ISAR EXPRESS

indian society for assisted reproduction

ISARexpress the newsletter

For Free Distribution In The Medical Fraternity Only

march 2015

From the Editors’ desk Dr Nayana Patel

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“

Dr Kanthi Bansal

To produce a mighty book, you must choose a mighty theme.

Dear Readers,

tion as its one of the most popular method of reproduction & has worldwide attention due The Indian Society for Assisted Reproduction to medical tourism.

The other highlights of the bulletin are the prois going a long way in spreading knowledge, files of the Chairperson & Secretary of all the academics & general information on all aschapters of ISAR & the details of the activities pects of human reproduction.

During the initial designing of this bulletin, Dr. that have been conducted by each chapter.

Suggestions towards ISAR EXPRESS would be Hrishikesh Pai, the President of ISAR wanted highly appreciated. the bulletin to be formatted in a way that it is made so interesting that readers would want more of it.

Happy Reading, We have therefore placed scientific articles which give all the related information at the same time light in understanding & reading.

This issue has articles related to infertility management at India & our neighboring country Pakistan.

Dr Kanthi Bansal Dr Nayana Patel There is one article on third party reproducEditors

Please email your comments & suggestions to: editor.isarexpress@gmail.com

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For Membership of IsAr log on to:

ContEnts

www.isarindia.net

page

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My Vision Is Growth & Consolidation

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The Vision of ISAR is to cultivate excellence

dr Rishma dillon pai (Immediate Past secretary General)

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Improving awareness is the top priority

• Orissa State Chapter • Madhya Pradesh State Chapter • Chhattisgarh State Chapter • Punjab State Chapter • UP State Chapter • Gujarat State Chapter • Karnataka State Chapter • Maharashtra State Chapter • Haryana State Chapter • Rajasthan State Chapter • Tamilnadu Chapter • Kerala State Chapter • Bengal State Chapter

Roundup

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page

state chapteRs isaR page

dr nandita palshetkar (secretary General)

dr Manish Banker (Immediate Past President)

We have brought ISAR to a global level

dr h.d. pai (President)

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pRofiles

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suPPorted by phaRMaceuticals ltd. unexplained infeRtilitY page A New Treatment Paradigm

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tRouBle shooting and Risk ManageMent in aRt

page thiRd paRtY

59 RepRoduction

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45 fiRst Yuva national confeRence of isaR page

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isaR 2014 page

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oveRview of feRtilitY & its ManageMent in india page

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oveRview of feRtilitY & its ManageMent in pakistan page

56 Conceptualised & Produced by: Vicky bhargava

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dr Hd Pai President

“

my vision is Growth & Consolidation

• Help members to standardize ART practice in the areas of training, establishment of clinics, performance, documentation, record keeping, quality control and accreditation (both ISAR,PCPNDT & ICMR).

• Liaison with state/central government, ICMR and PNDT to bring about rationalization in clinic implementation, documentation and third party reproduction.

• Broadening ISAR’s digital signature by increasing our web & social media presence.

• Initiating multicentric trials on various subjects of academic interest.

• Launching the first nationwide Fertility Survey to analyze fertility trends in our country.

• Launching ISAR Corporate Social Responsibility (CSR) by conducting free infertility camps, public forums, and offering infertility treatments at subsidized cost. This will be done through the nationwide chain of infertility clinics run by our members.

Dear Colleagues, • Initiate training programs and It is my pleasure and privilege to accreditation for clinicians, take over the responsibility of this embryologists and counselors. wonderful organization, and steer • Starting two new conferences on it towards greater heights during a yearly basis namely the YUVA my tenure. I am sure that I will be strongly supported by the Secretary ISAR (focusing mainly on the General Dr Nandita Palshetkar and promotion of the young infertility the able team of newly elected ISAR specialists) and Embryology ISAR (encouraging our embryologist managing committee.

My slogan for the next two years is colleagues). The first YUVA ISAR has been successfully conducted in “Growth & Consolidation”. My top Jodhpur in 2014. priority is to achieve the following Today nearly 30 million Indian goals: couples face the problem of • Complete the formation of state infertility. The only way to reach chapters in the remaining states. these people is through proper • Increase ISAR’s membership.

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From the prEsidEnt’s desk

communication channels. We need to have more information in the print as well as the digital media.

We need to have public forums, press articles and TV shows addressing these issues. In this way more and more information will reach the people. We need to concentrate on patient care .This can be done by educating health providers through workshops, training programs & interactive sessions.

We already have the NARI ART registry, but only 150 clinics have volunteered to report in the 2012 survey . It will be my endeavor to encourage more reporting from the more than 500 plus ART clinics operating in our country.

As mentioned earlier, my theme is consolidation and growth. We have to consolidate whatever we have gained over the past 20 years of ISAR and also grow the organization - make it larger and stronger, make the people in the organization more aware, train them well so that they can effectively implement the techniques , make them ethically aware and responsible, see that they put patient care first and are not in conflict with the society at large.

I would also like to thank Dr Kanthi Bansal and Dr Nayana Patel, the Editors’ for taking out this excellent issue of ISAR Express.

Long live ISAR.

Dr Hrishikesh Pai MD FCPS FICOG MSc (USA) President, ISAR

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From the sECrEtAry GEnErAl’s desk

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isAr’s Vision is to cultivate Excellence

This is the first issue of the ISAR Express for the year 2015. We hope you will like this issue as much as our previous newsletter, which was received very well. We would like to call upon all of you to make use of this channel to exchange information, and to help in building and extending our ISAR Society. The way the ISAR Express is set up is flexible and may change over time, depending on the feedback and requests we receive, just as we continuously try to improve our Web site and add new content to it.

This year our President Dr Hrishikesh Pai has introduced Yuva ISAR for the 1st time. The body of knowledge contained in this conference reflects the creativity and commitment of hundreds of young minds. We hope the excitement of being given the platform will continue to inspire them. If our Nation is to remain at the forefront of science and technology, a condition for our continued economic vitality and energy security, it is essential that we develop this reservoir of talent. We are also looking forward to the ISAR Embryology Conference in Gurgaon this year.

Like any successful Society,

dr Nandita Palshetkar secretary General

ISAR has been built progressively by successive generations of its members, clinicians and pioneer fertility doctors and beginning with this issue we have decided to profile those key people who have contributed to ISAR. ISAR Express is an ideal opportunity for our members to present their work. We hope you will find interesting information in this Newsletter, and we hope you will enjoy it. As Secretary General of ISAR, I again express my pride in the achievements of these extraordinary minds. I thank them for their dedication to science and for their accomplishments.

I wish them well for an exciting future.

The vision of ISAR is to cultivate excellence in all our programmes to prepare us for a modern, globalised field in medicine. I thank the dynamic Dr. Hrishikesh Pai for enriching my tenure as a Secretary General. I would also like to congratulate the editors Dr Kanthi Bansal & Dr Nayana Patel for their excellent work.

With best regards, Dr Nandita Palshetkar, Secretary General, ISAR

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profilE DR

MANISH BANKER is a consultant in infertility and invitro fertilization at Nova Pulse IVF Clinic and Pulse Women’s Hospital, Ahmedabad.

He had a special interest in Infertility and Assisted Reproduction since his early days of medical education and wished to do something revolutionary in this field. After finishing his MBBS and MD from Gujarat University with flying colours – he was a Gold Medal winner in his batch – he moved to complete his Diploma in Endoscopy from University of Kiel, Germany.

His work in the field of assisted reproduction and infertility treatment is recognized worldwide. He is a member of the International Affairs Committee of the American Society for Reproductive Medicine (2007-2013) and has been a Founder Board Member of Asia Pacific Initiative on Reproductive Endocrinology (ASPIRE). He has been the Chairman of Infertility Committee of FOGSI. He is a Member of the Draft Committee for the ART Bill of India, ICMR and also a Member of the 2011, 2014 Surveillance Editorial Board of the International Federation of Fertility Societies (IFFS). He is involved in the compilation and publication of the National ART Registry of India for the last 10 years.

With his deep experience in all aspects of this field, he was a regional representative on the International Committee Monitoring Assisted Reproductive Technologies [ICMART], a WHO affiliate.

He has published numerous papers in journals, contributed chapters in numerous textbooks and delivered lectures at various international and national conferences.

His training programmes in this field are acknowledged as being extremely useful for the participants. His training programme on basic infertility is recognized by the Federation of Obstetrics and Gynaecological Societies of India (FOGSI)). Another training programme on gynaecological endoscopy is recognized by FOGSI as also by Karl Storz, Germany, for demonstration of diagnostic and operative endoscopy.

He is considered a trend-setter for the new techniques and direction in the

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dr Manish banker MD field of assisted reproduction. His President Oration on the theme ‘Patient Centric IVF: Are we moving in the right direction?’ delivered at Raipur, Chhattisgarh during ISAR 2012, is widely discussed.

He collaborated with one of Australia’s biggest IVF clinics way back in 1996 and now with IVI, Spain and has been offering complete state-of- the-art facilities since then.

He admits that even though in early years terms like test tube babies, invitro fertilization, surrogacy were not very popular but the demand had always been there. There were small clinics which offered IVF treatments, but the success ratio was below international standards. There was no facility which took care of all aspects of the IVF procedure. Rather than learning the processes and letting more time go, he joined hands with an international clinic with an established track record and started off immediately.

He feels that times have changed, awareness and acceptance has increased.Social networking sites, media, blogs etc. have also been instrumental in spreading awareness about the same and this treatment is viewed today with a lot of positivity.

He also thinks that recent films like Vicky Donor and Filhaal have also helped spread awareness about assisted reproduction.Patients, according to him, come to them with a ray of hope, a hope of getting a solution. IVF should not be viewed as the last resort and there is a lot more which can be done today than 10 years back. For the rural masses, audio-visual medium in regional languages can prove fruitful.

On his achievements as President of ISAR he said, “For the clinicians it is to bring ISAR on the global level. For the people at large to keep the ART registry updated even if it does not cover the entire ART market, it should cover 30-40%. And for students to have a PG course about what lies ahead in ART, so they can make their choice wisely.”

He says he plans to set up a research foundation for advanced technology development and publication.

When not working, he loves listening to music and exploring places. He admits to being a hard core foodie and loves trying out different cuisines.

President IsAr (2012-2014) Immediate Past President IsAr (2014-2016)

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We have brought ISAR to a global level

dr rishma dhillon Pai MD, DGO, FCPS, FICOG, DNB

secretary General IsAr (2012-2014) Vice President IsAr (2014-2016)

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Improving awareness is the top priority

profilE DR

RISHMA PAI graduated from KEM hospital and Wadia Hospital, Mumbai. She received training in Laparoscopic and Hysteroscopy surgery at the Jan Palfin Hospital, Antwerp (Belgium) where she was Clinical Fellow in advanced operative endoscopy. She also completed training in Micromanipulation (ICSI) at one of the leading centers in the world, the Schoysman Institute in Brussels, Belgium. She then trained in egg and embryo freezing at the world’s largest IVF centre at Kato’s Clinic of Japan and underwent short training courses in advanced infertility treatment in Italy, China and Portugal.

In 2010 Dr Pai got elected as the First (Senior) Vice President (2010) of Federation of Gynecological Societies of India (FOGSI). She was organizing secretary of the highly successful All India Conference of OBGYN AICOG 2013 held at Mumbai. Presently, she is the Vice President (2014-2016)) of the Indian Society for Assisted Reproduction (ISAR) and the Chairperson of the Maharashtra Chapter of the Indian Society for Assisted Reproduction. She is also the Treasurer of the Indian Association of Gynecological Endoscopists . Dr Pai has the privilege of being presently the Board member of the World Endometriosis Association.

She has been honorary consultant Gynecologist at the Jaslok Hospital, Mumbai for the past 22 years. In Jaslok she is part of the group that introduced MRI focused ultrasound treatment of Fibroids, a first in India. Dr Pai is an Advanced endoscopic surgeon and ART specialist and is one of the lead gynecologist in the Bloom IVF group with ART centres in Lilavati Hospital, Mumbai, Fortis Hospital in New Delhi, Gurgaon and Chandigarh. She is also the joint organizing secretary of the IFFS world congress 2016 in Noida, India. Dr Pai has been a guest speaker at more than 300 national and international conferences and has numerous articles and publications to her credit Dr Rishma Pai says “The patients expect not only excellent medical care and results, but also expect a lot of information, education and interaction with their care giver. ISAR through its many workshops and conferences helps sensitize the doctors to cater to the needs of the patients. Considering the population of India, the number of ART cycles

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is indeed very low. It is a constant endeavor of ISAR to reach out to the people through public forums and media to educate them and to remove the taboo associated with IVF treatments.”

She further adds, “There are many challenges before the Indian ART scenario.

But most important is to deal with haphazard mushrooming of IVF centers.

Unfortunately, not all of them are standardized or have appropriately qualified doctors manning them. This creates distrust amongst people and results in poor outcomes. These need to be monitored and ISAR needs to accredit IVF centers all over. Also the cost of IVF is intimidating for a large population so it is important to have insurance companies cover some ART procedures”.

Dr Pai says “It is very disappointing that India is one of the few nations where there is no proper count of the number of centers and the kind of work being done there. Also, the success rates are not properly documented which makes it difficult to bring out substantial data.

It also makes it difficult for patients to select a good IVF centre in their area.

ART registry is voluntary at present and hence only a few centers submit their reports. A good comprehensive registry is definitely the need of the day”.

During her earlier tenure as ISAR secretary, she focused on increasing awareness about ISAR and to increase its membership. Some important developments during her tenure were: • Completion of formation of 13 state chapters all over India. Each one of them did many activities under the guidance of ISAR and outreached a large number of doctors.

• ISAR Post Graduate training programs were carried out in many states.

• ISAR newsletter and journals helped spread knowledge and information.

• The website as well as the online registration for membership made connectivity with the main office much easier for all members.

• ISAR had its successful national conference at Ahmedabad under the leadership of President Dr Manish Banker, and with her as Honorary General Secretary.

Dr Pai likes to spend time at home with the family. Dining out with friends and spending a leisurely evening with them rejuvenates her.

