" The Joy of Medicine - finding meaning in medicine" - by Dr. Aniruddha Malpani

Dr. Aniruddha Malpani, MD

This  post  is written by Dr. Malpani and I like it so much ! The words flow direct from his heart and it says so much about who he is - as a doctor, as a human ! I know him for more than a year now, and I have learned so much from him. His writings are a source of great inspiration for me, and I derive the strength and courage to carry on with my IVF struggle from them. He patiently corrects the articles I write (every article), and provides great ideas for the posts too ! This blog wouldn't have been possible without him. I wish every patient gets a Dr like him. I respect and admire him a lot ! Thank you very much Dr !

Even though medicine has traditionally been regarded as a profession which provides tremendous job satisfaction, many doctors are finding themselves increasingly dissatisfied with the practice of medicine. In the past , when doctors met, they used to talk about the interesting patients they helped to treat. These days they usually talk about financial stresses, job pressures, bureaucratic hassles and red tape. Doctors are increasingly toying with the idea of changing careers , while others are burning out in their mid-forties. Where has the joy of practicing medicine gone ?

In order to find joy in medicine, we need to find meaning in our profession. Work is an essential part of being alive and physicians are fortunate to work in a job which can provide so much satisfaction . They are presented with new challenges daily ; they can apply their mental abilities and their physical dexterity to successfully solve many of these problems; they are accorded respect and status; and they have control and autonomy . Unfortunately, many doctors no longer work for the sake of working - they’re working for a car, a new house, or a vacation. It’s no longer the work itself that’s important to them, and this is a shame, because there is such joy in doing work well.

We are privileged to help take care of patients, and we need to respect our role, so we can learn to respect ourselves. If you do what you love and love what you do , you will find a higher purpose in life - and if you are passionate about your work , your life will be full of meaning. Getting paid for this should be seen to be the ultimate bonus !
We are fortunate to be doctors, because we can learn so much from our patients. They bare their heart to us, and make us privy to their innermost confidences, so that daily we get a ringside view of human drama, suffering, courage, life and death – the stuff of which life is made ! Doctors have a chance to plumb the depths of the human soul, as they accompany their patients through their suffering. Our work lends itself to contemplation and introspection – allowing us insights which few other people are privileged to have. Our patients can teach us how to live and how to die – and we need to keep our hearts open to their lessons. While it is true that daily exposure to misery and suffering can drain some doctors, causing compassion fatigue; and leave others hardened and unfeeling, these same experiences can also invigorate and rejuvenate you.

Watching patients die should remind you of your own mortality , so that you remember to learn to live each day well . Seeing very ill patients recover should renew your sense of amazement at the marvels of the human body , so that you appreciate the perfection of your own body every day. Observing friends and loved ones provide comfort and courage to the ill should awaken your own feelings of compassion, so that you remember to touch all your near and dear ones with love every day. To live life to the fullest, we need to recapture our sense of wonder at life daily – and being a doctor allows you the privilege of doing that at close quarters !

It is true that physician morale is declining today, and doctors are hard pressed to find job satisfaction. However, instead of focusing our efforts on trying to identify what is wrong with medicine today, we should identify happy doctors and delve into their secrets. I am sure we all know doctors who still look forward to each day as an opportunity to do good, and to become more skilled physicians. We should try to learn from their successes. Many of these happy physicians may never become the president of the medical association, or grab media headlines , or be written about in House Calls, but they are the true stars of our profession, because they have found meaning in their lives. My personal role model is my father, who is one of the most satisfied people I know. His primary source of happiness is his patients , and they have provided him a major source of personal sustenance. He enjoys talking to them, they enjoy talking to him, and his links with them are deep and personal. Even more importantly, I have learned that professional satisfaction does not come from acquiring money, but instead from gaining “social capital” through community ties. He has numerous extracurricular activities , and is very well connected with his family, friends and neighbors, and these social bonds contribute enormously to his satisfaction.

