions leading to chronic pelvic pain

b) Some patients may be harboring metastatic cancer in the ovaries, which may skip the radiation treatment

c) Transvaginal ovum pickup is not a viable option if the ovaries have been transposed and the patient may need laparoscopic egg pick up for IVF.

5. In vitro maturation

In vitro maturation (IVM) is another technique of fertility preservation for patients with cancers, but the success rate of IVM remains lower than egg/ embryo freezing. IVM involves aspiration of immature follicles (with/ out hormonal stimulation) for maturation outside of the body. The mature oocytes or embryos thus generated are then frozen for use at a later occasion.

Menstrual irregularities among women

Almost every woman experiences some kind of menstrual irregularities at some point in her life. While there can be many causes for these irregularities, simple remedies are available for most of these women.

Some kind of menstrual irregularity, often accompanied by pain in lower abdomen is one of the most common presenting complaints for a gynecologist.

Irregular period is generally a symptom of some hormonal imbalance (estrogen and progesterone) in the body and is commonly encountered in young girls at the time of menarche (time when a girl starts to have menstrual cycle) and around menopause. Menstrual irregularity can also be seen immediately after child birth or after removal of intrauterine contraceptive device (IUCD). Other common causes include thyroid gland dysfunctions, presence of fibroids or polyps inside the uterus and excessive stress, including examination stress.

mens irreg

It is important to know a few more important details in order to evaluate and understand the same and make any recommendations. These include-

  • Duration of menstrual irregularity
  • Kind of irregularity- interval between two cycles, amount of blood flow and no of days of flow.
  • Any associated pain in lower abdomen.
  • Associated weight gain, growth of excessive facial hair or discharge from nipples.

Early assessment of menstrual disorders also requires an ultrasound scan of lower abdomen to assess condition of uterus and ovaries, specifically to rule out polycystic ovaries (read more about PCOS here), and estimation of following hormone levels in the body – TSH, FSH, LH, Prolactin and testosterone. These blood tests should be done on the second or third day of the periods.

The women experiencing menstrual irregularities should try and manage their weight so as to maintain a BMI of less than 25 Kg/M2. Healthy lifestyle including intake of balanced diet, moderate exercise and avoiding any stress are very useful simple steps every woman can take on their own. In cases with severe irregularity, the woman may be required to get rid of the IUCD, start a birth control pill to regulate the sex hormone levels during cycle and treatment for thyroid dysfunctions, if required.

You can consult with me for more information or treatment for menstrual disorders.

Dr Parul Katiyar

Does infertility treatment put women at higher risk of cancers?

Many patients ask me if IVF treatment leads to a higher risk of cancers, especially in breasts and ovaries. As per the latest published scientific literature on this subject, there is no real evidence to link IVF with higher risk of cancers among these women.

As an infertility specialist, I am required to counsel mcancery patients about potential complications of fertility treatment. One of the most often asked question is if infertility treatments put the women at a higher risk of cancers.

Fertility drugs like clomiphene citrate and hormones used for ovarian stimulation & assisted reproductive technologies like IVF and ICSI have all been implicated to causes various cancers among women, including not only cancers of cervix, uterus, ovaries and breast, but also melanoma and cancers of the central nervous system.

A simple answer to this question is that as per the latest studies, there is no conclusive evidence to suggest a higher risk of invasive cancers in women receiving infertility treatment.

Why has infertility treatment been linked with higher risk of cancers?

There are multiple theories as to why fertility treatment may increases the risk of cancer in women.

  1. Hormonal treatment with Clomiphene and Gonadotropins causes cancers because elevated levels of estrogen and progesterone hormones can trigger carcinogenic activity in the ovarian , uterine and breast tissues
  2. Ovarian enlargement due to development of multiple follicles causes trauma to the ovaries, which may result in carcinogenesis.
  3. Injury to ovaries resulting from multiple needle punctures made during egg retrieval has also been suggested to cause cancers of ovaries.

However, at the same time, it has also been suggested that infertile and nulliparous women are inherently at an increased risk of certain cancers so actually infertility treatment may not be the cause of cancers in these women.

What does the scientific evidence tell us?

