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AMH, Vitamin D and my ovaries!

An AMH value of 0.6 ng /ml is bad, really bad. In the report I got in hand, it was written that, an AMH value of less than 1.6 ng/ml might indicate a poor response to ovarian stimulation. I was heartbroken and angry; my reproductive life is nearing its end! I expected it, but I didn’t expect such a drastic fall in my AMH. After I returned home with the results, I called Rajender. He was cool as a cucumber. He said, I read about women who produce eggs even with much lesser values. I was irritated by his positivity; I thought, why won’t he leave me in peace, take an alternate solution (donor eggs) and move on. I had no energy to argue with him or break his enthusiasm. Dr. Malpani gave me one more suggestion. He asked me, from which lab did you measure AMH. I told him that I got it measured from Thyrocare. He replied, Thyrocare is not so reliable, please measure your AMH again from SRL (Ranbaxy)! I was not hopeful, but I was badly in need of a miracle. I gave blood to SRL for AMH and Vitamin D measurement and waited for a couple more days.

From now on, this post will turn a bit more scientific.  Many of you might wonder why I measured Vitamin D along with AMH. Is it necessary? What is the rationale behind that? There is a connection between Vitamin D and AMH. AMH gene (the sequence of our DNA which codes for AMH protein) has a Vitamin D-response element (a region which is responsive to the presence of Vitamin D in a positive manner). To put it in a more simple way, Vitamin D can bind to the AMH gene and increase its expression.  If this is so, can low Vitamin D level lead to low AMH levels in blood? When they initially found the presence of Vitamin D-response element in the AMH gene of prostate cancer cell line, frenzied researchers, as usual, hyped out of proportion the importance of Vitamin D in reproductive biology.  Their understanding was and still is, if high AMH levels in blood indicate good ovarian reserve, increasing AMH levels by increasing Vitamin D intake, especially when one is deficient,  (since Vitamin D could increase AMH level) will lead to good ovarian reserve too. What a simple way to solve the problem of poor ovarian reserve! Just pop in Vitamin D, and the problem will be solved! But, this kind of (il)logical reasoning without understanding the basics of the science of AMH is half-witted! To read more about the science of AMH please refer to:  http://myselfishgenes.blogspot.de/2012/08/amh-paradox.html

It is true that Vitamin D could increase AMH levels. But increasing the expression of AMH from the already existing follicles (antral follicles) cannot increase ovarian reserve. More antral follicles lead to more AMH production, but increasing your AMH levels artificially (either by taking substances which increase AMH production, like Vitamin D, or by injecting AMH into your body) cannot increase your ovarian reserve. Actually, increasing your AMH level artificially, could lead to opposite effect - high AMH can decrease the amount of antral follicles available for FSH stimulation. So, if you are having poor ovarian reserve, taking Vitamin D is unlikely to help and in worst cases it can bring down your antral follicle count (AFC) too.  In case, if your Vitamin D levels are low, or if you are Vitamin D deficient, your AMH levels might be artificially lowered even though your ovarian reserve is good (there is no solid proof for this statement!). And, this is the reason I measured my Vitamin D levels too when measuring AMH. 

After two days, I got my blood test reports from SRL. My AMH level was 1.6 ng/ml and my Vitamin D levels was 17ng/ml, while the minimum recommended Vitamin D level in blood is 20ng/ml. Need not to say that I was happy and hopeful again.  A value of 1.6 appeared very great when compared to 0.6.  My thoughts used to wander, and I would wonder, which lab result is correct! But, as per natural human tendency, my mind decided to stick with the more promising value.  I had only 12 more days for starting the stimulation. I was waiting for my periods so that I can measure my antral follicle count (AFC). I knew well that, AMH value could only be interpreted sensibly with antral follicle count (AFC). I was afraid, yet eager to know my AFC! I was wondering, what if there were only few antral follicles left!