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ExECutivE CommittEE isAr

Dr Nandita Palshetkar Hon. Secretary General

Dr Hrishikesh D Pai President

Dr Narendra Malhotra Dr Manish Banker Immediate Past President President Elect

Dr Virendra Shah Hon. Joint Secretary

Dr Prakash Trivedi Hon. Treasurer

Dr Duru Shah Vice President

Dr Rishma Pai Second Vice President

Dr Vijay Mangoli Chairman for Embryology

Dr Kanthi M Bansal Hon. Joint Treasurer

Dr Jaideep Malhotra Hon. Clinical Secretary

Dr Sunita Tandulwadkar Hon. Librarian

Dr Kamini Rao

Dr Sadhna Desai

Dr Dhiraj Gada

pAst prEsidEnts

Dr Mahendra N Parikh

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Dr Firuza Parikh

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mEmbErs

Dr Ameet Patki

Dr Parul Kotdawala

Dr Rajat Kumar Ray

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Dr A Suresh Kumar

Dr Asha Baxi

Dr Milind Shah

Dr Sanjay Makwana

Dr S Krishna Kumar

Dr Nimish Shelat

Dr Sudesh Kamat

Dr Sujata Kar

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state chapters isAr DR MONU PATTANAYAK Chairperson

Secretary

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for different centers it become a tough situation for them because of the high financial cost they have to bear. Another issue he faces as a male gynecologist is that in certain areas of our country, male gynecologists have to prove themselves to achieve the confidence of the patients.

He has a lot of expectations in the field of reproductive medicine. According to him the future of IVF in India is very bright as our IVF centers are very organized and their functioning is very transparent. Our doctors are also very professional and because of all this India’s IVF industry has all the ingredients for success in a global scenario.

Needs of the patients and an urge to provide better treatment are the guiding forces for him in this profession. He holds the credit to have the first IVF baby of Odisha named Janaki in 1999 at his centre in Rourkela.

“IsAr should create infertility awareness in the society. It should also make efforts that the benefits of IVF reach the common man and does not remain confined to the elite and affluent class.”

DR RAJAT RAY did his Diploma in Gynaecology and Endoscopy from France and is MD, FICOG. He got his training in advanced embryology from Singapore. He is an executive member of Indian College of Medical Ultrasound and also the Chairperson of Public Awareness Committee, FOGSI (2010-2012).

At present he is Associate Professor at Hi-Tech Medical College, Rourkela and also Director of Ray Hospital & Test Tube Baby Centre, Rourkela.

He opted for IVF to serve patients better as he believed traditional treatment did not cure the problem in certain most complicated cases. Like most of the IVF specialists he also feels that low success rate is the major

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established: 7th August 2010

“IsAr should function as a strong body which could facilitate best possible treatment in every part of the country. It must become a platform for sharing of experience and expertise from all over the country. IsAr should not lag behind other organizations and must achieve more in the years to come.”

DR MONU PATTANAYAK completed his MBBS with distinction and completed post graduate in Obstetrics and Gynaecology at AIIMS in 1979. He had always been interested in the branch of infertility and keenly wanted to do something for patients suffering from infertility. He has an intense desire to be a ‘women’s health provider’ and in 1976 started his mission towards women's health.

The high cost of the treatment is certainly a big hurdle for both doctors and patients.

If the patients do not get success in one centre and go

DR RAJAT RAY

orIssA

problem. But he is also confident that future of IVF is very bright and with advancement in technology, the success rate will also improve.

To keep learning about new developments and applying them in solving new cases is the real challenge and motivation for him. He always wants to provide benefits to the common people. According to him the need of the hour is to have more super specialized IVF hospitals in every part of the country.

He has received Kamini Rao Yuva FOGSI Orator (East zone)-2004 Award and Dr. R.N.Mishra Award for Best paper published in Orissa Medical Journal-1996. He was also the organizing Secretary of ISAR 2008, Bhubaneswar and ISAR 2013, Rourkela and also the organizing secretary of several zonal and state conferences.

Dr P.C. Mohapatra addressing ISAR 2013

Dr Craig addressing ISAR 2013

Dr W.E. Gibbons addressing ISAR 2013

Inauguration address by Dr Banker, President ISAR

We organized ISAR-2008 at Bhubaneswar. After the Conference was over, under the leadership of Dr. P. C. Mahapatra, we applied to ISAR to form a State Chapter. It was put to discussion in ISAR Executive Body meeting. Finally the Executive Body under the leadership of President Dr Sadhana Desai agreed to our proposal & necessary changes were made to allow State Chapter formation.

The Odisha Chapter of ISAR, the pioneer of State Chapters of ISAR was formally inaugurated on 7th August 2010 at Cuttack by the Founder President of ISAR Dr Mahendra Parikh during the presidentship of Dr Dhiraj Gada. Dr Monu Pattanayak & Dr Rajat Ray took charge as founder Chairman & Hon Secretary respectively. A CME on Endometriosis & Infertility was organised on 7th & 8th August 2010.The renowned faculty included stalwarts like Dr Mahendra Parikh, Dr Firuza Parikh, Dr Dhiraj Gada, Dr Hrishikesh D. Pai, Dr Narendra Malhotra, Dr Nandita Palshetkar, Dr Pravin Patel, Dr Kanthi Bansal, Dr A. Suresh Kumar & others.

Subsequently several CMEs & infertility awareness camps have been regularly organized.

We organized ISAR-2013 at Rourkela from 15th to 17th February 2013. Four pre-congress workshops were held on 15th.

(a) IVF/ICSI workshop at Shanti Memorial Hospital & Assisted Conception Centre. (b) IUI/ART lab set up workshop at Ray Hospital & Test Tube Baby Centre. (c) Ultrasound workshop at ABM Hospital & Test Tube Baby Centre. (d) Hysteroscopy workshop at Ispat General Hospital.

Conference was inaugurated by Dr B.N.Chakrabarty on 15th evening at Bhanja Bhawan. Four international faculties along with a large number of national faculties participated. Three orations were delivered by Dr Manish Banker, Dr William E. Gibbons & Dr Craig Neiderberger.

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state chapters isAr DR ASHA BAXI Chairperson

DR ARCHANA BASER

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gynaecology. The were only a few IVF specialists at that time.

“The major obstacle for doctors and professionals is lack of easily available proper training. IVF is not practiced in government hospitals. The doctors in this field come to know about most of the things by trial and error and with their own experiences”, she says.

In coming years she foresees greater professionalism in IVF practices. Practice will be done in an ethical manner and guidelines for this field will also become much clearer.

She always wanted to do something different. On her visit to United Kingdom she observed these practices even in simple clinics, and this motivated her a lot. On the personal front, at one point of time in her life she herself had undergone this treatment and that is why she knows its importance.

She has published many papers in national/international journals and various chapters in text books. She received FRCOG in 2007. She is a recipient of Dr Kumud Tamaskar award in 2011, awarded by FOGSI and best Paper in FOGSI Journal (JOGI) in 2013. She has delivered 1st ICSI & TESA-ICSI babies of M.P.

“IsAr is a strong organization and needs to become stronger. It should be turned into an international standard organization where different infertility associations from developed countries should come to seek association.”

DR ARCHANA BASER completed her MBBS from Indore and postgraduation in Obstetrics and Gynaecology. Later she moved to Mumbai and worked as a lecturer at Wadia, Nair, KEM and Rajawadi Hospitals. Her desire to achieve more in terms of academics made her move to UK to do MRCOG. Her center is recognized by FOGSI for Ultrasound and Endoscopy training and there are regular trainees in her hospital.

She was always among the top performers in class and her parents motivated her to pick medicine as a profession. She too wanted to join this profession as she wanted to help people. The healthcare infrastructure in India was very poor when she was studying and female healthcare issues were not even a topic of debate. After working in this field, she got to hear a lot of stories of women being mistreated because of infertility and she saw a need to address the situation. She entered the field of IVF about 10 years ago and has been practicing infertility treatment from the beginning. She

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established: 13th November 2010

“IsAr will provide a proper platform to young doctors and professionals along with the experts. It will generate optimum awareness in the society regarding IVF. It will continue to do wonderful job as it has been doing till date.”

DR ASHA BAXI completed her M.B.B.S. and M.S. (Obstetrics and Gynaecology) from M.G.M. Medical College, Indore in 1984 and then joined Dr Sadhana Desai as a clinical assistant, where she got inspired to pursue MRCOG and specialize in infertility. Later she travelled to the U.K., where she pursued MRCOG and got an opportunity to receive infertility training at Northampton, Oxford and Bourne Hall.

Eventually she returned to India in 1994 and began her practice. She started her own ART centre (Disha Fertility & Surgical Centre) in 1998 which is credited with the first ICSI & TESA-ICSI pregnancies of M.P. Her centre is recognized by FOGSI for IUI, Basic & Advanced infertility training. It is accredited by ISAR & ICMR. She was attracted to this field because it was a new branch with a lot to explore as compared to traditional

Secretary

MAdHyA PrAdesH

has her own IVF unit at Akash Hospital In Indore.

She feels that the obstacles change with the era you practice in. In her initial years the lack of imaging equipment was an obstacle and these days, doctors need to be careful of an over - reliance on equipment for clinical observations.

In IVF regime, the biggest problem is getting it accepted as a kosher treatment by patients’ families and the management of expectations of patients.

IVF holds a lot of potential, it is being accepted more readily by the patients and now more people come forward for treatment than would have possibly come in the past.

She has been an obstetrician for about 25 years and in 2014 she delivered the 10,000th baby of her career. Every time she hands over a mother her newborn child, the light in the mother’s eyes and the rush of emotions is simply beautiful. It is their joy that motivates her.

She loves teaching and there are regular trainees in her hospital which is recognized by Fogsi for Ultrasound and Endoscopy training. Dr Archana has been awarded by many organizations for her contribution to women’s health. Some awards are Nai Dunia Naika Award, Vanita Kirti Samman and Guinness book of World Record for removing the largest fibroid.

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MP ISAR is a Vibrant chapter of ISAR Ready to Host ISAR 2016 at Indore.

We welcome you all to Indore in February 2016.

We took charge in November 2011.

We started off with an infertility update with Dr Nayana Patel as chief guest and speaker for the installation ceremony. This ceremony was in association with Indore Obstetrics and Gynaecology Society. 100 delegates attended the meeting.

Regular once a month meetings were organized to discuss topics of common interest. Âë‰ßè ç¼ßâ ·¤ô ÂãÜè ÕæÚU ww ¥ÂýñÜ v~|® ×𴠧⠩gðàØ âð ×ÙæØæ »Øæ Íæ ç·¤ Üô»ô´ ·¤ô ÂØæüßÚU‡æ ·Ô¤ ÂýçÌ â´ßðÎÙàæèÜ ÕÙæØæ Áæ â·Ô¤Ð §â×ð´ ·¤ô§ü â¢Îðã Ùãè´ ãñ ç·¤ ¥×ðçÚU·¤æ ·Ô¤ Âêßü ©ÂÚUæcÅþUÂçÌ ¥Ü »ôÚU ·¤è ÂéSÌ·¤ Ò§Ù·¤‹ßèçÙ°¢ÅU ÅþåU ÍÓ ¥õÚU w®®| ×ð´ ©‹ãð´ â¢Øé ̤ÚUæcÅþ ·Ô¤ ¥æ§üÂèâèâè ·Ô¤ âæÍ â¢Øé ̤M¤Â âð ç×Üð ÙôÕðÜ ÂéÚUS·¤æÚU Ùð §â ¥ôÚU Áæ»L¤·¤Ìæ ÕɸæÙð ×ð´ ×ÎÎ ·¤è ãñÐ ¥ UâÚU Øã â×æ¿æÚU âéÙÙð ·¤ô ç×ÜÌð ãñ´ ç·¤ © æÚUè Ïýéß ·¤è ÆUôâ ÕÈü¤ ·¤§ü ç·¤Üô×èÅUÚU Ì·¤ çƒæÜ »§ü ãñÐ âêØü ·¤è ÂÚUæÕñ´»Ùè ç·¤ÚU‡æô´ ·¤ô Âë‰ßè Ì·¤ ¥æÙð âð ÚUô·¤Ùð ßæÜè ¥ôÁôÙ ÂÚUÌ ×ð´ ÀðUÎ ãô »Øæ ãñÐ çȤÚU ÖØ´·¤ÚU ÌêȤæÙ, âéÙæ×è ¥õÚU Öè ·¤§ü Âýæ·ë¤çÌ·¤ ¥æÂÎô´ ·¤è ¹ÕÚUð´ ¥æ ̷¤ Âã颿Ìè ãñ´, ã×æÚUð Âë‰ßè »ýã ÂÚU Áô ·é¤À Öè ãô ÚUãæ ãñ, §Ù âÖè ·Ô¤ çÜ° ×æÙß ãè çÁ ×ðÎæÚU ãñ´, Áô ¥æÁ ‚ÜôÕÜ ßæç×Z» ·Ô¤ M¤Â ×ð´ ã×æÚUð âæ×Ùð ãñ´Ð ÏÚUÌè ÚUô ÚUãè ãñ, çÙà¿Ø ãè ã× ãè Îôáè ãñ´Ð ÖçßcØ ·¤è ç¿¢Ìæ âð ÕðçȤ·ý¤ ãÚUð ßëÿæ ·¤æÅUð »°Ð §â·¤æ ÖØæßã ÂçÚU‡ææ× Öè çιÙð Ü»æ ãñÐ âêØü ·¤è ÂÚUæÕñ´»Ùè ç·¤ÚU‡æô´ ·¤ô Âë‰ßè Ì·¤ ¥æÙð âð ÚUô·¤Ùð ßæÜè ¥ôÁôÙ ÂÚUÌ ·¤æ §âè ÌÚUã âð ÿæÚU‡æ ãôÌæ ÚUãæ Ìô ßã çÎÙ ÎêÚU Ùãè´ ÁÕ Âë‰ßè âð Áèß-Á‹Ìé ß ßÙSÂçÌ ·¤æ ¥çSÌˆß ãè â×æŒÌ ãô Áæ°»æÐ Áèß-Á‹Ìé ¥¢Ïð ãô Áæ°¢»ðÐ Üô»ô´ ·¤è ˆß¿æ ÛæéÜâÙð Ü»ð»è ¥õÚU ˆß¿æ ·ñ´¤âÚU ÚUôç»Øô´ ·¤è ⢠Øæ Õɸ Áæ°»èÐ â×éÎý ·¤æ ÁÜSÌÚU ÕɸÙð âð ÌÅUßÌèü §Üæ·Ô¤ ¿ÂðÅU ×ð´ ¥æ Áæ°¢»ðÐ

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MAJOR EVENTS Annual conference at Gwalior in 2012 organised by Dr YS Verma Vice Chairperson of MP ISAR. It was a very successful meeting.

Annual conference at Indore on 23rd June 2013 with ISGE. Very good attendance with 10 national faculty.

There were lectures, panel discussions, free paper presentation done at Fortune Landmark Hotel, Indore.

Annual Conference at Bhopal - 19th & 20th April 2014.