Extensive research has been conducted on this subject, but the results so far have been pretty inconclusive. We need to appreciate that it is indeed difficult to study direct relationship between cancers in women and infertility treatment because many of these cancers appear many years after the treatment/ causative injury. Therefore, large populations have to be studied over a long period of time in order to arrive at any meaningful conclusions regarding the relationship between fertility treatment and cancers.

Of all the cancers suspected to be associated with infertility treatment, cancers in ovaries are most often linked to the infertility treatment. The overall evidence in this regard is mixed. While some studies have found the risk of ovarian cancers to be higher in women with a history of fertility treatment, others have ruled any such association out.

A research group from Israel retrospectively studied possibility of such an association in over 106,000 women, who had delivered between 1998 and 2013.1 The researchers found that women with conceived with IVF treatment had a significantly increased risk of being diagnosed with ovarian and uterine cancers as compared to women who had conceived either naturally or using ovulation induction. However, another study of over 87,000 women from Israel only conducted around the same time did not find any significant relationship between IVF exposure and risks of breast, endometrial, or ovarian cancers.2

In a population based cohort study of 812,986 women from Norway, who had delivered between 1984 and 2010, the researchers tried to assess the overall risk of cancers and specifically of cancers of cervix, uterus, ovary, thyroid, the central nervous system and melanoma among the women who had conceived using ART. 3 They found that the overall risk of cancers was not higher among the women conceiving using ART and delivering at least one baby. Although there was a hint of higher incidence of some cancers among women undergoing IVF, this could not be statistically proven owing to the weak nature of this kind of population based study.

A Cochrane review of 25 studies (consisting of 11 case-control studies and 14 cohort studies) covering 182,972 women did not find any convincing evidence supporting an increased risk of invasive ovarian tumors with fertility drug treatment. However, the researchers concluded that there may be an increased risk of borderline ovarian tumors in subfertile women treated with IVF.4

Cancer of the breast is the second most commonly discussed cancer that is assumed to be linked with hormonal treatment for infertility. Large studies and meta-analyses have not found any significant correlation between treatment for infertility and breast cancer. 5,6 While some studies have suggested that the risk of breast cancer increases after exposure to ovulation inducing agents (especially clomiphene citrate)6, many other studies do not support such an association.5 Therefore, I don’t advocate long term administration of Clomiphene, as the risk of breast cancer is not fully ruled out with its long term use.


Overall we can say that on the basis of existing scientific evidence, there is no conclusive proof of a causal link between ovarian and breast cancers and fertility treatment. Therefore, treatment of infertility using hormones and ART is by and large safe. The cancers of ovary and breast detected among women with history of treatment for infertility are more likely to be related to their infertile status than to the effect of fertility drugs. However, we must keep in mind that majority of the available studies on this subject suffer from methodological limitations and therefore cannot be fully relied upon. Further research on this subject will certainly enlighten us more on the possibility of any such association.


1.       The risk of female malignancies after fertility treatments: a cohort study with 25-year follow-up. Kessous et al. J Cancer Res Clin Oncol. 2016 Jan;142(1):287-93.

2.       In vitro fertilization and risk of breast and gynecologic cancers: a retrospective cohort study within the Israeli Maccabi Healthcare Services. Brinton et al. Fertil Steril. 2013 Apr;99(5):1189-96.

3.       Cancer risk among parous women following assisted reproductive technology. Reigstad et al. Hum Reprod. 2015 Aug;30(8):1952-63.

4.       Risk of ovarian cancer in women treated with ovarian stimulating drugs for infertility. Rizzuto I, Behrens RF, Smith LA. Cochrane Database Syst Rev. 2013 Aug 13;8:CD008215.

5.       IVF and breast cancer: a systematic review and meta-analysis. Sergentanis et al. Hum Reprod Update. Sergentanis et al. 2014 Jan-Feb;20(1):106-23.

6.       Breast cancer incidence after hormonal treatments for infertility: systematic review and meta-analysis of population-based studies. Gennari et al. Breast Cancer Res Treat. 2015 Apr;150(2):405-13.

For further information or queries on this subject, please write to me at

Dr Parul Katiyar

IVF- Frequently Asked Questions – I

Some frequently asked questions about fertility treatment in general and IVF in particular.

In today’s post I am going to address some questions I get asked very often by my patients undergoing fertility treatments, including IVF. I am sure there are many people with similar queries and they will all benefit from this post.