The first rule for being a happy doctor is very simple – it simply means caring for your patients. Treat all your patients like VIPs – whether they come from Dharavi or from London . Remember that the relationship with our patients is at the heart of our professional role – and a healthy doctor-patient relationship can nurture both patient and doctor ! Medicine is really about service, not science - and the true meaning of medicine is found in the relationships we have with our patients. Savor your patients. When a patient thanks you for your work or says that you've become like a family member, stop and relish that moment. Those moments are the real reward for being a doctor, if you can slow down to let them in. When it comes to getting positive feedback, no profession in the world comes close to medicine ! The joy of medicine is in doing good , which is why patients still confer a special status on us – we need to prove ourselves worthy of it..

Find an area of special interest in your field which you enjoy, and acquire a depth of knowledge in this focused area. Once you've mastered an area, then master its intricacies. Not only is it personally rewarding, it'll be professionally rewarding, as well. Your colleagues will refer problem patients in this area to you ( allowing you to become even more expert in the topic), and you will also acquire a reputation amongst patients as being very good in this area.

If you find your practice has become boring, tedious and monotonous, you need to recharge your batteries. Be willing to do something new, even if it involves a risk – after all, if you continue doing the things which bore you, the situation will get even worse ! You can consider hiring an assistant, to take care of the parts of medicine you find boring, so you can concentrate on what interests you. Other doctors have rediscovered joy not by narrowing their scope but broadening it to encompass a new area of expertise – for example, by exploring alternative medicine, such as acupuncture, homeopathy and chiropractic.

Try to publish and present your clinical experiences. This will force you to read the medical literature and provide intellectual discipline as well , as you have to carefully document your experiences and answer your colleague’s queries. Advances in medicine depend upon clinical acumen, and if we apply scientific rigor to our clinical experience , we can all contribute to improving medical practice. Treasure your rare patients and your difficult cases – they can teach you the most !

Develop humility. Often you will find that the reason you are unhappy in your professional life is that you have let your ego get out of control. Practicing medicine can make us feel that we are indispensable, and self-importance is a serious malady that stands in the way of professional satisfaction.

Learn to develop interests and friends outside medicine. While it is true that medicine can be a demanding mistress, don’t let her take over your life. Good doctors are well-rounded individuals , who have an open mind and are curious about everything. Having outside interests will not only make you a better person , it will also help make you a better doctor, as you apply what you learn from other fields to your medical practice. For example, I enjoy playing tennis, and have found that learning how to serve has helped improve my surgical skills by honing my hand-eye coordination.

Do some charitable work – for example, offer a free clinic once a week. One of the best ways of feeling good about yourself is by doing good for others , with no strings attached. The gratitude of the patients you see free of charge is worth much more than any amount of money . As a doctor you have many opportunities for being altruistic – make the most of them !

Don't make the mistake of equating wealth with happiness - the pursuit of wealth only complicates our search for happiness. . As physicians, we should be grateful that we get the opportunity to make a positive difference in the lives of others every day – a goal most humans aspire to. Be thankful daily that you can help others - expressing gratitude is a powerful tool in the search for contentment and self-worth.


Most of us become doctors in order to help others, and all of us get this opportunity to do so on a daily basis, whether we work in Mayo Clinic, or in the heart of rural India. We should remember how lucky we are to belong to such a privileged profession. Even in ancient India, vaidyas were considered to be very fortunate, because their lives offered them the opportunity of fulfilling all the three aims of a good life – dharma ( religious gain, by relieving the suffering of patients); artha ( material gain, by building up a rich practice); and kama ( personal satisfaction, by curing those whom he loves and respects, and by acquiring fame for his expertise). This is as true today as it has been through the centuries ! Medicine is a wonderful way to make a living – be glad you are a doctor and make the most of your profession – for your sake, and for the sake of your patients !

From 3 eggs at the age of 29 to 24 eggs at the age of 33!