Organized By Dr Randhir Singh Vice chairperson MP ISAR. Chief guest was Governer of MP. The meeting was for 2 days with live Endoscopy, Sonography, IUI and Embryology workshop on day one.

Day 2 was the conference with Bhopal Obst & Gynec society. In all these meetings there were good number of delegates.

We organized a PG teaching course in association with infertility committee of FOGSI on 26th January 2014.

This meeting our invited speakers were Dr Prakash Trivedi and Dr Sujata Kar. Meeting was well taken by PG students with good response.

We participated in ACE conference at Indore on 9th August 2014.

Our members were invited as guest speakers in different scientific meetings on infertility in India like ISAR, IFS, ESHRE, ASRM and ASPIRE. We all members of MP chapter of ISAR are actively participating in the preparation of ISAR 2016 awarded to us.

We invite you all to the ISAR 2016 at Indore.

suPPorted by

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state chapters isAr DR A. SURESH KUMAR Chairperson

CHHAttIsGArH established: 19th december 2010

“IsAr will be a nationwide society uniting not only gynaecologists, fertility specialists and embryologists but also people & professionals from all walks of life. It should strive to create an easy, palatable and treatment-friendly environment for infertile couples.”

DR A. SURESH KUMAR has been awarded MBBS and MD in Obstetrics & Gynaecology from V. S.S. Medical College, Burla, Sambalpur University, Odisha. He is trained in Gynaecological Laparoscopy, Hysteroscopy & Ultrasonography, Infertility, Andrology and Assisted Reproductive Technologies, basic and higher ultrasonography.

He also received a Fellowship from Down Under Fertility Service, Sydney, Australia, and Diplomate Certificate in Ultra Sonography from Ian Donald Medical School University.

His reason for joining this field is rather emotional. He was brought up by his mother after the demise of his father in early age. He had decided to serve motherhood and therefore decided to go for Obstetrics and Gynaecology. His vision became a clear path for him

when he was in JIPMER, Puducherry and he entered this specific field in 1990.

According to him success in IVF is like a “Roller Coaster Ride”. It has been generally observed that sometime good embryos yield bad success rate and some time moderately good or bad embryos give good success rates. High cost of the treatment is also a big hurdle for both doctors and patients.

He foresees that most of the researchers will aim towards decreasing implantation failure and will increase quality of embryos and quality of endometrium and assessment of all these.

According to him a satisfactory and winning smile on the face of new born baby’s family members motivates him further to serve the nation and motherhood in this fashion.

Dr A. Suresh Kumar has received various national and international awards. Some of them are Dr. B.C. Roy award and award for first ICSI baby of Chhattisgarh. His name is also in Limca book of records 2003 and 2004 for delivery of five ICSI babies in shortest time and for delivery of a baby from a fifty plus lady, respectively.

DR TRIPTI NAGARIA Secretary

“Considering the number of infertile couples in India and the cost of Art, IsAr should develop indigenous techniques to reduce the cost and make it easily available and affordable to all needy couples.”

DR TRIPTI NAGARIA did her MBBS (University topper, Gold Medalist) and MD (Obst & Gyn) from Pt Ravishanker Shukla University, Raipur. She joined Pt JN Medical College in 1992 as Assistant Professor and is presently working as Professor and Unit head in the same college.

In spite of high population of India there are still many couples who are childless and deprived of the joy of parenthood. It drove her to work in the field of infertility. She feels the high cost and the unpredictable success rate of the ART are major obstacles in this field. She expects uterine implantation and more

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development in fields of male infertility would occur in this field.

Her real motivation comes from successful management of cases and a smile on the faces of the cured cases and their attendants. A healthy baby in the lap of a healthy mother also motivates her.

Suffering of women and their condition in the community also motivate her to do everything possible to help them out. She received Dr Bhalerao Memorial award and is National Corresponding editor of Journal of FOGSI. She is invited as faculty to many national and international conferences and has presented papers and delivered lectures in the national and international conferences and published many papers in indexed journals. She also contributed chapters in books. She has organized international, national and many state conferences, workshops and CME.

activities

DR. RATNA AGRAWAL Acting General Secretary cum Treasurer ISAR 2012 Chhattisgarh Chapter of Indian Society for Assisted Reproduction was formed on December 19, 2010 at a regional conference on Practical Approach to Infertility Management and Setting up IUI and IVF Laboratory. The then Governor of Chhattisgarh Shekhar Duttji inaugurated it and the total presence was around 270. Methods of semen processing and IUI procedure were relayed from Ashoka Hospital to Hotel Babylon Inn. Founder President of ISAR Dr M. N. Parikh and President Dr Dheeraj Gada graced the conference.

In 2011, organizing team members Padmashree Prof. A T Dabke, Prof. Tripti Nagaria, Dr Ratna, Dr Wakodkar, Dr Veronica, Dr Palak, Dr Priti, Dr Neeraj, Dr Manoj, Dr. Sangeeta, Dr Kanwar, Dr. Nalini and other members of CG State, worked day in and day out for hosting the national conference. The 17th National Conference of ISAR was held at Raipur from March 1st to 4th, 2012.The Chairperson of the conference was Dr A Suresh Kumar. Over 1250 dignitaries, eminent speakers of national and international fame, volunteers etc attended.

Interactive workshops were held on Advanced Practical Andrology; Embryology; 3D-4D Reproductive USG; Counseling in ART; Research Methodology and Biostatistics. ADVANCED STEM CELLS & PGD WORKSHOP WAS HELD FOR FIRST TIME IN ISAR NATIONAL CONGRESS. Chhattisgarh Health Minister Hon’ble Amar Agrawal inaugurated it. Public forum “Pregnancy after ART – Is it Special?” was exciting, clearing myths of test tube babies. CG Chapter handed over highest amount to the Central body of ISAR till that date.

American Society for Reproductive Medicine President Dr (Prof.) Dolores J.

Regional Conference, Raipur Lamb, National & International stalwarts appreciated the efforts of the organizing team.

In 2013, IUI workshop was organized on 25th August at Ashoka Hospital, focusing on Semen Processing & Practical Management in Infertility & Hands on training in IUI techniques to 22 gynaecologists. Semen Analysis, IUI Lab Setup and training on IUI processing were discussed by Dr Rajvi Mehta, Dr A Suresh Kumar & Dr Ratna Agrawal supported by Akumenties and Trivector International, Mumbai.

In 2014, the state chapter of ISAR and Bhilai OBGY Society jointly organized State Conference on “Enhancing Success Rate of Pregnancy in Infertility” at Hotel Grand Dhillon, Bhilai on 18th January. Infertility related topics like IUI & ART technologies were discussed and enhancing Success Rates in infertility was discussed. Panel discussion on “Recurrent Abortion - Are we near helping?” was moderated by Dr Bharti Dhorepatil (Pune). Total presence was around 180.

Another such conference was on “Different Aspects of ART”, organized on 17th August 2014 at Hotel COURTYARD MARRIOTT, Bilaspur, along with OBGY Society & IMA - Bilaspur. Different topics and management of IUI & ART were discussed and also newer Lab Techniques to improve ART Result. Prof. G. D. Sharma, Vice Chancellor, Bilaspur University has inaugurated the Scientific session. “An overview of PC & PNDT Act and brief introduction of ART Bill”, presented by Dr Lunawat from Bhopal and panel discussion on “Optimizing Success Rate in ART” was moderated by Prof Dr N.S. Reddy, from Chennai.

IUI Workshop, 2013 Bhilai Conference

DR. RATNA AGRAWAL is Scientific Director cum Senior Embryologist of Ashoka Super Speciality Women Hospital & IMSI, ICSI Test Tube Baby Centre, which is a unit of Ashoka Super Speciality Hospital & Research Pvt. Ltd., at Raipur, Chhattisgarh.

She did her Clinical Embryology from Leeds University, U. K. She has been specifically trained in “Advances in the Assessment of Semen Parameters & Detection of Sperm Pathologies” by Department of Reproductive Bio-medicine, National Institute of Health and Family Welfare, which was sponsored by ICMR, MCI and National Academy of Medical Sciences (India). Her qualifications include a Fellowship from Belgium (Europe) & Down Under Fertility Service, Sydney, Australia in Specialized ART techniques like IVF, ICSI, Laser Assisted Hatching, blastocyst Culture & Vitrification. She has been trained in comprehensive course on PGD & PGS in March 2014 by scientists of Spain with live demonstration.

She is the Life Member of ISAR Society and is the Acting General Secretary cum Treasurer of Chhattisgarh Chapter of ISAR. She is also member of Alpha Scientist in Reproductive medicine, Istanbul – Turkey and has attended many National and International Infertility conferences, presented scientific papers & Chaired sessions in many conferences and has conducted teaching programmes for the Gynecologists, embryologists & scientists in IUI Techniques, Laboratory Set-up, semen preparation & ART techniques.

She was the organizing Secretary of many conferences including the 17th National ISAR Congress, which was held at Raipur.

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punjAb Established: 23rd December 2010

DR SURENDRA “ISAR is doing remarkable job in this field. It is bringing together all experts under PAL SINGH VIRK one umbrella. It is a very strong body having excellent mentors. ISAR should Chairperson

organize conferences all over India to spread awareness about ART among not only gynaecologists, fertility specialists and embryologists but also surgeons, pharmaceutical companies, politicians, journalists, health insurance providers, medical tourism operators and others. ISAR should also help the Government to make laws that will help in making proper guidelines for practicing in this field.”

DR SPS VIRK did his Ph.D. from Sherwood University, London and M.Sc. (Hon) from Department of Life Sciences, Guru Nanak Dev University, Amritsar. His field of specialization was Human Genetics.

He realized that the process of tissue culture and IVF techniques are the same. So it was very easy for him to switch to this branch. In those days infertile couples from Punjab went to Mumbai for treatment. But now these facilities are easily available for them in Punjab.

Dr Virk feels the low rate of success is a major hurdle for doctors and professionals

DR SARDA VANIE THAPAR Secretary

“ISAR as a body needs to be become stronger and data registry should be strict.

Right now it is largely an academic forum but it can grow to become a guiding force for new practitioners and also become instrumental in formulating guidelines for accreditation.”

DR SARDA VANIE THAPAR did her M.B.B.S. from Christian Medical College and Hospital, Ludhiana and M.D. from PGI Chandigarh. She worked as research fellow in PGI and did training in laparoscopy from Kiel, Germany. She had undertaken training in IVF and ART from Institute of Reproductive Medicine, Kolkata.

She had a keen interest in science and therefore choosing medicine as a career was rather inevitable. She entered this specialty in 1996 because of her keen interest in laparoscopy and way back in 1996 there was hardly any work being done in this field in Punjab.

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in this field. In initial days, the success rate was as low as 35% and now it is as high as 70% but having 100% success is still a dream. Another obstacle is the high cost of the treatment. But he feels that with hard work, dedication and passion any obstacle can be surmounted.

He feels the future of IVF is very bright. It is not just a medical branch but also a large profit-making industry worth over Rs 5000 crore. More research is required in coming years.

His main motivation is blessings from the newborn’s family. Similarly advancement in this field also motivates him. Selection of real time embryo is a thrilling experience. He said babies born from his treatment are the best award for him.

He has been honoured in USA for outstanding work in infertility. He has received many awards, among them Vikas Rattan Award, Vidya Rattan Award, Best citizen of India Award (1999) etc.

She feels there are no clear-cut rules and accreditation regarding various aspects of ART. Various government bodies still continue to harass fertility specialists taking the cover of PCPNDT Act because of lack of uniform guidelines.

The future of IVF is bright and a lot growth and development is witnessed. But there are real problems in related areas of gamete donation and surrogacy. This leads to exploitation and malpractices.

Interacting with infertile couples is not only academically challenging but also an emotional experience.

Results in the field of ART are governed by many variables therefore updating oneself with all the latest developments should be constant endeavor on the part of any practitioner who wants to excel in this field.

She was honoured by the United Nations Youth Organization (Punjab Unit) for providing medical services as gynecologist to women from the weaker section of society.

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Inauguration of Punjab State Chapter

CME at Jalandhar

Seminar held in October, 2014; Organized by Virk Fertility Services, ISAR and IMA Jalandhar. The talk was on ICMR guidelines and PNDTA act.

CME held on 14th Dec’2014. The talk was given

by Brigadier Dr R.K Sharma on PCOS and its Management at Hotel Radisson, Jalandhar.

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uTTAR pRADESh Established: 26th December 2010

“ISAR is involved in many academic practices. It always encourages good and PROFESSOR CHANDRAWATI ethical practices by the doctors and medical professionals in the IVF treatment.”

Chairperson DR CHANDRAVATI is M.S. and D.G.O. from K.G. Medical College, Lucknow, DFPA from England, Fellow of International College of Surgeons (FICS), Fellow of College of Maternal and Child Health (FICMCH) and from and Fellow of Indian College of Obstetrics and Gynaecology (FICOG).

She has long experience of clinical practice and feels that a large number of patients do not get proper advice on time due to which they miss fertile time and do not got success after treatment. Therefore she started ART on subsidized rate in her clinic about two years ago.

She feels the major problem in this treatment is the

DR JAIDEEP MALHOTRA Secretary

“ISAR must focus of quality control, evidence-based documentation of work and advance researches in the field of IVF. India must emerge in the leading position in the Asia pacific region and our practices should compete with the quality of work done by countries like Australia and Singapore.”

DR JAIDEEP MALHOTRA is a pioneer in the area of women’s health for over three decades, a super specialist in infertility, an ace sonologist in 4D ultrasound, an eminent speaker in national and international conferences on all possible facets of Obstetrics and Gynaecology, Editor of a variety of publications on Infertility, High risk pregnancies, Operative gynecological endoscopy, Imaging sciences, Managing infertility in a low resource setup etc.

As a young doctor she was very fascinated by IVF as she regarded it as the ultimate solution for the most complicated cases of infertility. In 1997 she started IVF in her maternity hospital when there complete absence of these facilities in Uttar Pradesh.

As for hurdles, she feels that IVF centers are mostly individual efforts and they are big investments both in

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absence of proper follow-up. Secondly, most of patients don’t get proper treatment and advice in their prime years and treatment becomes very difficult in advanced age.

She feels the future of IVF is very good. Now both patients and doctors are much aware about it. Patients now come in early stage of their problem. Her eagerness to help patients is her real motivation. She also gives treatment at subsidized rates and never misguides patient about their actual medical position. In case pregnancy is not possible by the treatment she advises them to go in for surrogacy/donor as per the case requirement.