Q 1. Will there be an increased risk of birth defects in my baby if I conceive with IVF?

A. No, there is no merit in such an argument. The risk of birth defects in babies conceived by IVF is the same as for babies conceived naturally. From a scientific perspective, birth defects or congenital anomalies mostly result from alterations in the genetic material (known as mutations) and the process of IVF doesn’t cause any mutations. In fact, the incidence of chromosomal abnormalities such as Down syndrome and Turner’s syndrome with fertility treatment is also same as for general population.

Q 2. Can fertility treatment including the IVF procedure damage ovaries? 

A. There is no real evidence to suggest that either pre-IVF diagnostic laparoscopy or ultrasound guided ovum pickup through vagina causes any major/ permanent physical trauma to the ovaries. These are well established procedures now and carry only as much risk as any other medical intervention/ procedure.

What is more important is the expertise and experience of the treating doctor and quality of equipment and support functions at the treatment facility. So, I encourage my patients to do proper research and due diligence to find out whats the best and most convenient place to seek such treatment.

Q 3. Since IVF can lead to twin pregnancy, should I get only one embryo transferred?

A. It is true that transfer of more than one embryos carries a real risk of twin pregnancy. In fact, as per the collective evidence, the chance of twin pregnancy with IVF is 1 in every 4-5 pregnancies, whereas it is 1 in 80 in naturally conceived pregnancies. The chances of conceiving triplets and quadruplets is also much higher with IVF than naturally. It is also a well known fact that the chance of multiple pregnancy in an IVF cycle goes up as the number of embryos transferred increases.

IVF being a very costly treatment, we need to weigh the risk of multiple pregnancies with the chance of success in a cycle. So, the real questions to ask are how many embryos should be transferred in an IVF cycle and if it is justified to transfer only one embryo during an IVF cycle? While there is no single definite answer to this question, I generally recommend transferring 2-3 embryos – of course, the final count depends upon the quality of the embryos, age of the woman and affordability of the couple seeking IVF.

If the woman treated with IVF actually gets twin pregnancies, I generally advice her to carry on with the same and accept that as God’s gift. However, in case of triplets and quadruplets  I suggest the woman should try selective reduction of implanted embryos in order to increase the chances of successful pregnancy.


Q 4. What precautions should we take after the embryo transfer?

A. As such there are no special precautions to be taken after embryo transfer. The woman can continue with routine diet and regular activities. However, the woman should avoid excessive physical exertion after the transfer. There is also no additional advantage of bed rest after the transfer. I am also often asked if the couple can have intercourse after embryo transfer. While there is no rule regarding this, I advise couples to abstain for two weeks after the transfer just to give some rest to the uterus. 

Q 5. Can we also attempt naturally while going for IVF?

A. Yes, you can because you never know when your prayers get answered! As such there is no medical reason to avoid intercourse while undergoing fertility treatment However, in order to maximize the chances of success with IVF, I recommend that the couple avoids intercourse for 48 hours preceding collection of semen sample to ensure that the semen sample collected for ART is of optimal quality. For the same reason, the male partner should also abstain from masturbating for at least 48 hours preceding sample collection/ egg retrieval.

There are some more frequently asked questions, which I will take up in my subsequent posts.

Birth control pills and Infertility

One of the most common myths around infertility is whether past usage of birth control pills by a woman can result in infertility later on. If you also have a similar query, please read on for an answer!

Many women with suspected/ diagnosed infertility often ask me if their infertility could have resulted from usage of birth control pills in the past. There is clearly no such association between using birth control pills and infertility and suppression of fertility by birth control pills gets completely reversed on discontinuing the pill. Let us first understand how the birth control pills actually work, and, then we will discuss why these pills cannot lead to infertility.

History of birth control pill

Birth control pills have been in existence since year 1957, when the US FDA approved using these hormonal tablets for treatment of severe menstrual disorders. However, they became much more popular some three year later, when the same US FDA approved using these pills as “birth control pills”. Over these 55 years, this magical medicine has been safely used by millions of women all over the world to control when they want to be mothers, and therefore, have been touted as a “woman’s best friend”.

The pills have evolved over all these years and the new generation birth control pills, which are uses these days contain much lesser quantity of hormones than their original predecessors. This makes the modern pills much safer for women, while being equally efficacious in preventing ovulation and controlling the menstrual cycle.