You might ask whether I took Vitamin D to correct my deficiency. Again, I have a very different view of the whole Vitamin D story. I was in India, I was getting ample sunshine. I had no signs of Vitamin D deficiency. I read somewhere that 99% of Indian population is Vitamin D deficient. This kept me wondering! If 99% of Indians contain a particular range of Vitamin D in blood, then, which is the normal range for that population ( whether the value which occurs in 99% or the one in the remaining 1%) ?  There are not enough studies to show the normal range of Vitamin D for a healthy, Indian population. No one still knows how Vitamin D is processed by our body. People who live in places where sun light is meager, must have or must need mechanisms to store Vitamin D in body, so that they can utilize it during days where sunlight is not available. But, do people who live in tropical regions like India have such mechanism? If not, then what should be their normal blood levels? Nobody has the answer for these questions. After, all the initial hype about Vitamin D, and connecting its deficiency to almost all the diseases in the world, researchers have recently started to understand that, measuring Vitamin D or supplementing Vitamin D to a healthy person is not advisable. As more randomized clinical trials are performed, the results of such studies shows that there is no benefit of Vitamin D supplementation whatsoever, and some studies even showed a negative effect (17% increase in kidney stones!).  For further reading: To [Vitamin] D or Not to D? That Is the Question. After considering everything, I decided to not take Vitamin D. Since I had only 12 more days to start the stimulation, I was too chicken to change anything in my body drastically! Vitamin D has the ability to change the expression of 3000 different genes (not only AMH!) in our body and I didn’t want to take any invincible risks.

My periods arrived after making me to panic a little! Have you ever noticed this - when you don’t need it, it comes on time and when you are waiting for it there will be no sign of it? I went to a nearby scan center to have my antral follicles counted on day 3 of my menstrual cycle.  I was too nervous. I entered the scanning room and there stood a lady doctor and her assistant. I told them that they must measure my antral follicle count, ovarian volume and make sure my uterine lining is thin and the cavity is free from any abnormality. She asked me where the doctor’s prescription was. I said, I don’t have one, I do my IVF in Mumbai and my Dr emailed me that I should measure all this. She looked at me uninterestingly and said, we do only follicle tracking studies. I had no energy to argue with her or teach her about IVF and the importance of measuring AFC! She was not ready to hear any of my lectures too; there were so many people waiting outside. She was still looking at me as an unwanted intrusion. The assistant was smirking. I felt so helpless and then I literally pleaded them, please do what I say. Since I have to do IVF, I need all these details. I must say that the scanning machine they had was excellent. The lady doctor counted my antral follicles. Unable to control my curiosity, I asked her, do I have antral follicles. She said 8 on one side and 10 on the other. I was so happy; I forgot how they behaved with me. With a broad smile I thanked them and came out, ignoring their strange looks. I waited for some time to get the results in hand. From the beautiful picture of my ovary they gave me, I counted my AFC once again. The result read: one of the ovaries is bulky – possible PCOD! I was too happy to have PCOD or anything that could give me more follicles and more eggs. I thanked my ovaries. Immediately after reaching home, I conveyed the results to my hubby and Dr. Malpani. I started to eagerly look forward to go to Mumbai- our happy vacation after staying away from each other for so long !

Happy Birthday Dr !

Hi everyone,

I am updating my blog after a long, long time. We will be in India until today morning. Six months have gone by so fast and taking this long break is the best decision we took in our life. It helped us a lot to heal, to pick ourselves up and move on. I have so many things to update, especially, our six months adventure filled with several ups and downs.  Our journey this  past 6 months is truly incredible. So stay tuned for the updates :) And I really, really missed blogging. If I haven't replied to any of your e-mails please bear with me ! I will definitely get back to you. 

Today is my Dr’s birthday, a person whom I admire and respect a lot. I wish him a very long, healthy life filled with lots of joy and happiness! I now know him for more than 3 years. My infertility journey has become a lot easier because of his constant encouragement and support. There were moments when I was completely shattered, lost all hopes and was in the grip of fear and depression.  He is the most important person who helped me get through all that by his strong presence.

As I have always mentioned, this blog is the result of his constant help and encouragement.  Without this blog I would have been a very different person. This blog helped me a lot to stay stronger and to become a better human too.