She has received several awards and some of them are: Countess of Dufferin award in medical course, Commonwealth Medical fellowship, Best teacher award from K.G’s Medical College and LIONS International, Best Fellow Guide of the College in Obst. & Gynae. by the Governing Council of Dr. C. S. Dawn Memorial Society and Fellow of Indian College of Maternal & Child Health (ICMCH).

terms of money and time. The success rate is very low, and the government does not have any budget allocation for IVF. Absence of an insurance cover and shortage of properly trained persons are also hurdles.

According to her the future of IVF in India is very bright.

Now rural areas must be given proper attention since most of the IVF centers are in metros and big cities. It is emerging as a lucrative business and many centers are getting patients from abroad. But one should not ignore the basic right of rural Indian people to overcome infertility issues. She is associated with 14 different centers all over India, besides some others in Nepal and Bangladesh. She always had an intense desire to help people to overcome infertility and improve the quality of their life. She has an extensive and exhaustive list of achievements on her platter: She is the first Indian woman gynaecologist to be elected as President-Elect of Asia Pacific Initiative in Reproductive Endocrinology (ASPIRE), Vice President FOGSI 2010, Editor of the Journal of South Asian Menopause Society, Treasurer of Indian Menopause Society, Secretary of Indian College of Obstetrics and Gynecology (2012 -2015), and has recently been appointed Professor at the University of Dubronivic (Croatia).

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ISAR UP CHAPTER CONF-2014 “INFERTILITY UNPLUGGED” ISAR UP Chapter conference 2014 was organized on 12, 13 and 14 December 2014 at Hotel Ramada, Varanasi, under the able guidance of Dr Jaideep Malhotra, President ASPIRE (organizing chairperson), Dr Narendra Malhotra, President Elect ISAR (patron). Dr Gajendra kant Tripathi and Dr. Seema Pandey were the Organizing Secretaries, while Dr. Neelam Ohri was the Organizing Co-chairperson and Scientific Chairperson. Workshops were co-ordinated by experts like Dr Tarini Taneja and Dr Ritu Khanna. Looking at the doctor patient ratio of this region and fewer numbers of specialized clinics this conference held a great value. There were four pre-congress workshops on andrology, embryology basics, hysteroscopy and ultrasound. Distinguished faculties like Dr Jaideep Malhotra, Dr Narendra Malhotra, Dr Vinit Mishra, Dr Ashok Khurana, Dr Neena Malhotra, Dr Rajalaxmi Walavalkar from all over the India had participated in teaching and training program of these workshops and more than 200 delegates got benefitted by these workshops. Scientific congress started on 13/12/2014 and it was attended by all the aspiring gynaecologists of the region. The main attractions were orations and key note sessions delivered by our guest of honours Dr Hrishikesh Pai (President ISAR), Dr Nandita Palshetkar (Secretary ISAR), Dr Dheeraj Gada (Past President ISAR), Dr Jaideep Malhotra and Dr Narendra Malhotra. While our president Dr H.D.Pai focussed on the need of more state chapters and continuous teaching and training programs, President ASPIRE Dr Jaideep talked about the current position of fertility treatment in Asia Pacific region and her emphasis was on improving the quality and accessibility of ART services in this region. Role of hysteroscopic surgeries in ART was highlighted by Dr Nandita Palshetkar. Dr Dhiraj Gada spoke about the non surgical management of fibroids which was really appreciated by the audience. Our various panels on PCOS and TB and sub-fertility and ART in endometriosis and adenomyosis were well attended and admired. All the distinguished faculties took special care to make the sessions interesting and interacting. Our chief guest Dr R. S. Sharma inaugurated the congress and discussed the various aspects of ART Bill and its flaws and strength. Inauguration was followed by a cultural program by the students of BHU and VOGS doctors. New ISAR UP CHAPTER team was announced and all the guests were felicitated. Valedictory was done on a positive note to organize the chapter annually and increase the number of delegates in the society followed by a note of thanks by both the secretaries.

ISAR UP Chapter 2014 pre-congress workshop “Advanced Andrology and IUI Workshop” was organized at Khanna Test Tube Baby Centre, Krishnapuri, Sigra, Varanasi on 12th December 2014.

National President elect ISAR Dr Narendra Malhotra was the coordinator of the workshop, Dr Jaideep Malhotra was a chairperson of the conference & Dr Ritu Khanna was the convenor of the workshop.

Andrologists and Infertility specialists from Varanasi and all over the country and abroad participated in the workshop enthusiastically in large numbers. Latest advances in the management of both male and female infertility were discussed. Controversies in the infertility management were debated by the experts. Consensus and guidelines were explained to the upcoming doctors to streamline the infertility treatment.

Dr Jaideep Malhotra explained the methods of using ultrasound for monitoring follicles in an IUI cycle.

Dr Sameer Trivedi, Dr R K Sah and Dr P K Jindal (leading andrologists of Varanasi) also participated in the workshop. Dr Suresh Kattera (leading embryologist) from Singapore specially came all the way from Singapore and explained his new simplified technique of semen processing for IUI. Dr Kedar Ganla from Mumbai elaborated his tips and tricks to increase the success in IUI. Dr Mujibur Rehman from Gawhati and Abhishekh Singh Parihar explained the management of an infertile male.

Dr. Pramod Bajaj from Arungabad explained new techniques in diagnosis of male infertility and showed videos of semen processing methods.

Dr Ritu Khanna elaborated the advantages of different drugs used for controlled ovarian stimulation.

Dr Rutvij Dalal from Kathmandu explained the requirements of setting up an IUI lab. The workshop was declared the best of the conference.

EMBRYOLOGY BASICS WORKSHOP EMBRYOLOGY BASICS WORKSHOP conducted under aegis of ISAR UP Chapter Varanasi on 12th December, 2014 at NEWLIFE HOSPITAL, SIGRA, VARANASI. This workshop covered all relevant areas starting from Setting-up an IVF UNIT, including various procedures and ended up with recent updates in the lab.

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dle which must be removed.

As the rate of infertility is increasing day by day due to various reasons such as late marriages, pollution, change in life style etc, more research is the need of the hour. The objective of such researches should be to achieve 100% results in these treatments.

Her aim to get best result is the real motivation for her.

At the same time dealing with new cases every day works as catalyst in her career.

She has to her credit 800 surrogate babies born at her center till date. It is the first surrogate services centre in India that works on such a large scale. The first successful transnational surrogacy case of India was achieved in her centre where a South Korean couple’s IVF baby growing in an Indian surrogate was delivered in 2007.

She has to her credit Asia’s first and the world’s fifth case of surrogate grandmother who delivered in October 2004. Her work was also featured in the celebrated programme ‘The Oprah Winfrey Show’ and a documentary on her achievements was screened on the National Geographic Channel.

“ISAR should grow into one of the best organizations in ART of the world. ISAR in the future would be a guiding institute for the academic and social issues of infertility management.

ISAR should be offering education facilities and train the best clinicians, embryologists, lab technicians and counselors who will perform par excellence in this field. My vision is to see ISAR become one of the largest, best and finest organizations in the world.”

DR KANTHI BANSAL started her training in IVF in 1989 and exclusive infertility work from 1992. Her IVF center known as Safal Fertility Foundation was started in 1996. The first IVF baby in Ahmedabad, Gujarat was born here on 12th March, 1997. Since then there has been no looking back and many firsts have been achieved by this centre.

During her childhood, she wanted to be a scientist and was fascinated with new technologies. She was one of the first to have ultrasonography machine as early as 1985. She was so impressed with this machine that she purchased transvaginal sonography machine as soon as it was available. This lead to viewing of ovary and the pelvic region with proximity

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“having grown from a small body, ISAR has achieved tremendous success and now is huge organization. It is self-regulatory body and helps in creating favorable working environment for new-comers in this field along with the experts. ISAR must strive to make India most favorable place for ART treatments.”

DR NAYANA PATEL did her M.B.B.S and M.D. with 5 gold medals. She is Expert Examiner for Infertility related doctorate thesis subjects at Monash Institute of Medical Research, Australia. She has guided various PG students and research scholars in ART Techniques, stem cell biology and surrogacy concepts with research projects and dissertation works.

Successful IVF procedure gives a lot of satisfaction to her even though it is very challenging.

She opted for this field because of these reasons.

The major obstacle for the doctors is the low rate of success. Even though the same technique applies on different couples but the results are different. Doctors give their 150% but even then the success rate is not even 100%. High cost of the treatment is another hur-

DR KANTHI BANSAL

GujARAT

and this resulted in good ovulation and pregnancy in infertile patients. For her, this was a turning point for concentrating on exclusively infertility practice.

The major obstacles for doctors and professional in this field are high cost of setting up the IVF lab and getting proper training. The low rate of results is also a big problem. The high cost of the treatment is another hindrance as all the patients may not be financially self sufficient. She feels the future of ART is superb.

The centers must properly adhere to the norms of rules and regulations given by ICMR. The quality control of laboratories has to be of highest degree to give high success rates.

She gets her motivation by seeing happiness on the faces of infertile couples who are miserable & dejected before the treatment.

Among her distinctions is delivering the first IVF - ET baby of Gujarat, the first IVF - ET baby of a single mother and triplet pregnancy in one infertile patient with successful delivery by LSCS in 1997.

activities

Gujarat Chapter of ISAR was installed on: 6th Feb 2011

by Dr Dhiraj Gada, President of ISAR. Activities of GCISAR: 1. Conference on Fertility Focus - 6th Feb 2011 The venue was: H.T.Parekh Convention Hall, AMA , Ahmedabad. There were around 175 delegates who attended the conference. There were seven lectures & two panel discussions.

The conference had 3 sessions: Dr Nimsh Shelat & Dr Sunil Shah were the chairperson for the first session.

Inauguration & Installation of Gujarat chapter of ISARwas done by Dr Dhiraj Gada, President of ISAR. Dr.Dhiraj Gada spoke on “Do we play GOD?”, Dr Nayana Patel spoke on “Managing infertility in advanced age patients”, Dr Vilasben Mehta & Dr Kiran Shah were the chairperson for the second session.

Dr Kanthi Bansal spoke on “ART: A gynecologist's perspective”, Dr Bharat Joshi spoke on “Setting up of IVF lab and Quality Control”, Dr Himanshu Bavishi spoke on “Improving outcomes in IUI cycle”.

The panel discussion was on “Adnexal masses and infertility” Dr Sushma Baxi & Dr Manish Pandya were the moderators and the panelists were Dr Tushar Shah, Dr Ajay Valia, Dr Pawan Dhir, Dr Rajesh Gorasia Dr Sanjay Patel, Dr Sanjay Gandhi, Dr Mehul Damani, Dr Kamini Patel. Dr Ajit Raval & Dr Kiran Desai were the chairperson for the third session.

Dr Tejas Dave spoke on “Reproductive issues in women with Myomas”. Dr Pravin Patel spoke on “Role of Hysteroscopy in Infertility”. Dr C.B.Nagori spoke on “Ovulation induction for PCOS patients” The panel discussion was on “Troubleshooting in Infertility”.

Dr Manish Banker & Dr R.G.Patel were the moderators

for the panel discussion and the panelists were Dr Dhiraj Gada, Dr Sonal Kotdawala, Dr Sonal Panchal, Dr Jitendra Prajapati, Dr Hasmukh Agarwal, Dr Jayesh Amin, Dr Pooja Singh & Dr Dharmesh Kapadia.

2. Scientific meet - 18th Dec 2011 The venue was: Hotel Imperial Palace, Rajkot. There were around 100 delegates, four lectures, one panel discussion & one stump the experts.

The national faculty was Dr P. M. Gopinath from Chennai.

The scientific meet had 4 sessions Dr Pravin Patel, Dr Gayatri Thakkar & Dr Kiran Gosai were the chairpersons for the first session.

Dr Manoj Bharwada spoke on “Understanding errors during laparoscopic surgery”, Dr Jitu Prajapati spoke on “Endometrial Receptivity”.

Inauguration was done by Dr P.M. Gopinath who was the national faculty, Dr Kanthi Bansal, Dr C.B. Nagori, Dr Pravin Patel.

Dr P.M. Gopinath was the moderator for the panel discussion named “Endometriosis & Infertility Management” in the second session.

The panelists were Dr Nayana Patel, Dr Manish Banker, Dr Kanthi Bansal, Dr C.B. Nagori, Dr Kiran Desai, Dr Rajesh Gorasia.

Dr Tushar Shah, Dr Nimish Shelat & Dr Lata Jethwani were the chairperson for the third session.

Dr Raman S. Patel spoke on “COH in IUI – An update” Dr P. M. Gopinath spoke on “Low cost IVF Myth or Reality”.

The fourth session was named as ‘Stump the Experts’ (Day to Day Problems in Infertility). The experts were Dr P.M. Gopinath, Dr Kanthi Bansal, Dr Manish Banker, Dr C.B. Nagori, Ms Harsha Bhadarka. The pro-

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gram was coordinated by Ms Khuhsboo Patel.

3. Executive Committee Meetings • The 1st Executive Committee Meeting, Gujarat Chapter of ISAR was held on 5th of March, at Agra.

The venue was BSV lounge, Board room at Hotel Jaypee Palace from 8.00 am to 8.45 am.

The following was the agenda for the meeting; A. Future program B. Appointing committees C. Confirming about the Co-Opt member & issues arising of it.

D. Initiation for starting Embryology/ART related courses / training.

E. Anything with permission of chair Minutes of the 1st Executive Committee Meeting A. Future Program: Dr.Pravin Patel suggested that the next Conference would be held at Baroda in the month of September. The proposal was seconded by Dr C.B.Nagori.

B. Confirmation about the Co-opt member & issues arising of it: Dr.Nayana Patel had suggested that an embryologist should be made the co-opt member. Dr Kanthi Bansal reminded that as discussed in the GBM in “Fertility Focus” Conference at Ahmedabad on 6th February 2011 that as there was no one from the north Gujarat Dr Jitendra Prajapati would be made the Coopt member. Dr Purnima Nadkarni seconded the proposal.

C. Anything with the permission of chair: Dr Kanthi Bansal suggested that the fees of Rs 2750 (2500+250) be decided for a 3 years membership, should be made

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as the life membership fees. The suggestion was seconded by Dr.Nayana Patel.

The meeting ended with thanksgiving.

• The 2nd Executive Committee Meeting, Gujarat Chapter of ISAR was held on 2nd December 2011 at Mehsana. The venue was “Rotary Bhavan”- Rotary Bhavan Road, O/S.Gopinala, Mehsana, from 6.30pm to 7.00pm.

The following were the agenda for the meeting; A. Suggestions from executive members from Gujarat Chapter ISAR for regulating membership guidelines for state chapters.