How do birth control pills work?

Birth control pills are essentially hormone pills containing female sex hormones – estrogen and progesterone. These hormones send negative signals to the pituitary gland located within the brain, thus stopping production of follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland. FSH and LH are responsible for maturation of a growing follicle and ovulation during the normal menstrual cycle. Circulating FSH and LH do not allow the uterine lining to grow appropriately. This, in turn, leads to formation of abnormal cervical mucus, which inhibits swift movement of sperms and also doesn’t allow the embryo (if it forms) to settle in the endometrium.

Can use of birth control pills lead to infertility?  

The simple answer is “No”, because the pill just contains the synthetic version of the hormones which are otherwise also produced inside the woman’s body!

There is now enough scientific evidence to refute any cause- effect relationship between intake of birth control pills and subsequent infertility. Some temporary disruption in menstrual cycle for a few months after stopping the pill is known to occur in some women and is known as “post-pill amenorrhea”. But even this phenomenon is mostly unrelated to intake of pill per se and is rather caused by coexisting problems such as being underweight or depressed. Most of the women resume their normal “pre-pill” cycles within 1-3 month of stopping the pill and are ovulating normally by this time.

What are the benefits of using birth control pills for subfertile women?

Birth control pills provide some additional benefits to enhance fertility among women.

  1. In women with irregular cycles, especially due to polycystic ovaries (PCOS), birth control pills are used to improve hormonal imbalance as a premedication before starting fertility treatment. Read here for more information on PCOS and infertility.
  2. Birth control pills are very useful in managing the excessive facial hair growth (hirsutism) in patients with PCOS. The pills suppress the level of circulating male hormones in the body of these patients, which is the major cause of facial hair growth. Read more about hirsutism and role of birth control pills in its treatment here.
  3. Birth control pills also provide some protection against Pelvic Inflammatory Disease (PID) – an infective condition of the female reproductive organs leading to inflammation and blockage of tubes. The pills cause thickening of cervical mucus, which protects the reproductive organs from infections by preventing transport of infective organisms into uterus and tubes. You can read more about PID and infertility in my upcoming post.
  4. Birth control pills help in improving the symptoms of endometriosis, especially the pain associated with it. Using the pills also slows down the progression of the disease by reducing the level of circulating estrogen in body. I will be writing on this subject soon.
  5. Intake of birth control pills is also known to reduce the risk of cancers of ovaries and uterus, which themselves could affect the woman’s fertility.

Are there any risks associated with use of birth control pills?

Birth control pills falls under the category of “Schedule H” drugs in India, which means that a physician’s prescription is required to purchase these pills. Irrespective of this regulations and like for any other medication, birth control pills should always be started only on a doctor’s advice. Although the modern pills are very safe and have minimal side effects/ complications in vast majority of users, there are situations in which the pills should be used with caution/ not used at all, such as women over 40 years of age, smokers, women with known liver diseases or clotting disorders etc. Please read more about such contraindications in the suggested readings below and consult your gynecologist before starting the pill.

Further readings


Making IVF Patient Friendly with Milder Stimulation

It is time to adopt more physiological and patient friendly ovarian stimulation strategies for IVF, which require lesser amount of hormonal stimulation and still produce 2-3 follicles for IVF. Such minimal/ mild stimulation protocols should preferably be used in the modern infertility practice.

There has been good debate on what is the correct number of eggs to be retrieved and number of embryos to be transferred during an IVF cycle. The debate revolves around success rate and cost of the procedure and patient comfort and compliance. I will try to address the first of these two questions, i.e. whats is a good number of eggs to retrieve during an IVF cycle and how should one go about it.

Technically speaking, a single egg has the potential for fertilization and the first IVF baby was born from a natural cycle IVF. But, not every egg gets fertilized on being exposed to sperms and not all embryos have the potential to result in a pregnancy. This inherent failure of assurance of pregnancy resulting from the transfer of a single embryo (fertilized egg) after IVF has resulted in evolution of the practices of artificially inducing the ovaries to produce many eggs in a cycle and of transferring more than one embryo into the uterus. However, even these interventions do not guarantee success of the IVF cycle and the outcome of such IVF cycles can also be measured only in terms of probability.