Thank you so much Dr for the constant support, for being there for us during our very difficult time, for bearing lot of my pestering, for being very patient with me, for being my 'Guru',  for the wonderful medical care we receive and more than everything for being so kind, compassionate and empathetic ! I will always keep in mind what you say always : "Never hurt anyone even unintentionally" :)

May you have a very happy and blessed birthday !

Manju

A query about Malpani Infertility Clinic

This query which I got from one of my blog reader is very honest. Many will hesitate to ask these questions but she was so good in putting her doubts in words.

Question : 

 I am a regular visitor of your blog and found very useful information.  We are facing fertility problem since long. We are living in Delhi and belong to a medium family. Two failed IVF(ICSI) cycles in Delhi.  Reason for IVF failure was poor embryo quality. They were little  fragmented. So doctor suspected my egg quality is poor. I am taking Coq 10 now and planning for next round in November. We are planning for Dr Malpani guaranteed Success program, although it cost too much , which is bothering us. To manage such a large fund is really very difficult for us, but we will try to do. As we became so much frustrated with this issue and want to give our  best and final. Here I need your opinion as an elder sister, i am 32 now. I have read about doctor Malpani and one of my friend told me that he is too commercial, but whenever I  saw your blog I was convinced you would tell me the truth.

Now my decision depends on your reply , so please try to answer my queries- 

1. Does Dr Malpani pay attention to all his patient or only to  some specific VIP patients like you who is a blog writer((Please do not get angry))

2. My husband has motility issue, does it make our case weak ?

3. Does IVF protocol make any difference in embryo quality.

4. Is it safe to fly after embryo Transfer. 

5. Is it ok to do follow up with other doctors after positive pregnancy test.

6. Why did you choose Dr Malpani over others ?

7. Is doctor Malpani commercial ?

8. Do they handle each case on their own or handover to associates ?

How can I contact you by phone.

I am waiting for your reply.

 

Answer :

Nice to hear from you. I appreciate your questions :) and I am not a bit angry ! I am sorry that two of your attempts failed - Is your husband's sperm motility issue the reason for IVF ? Can you please send me the photos of embryos transferred to you ? This will give me a better idea about their quality. You should remember quality of an embryo also depends on the competency of the embryology lab. Can you send me the complete details of your IVF cycle in Delhi ? What is your AMH value ? Dosage of meds used ? How many eggs retrieved, how many fertilized and how many transferred ?

 1.   Does Dr Malpani pay attention to all his patient or only to  some specific VIP patients like you who is a blog writer

 He treats all his patients the same, including me ! I had a chance to see him and talk with him less than 10 mins this time. I had nothing much to ask and my FET is quite straight forward. He gives the same treatment to all his patients and  treats everyone as a VIP. Dr. Anjali does the egg collection and scan, the embryologist , Dr Sai, does all the fertilization work and loads the embryo into the catheter and Dr. Malpani does the consultation and ET.

 

2. My husband has motility issue, does it make our case week.

No, definitely not ! ICSI will give you the best chance for success.

3. Does protocol make any difference in embryo quality?

I think so, because better eggs will give rise to better embryos.

4. Is it safe to fly after embryo transfer?

I did fly after my ET :)

5. Is it ok to do follow up with other doctors after positive preg test.

Sure, you have to !

6. Why did you choose Dr Malpani over others.

1.    I am comfortable with his conservative approach (He doesn't order unnecessary tests and therapies)

2.     He is very knowledgeable (He knows what he does!)

3.    It is very easy to contact him (available 24/7 via e-mail)

4.    He is not over optimistic nor does he promise the moon; he doesn't think he is God or the final authority on IVF. He clearly understands that only certain things are in his hand and does that part of the work well good. They are very transparent in what they do, from embryo photos to medical bills everything is open and documented !