How many eggs will I lay, sorry : ) how many eggs will they retrieve from me is the most important question in my mind during all my IVF attempts.  I have thought about my eggs more than anything else after my marriage. When we started our journey to conceive; I would tell my DH, ‘I think today my egg will be released, I have all the signs of ovulation’. I will be saying it very seriously and with a determination to catch it and make a baby out of it : ) (poor DH!) He will respond with the most innocent face ‘Manju, why can’t you make an omelet out of that for me’ : ) I will break into laughter. These kinds of “eggie talks” have become a part of our life after starting TTC.

The most important question which lingers in the mind of many women who are undergoing IVF is - why didn’t I get more eggs during my IVF cycle? When I started my IVF journey I was young. I saw so many young women (even some 35+ women!) in infertility boards reporting that they got more than 20 eggs. I am so confident of my ovaries : ) I thought, I am only 29 and my problem is just fallopian tubes; I am a great candidate for IVF and for sure I will produce so many good quality eggs and will be successful very soon. I have read that young women with fallopian tube blockage are the best candidates for IVF and they get success very easily. With so much confidence in mind I started my first IVF cyle. My RE in Germany was too cautious. He started my ovarian stimulation regime with 112.5 iu of Gonal F! Each successive ultrasound for monitoring follicle development shrivelled up my hopes of getting large amount of eggs. After a week or so of stimulation my RE increased the dosage to 150 iu of Gonal F. There were only very few follicles developing and I was really worried. I was not prepared for such an outcome. When I asked my RE why am I responding so poorly to stimulation; he replied very coldly ‘it's your ovaries; how will I know?’(Great answer!).  When I didn’t get a proper reply from him I searched the internet for answers. I will always be grateful to the women in infertility boards who patiently answered all my questions and put my mind at ease.  I ended up with only 3 eggs during that cycle. Out of the three eggs only one fertilized via IVF and that lone embryo was only 4 cells on day 3 of fertilization. I felt so happy to see that single embryo – my first embryo sighting experience!

The next four cycles in Germany lead to the collection of 9, 5, 8 and 5 eggs respectively. I thought that the second IVF cycle was a bust too! Out of the 9 eggs retrieved 7 were mature. Since only one out of three eggs was fertilized during my 1^st IVF, my RE suggested that we should try ICSI. We agreed. But I could not accept the fact that my eggs and his sperms cannot even make love in a petridish without help :). I had a notion that IVF is more natural than ICSI. So I came up with an idea. I told the embryologist ‘please keep 3 eggs for normal fertilization (IVF) and do ICSI on the other 4 eggs’. He looked at me strangely and asked ‘do you think that will make a difference?’ I had no real answer but just nodded my head affirmatively. The day after egg retrieval I have to call the embryology lab to get the fertilization report. To call the embryologist and to take the fertilization report is the scariest part! The thought that there were only few eggs and the possibility of complete fertilization failure or any other unfortunate happening haunted me all the time. My heart used to race during those few minute conversations with the embryologist. The day after my egg collection I called the embryology lab for getting my fertilization report. The embryologist said ‘only two of your ICSIed eggs fertilized and there was no fertilization in the eggs which were kept for IVF’. I cried! I could not believe that I have only 2 embryos from 7 eggs. I kept on blaming myself for opting to use 3 eggs for normal fertilization. After the initial crying spell, I was happy that I had at least those two embryos. This is the first lesson my IVF journey taught me – always try to look at the positive side of the story and be happy! When I talked to my doctor he said, ‘come on Friday (which is actually day 2 of fertilization) we will transfer those two embryos’. I told my husband ‘anyhow they cannot select embryos after cleavage (in Germany, embryo selection after cleavage is prohibited by law!) that is why God has selected himself and gave us only two embryos.

I am so happy the day I saw those two perfect four celled embryos! They looked 100% perfect. The embryologist was beaming with pride. He said that my embies looked picture perfect. My hope was high again after the initial tragedy. After transfer I rested for 5 minutes and left the clinic. You know what? One of those 4 celled embryo was actually a fighter – it implanted in my uterus! I always think of that little one. Even though it didn’t become a full-fledged baby (I lost my precious baby at around 7- 8 weeks); that embryo is the one which keeps my hopes high even after undergoing 6 further futile embryo transfer attempts!