What is the standard IVF practice?

The standard practice is to give daily hormonal injections to induce the growth of many eggs (targeted number of eggs varies from 5-6 to up to 10), which is coupled with strict monitoring using ultrasounds and blood tests. This process is often very stressful and unfriendly for the patient. This also entails a risk of some complications due to the stimulation which can be short term and may have some long term sequel as well.

What are the disadvantages of conventional stimulation protocols for IVF?

The conventional stimulation protocols have following disadvantages-

  1. Patient discomfort associated with daily injections
  2. Risk of complications like ovarian hyperstimulation, which occurs as a result of recruitment of excessive number of follicles.
  3. In patients with poor ovarian reserve, higher dosage of hormones may not yield more eggs because stimulation helps in recruitment of follicles already present in the ovaries.
  4. Quantity does not correlate with quality – Retrieval of a larger no of eggs may not necessarily mean better quality of eggs. In fact, many of these eggs may be of poor quality and some may even have aneuploidy.
  5. Excessive production of hormone Estradiol (produced by a larger no of growing follicles) has a negative impact on the endometrial receptivity, i.e. the ability of endometrium to allow implantation of the embryos. This may negatively affect the outcome of the cycle.


Standard ovarian stimulation – Growth of multiple follicles

What is minimal/ mild stimulation IVF?

Minimal/ mild stimulation strategy aims to optimally stimulate the ovaries to produce a few (typically 2-7) follicles, rather than bombarding them with hormones in order to produce a larger numbers of follicles. This strategy yields a smaller no of follicles, but these follicles are optimally primed to grow and are likely to be healthier. These protocols use either only oral medications or a combination of oral medications and lower dose of hormones given for a shorter duration. Mild stimulation strategies are specially beneficial for IVF in women, who are at higher risk of hyper-stimulation or are known poor responders.

What are the advantages of minimal/ mild stimulation IVF?

Minimal/ mild stimulation IVF, sometimes also called as micro IVF or mini IVF offers several advantages to select group of patients. These include-

  1. The minimal/ mild stimulation protocols are more patient friendly as they require relatively lesser medical intervention.
  2. Minimal/ mild stimulation is more physiological and in sync with woman’s natural cycle.
  3. Growth of lesser number of follicles means a less steep rise in the levels of hormone Estradiol, as a result of which endometrium is likely to be more receptive, thus achieving good pregnancy rate despite of lesser number of eggs.
three follicles
Minimal ovarian stimulation – growth of three follicles

This is the time to reconsider ovarian stimulation strategies for IVF, so that a good pregnancy rate can be balanced with more physiological and patient friendly treatment.

Further Readings



Hirsutism- There is far more to a woman than just her looks!

Concept of Hair Growing At Wrong Places Do You Have Hirsutism
Hair growing at wrong places – Do you have Hirsutism too?

I often come across women who are concerned about their looks, which they feel are spoilt due to presence of excessive body hair. This is a serious concern in our society- which is just too influenced by one’s looks- and this can potentially cause serious mental and emotional  stress among young women. If you or someone you know of is having anxious moments because of presence if facial hair, this is a very useful piece of information.

What is Hirsutism?

Hirsutism can be defined as growth of excessive facial and body hair in women.

With the world obsessed with flawless skin, such changes from feminine hair pattern (soft, fine, vellus hair) to masculine hair pattern (hard, dark, terminal hair) in a woman is generally unwelcoming and, hence, very distressing for the woman.

Why do some women develop Hirsutism?

In order to understand the reasons for such excessive growth in some women, we need to understand the differences in physiology of men and women. The male or female appearance of one’s body is dependent on a delicate balance between male and female sex hormones. There is predominance of hormone estrogen in a woman’s body, whereas androgens (testosterone) are the predominant sex hormones among men. However, some amount of androgens is secreted by the ovaries and adrenal glands (located next to kidneys) in women also. But, an excessive production of these hormones results in hirsutism. Hormonal imbalance is by far the most common cause of Hirsutism.

What are the causes for Hirsutism?