B. Future program C. Anything with permission of chair Minutes of the 2nd Executive Committee Meeting Dr Kanthi Bansal requested the executive members of GCISAR to give suggestions to increase the members in the state chapter. Dr Nayana Patel & Dr Manish Banker seconded the opinion. The second scientific meet of GCISAR in Rajkot was finalised.

Report of GCISAR Activity on Infertility and Endometriosis held on 27th Feb 2011 at Mehsana,Gujarat.

Endometriosis activity was held on 27th Feb at Mehsana, Gujarat.

The venue was Hotel Orica-Himalaya Mall, Mehsana.

There were 45 delegates present in the program.

There were three sessions followed by panel discussion. Chairpersons for all sessions were Dr Bharat Patel, Dr S.P. Patel, Dr Mahesh Gupta.

The first session was on “Management of Infertility in

advance age patient” by Dr Nayana Patel.

The second session was on “Tricks & Tips for Ovulation Induction” Dr C.B.Nagori.

Dr Kanthi Bansal spoke in the third session & her talk was on “Recent Trends in Endometriosis”. She gave an overview of Endometriosis including sites, etiology, diagnosis, management. She also talked about the recent advances in the management of Endometriosis.

Panel Discussion was moderated by by Dr Jitu Prajapati, panelists were Dr Jignesh Shah, Dr Mahesh Gupta, Dr Dilip Gadvi, Dr Nayana Patel, Dr C.B. Nagori and Dr Kanthi Bansal.

There was active interaction from the delegates. The active interaction lasted for 45 minutes. The interaction was mainly on staging of Endometriosis, right method of IUI & timing of IUI. The whole program was sponsored by Akumentis Healthcare Ltd. ISAR 2014 - A Mega, Memorable and Magical Conference - 14th, 15th and 16th February 2014.

The Gujarat Chapter ISAR won the bid to host the prestigious conference during the ISAR Conference held at Raipur 2012. The preparations for the mega event started immediately after returning from Raipur.

In the first meeting, decision was made regarding the organising committees which consisted of Organising Chairperson Dr Manish Banker, Organising Vice Chairperson Dr Nayana Patel, Organising Secretaries Dr Kanthi Bansal and Dr C.B. Nagori, Treasurer Dr Tushar Shah, Jt.Treasurer Dr R.G. Patel. The scientific committee chairpersons were late Dr Pravin Patel & Dr Sanjay Patel. There were several other sub committees. Thereafter regular meetings were held on a monthly basis for a year, once in 15 days for 6 months and every week for next 6 months.

On 14th we had a magical and spell binding performance by great danseuse Dr Mallika Sarabhai. The inaugural function was held on the 15th so that it did not disturb the scientific proceedings. To add more weightage to the evening we had our Honourable Chief Guest “Dr Amrita Patel “Chairman of the National Dairy Development Board (NDDB) and Founder and Chairman of the Foundation for Ecological Security (FES) and Guest of Honour was “Ms Diana Hayden” the former “Miss India and Miss World”. Both their speeches were apt and to the point. It was very well organized inaugural program. Handing over of president ship from Dr Manish Banker to Dr Hrishikesh Pai was

executed. The new President of ISAR, Dr Hrishikesh Pai is like an evergreen hero, liked by one & all, as popular as he is ever smiling, enigmatic & intellectual. Dr Hrishikesh Pai gave a powerful spell binding speech; he wants to complete many tasks in his tenure. One of

the greatest ideas was to start Yuva ISAR conferences.

The cultural program on 16th was once again a big hit with playback singer Mr Kunal Ganjawala who gave his best to the audience. All the delegates were dancing and singing to his tunes. It was a great treat to all the delegates as a celebration to the grand success of the conference. The valedictory program was the most important as the hard work done by everyone making this event a mega conference was appreciated. The inaugural and valedictory function were important and carried out in a sophisticated manner and the prime time was not compromised and conducted only in the evening so that the delegates did not lose on the educational events, which were the main focus of the conference. ISAR 2014 is an example of what a good team can do. It’s heartening to get compliments that it’s one of the best conferences so far & comparable to International standards.

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state chapters isar DR MADHURI PATIL Chairperson

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a difficult decision to take at the age of 45 years but she does not regret the decision.

There are more failures than successes in the field of infertility and it involves a lot of financial burden with a emotional roller coaster ride. The major challenge is proper counselling of patients on success and dealing with failures. Most of the educated patients read up a lot of information on the net which may not be evidence based, and so it makes it mandatory that you explain the cause, treatment and success of every procedure you perform, which varies from patient to patient.

The field of reproductive medicine will see a lot of growth as the incidence of sub fertility is increasing mainly due to our changed lifestyle and social values. With a lot of third party reproduction and several clinics mushrooming one needs to maintain the standard and the ART law should be in place for the same.

She considers serving the sub group of sub fertile population and training and teaching several youngsters as her achievement. As for awards, she feels they are always there and these should not affect your practice. She has been a member of ISAR since 1985 and has contributed her bit as an Assistant Editor from 2008 to 2012 and editor in chief from 2013. She is also the founder president of KISAR.

“There should be more democratization and decentralization of ISAR in the future. Greater participation of members is required for better functioning. With these steps more doctors and professional would feel in direct touch with ISAR which is sometimes lacking at present. ISAR should also show its presence in small cities also.”

DR SHARATH KUMAR started his career as a radiologist and sonologist. During his early days of investigation of infertility cases he came in close contact with IVF techniques which fascinated him very much. In 1996 he went to England to acquire his MS in infertility. He did his PhD in male infertility and the subject was “Analysis of Male Infertility in Humans in relation to Anatomical and Pathological Changes in the Reproductive Organs.” He entered in the field of IVF in 1998.

Besides other factors, the low rate of success is the major obstacle for the doctors and professionals in this field. In many cases even after several investigations no positive result is achieved. These investigations are expensive and patients blame doctors for negative outcomes. Whereas in case of other diseases

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Established: 13th March 2011

“ISAR has grown tremendously since its formation and has established an international value to its name. hopefully it will become a well recognised international body with the work of the past, present and future presidents.”

DR MADHURI PATIL did her under graduation and post graduation from Seth GS Medical college and KEM Hospital Mumbai. Her Obstetrics and Gynaecology training was at Wadia Hospital. During her post graduation she liked reproductive endocrinology and this made her select the field of reproductive medicine. After her MD in 1985 she continued working at Wadia till 1988 and thereafter started her private practice at Sangli in Maharashtra.

At that time she was doing everything from obstetrics, gynaecology, infertility and endoscopy. There were no specialized courses in India in the field of infertility so in 1993 she went to NUH Singapore to train in reproductive medicine. These trainings gave her only insights into the problem as she could not treat the patients. She then put this training to practice and learnt a lot from her initial mistakes. Sangli was a small town and everything for the ART clinic had to be procured from Mumbai. After 10 years she thought of moving to Pune or Mumbai, but her longtime friend Dr Hema Divakar suggested Bangalore. It was

DR C SHARATH KUMAR

kARnATAkA

the patient is satisfied by some small relief but here patients expect doctors to give 100% result. Not only the patients would like to have a baby but the baby must also be 100% genetically fit otherwise again it is a cause of concern. Therefore it is very delicate job.

He is motivated by the response of his patients who worship doctors as God after having successful treatment. He feels much more advancements will take place in the area of male infertility which is less researched at present.

He has been honoured with Vaidya Rathna, Vaidya Vartha Pathrike, Karnataka Rathna Prashasti by Vishwamanava Rashtra Kavi Kuvempu Kalanikethana of Bangalore.

He is professor and Principal of Mediwave Institute of Medical Science affiliated to Karnataka State Open University, Registrar (Administration) of National Association for Reproductive & Child Health of India (NARCHI), Kolkata, which is also affiliated to Karnataka State Open University, and Editor of Karnataka Medical Journal.

activities

Claus Yding Andersen - KISAR 2014

Focused Symposia - Andrology. Belgaum Focused Symposia - Endometrium.

May 2012 Belgaum Aug 2014

Johan Smitz- KISAR 2014

KISAR 2014 Congress

KISAR Inaugural Function

KISAR-ISMAAR 2013

Svend Lindenberg - KISAR-ISMAAR’12

Willem Ombelet, KISAR - ISMAAR’ 12

Since the inception of KISAR, the following programmes have been conducted: 1. Inaugural Symposia on 'Ovulation Induction'. Bengaluru, March 2011.

2. Focused Symposia on 'Ovarian Reserve'. Bengaluru, Oct 2011.

3. International Conference of KISARISMAAR on 'Optimizing ART outcome through individualized protocols.' Bengaluru, Feb 2012.

4. Focused Symposia on 'Andrology'.

Belgaum, April 2012.

5. Focused Symposia on 'PCOS'. Hubli, July 2012.

6. 1st ISAR PG programme on 'Update in Reproductive Medicine'. Bengaluru, Oct 2012.

7. Focused Symposia on 'Ovulation Induction'. Gulbarga, Nov 2012.

8. KISAR Annual Conference on 'Best Practises - An evidence based ap-

proach', Mysore. Feb 2013.

9. Focused Symposia on 'Ovulation Induction & IUI' in collaboration with Mangalore OBGY Society, May 2013.

10. KISAR Annual Conference on 'The determinants of a successful pregnancy'. Bengaluru, May 2014.

11. Focused Symposia on 'Ovulation Induction & IUI'. Davangere, July 2014.

12. Focused Symposia on 'Endometrium'. Belgaum, Aug 2014.

13. Focused Symposia on 'PCOS'. Udipi, 16 Nov 2014.

14. Focused Symposia on 'PCOS'.

Mysore, 7 Dec 2014.

Planned Activity for forthcoming month: 4th KISAR Annual Congress. Bengaluru, 14-15 Feb, 2015.

Geeta Nargund at KISAR-ISMAAR 2012

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state chapters isar

MAhARASTRA Established: 26th March 2011

DR HRISHIKESH “My vision is to ensure universal reproductive health. The community of doctors should unite under the purpose of women’s health and make a sustainable D. PAI Chairperson

change to the most common problems that underprivileged women face.

Information made available to women all over the nation will help to dispel the myths that shroud a clear existence.”

DR HRISHIKESH D. PAI finished his undergraduate studies in medicine from the G S Medical College & KEM Hospital, Mumbai. He completed his M.D. in Gynaecology from the University of Mumbai, and was awarded 2 gold medals for his academic success.

He acquired super-specialization in infertility and in 1989, he went on a Clinical Fellowship in Reproductive Biology to the Royal Women’s Hospital, Melbourne, where Australia’s first test-tube baby was born. He returned to Mumbai to set up his first IVF Centre in 1991. His first test tube baby was born in 1992, and in the years that followed he performed more than 10,000 test tube baby procedures and enriched the lives of hundreds of infertile couples with a high pregnancy rate. In 1998, Dr Pai shifted his IVF clinic to the prestigious Lilavati Hospital, and started new centers at Fortis La-Femme Hospital, New Delhi and D.Y. Patil

DR SUNITA TANDULWADKAR Secretary

“ISAR is a strong body with experts in the field of ART from India. It aims to deliver knowledge and advances in the field of infertility across the country to every gynecologist, as there is a tremendous growth in the technology happening in this field everyday. ISAR would develop as one of the strongest infertility bodies in the world.”

DR SUNITA TANDULWADKAR did her MD, FICS, FICOG, Dip. in Endoscopy. She is a Post Graduate guide for DNB (Diplomate of National Board) in Obstetrics & Gynaecology.

Her academic excellence has taken Ruby Hall IVF & Endoscopy Center to great heights at international levels.

It is the only center in India recognized for the ‘International Fellowship of Institute of Reproductive Medicine and Endoscopic Surgery (IRMES)’. She is also manuscript reviewer to the esteemed journal ‘Fertility Sterility’ and Journal Of Human Reproductive Sciences.

She is very passionate about IVF and finds it fascinating. She feels that every family is eager to get a child but in some cases when normal pregnancy is not possible it is the IVF specialist who plays a crucial role.

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Medical College, Navi Mumbai. Presently his Bloom IVF group runs 8 standalone IVF clinics and 5 fertility care centers all over India.

He says he believes in his job when he sees so many couples’ lives incomplete without children. He wants to give them the best that science can offer.

Dr Pai is one of the pioneers in the field of infertility treatment in India. He was the first in India to introduce assisted laser hatching, the technique of spindle view, the technique of ovarian tissue freezing, technique of oocyte freezing and the technique of freezing embryos with vitrification.

He is also President, Indian Society of Assisted Reproduction (2014-2016), Chairman, Indian Society for Assisted Reproduction (Maharashtra Branch), Secretary General – The Federation of Obstetric and Gynaecological Societies of India (2015-2017) and Board member of the International Federation of Fertility Society (IFFS).

He is the recipient of Rashtriya Ekta Award, in 2002, Best Doctor Award, from the Indian Medical Association, Mumbai in 2006, Navshakti Award 2008 for service in the field of Medicine and many other honours.

This gives happiness not only to the couple but also to the entire family. According to her, “IVF is not simply a technology but it has the power to provide endless joy to the whole family”.

The low rate of success in implantation is a major hurdle for doctors and professionals in this field. In future serious research is needed in this area. Development of techniques for the selection of best quality embryo is another area of focus for the future.

Her real motivation comes from the look of happiness on the faces of the family members. Those couples who delivered after spontaneous conception may not remember you on every birthday of their baby but those who conceive after ART will remember you and send you the pictures on every birthday of their children. So you end up receiving 1-2 photographs and messages practically everyday after a period.

She has received Sewashree award, gold medal from chairman of Ruby Hall clinic, Punyashloka Ahilyabai Holkar award and letter of appreciation from the President of India.

activities

Inauguration of the 1st Nodal Conference - 19th & 20th July, 2014 Clinical Practice in the past was based on the clinical experience of our peers and our teachers. Today, it is based on evidence accumulated from very diligent and precise research. It is necessary for all of us to be updated with the latest advances. Excellence in fertility treatment outcomes is the ideal goal for which to strive, and may be achieved, but is often tantalizingly beyond reach. What is important is to keep learning, to enjoy the challenge, and to tolerate ambiguity.

With this aim, Maharashtra chapter of ISAR was formed and launched under the Chairmanship of Dr Hrishikesh Pai in 2011 with Dr Mandakini Parihar as Chairperson Elect, Dr Rishma Pai and Dr Nandita Palshetkar as the Vice Chairpersons, Dr Prakash Trivedi, Dr Kundan Ingale and Dr Padmarekha Jirge as Executive Members.