I think I have deviated a lot from the original topic. Now back to the topic - why some women get fewer eggs and some more?

As the women age their ovarian reserve gets depleted. Depletion of follicular reserve begins during foetal life and continues throughout a woman’s life.  At around 20 weeks of gestation a female foetus carries 7 million follicles and during menopause (approx. 51 years later) it is reduced to a few hundred. So younger women are expected to produce more eggs and older women tend to produce fewer eggs. PCOD otherwise called as Stein-Leventhal syndrome is a collection of metabolic derangements. Ovaries of women with PCOD produce excess androgen (male hormone) and they might also have more insulin circulating in their body. Women with PCOD have very high antral follicle count (AFC) and hence they produce lots of eggs when stimulated with gonadotrophins. Women, who undergo premature menopause at a younger age, will have very less AFC count, increased FSH and low AMH. They produce less number of eggs too!

Is poor ovarian reserve an indicator of poor egg quality ? The answer is yes as well as a no! When women get older, their ovarian reserve decreases as well as their egg quality. But younger woman with less ovarian reserve can produce good quality eggs. AMH, FSH and AFC are all indicators of ovarian reserve. If a younger woman has higher FSH, low AMH and AFC her chance of producing good quality eggs and embryos is as high as her similar age counterparts. That is why young women with premature menopause are more successful in getting pregnant via IVF when compared to older woman who have low FSH and high AMH. The message here is age of the women is the best indicator of egg quality and not their AMH or FSH.

What helped me to get 24 eggs in my 6^th IVF cycle?

I made two important changes during my 6^th IVF cycle. I was advised to take DHEA (75 mg) by Dr.Malpani.  I started to take it regularly. I took it for 9 long months. The good thing is, I never had any bad side-effects. On taking DHEA I started to ovulate regularly. I had lots of fertile quality mucus during my ovulation time. I also had ovulation pain which is very prominent. People say DHEA can give them bad hair days. I never had problem with my hair. I should say my hair fall was reduced when taking DHEA.  Please visit CHR (Center for Human Reproduction) website for further details. DHEA was found to increase oocyte production (PMID: 16169414). The mechanism behind it is not so clear. DHEA is used in mice to induce PCOS phenotype in previously normal ovaries (PMID: 16514202). DHEA supplementation was also shown to decrease embryo aneuploidy (genetic defects) (PMID: 21067609)

The next change I made was to stop taking metformin (1500mg). I was on metformin from the age of 26 years. I was diagnosed as having PCOD using ultrasound pictures of my ovaries. My ovaries had a characteristic pearl-like structure. I also have insulin resistance. When I started taking metformin I started to ovulate regularly. I lost weight and felt a lot better. Metformin is found to have anti-cancer and anti-aging properties. It is also touted to prevent or postpone diabetes in PCOD women who are prone to it. So from the age of 26 I was on metformin. I never had a second thought about it. I never thought it can reduce my AFC count and can lead to less egg yield during my IVF cycles. Metformin can reduce your AFC count. A scientific study showed that one week of low-dose metformin therapy can bring down your AFC count (PMID: 17224152).  A recent publication which studied IVF cycles among PCOD patients with and without metformin administration showed that the stimulation length and gonadotropin doses were significantly higher in metformin group than in control group.  The number of dominant follicles on the day of ovarian maturation triggering and peak oestradiol levels was significantly lower in metformin group than in control group (PMID: 21770836).

I believe these two changes (taking 75 mg DHEA and stopping metformin) made a big difference in the egg yield during my 6^th IVF cycle. To be exact, I had suppressed my bodies PCOD tendency using metformin. So by stopping metformin and starting DHEA (which is a PCOD mimetic) I was successful to coax my ovaries to produce more follicles and hence more eggs. After 9 months of DHEA intake and stopping metformin my AFC count increased form 7-9 to 18-20!

Moral of this story is .......