5.    The clinic is so compact there is no need to run around. I felt very comfortable.

6.    I believed in him - this is my intuition! When you select a doctor you can't know 100% about their honesty or competency. Our intuitions play a major role. I like his honest writings and I believed him whole-heartedly. The vibes we create around us (the way think about a person) play a very important role about how the opposite person reacts with us :) I went with good vibes. I didn't look at Dr Malpani with suspicion. Once I selected them I believed them :)
    

7. Is doctor Malpani commercial ?

Every doctor needs money to survive-aren't they humans? What do you mean by commercial? His clinic is in a costly area and he has staff to feed. They charge a bit more than others but it is all worth at the end because of the service they provide. They don't charge anything extra.

8. Do they handle each case on their own or handover to associates ?

    No, Dr. Malpani and Dr. Anjali handle everything themselves. They do not have any assistants.

I hope this helped ! :)

Alternative Medicine Versus Western Medicine for IVF patients – Friend or Foe ?

This article is the brainchild of Dr.Malpani. Thank you Dr for giving me permission to reproduce it in my blog!

Indians were unaware of western medicines up to until three centuries ago. Ayurveda, a form of traditional and alternative medicine was practised in India for centuries. Infertile couples in olden days were treated by Ayurvedic or Unani medical practitioners by using plant-based medicines and, in addition, they provided life-style advices too. Undoubtedly, such medical practices are very effective for some forms of infertility and many infertile couples would have achieved their dream of starting a family via using them. When some couples found no luck with such treatments, they sought the help of the supernatural power to give them a baby; many went from temple to temple in search of God’s grace! Since knowledge about the functioning of the reproductive system and its defects were very much limited during that time, infertile couples at one point of time had to accept their fate and move on with life. Many resorted to adoption as a means of enjoying parenthood and some remarried so that they got a chance to propagate their genes and made sure their generation didn’t end prematurely!  

Times have changed today. Since the practice of Ayurvedic medicine was done by word of mouth during ancient days and is vigilantly guarded among families, the enormous knowledge our ancestors possessed about different curative plant compounds, their mode of preparation and the principle behind such practices are eventually lost! Although there are medical schools which teach Ayurveda, there are very few Ayurvedic practitioners existing in India today. Western medicine being based on strong scientific-evidence and rationality, gained importance eventually and is widely followed in today’s India. With improvement in biomedical research and the knowledge gained thereof, ground-breaking discoveries have emerged in the field of reproductive medicine. As a result, modern age infertile couples have enormous treatment options to deal with any kind of infertility problem. With patience and persistence most infertile couples can hope that their dream of having a baby will become a reality!

But the ironical truth is, even today, many infertile couples feel uncomfortable to use western medical advancements that are available in the field of reproductive medicine. The reasons are twofold: many western medicine based infertility treatments are costly and not everyone could afford to spend so much, as a result, many resort to traditional medical practices like Ayurveda or Unani (which are comparatively much cheaper) even though the chance of success is very low or even nonexistent for many infertility ailments using such traditional approach. The other reason is that, unfortunately, still many Indians believe that western medicine is evil and pose many unpleasant side-effects. Especially if you have a granny at home who never went to a modern hospital and managed all her and her family illnesses using traditional medicine, the first advice you receive will be to seek the help of an Ayurvedic medical practitioner for your infertility problem! Some even depend on “faith healers” like “witch doctors” to cure their infertility problem.

So, if you are faced with infertility problem what will you do? If IVF patients depend on such alternative medicine for improving their chance of success, does it make sense? How do doctors who practice western medicine view it when their patients depend on alternative therapies to cure their infertility problem or to improve their chance of success?  Although alternative medicine is practiced world-wide, a lot of infertility specialists are not always happy when patients depend on such treatments. They feel that the patients are being fooled by these primitive systems of healthcare and they pity them for wasting their precious reproductive period by following treatments, which they think, are fruitless.