Stalwarts in the field of infertility and ART Dr M N Parikh, Dr Sadhana Desai, Dr R P Soonawala, Dr Firuza Parikh, Dr Sanjay Gupte, and Dr Duru Shah graciously accepted to be the Patrons for The Maharashtra Chapter of ISAR. The committee members include Dr Varsha Baste, Dr Meena Chimote, Dr Shyam Kulkarni, Dr Vijay Mangoli, Dr Shreyas Padgaonkar, Dr Sad-

Launch of MSAR News Bulletin

hana Patwardhan, Dr Milind Pishawikar, Dr Anuradha Shevale and Dr Krishnakumar. Dr Sunita Tandulwadkar remains as the Founder Honorary General Secretary of MISAR, with the Secretariat at Tandulwadkar’s Solo Clinic, at Sasoon Road, Pune.

Maharashtra has always been on the cutting edge of Technology and has always been a leader in the medical field.

With the formation of Maharashtra Chapter, we aimed to reach out to many more gynaecologists, offer training programs along with dedicated continuing medical education programs. One learns more quickly under the guidance of experienced ART consultants.

We conduct two nodal conferences in each half of the year and annual conference in November. Apart from this, we conduct many activities and workshops under the Maharashtra chapter ISAR banner.

We had started a news bulletin ‘Knowledge Café’. The first bulletin was brought out with Dr Padmarekha Jirge as Chief Editor and Dr Sadhana Patwardhan as Co-Editor.

The launch of the newsbulletin was during a live Hysteroscopy and IUI workshop in Kolhapur.

‘Knowledge Cafe’

Inauguration of a Hysteroscopy Workshop

Forthcoming conFerences MSR nodal Conference, March 2015, Aurangabad.

MSR nodal Conference, july 2015, kolhapur.

MSR Annual Conference, november 2015, pune.

Felicitation of Guest of Honour

Inauguration of the 2nd Annual Conference of MSAR

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state chapters isar DR POONAM LOOMBA Chairperson

hARyAnA Established: 6th november 2011

“ISAR has undergone tremendous growth in last few years. Starting from a small platform with few members it is now a large national body. ISAR must also regulate the practices of IVF clinics in India to bring about uniformity in treatment plans and management options. It should formulate a strategy for egg donors and surrogates to reduce the risks to them from unethical practices. It must also organize workshops for medical students to generate awareness about ART.”

DR POONAM LOOMBA did her MBBS from Government Medical College, Patiala and Clinical Internship from Christian Medical College Ludhiana. In 2011 she completed advanced laparoscopic surgery training at Kiel, Germany. Earlier in 2010 she completed IVF/ICSI from Cleveland Fertility Centre in Ohio USA and advanced ultrasound in fetal medicine at Brigham and Women Hospital, Harvard medical School, Boston, USA. She was fascinated by IVF techniques as she found them to be highly advanced and an emerging field as compared to traditional gynaecology. Since infertility is rising on account of pollution, life style changes and late marriages etc, the role of IVF professionals will become more important in the future.

More than 1000 babies have been delivered at her centre. The delivery of every new baby gives refreshing energy and motivation for giving 100% in all cases. She always wants to make the procedures as simple as possible at her centre so that patients can interact with her easily. Like other professionals she also feels the high cost of treatment is a major hurdle for both patients and doctors.

She was a Gold Medalist at the University level. She has been working in infertility since 1995 and has to her credit many babies born through IUI. She established her first IVF Centre at Loomba Hospital, Ambala Cantt in 2000 and delivered Haryana’s first IVF baby in 2003 in collaboration with Dr Narendra Malhotra and Dr Jaideep Malhotra. Her specialised team manages high-risk pregnancies, MIS in infertility and looking after PCOD adolescent as well as adults. She is the founder chairperson of Haryana chapter of ISAR and a faculty and speaker at many National and International conferences.

DR. JYOTI GUPTA “ISAR is providing lots of training opportunity to young doctors through its Secretary

workshops and seminars. It is a great platform for interaction between young and expert doctors as well as professionals. ISAR is witness to major developments in the field of IVF and it is because of this that India is now major player in this sector worldwide.”

DR JYOTI GUPTA completed her MBBS and MD from Lady Harding Medical College, New Delhi. She did her DGO from Safdarjang Hospital, New Delhi. She also attended various training workshops to learn laparoscopy, ultrasonography and other advance technologies.

She had always been fascinated by reproductive science and is always curious about new developments in this branch. In 2010 she opted for IVF in her clinic to serve infertility affected couples.

According to her, having properly trained staff in small cities like Ambala is a big challenge. Learning is also not easy for new people. Setting up labs and other infrastructures are also difficult task as everything has to

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be brought from other cities.

She feels that future of IVF is very bright as a lot of research work is being undertaken which will certainly help in increasing success rate. Low success rate is major cause of concern for both doctors and patients.

Quality of work will also improve as techniques for detecting and removing chromosomal abnormalities are important area for researchers. Embryological researches are also entering advance stages. Both these researches will help tremendously in preventing genetic diseases in the new born babies.

Positive results are always a reason of joy and fulfillment. At the same time they provide source of motivation to doctors. Couples having baby in their arms will always be the ultimate aim in all cases.

Dr Jyoti Gupta has given many firsts to Karnal city, such as the first surrogate baby and first ICSI baby.

activities

It was three years ago that an idea of bringing all the fertility specialists in Haryana together was floated by Dr Poonam Loomba, and the Haryana Chapter of ISAR came alive on 6th Nov 2011. Many enthusiastic members of ISAR came forward to make it a successful venture. Dr Jyoti Gupta and Dr Neeru Batra were the pioneers and soon Dr Mala Arora, Dr Maninder Ahuja, Dr Prabhjot Kaur, Dr Manju Khurana, Dr Sarita Sukhija, Dr Sangeeta Jain, Dr Jatinder Chadha, Dr Ritu Prabhakar joined. An executive body was formed & Memorandum of the society under the aegis of national body was constructed. We would like to mention names of Dr M.N. Parikh, Dr Gada, Dr Narendra Malhotra, Dr Hrishikesh Pai and late Dr Mandakini Parihar without whose guidance we would not have been able to achieve all this.

The first inaugural CME was at Ambala Cantt on 6th Nov 2011, attended by 150 delegates. Dr Narendra Malhotra was the chief guest. The scientific sessions were very much appreciated and were followed by quiz and workshop on IUI. Dr Narendra Malhotra, Dr Lakhbir Dhaliwal, Dr Umesh Jindal and Dr Ladbans Kaur were among the eminent speakers. The quiz was a big hit and was decided to have it in all our CME’s. The half yearly meet was at Faridabad in April 2012 organized by Dr Maninder Ahuja and was adorned by the presence of Dr Dhiraj Gada, President ISAR. The topics covered were Amenorrhoea, Male infertility, Hypoplatic uterus followed by panel on endometriosis by Dr Abha Majumdar. About 60 delegates from Delhi, NCR and Haryana participated. Our first newsletter, VOICE, edited by Dr Neeru Batra was released.

On 4th Nov 2012 we had our annual CME at Karnal organized by Dr Jyoti Gupta. It was again an event of excellence and well attended by more than 150 delegates. Dr Abha Majumdar and Dr Ashok Khurana were the chief guests. The theme was “Dilemmas and decision making in Infertility”. Talks were delivered on Myomas in infertil-

ity, Genital Tuberculosis, Ultrasound in infertility, Use of AMH, followed by an interesting panel discussion on case reports sent by various doctors, moderated by Dr Abha Majumdar. Dr R S Sharma from ICMR threw light on the Rules and Regulations in ART and also discussed the medico-legal aspects. Workshop on IUI was also conducted.

In March 2014 a Laparo/Hystero workshop was conducted at Loomba Hospital, Ambala Cantt where live surgeries like Lap Hysterctomy, Lap myomectomy, Adhesiolysis, Tubal Cannulation, Endometriotic cyst removal were shown live on a perfect AV system. Dr Akhil Saxena and Dr Anupama Sethi were among the operating faculty. Hysteo trainers were installed and the event was supported by Karl Storz.

On 7th Sept, 2014 again an Annual CME was conducted at Sirsa by Dr Manish Mehta with the theme “Successful Pregnancy- The Ultimate Goal”, which was an absolute novelty for that region and was very well attended by the doctors of surrounding areas. The academic session was nicely planned with topics like Amenorrhoea, PCO, Endometriosis, TVS in Infertility. A panel discussion on Male Infertility was conducted by Brig. R.K. Sharma.

Other activities include: An Agenda was handed over personally to the health minister of Haryana by executive members regarding insurance cover for ART procedures.

Meeting was held with principal secretary as well as DGHS Haryana.

We bid for the National ISAR Conference and shall be organizing it in the year 2017 under the chairmanship of Dr Poonam Loomba. The honourable CM has given his letter of support for the same.

We are also given the honour of conducting the First Embryology Conference under the banner of ISAR, which would be held on the 4 & 5th of September at Hotel Leela, Gurgaon, Haryana.

state chapters isar

RAjASThAn Established: 21st january 2012

DR M.L. SAWARANKAR Chairperson DR ML SWARANKAR iis a founder member of ISAR, life member of Federation of Obstetrics & Gynaecological Society of India, member of American Society of Reproductive Medicine, European Society of Human Reproduction & Embryology amongst others.

He did his MBBS from Sawai Mansingh Medical College, University of Rajasthan, JAIPUR (INDIA) Passed with 1st Division & Position with Hons. in Obstetrics & Gynaecology.

He did his M.D. (OBST. & GYNAE) from PGI, Chandigarh and has done numerous advanced training programs both in India and abroad.

He was a junior resident (Obstetrics & Gynaecology) from January, 1981 to January, 1983 at Post Graduate Institute of Medical Education and Research, Chandigarh. He then worked as senior resident with late Padma Bhushan Dr. B.N. Purandare, M.D. FRCS for Family Welfare & Research for a period of 5 months in Dr. N.A. Purandare Medical Centre, Mumbai. He then worked as Senior Resident and assistant to Padma Shri Dr. R.P. Soonawala, M.D., FRCS from 1st Oct., 1983 to 30th Sept., 1985 at Petit Parsi General Hospital, N.J. Wadia Hospital, Cumballa Hill and Breach Candy Hos-

DR RENU MAKWANA Secretary

“ISAR is a big organization. It is doing a great job for young trainees. It is providing them a platform to interact with the senior and expert doctors. They are also able to share their experiences here with their colleagues. I hope this will be further strengthened.”

DR RENU MAKWANA has done MBBS from S.M.S. Medical College, Jaipur in 1990 and Post graduate from S.N. Medical College, Jodhpur in 1994. She has received her Trans Vaginal & color Doppler Sonography training at Singapore and her Diploma in Endoscopic surgery from Keil University, Germany. She also received Hysteroscopic surgery training under Prof. Bettocchi of Italy.

Dr Renu Makwana Working in the field of infertility since 1995 and now is one of the leading infertility experts in India. In the starting years of her career, this treatment was not available in Jodhpur, therefore, to serve the patients in better way she introduced IVF at her centre. She feels lack of awareness regarding IVF

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pital, Parel, Mumbai etc. For three years he worked as Consultant Obstetrician & Gynaecologist at Oraifo Medical Centre, Nigeria. From 1989 onwards he has worked in Jaipur as Consultant Obstetrician, Gynaecologist & Specialist in Microsurgery in Infertility and Advance Reproductive Technology and founder Medical Director of Jaipur Fertility & Microsurgery Research Centre.

He has many firsts to his credit & is recognised at National & International Level for pioneering the infertility treatment & Advanced Reproductive Technology by giving births highest Number of Test Tube Babies (IVF/ICSI). First to achieve IVF & GIFT pregnancy and birth of the resulting Test-Tube Babies in Rajasthan & Northern India (1989). First to deliver IVF (Test Tube Babies) triplets babies in Rajasthan & Northern India (1993). First to deliver an IVF baby through Microsurgical Epididymal Sperm Aspiration combined with In Vitro Fertilisation (MESA-IVF) in India (1993). One of the first two centres in the country to develop Intra Cytoplasmic Sperm Injection [ICSI] {Microfertilisation in IVF technology} (1994). First to introduce 3-D-Digital Volumetric (Real Time 3-D) Ultrasound & Colour Doppler in India (1998). Organised 2nd National Congress on ART & Infertility Management in Jaipur.

(1996). To organise the first Test Tube Baby Meet of India at Jaipur (1997) amongst many more.

was a big problem in the initial years of her career.

This issue is still relevant in small cities. Making one’s own team of experts is another difficult task. But after many years of hard work she not only has an efficient team but she also runs an IVF training facility in her centre. She is very optimistic about the future of IVF. With the advancement of technology, IVF practices are becoming common rapidly.

Solving cases successfully is always a great motivation for her. At the same time, unsolved cases challenge her to work harder. She has made more than 30 presentations and publications at National and International Congresses and journals. She is the recipient of many awards on Infertility including Young Scientist Award.

She has served one term as executive member of ISAR. She is the Life Member of ISAR, IHAR, IMS, FOGSI and IMA. She is also secretary of Jodhpur chapter of Indian Menopause Society.

activities The First Yuva Annual Conference of Indian Society for Assisted Reproduction was organized by ISAR, Rajasthan Chapter from 26th July 2014 to 27 July 2014. There were 3 Pre congress workshops on 26th July 2014 which a large number of people attended & had a good interactive session with the faculty. The two workshops were conducted in Hotel Indiana and a Live Surgery Workshop was held in Vasundhara Hospital & Fertility Research Centre, Jodhpur. (Details on page 49)

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state chapters isar DR KAMALA SELVARAJ Chairperson

Secretary

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cles in coming up with the right diagnosis and treatment plan. “Many times it so happens that when the patient comes to us after trying out many other fertility centers, they pay a price for the time wasted”. She wishes all infertility specialists involve themselves in the field of infertility with dedication and devotion instead of treating it as a business opportunity.

She sees substantial increase in the number of successful ART procedures at par with past data. The patients’ success and smiles are great motivators for her.

When her patients take home babies, their satisfaction and happiness are a big inspiration and bring joy to her life.

She has also received many national awards. Some of them are Rajiv Gandhi National Unity Award (1991), Best Lady Doctor Award (1993), and Rajiv Gandhi Memorial National Integration Award (1995). Her major achievements are first Surrogate Baby of India (1994), first test tube baby to a 50-year-old woman put on HRT in India (1994) and first pregnancy in a Single Woman in India (1997) and many more.

“IsAr must spread the awareness of infertility in rural areas by organizing CMes in the peripheries and also train as many gynaecologists as possible in this field.”

DR SANJEEV N. REDDY did his MD (Obst & Gyn) from Sri Venkateswara Medical College, Tirupati, Andhra Pradesh and worked as Senior Resident and later as Assistant Professor in the Department of Obstetrics and Gynaecology, JIPMER, Pondicherry form 1985 to 1991. In May 1991 he joined Sri Ramachandra Medical College and Research Institute, Chennai.