If you are a woman who is having diminished ovarian reserve please try DHEA. It worked for many, might be it works for you too. Metformin is a wonderful drug. It really helps woman with PCOD and insulin resistance. If you are young, have excellent FSH and AMH value, have extremely high AFC count, if you are overweight – metformin is for you. It can reduce your insulin levels and thus can help with improving egg quality. It can prevent OHSS by reducing AFC count. If you have extremely high AFC you are prone to develop several follicles in response to gonadotrophin stimulation. More the number of growing follicles, higher will be your estrogen levels. A higher estrogen level is a risk factor for developing OHSS. But if your are a woman who has less AFC count, higher FSH, lower AMH and normal BMI metformin will not help you. I do not think it can improve egg quality in such woman and it can even lead to cycle cancellations by reducing your ovaries response to gonadotrophins! 

Reason for the genesis of this blog!

Why I wanted to write this blog? There are several reasons. I love writing. I can express my emotions in a better way when I write. After going through infertility for five long years, I am tired. I just need a change. My life has become too routine. All these five years I am foccused on only one thing- MY BABY. Not even a single day passes by without thinking about him/her. The beauty is, my baby doesn't have a LIFE still. But before it can acquire a life the little one has everything it needs- wonderful parents, a beautiful name and more than anything else lots and lots of LOVE. Sometimes I think what kind of insanity is this? You can live by thinking about someone who is alive or dead but can you live by thinking about someone who is not yet born. I am a living example and there are many women like me. I just want to reach out to them. I want to share my infertility experiences and the knowledge I gained during this journey. Only a person going through infertility can understand how painful it is! Getting in touch with women who are in  similar situation like me will give me immense support and strength. This will help me to remain sane and confident. I do not know what I can contribute through this blog, but I am sure it will bring about a positive change in my life.

I always wanted to write this blog. But I had many inhibitions in my mind. Will I be able to spend time for this? Am I efficient enough to write about my infertility in a rational way? Won't it be more nicer if I win this infertility battle first, and then write about it? With all these questions in mind, I postponed my urge to write. But all these changed because of another blog (blogger!) which I read more often. To tell the truth, that blog gave me lots of confidence. When I suffer emotionally, I open that blog and read some posts written by the infertility specialist. Yes, it's a doctor's blog and it's my doctor's blog! You may think, because he is the infertility specialist I am getting treatment from I am giving undue importance to it, or I am attempting to please him in order to get better care. Definitely not! If you are a woman suffering with infertility there are lots of possibility that you know him already. I am taking about Dr. Aniruddha Malpani and his blog. I think every woman undergoing infertility should read his blog posts. You can get immense intellectual and emotional support from it. The best thing about his writing is, he really puts himself in his patient's shoes. I always wonder how could a doctor empathize so much with his patients!  It just shows the passion he has for the work he does. I did my last IVF with him. I met him perhaps thrice during my treatment. Had very few things to talk with him because I am a graduate  in IVF treatment, (I have already done 5 IVFs, great or ;) ) so didn't have much to talk about the treatment as such, and I am very afraid to talk anything else which is beyond the scope of the treatment (Will I spoil his valuable time?). I mail him whenever I have some doubts, and he replies very promptly. I have many things to say about him which I will talk later. Now, I just wanted to say that he is one of the most important person for the genesis of my blog. He wrote 'I do wish you'd keep a blog - this will help you let out your bottled emotions in a constructive fashion. Keeping a journal has been proven to help patients cope better - and helping others is the best way of helping yourself !' Thank you Doctor! The interesting part is, he did not know to whom he said this ( I donno whether he guessed that it is me !) since I used to comment in his blog as an anonymous! But he did know that the anonymous commenter is one of his patient :)

Whatelse I have to say, hmmm perhaps a bit about me : I am emotional, loving, intuitive, imaginative, shrewd, cautious, protective and sympathetic.  My darker side : Constantly changing, moody, over-emotional, touchy, clingy, and unable to let go. This is what they say about cancerian traits and it applies 100% to me!  I want to write a lot about many other things apart from my (in)fertility journey. Wish me good luck and with this note I start my blogging journey. Happy blogging! :)