Doctors who practice western medicine spend many years in medical school, acquiring their degrees. They then work hard at acquiring practical experience in a hospital, so that they can get a license to practice medicine. IVF doctors study for as long as 10 years before they can hang out their shingle as IVF specialists. Not only are they proud of their expertise and experience, they naturally want to guard their domain jealously. They have a low opinion about alternative medicine and its practitioners because they are poorly trained and they acquire a degree in as little as 6 months. Many IVF doctors feel that such degrees are of no value and are just a “license to kill”. Also, they often have a superiority complex, because only western medicine has modern technology (such as vaginal ultrasound scans and endoscopy) at their disposal, to make an accurate diagnosis, based on which they can recommend the right course of treatment on a scientific basis. They think that alternative medicine practitioners do not have the same depth and breadth of training as they posses and many doctors feel that alternative medicine clinics are encroaching on their territory. They look down on these doctors as being quacks, who have no effective therapeutic interventions to offer because they lack any evidence to prove their efficacy.

On the other hand, many alternative medicine practitioners are equally happy to bad-mouth infertility specialists who practice western medicine. They scare their patients by telling them that IVF is “artificial” and the babies born out of IVF are “weak” or abnormal. While some envy the high income an IVF doctor gets, others genuinely believe that the holistic options which they offer have a higher success rate. They feel that IVF is like band-aid therapy, and does not attempt to fix the underlying problems in the infertile couples.

As a result of this conflict between the doctors who practice western medicine and alternative medicine, patients end up getting confused as to which is the reliable argument. In order to try their luck, they shuttle back and forth between these two medical practitioners and finally get frustrated with the treatment process and many end up sacrificing their dreams of a baby being born to them. If this is the case, how should a responsible doctor react? What advice should they give their patients?

We need to remember that many infertile couples will actively seek out alternative medicine options, even when undergoing treatment for IVF. These options are highly respected by their family elders and deeply rooted in their culture. They are also much less expensive. Hence they believe quite logically that even if they have not been proven to help, they will not cause any harm (although this is not true)! This is why they want to cover all possible bases and try them out, to ensure that they have not left any stone unturned in their baby chase. There are tons of anecdotal success stories of women who have conceived after taking a particular herbal concoction; and this, even as the scientific base of alternative medicine is not always strong.

Doctors who practice western medicine must understand that unless and until they take into account the cultural healing beliefs of the patients and learn to incorporate them within their treatment regimen in a rational way, it is impossible to achieve patient satisfaction. Improved patient satisfaction will lead to better compliance to therapy. Cultural competency of the healthcare provider is very important to help patients get the best medical care and also to be successful in one’s own medical profession.

Alternative medical practitioners should also understand the limitation of the treatment they can offer to an infertile couple and encourage them to seek appropriate infertility treatment from western medical practitioners when needed. After all, a patient with a blocked fallopian tube cannot be cured with Ayurveda and Unani medicines. Giving patients false hope and wasting their precious fertile period is very unethical on their part.

Every infertile couple has to decide wisely about their treatment options. Of course, there are some problems which can be cured by alternative therapies (for example anovulation due to PCOD!). But there are problems like low sperm count, blocked fallopian tubes and much more which cannot be cured using herbal concoctions. A well-educated patient will know for sure which treatment should be opted for, after analyzing their medical problem. It is also wise to find a balance, for example when you are going through IVF and if your alternative medicine practitioner advices you to take a herbal potion which he might think will help create a healthy environment for embryo implantation or which might balance your hormones, then it is nothing wrong in trying it, provided such advice is given by a reputed practitioner who is not a quack. Please do not believe in the claims of mushrooming internet sites which are claiming to provide you with herbal therapy to make your IVF a success. First, you will never know if what they are providing you will be of benefit and the next concern is, it should not harm you or your IVF cycle. Remember, many herbal medicines carry the risk of being contaminated with heavy metals!

Rather than taking a confrontationist approach, patients would find it a lot easier if IVF doctors and alternative medicine practitioners could learn to work together for the wellbeing of the patient.

Dr.Malpani's Blog: The Medical Report Jargon Buster at www.medexplain.in

Dr.Malpani's Blog: The Medical Report Jargon Buster at www.medexplain.in

Medical Report Jargon Buster is a free application which will help you to make sense of your medical reports. Are you confused by the acronyms, jargons and medical terms in your reports ? - Please visit www.medexplain.in.