He finds reproductive medicine most interesting, and the happiness in patients after they become pregnant is phenomenal. “In no other specialty one will get this type of self-satisfaction”, and that is why he chose this branch.

He has been practicing for more than 20 years. He feels that since there is no structured training program

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“the quality of knowledge and time spent in acquiring it counts more. IsAr should consider reducing the number of medical conferences not inclusive of CMe across many locations to add more meaning to the time spent at such events.”

DR KAMALA SELVARAJ did her medical graduation from Kasturba Medical College in Manipal in 1962-67. She did her MD, DGO (Obstetrics & Gynaecology) from Madras Medical College, Chennai and was awarded her PhD in 2002 in Premature ovarian failure and its management.

She believes it was her destiny to become an IVF professional.

She is always thankful to her childhood teacher Ms Emma Devapriyam who was a source of great inspiration for her. Ms Emma helped in getting details about Dr Carl Wood at Melbourne. From Dr Carl she got to know more about the science behind IVF. She believes that when you have complete faith in God and work hard towards your destination, nothing can really fail.

In her opinion, doctors themselves are major obsta-

DR SANJEEV N. REDDY

tAMIlnAdu & pondICherry

for this specialty therefore getting training is difficult.

The Medical Council of India has realized the importance of this specialty and asked medical colleges to start the super specialty course DM (Reproductive Medicine.) Sri Ramachandra Medical College and Research Institute, Chennai was the first college to start this course in August 2012.

Since all disposables, culture media and most of the drugs are imported from abroad, the cost for the procedure is high. Therefore many people cannot afford this treatment. He feels that the government should come forward to motivate Indian companies to manufacture all the required disposables and drugs in India itself so that their cost can be brought down.

This specialty has got a bright future as the technology is fast developing. The awareness about it is also rising among both educated and common people.

Patients’ satisfaction and joy has always motivated Dr Reddy to give his best to each and every case.

His biggest achievement is to start the courses DM Reproductive Medicine and M.Sc in Clinical Embryology.

activities

Our Annual International Conference. INSIGHT’ 14 started with a bang.

INSIGHT’14 was conducted in Association with “Covai Obstretic and Gynaecological Society”, COGS and “Tamil Nadu and Pondicherry Chapter of Indian Society of Assited Reproduction, TAPISAR. Credit hours from Tamilnadu Dr MGR Medical University was 20 points.

On 11th October we had our “Hands on Hysteroscopy Workshop”, at Rao Hospital from 9 am to 5.30 pm. We had eminent faculty Dr Anju Sinha, Consultant Gynec from U.K & Dr Vidya V. Bhat from Bangalore. The registration were in excess & therefore we had to split it in two batches of 15 delegates each. Our Chief surgeons, Dr S.R. Rao with 30 years experience in Laparoscopy & Dr Damodar R Rao, a young energetic Laparoscopy surgeon mentored the delegates. The theory topics covered were Instrumentation, Optimal Distinction, Energy sources and complications.

Surgical Demonstrations were 1) Fallopian Tube Cannulation.

2)Hysteroscopic Polypectomy 3) Hysteroscopic Metroplasty and 4) Pre IVF Hysteroscopy. The session ended with a healthy feedback from the delegates.

On the 12th October, we had our Scientific Programme at Hotel Residency, Coimbatore attended by 200 delegates from all over India. Eminent faculty from Australia Dr Mark Bowman – President Fertility Society & Asst. Professor & Medical Director Genea, Australia & Dr Anju Sinha, Consultant Gynaecologist from U.K were our Inter-

national faculty. Our National faculty included Dr Kuldeep Jain, Dr Sanjeeva Reddy, Dr Muralidhar Pai & Dr Mohan Kamath.

We started with a prayer song followed by - “Selecting the Best Embryo” by Dr Sivakumar, “Using Biomarkers to Optimize Ovarian Stimulation” by Dr Muralidhar Pai, “Paternal ageing and impact on fertility” by Dr Sanjeeva Reddy.

Keynote address was by Dr Mohan Kamath.

“Unexplained Infertility – Seeking Answers.”

“Recurrent Implantation failure”, by Organizing Chairperson Dr Asha R Rao. Insight Oration - “What is the ideal stimulation dose?” by Dr Mark Bowman for 20 minutes was very interesting. This was followed by “Preserving Ovarian function during Endoscopic Surgery” by Dr Damodar Rao Organizing Secretary, Insight’14.

Various speakers such as by Dr Padmashri,Dr Anju Sinha, Dr Kuldeep Jain, Dr S.R. Rao, Dr Mark Bowan, Dr Karishma & Dr Annapoorna contributed excellent talks. Panel Discussion on “Management of Adnexal Mass Current Perspective”, was moderated by Dr Anju Sinha. The last session was on “Challenges in Managing Infertility, GDM Neonates & AMH & PCOS”. The conference ended with a vote of thanks.

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state chapters isar DR K K GOPINATH Chairperson

Secretary

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According to him lack of guidance is the biggest hurdle for the young doctors in this field. There is no planned structured course for IVF in any of the government universities. But he hopes very soon some centers would be able to provide proper guidance to young doctors. He feels it takes 15 years to gain basic knowledge of IVF before opening a center.

In India he is one of the few male specialists in this field.

He says this is an asset for him. In some cases when there is problem with the male partner, he feels they are more comfortable with the male specialist.

He has received the Business Wizard Award 2011 for the Successful Entrepreneur (The India Today Group), the Goal Mentor Award 2010 for contribution to Mentoring and Innovation in the Field of Obstetrics, Gynaecology and Infertility Gynecology & Obstetrics Advanced Learning.

The Centre for Infertility Management and Assisted Reproduction (CIMAR) is the centre behind first ICSI baby in Kerala and first recombinant FSH baby of India. This centre performed the First Intra-Uterine Fetal Transfusion in Kerala and has done the First Laser Assisted Embryo Biopsy and Pre-implantation Genetic Diagnosis for Embryo Selection and a live baby born through it in India.

“IsAr is an association of like minded professionals. It is a platform to share the latest knowledge and experiences with each other. As IVF is mainly an experience based branch, therefore, sharing of experience is very important for both young and senior doctors and professionals.”

DR FESSY LOUIS completed his graduation from Government Medical College Thrissur, and DGO from Kasturba Medical College Manipal and DNB from Kottayam Medical College. The interest in infertility and laparoscopy gained from Manipal Assisted Reproductive Centre led him the path to join CIMAR (Center for Infertility Management and Assisted Reproduction), Edappal Hospitals at Edappal in 2002.

He is the all India Chairperson of FOGSI International Academic Exchange Committee and Secretary General of All Kerala Association Of Obstetrics & Gynecology. He is also the current Secretary of Kerala Chapter of Indian Society of Assisted Reproduction (ISAR).

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“IsAr should encourage all centers to do documentation based work so that experiences of one center are always available to other centers. this will create a large database of valuable information and save a lot of time and money. this will also increase efficiency of all centers if information sharing is in a proper and planned way.”

DR KK GOPINATH did his MBBS from Karnataka University and M.D. and D.G.O. from University of Kerala. He started his career in medicine with Government service and worked there for over 13 years at various Government Hospitals. Later he established Edappal Hospitals Pvt Ltd in 1990 and served as the Chief Consultant and Director of the Hospital. At present he is Head of the Department of Obstetrics & Gynaecology and Director of CIMAR. Dr Gopinathan was interested in infertility since the beginning of his career. The subject of his thesis was also related to infertility, wherein he studied about the problems of the uterus through X-rays.

In 1979 he started laparoscopy at his center. It was big milestone at that time and he was the only person in Kerala having this facility at that time. With this facility, he was successful in studying a problem without surgery.

DR FESSY LOUIS

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He entered in this field in 1997. According to him high cost of the treatment is the major hurdle for both doctors and the patients. Most of the medicines and culture medium are imported. This situation will improve only after more Indian companies venture in this field. At the same time low rate of success adds to the problems.

According to him importance of IVF will increase tremendously in the future, because of a negative population growth in most of Europe and infertility because of late marriages.

New scientific developments and complexity of the patient problems always challenge as well as motivate him to give his best.

He was the recipient of Prestigious FOGSI CORION Award in 2010 and was selected as Kamini Rao South India Yuva Orator in 2009. He also received FOGSI Imaging Science Award and selected for Dr Pravin Mehta Fellowship in Endoscopy. He also got Dr Silu Rudra Prize in Endoscopy and was selected for Kumudh Tamaskar Research Prize in Infertility in 2012.

activities 2ND ANNUAL KERALA STATE ISAR CONFERENCE: The conference was held at Thiruvananthapuram on 15th and 16th of January 2014. On 15th there was Semen Analysis and Hands on IUI workshop. The conference was inaugurated by the Past ISAR National President Dr Dheeraj Gada and presided by Dr K.K. Gopinathan, President, Kerala State Chapter of ISAR in

the presence of Dr Sathy M. Pillai, Vice President, Dr Fessy Louis, Secretary, Dr Parasuram Gopinath, Treasurer, Dr Kunjumoideen KU, Jt. Secretary and Dr Nirmala, President, TOGS. Several national faculties like Dr P.M. Gopinath, Dr Sanjeeva Reddy and Dr M.S. Sreenivasan actively participated in the deliberations.

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state chapters isar DR B N CHAKRAVARTY Chairperson

Vice Chairperson

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road which was devoted to clinical monitoring, Laparoscopic oocyte retrieval, identification of oocyte, insemination, observation of fertilization and cleavage, and subsequently embryo transfer. They successfully delivered a viable test tube baby in November 1986 immediately following the first documented delivery of a test tube baby in India by Dr Indira Hinduja and Prof. Anand Kumar in Bombay.

In appreciation of all these efforts the West Bengal Government offered him land and he set up the Institute of Reproductive Medicine in 1989.

While the initial efforts were personal, the current activities of IRM are based on a collaborative team work.

It has made significant achievements in these years.

Apart from delivering more than 4000 babies through ART procedure so far, the Institute has been credited for publishing more than 55 scientific papers in renowned peer reviewed journals.

He believes that cost is a major hurdle in taking IVF to the masses. He subsidizes the charges and provides some free ampoules of gonadotropins to needy patients at his clinic.

“In future IsAr must focus on implementation of strict guidelines at clinics and medical centers. IsAr must create right framework to protect the financial, psychological and health related rights of surrogate mothers. since India is important player in IVF therefore it is duty of IsAr to manage practices according to international standards.”

DR GITA GANGULY did her MBBS, MD, DGO from Kolkata Medical College. She is Fellow of Royal College of Obstetricians and Gynecologists (FRCOG) and Fellow of Indian Society of Obstetricians and Gynecologists (FICOG).

She believes that IVF is a very positive and effective technique. Earlier when it was not in common practice and infertility was treated only by medicines, the picture was not very bright. Infertile couple led a gloomy life but with the advent of IVF infertility is not a curse anymore. Patients having genital tuberculosis or having complication in uterus and ovaries have good chances of giving birth to healthy baby with the help of ART and IVF. These miracles attract her towards IVF. As far as problems of doctors and professionals in this field is concerned she mentions issues related to surrogacy. Third party reproduction is now essential but in most cases the condition of surrogate mothers is

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“I was one of the founding members if IsAr. over the years IsAr has grown from a small organisation to a premier institution in reproductive Medicine in India.

It’s contribution is invaluable and I want it to grow from strength to strength in the coming years.”

DR BN CHAKRAVARTY did his MBBS from Bengal Medical College and after he stood first in Obstetrics and Gynaecology in the final year examination, his teachers and colleagues encouraged and inspired him to go in for higher studies in this field. He had always been an excellent student and always had scholarships in his school and college education.

He conceived the idea of initiating the treatment of infertility in 1983 following the tragic death of Dr Subhas Mukherjee who had pioneered the delivery of the first ‘test tube baby’ in India and the second in the world. In the mean time he took training at King Edward Memorial Hospital, Perth, Australia under the guidance of his Australian friend Dr John Yovich. He then created a small team of doctors, all of them his students, at CIT

DR. GITA GANGULY

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miserable in the absence of strict guidelines. In many cases they do not get their due payments and many emotional aspects are also involved. Surrogacy is becoming an easy option to have a baby for rich and affluent who are figure conscious and don’t want to bear the pain of delivery. According to guidelines, surrogacy should be only adopted in those cases where the mother is unable to deliver a baby on her own due to any health related issue. However, the affluent section of people will pay any cost for their comfort whereas high cost of treatment is big problem for infertile couples belonging to lower or lower middle classes.

The future in this field is very bright because of advances researches.

Bringing joy and happiness in the life of childless couples is her biggest motivation.

Dr Gita Ganguly has edited many books and medical journals.

DR SIDDHARTHA CHATTERJEE Secretary

activities We felt the need to form a Bengal Chapter of ISAR and a meeting was held at the Institute of Reproductive Medicine under the Chairmanship of Dr B.N. Chakravarty on April 5, 2011. We discussed with Dr Manish Banker, President ISAR and we decided to launch the Bengal Chapter on 25th October 2013 during the festive session of Bengal i.e. Durga Puja, Dussehra & Diwali. ISAR Bengal was formally inaugurated on 25th October 2013 during the inauguration of ART-AIM Update 2013.

It was very gorgeous and colourful starting with Hymn

by Smt. Swagatalakshmi Dasgupta, the eminent singer. The dignitaries on the dais were Dr B.N Chakravarty, Organizing Chairperson, Dr Gita Ganguly Mukherjee, Organizing Secretary, Dr Manish Banker, President ISAR, Dr C.N Purandare, President Elect, FIGO, Dr Krishnendeu Gupta, President BOGS, Dr Hiralal Konar, President ICOG, Dr Hrishikesh Pai, President Elect, ISAR. Dr. Amit Banerjee VC, WB University of Health Sciences, inaugurated the programme by lighting the lamp. Launching of ISAR Bengal was done by Dr Manish Banker, President ISAR. Vote of thanks was given

by Dr Siddhartha Chatterjee, Secretary, ISAR Bengal.

Scientific Conference ISAR Bengal has held its first scientific conference “ART-AIM Update 2013 at Kolkata from 25th October to 27th October 2013. About 630 delegates and approximately 130 nos. Faculty including international faculty namely Dr Paul Devroey from Brussels, Belgium, Dr Peter Platteau from Italy, Dr Salim Daya from Canada, Dr A Pellicer from Spain, Dr Raj Raghupathy from Kuwait, Dr Peter Brinsden from U.K., Dr Rina Agarwal from U.K attended the conference.