The common causes of hirsutism include-

  • Endocrine causes
    • Polycystic Ovarian Syndrome (PCOS) – PCOS is a condition of hormonal imbalance in body, which can result in irregular menstrual cycle, enlarged ovaries with cystic appearance on USG, infertility, obesity and hirsutism. For more information on the causes and management of PCOS, read here.
    • Cushing’s syndrome – Excessive production of hormone Cortisol by the adrenal glands can lead to symptoms such as high blood pressure, abdominal obesity, skin discoloration, muscle weakness, irregular menstruation and hirsutism etc. This syndrome is known as Cushing’s syndrome.
    • Congenital Adrenal Hyperplasia (CAH) – CAH is condition of excessive production of hormones Androgens and Cortisol by the adrenal glands and generally manifests in childhood in form of virilization. In such cases, CAH can present with symptoms such as ambiguous genitals, obesity, hypertension etc. However, sometimes the manifestation of CAH is deferred to early adulthood and results in milder symptoms, hirsutism being one of them.
  • Tumors
    • Tumors in ovary or adrenal glands can again cause hirsutism due to excessive production of androgens
  • Medications
    • Long term steroid consumption (commonly used for immunosuppression, rheumatoid arthritis and multiple sclerosis)
    • Performance enhancing drugs (often used by athletes)
  • Idiopathic – the woman may be having hirsutism despite normal hormone levels

When to suspect hirsutism and consult an expert?

One has to understand that there is a difference between hairiness and hirsutism. Some women may have prominent hair on their arms and legs and may still be perfectly normal otherwise. On the other hand, women with hirsutism not only have excessive hair on arms and legs, but also have thick hair in other areas of body, such as upper lips, beard area, chest, breasts, abdomen, inner thighs and lower back. So, we suggest that patients who have got extra hair in abnormal locations in body should consult a reproductive endocrinologist for proper evaluation and early diagnosis.


Your doctor may advise you to undergo some blood tests, ultrasound abdomen, special X rays and some hormonal estimation to evaluate the function of your ovaries and adrenal glands. This will help the doctor in identifying a specific cause for hirsutism and suggest an appropriate treatment.

What is the treatment or hirsutism? Can it be cured?

There are essentially two lines of treatment for hirsutism- one is medical management and the other is cosmetic treatment.

Medical treatments for hirsutism –

  1. Birth control pills – It’s possible to reduce the severity and intensity of hair growth using birth control pills- the most commonly prescribed medical intervention! The birth control pills help by decreasing production of androgens by ovaries. Besides this, estrogen present in the pills also helps the liver to produce more of sex hormone binding protein- these proteins bind to circulating androgens, thereby reducing their action on body. Both these actions help in reducing the growth of hair on body.
  2. Anti-androgen medications – There are three categories of anti-androgen medications,whicharecommonlyusedfortreatmentofhirsutism.
    1. Spironolactone – Spironolactone is a diuretic medicine, which blocks the effects of androgens on the hair follicles, thus controlling hair growth.
    2. Finasteride – Finasteride works by blocking conversion of body testosterone into its more potent chemical entity, thereby limiting the effect of testosterone on hair growth.
    3. Flutamide – Flutamide is a potent anti-androgen, which blocks the actions of androgens and helps in controlling the hair growth.

However, we have to ensure that the woman is not pregnant when taking any of these three medications. These medicines are often combined with oral contraceptives, which also have a synergistic effect in reducing the severity of hirsutism. One should also seek an expert opinion before staring these medications as there can be serious side effects especially on liver.

  1. Steroids – Low dose dexamethasone can be used to control the overactive adrenal glands, when used carefully. However, long term steroid therapy has got its own side effects and this therapy should only be considered under expert care and guidance.
  2. Insulin sensitizing medicines – Medicines such as Metformin and Pioglitazone (Basically these are anti diabetic medications) help in reducing insulin resistance in the body, which, in turn, helps in controlling the effects of excessive circulating androgens.

Please be mindful that the medical treatment takes time to show its effects- it takes up to about 6 months in most of the cases to show any detectable reduction in body hair. All medications have got potential for side effects. So, they should be used only on prescription by an expert and proper follow up with the treating doctor is very important in order to pick up any potential side effects of the drugs.

Cosmetic treatment for hirsutism –

One very important aspect of cosmetic management of hirsutism is self-care. This can include shaving, waxing, use of depilators and bleaching creams. All these measures help to reduce the amount of visible hair in undesired parts of body. But, this needs to be done very frequently for a sustained visible effect.

Permanent hair removal is also possible using electrolysis or LASER treatment. In electrolysis treatment, electric current is passed into the hair follicle using a needle, which damages the root of the hair permanently. Similarly, LASER treatment uses LASER to destroy the hair follicle. Both these are effective methods to get rid of the undesired hair. However, we do not yet know if there are any long term complications or side effects of these methods and these methods are not yet approved by the US FDA.

I am sure you will find the above information on hirsutism and its management useful. Please go through the following resources for more detailed information on this subject.


Women should be able to discuss such issues more openly and should remember that “there is far more to a woman than just her looks!”


Alternatively, you can write to us at with your queries.

Living with PCOS- Survival Kit!

The affected woman has to take the ownership of her treatment in order to beat PCOS.

How to tackle PCOS?
How to tackle PCOS?

         If you are one of those 30% of women having PCOS, then this is your space! 

PCOS is a very common, yet often misdiagnosed condition and many women will call themselves as polycystic ovarian disease (PCOD) or polycystic ovarian syndrome (PCOS) without knowing its full meaning and implications.

What is PCOS?

It is important to understand that PCOS is not a disease, but a syndrome- which literally means that it is a group of symptoms resulting from involvement of multiple systems of body. It can affect anyone from a young adolescent girl to an adult woman even beyond a woman’s reproductive age. The name polycystic ovary is derived from the typical appearance of the ovaries, wherein multiple small cyst like spaces can be seen inside the ovaries. But, one must understand that this polycystic appearance of the ovaries is an outcome of the syndrome rather than being a cause for that. The PCOS can present in many ways, which can range from common symptoms such as weight gain, acne, facial and excessive body hair (hirsutism) and irregular menstruation to very serious medico-social issues such as infertility, diabetes, hypertension and uterine cancers.

Polycystic ovaries
Polycystic ovaries

So, how does one suspect if she is having PCOS?

PCOS can manifest for the first time right at puberty. The affected girls may gain a lot of weight all of a sudden and may continue to struggle controlling weight for many years. Weight gain could be accompanied by menstrual irregularities, facial hair and acne, besides many other similar symptoms. While diagnosing PCOS at this stage can be really tricky because there is no single test that’s diagnostic of this condition, most of the symptoms described above can actually be controlled with help of oral contraceptive pills. However, when these women on birth control pills start planning a baby and have to stop taking the pills, many of them discover that they are unable to conceive. Consultation with an expert is very helpful at this stage, as the expert can correctly diagnose the problem and also advise on the best way to manage the symptoms. But, the affected woman has to take the ownership of her treatment in order to beat PCOS. This would include maintaining an active lifestyle with regular exercise and having a low carbohydrate diet in an effort to keep the weight under check. These interventions go a long way in controlling the symptoms of PCOS, as weight gain initiates a vicious cycle of further hormonal imbalance, which in turn leads to more weight gain. Lifestyle correction coupled with appropriate use of medications to reduce the insulin resistance is the best way to manage PCOS.

What if one gets diagnosed with PCOS? Is it over for her now?

Most common question that I get asked is if PCOS can be cured? Very sadly the answer is No- PCOS cannot be cured! But, the symptoms of PCOS can most certainly be controlled using appropriate medical treatment and lifestyle interventions described above. The key to control of these symptoms is diagnosis at an early age and well titrated intervention from an expert. Remember that it is a condition of hormonal imbalance in the body, which results in irregular ovulation, over production of male sex hormones and resistance to the action of insulin. So, in very simple words, all the interventions would be focused on correcting this hormonal imbalance in the body.

So, what can be done to manage infertility in PCOS patients?

Most women with PCOS are able to overcome the challenge to their fertility with proper treatment. This treatment may vary from simple measures such as oral tablets to induce ovulation to IUI and all the way to IVF. One should always seek an expert’s opinion for management of PCOS when planning for a baby, as the doctor is the best person to support in this endeavor. Always remember that PCOS stays with the woman throughout her journey of life and she has to remain vigilant to identify its long term risks such as diabetes, hypertension and uterine cancers in their early stage!

Reading resources

You can use the following resources to understand more about PCOS, its implications and treatment options-




Alternatively, you can write to us at with your queries.