Various aspects of ART were discussed threadbare during the conference which continued for three days.

A public awareness programme (discussing about the social implications of various aspects of ART including adoption, surrogacy, single parenthood etc) was also held on 27th October 2013, the last day of the conference. It was attended by eminent personalities in the field of ART, Law, Paediatrics, Psychiatry, Sports, Reli-

gion, Literature and Films & Media.

In the late afternoon on the last day, an amazing and interesting ‘Quiz Contest’ was conducted excellently

by Dr Basab Mukherjee, Dr Chaitali Dutta Roy and Dr Shiuli Mukherjee all young stars in the field of infertility and gynaecology.

On 5th January 2014 a one day Post graduate Training workshop on Infertility was organized by ISAR Bengal at B R Singh Hospital, Kolkata. Introductory lecture was given by Dr. Gita Ganguly Mukherjee.

Panel discussions were also held in respect of ‘Basics of ART’ and ‘Endometriosis’ The lecture given by Dr B N Chakravarty on ‘Infertility Management – Present & Future’ was highly appreciated by everybody and particularly the young doctors who also found the same very interesting. Vote of thanks was given by Dr Hirala Konar.

A seminar was organized in March 2014. In this seminar various subjects were discussed by the concerned speakers such as Dr Sakshi Singh ,Dr Hiralal Konar, Dr B.N. Chakravarty In September 2014 a Seminar was organized on the following topic: ‘Fertility Preservation in young men and women’. A detailed discussion was made by the speakers such as Dr B N Chakravarty, Dr Rahul Roy Chowdhury, Dr Indranil Saha & Dr Indranil Ghosh.A seminar has also been arranged on 22nd February 2015 on Clinical approach to improve endometrial receptivity.A decision has been taken to hold the annual conference preferably in the month of April 2015.

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2014

haWaii

By Dr Kamini Patel, Dr Tanya Buckshee Rohatgi & Dr Rupal N. Shah

It was truly amazing to see the dedication that led to the birth of the world’s first baby after uterine transplantation

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Aloha !!!

The 70th ASRM meeting in the paradise city of Hawaii was an exciting and education packed scientific feast .The Scientific Program included state-of-the-art plenary lectures, oral & poster presentations, roundtable discussions, video sessions, interprofessional symposia, and inter-professional interactive sessions. The program also included the popular Contraceptive, Menopause and Surgery Days.

For the first time, using the latest in video technology, the American Society for Reproductive Medicine (ASRM) hosted a live online Journal Club and connected its live medical conference, in real time, with a worldwide community of specialists from 12 international medical societies. Dr. Palter moderated the event and 12 REI clinicians and embryologists presented their work from around the globe including Harvard University, Stanford University, the NIH, Europe, and India. Hundreds of physicians registered for the live-streamed event and discussed cutting-edge research presented at this year's meeting with a combined digital and in-person audience.

The highlight of the conference was the plenary session on uterine transplantation for absolute uterine factor infertility by Professor Bransstrom. It was truly amazing to see the dedication that led to the birth of the world’s first baby after uterine transplanta-

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tion. The lecture emphasized the importance of team work with the details of a very meticulous surgery with careful preservation of the vascular pedicles. The durations of donor and recipient surgery ranged from 10 to 13 hours and from 4 to 6 hours, respectively. His team did not encounter any immediate peri operative complications in any of the recipients and after 6 months of follow up seven uteri remained viable in his recipients who had regular menses.

Mild rejection episodes occurred in four of these patients. These rejection episodes were effectively reversed by corticosteroid boluses.

I will briefly delve into some of the topics that I found interesting: High Dairy Intake Improves Reproductive Outcome. Research presented at this meeting showed that higher calcium intake results in better reproductive outcomes than lower dairy consumption. One study – Dairy Intake in Women and In Vitro Fertilization Outcomes – reported a correlation between higher live birth rates and high dairy consumption for IVF patients. In the study, conducted at Massachusetts General Hospital Fertility Center, women in subfertile couples had their diets assessed using a food frequency questionnaire prior to undergoing IVF. Outcomes for fertilization rates, embryo quality, implantation, pregnancy and live birth rates were reported for patients who completed their cycles within 18

months of the questionnaire. When outcomes were correlated with patients’ dietary information, the researchers found that the women consuming the highest amounts of dairy (more than three servings per day) had a 21% greater chance of having a live birth than those consuming the least dairy (less than 1.34 servings per day).

Fertilization in the Vagina! Novel IVF Technology: Safe and Effective, May Cut Costs An alternative technology to incubating embryos in a laboratory during an IVF (in vitro fertilization) cycle, with and without ICSI (intra cytoplasmic sperm injection), has been found to be safe and effective and may reduce the high price tag of IVF. In vitro fertilization is the most effective treatment for infertility and the only one that is suitable for many, however it is also resource intensive and expensive. Thus this device can potentially be a pioneering Idea and a real alternative for ART. Two studies were presented demonstrating that the use of the INVOcell vaginal culture device to incubate embryos resulted in embryos that were of comparable quality and pregnancy rates as those that were cultured in laboratory incubators. In one study – A Randomized Prospective Controlled Trial Confirms the Safety and Efficacy of Extended Intravaginal Culture of Embryos with INVOcell Compared to Laboratory Incubators - at the Center for Assisted Reproduction

in Bedford, TX, 33 women between the ages of 18 and 38 undergoing IVF were randomly divided into two groups. One group’s embryos were incubated in the INVOcell device and the other group’s embryos were cultured in a laboratory. After egg retrieval, each patient’s eggs were conventionally co-incubated with sperm for two to four hours. Then, up to 10 eggs were placed in the INVOcell device or moved to a laboratory incubator. After five days of culture, patients from both groups had one or two embryos transferred to their uteruses. Ten of the 16 women from the incubator culture group and 10 of the 17 women from the INVOcell group reported ongoing pregnancies.

In the other study at the Columbian Fertility and Sterility Center in Bogota, couples went through 172 cycles of IVF in which their eggs were fertilized through ICSI and then placed in the INVOcell device and incubated vaginally for 72 hours. The patients incubated, on average, four or five eggs per cycle, 53% of which divided, with an average of two embryos transferred per cycle. Sixty-five resulted in pregnancies at a rate of 38% per cycle and 40% per embryo transfer.

The Exhibits covered not only all aspects of fertility but contraception as well. I particularly enjoyed an hands on practical simulated session on hysteroscopic trans-cervical sterilization with ESSURE. Additionally found SKYLA- the new low dose LNG with 13.5mg of LNG an interesting alternative to the traditional MIRENA. We had number of eminent speakers from all over India presenting their research and making us incredibly proud. The ISAR Symposium on Third Party reproduction presented

by Dr’s Narendra and Jaideep Malhotra and Dr Manish Banker was a huge success with a lot of audience interaction. It not only underlined India as an emerging leader in this field with a potential for huge benefits but

as a country with world class medical facilities.

SYMPOSIUM ON “THIRD PARTY ASSISTED REPRODUCTION” CONDUCTED BY ISAR This time ASRM was attended by 5000 plus ART specialists from different parts of the world. A very informative symposium to give clear ideas on “Third Party Assisted Reproduction” by our own ISAR leaders was held on Wednesday, 22th October 2014 between 3.45 to 5 PM. The Symposium was organized and chaired by FOGSI past president Prof.

Dr. Narendra Malhotra. Eminent faculties of the symposium were our ISAR past president, Dr Manish Banker, President ASPIRE Dr Jaideep Malhotra and Prof. Dr Narendra Malhotra. The main objective of the Symposium was to concentrate on the “Third Party Assisted Reproduction “ and to convey the world about cross border reproductive care by covering the topics of Surrogacy,Donor Gametes and importance of India in cross border reproduction.

Prof. Dr. Narendra Malhotra introduced the subject and our star ISAR faculties. Dr Manish Banker gave overall idea of Surrogacy discussing the Historical perspective, Definitions, Prevalence, Indications, Surrogacy process, Contentious issues in depth. He highlighted the reasons why patients seek surrogacy cross border and its pitfalls in details.

Dr Jaideep Malhotra discussed the importance and process associated with Oocyte donation in detail. She also gave overall idea on availability, screening process and other legal aspects on this delicate subject of “egg donation” in the Indian scenario.

With his typical aggressiveness Chairman of the symposium Dr Narendra Malhotra discussed Cross Border Reproduction in depth. He threw light on why Americans travel abroad for treatment and also discussed the reasons why India is excelling in surrogacy treatment, worldwide.

Multiple points were raised by the au-

dience and solved by our learned faculties. Chairman concluded the discussion by conveying the importance of “Cross border assisted reproduction” and also importance and status of India in the world in this field.

SPECIAL INTEREST GROUP OF ISAR INDIAN GROUP ACTIVITY The panel discussion on “Managing Infertile Male” was organised on 20th October at 8:00 am and was conducted by Prof. Dr. Jaydeep Malhotra and Prof. Dr. N. Malhotra under the Special Session of ISAR, in which the panellist were Dr. Craig Neidlberg (USA), Dr. Ranjit Ramaswamy, Dr. Pratap Kumar, Dr. Kanthi Bansal,Dr. Kamini Patel, Dr. Rupal Shah,Dr. Neeta Singh, Dr. Milind Shah& Dr. Kuldeep jain The main objective of the panel discussion was to concentrate on the male infertility, which contributes upto 40% of overall causes of Infertility, and to facilitate the ART Specialists to help the couple in having their own genetic link.

Prof. Dr Jaideep Malhotra introduced the panelists from USA and INDIA. Various issues such as Stepwise evaluation of Male Partner, Importance of evaluation of Male Partner, Importance of Physical Examination, Endocrine and Genetic Evaluation, varicocele and effects on male infertility, the Obstructive and non obstructive causes of Male infertility, Klenfielters and Kallman syndrome, results of TESA and MESA, PGD after TESA and MESA, CBAVD (Congenital Bilateral Absence of Vas Deference) ,stepwise treatment protocol for infertile male was shared by all & multiple points were raised by the audience and solved by the panelists.

Moderatos concluded the discussion by conveying the importance of Male partner treatment Kudos to ASRM for leading the way in expanding the reach of our traditional research and education in the most innovative way in this paradise city with gorgeous beaches and breath taking views. Mahalo!

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UNEXPLAINED INFERTILITY a New treatment paradigm ABOUT THE AUTHOR Richard H. Reindollar, M.D. is currently the Executive Director of the American Society of Reproductive Medicine and Adjunct Professor of Obstetrics and Gynecology at Geisel School of medicine at Dartmouth. Prior to January 1, 2014, he was Professor and Chair of the Department of Obstetrics and Gynecology at Geisel School of Medicine at Dartmouth having previously been the Director of the Division of Reproductive Endocrinology and Infertility at Beth Israel Deaconess Medical Center, Harvard Medical School and New England Medical Center, Tufts Medical School.

He is a past president of the Society for Reproductive Endocrinology and Infertility, the North American Society for Pediatric and Adolescent Gynecology, and the New England Fertility Society. Dr. Reindollar has been a member of the Board of Directors of American Society for Reproductive Medicine and a Board Delegate for the American Board of Obstetrics and Gynecology. He was President of the American Society for Reproductive Medicine from the conclusion of the 2013 ASRM annual meeting until he became the Society’s Executive Director. He is board certified in Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, and Medical Genetics. Dr. Reindollar was the principal investigator of two large NIH-funded infertility clinical trials, the FASTT and FORT-T trials. This article represents his interpretation of the literature and not that of the ASRM.

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nfertility is usually defined as the absence of pregnancy after 12 months of attempting to become pregnant. Based on large epidemiologic studies and the outcomes of other studies when one arm is expectant management, it is considered that after one year of attempted pregnancy, if the female partner is less than 40 years of age, the per cycle pregnancy rate is no higher than 4%.

A number of societies have recommended beginning treatment earlier (i.e., after 6 months) for women over age 35 years because 75% of them should be pregnant by that time and their window of opportunity is clos-

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ing. A study of the Hutterites in the US demonstrated that for this population whose religion dictates that they never use contraception and attempt pregnancy until they are menopausal, the average age of the last pregnancy for them was just before the 41st birthday. Unexplained infertility means that the couple has had a complete workup to rule out an obvious cause of infertility; such a workup usually includes a study of tubal patency, semen analysis, evidence of regular ovulation, screening for ovarian reserve, and a history and physical that rules out other obvious abnormalities.

Factors under consideration when thinking about the best treatment strategies include evidence by Level I studies, randomized controlled trials (RCTs), well conducted systematic review or well performed meta-analyses of homogeneous RCTs, that the outcome of a given treatment is improved over the control arm, preferably expectant management. In the absence of prior RCTs, there should be repeated studies that demonstrate a success rate for the treatment that is improved sufficiently over the success that is expected in the absence of treatment (i.e., sufficiently more than 4% per cycle). In addition, couples should have access to a suggested treatment and not be subjected to a high risk for adverse events such as high order multiple pregnancies.

Also, it is well known that some couples will want and pay for whatever treatment is needed and others may never want invasive treatments performed.

Treatment strategies for unexplained infertility that have been considered are those that seemingly will increase the odds of pregnancy over what usually happens in nature. After coitus, it has been shown that no more than 200 sperm will get to the fallopian tube for fertilization and it is usual in a natural cycle for monofollicular ovulation to occur. Treatments pro-

posed for increasing these odds that have been used and studied have included intrauterine insemination (IUI) alone, controlled ovarian stimulation (COS) with clomiphene or gonadotropins alone, IUI with COS, and IVF. A systematic review of the literature demonstrates that neither IUI alone nor COS alone increases the pregnancy rate sufficiently over 4% per cycle and thus, except for sexual dysfunction and organic male disease where IUI is helpful, neither of these treatments has support for use by itself. It appears that for unexplained infertility it is the combination of both IUI and COS in vivo or in vitro that consistently increases the pregnancy rates. Until recently few RCTs have compared clomiphene IUI to expectant management or to gonadotropin IUI treatment. Consistently, pregnancy rates for clomiphene IUI have been about double that of expectant management (i.e., approximately 8% per treatment cycle). In addition, a study of Dankert and colleagues comparing clomiphene IUI to gonadotropin IUI demonstrated no difference in pregnancy rates. A recent report of the NIH Reproductive Medicine Network at the 2014 ASRM Annual Meeting compared CC/IUI to gonadotropins/IUI and to Letrozole/IUI with 300 couples randomized to each group and couples receiving up to 4 treatment cycles.

These data favor gonadotropin therapy slightly over the success of CC/IUI but the very high triplet birth rate and the minimal difference in success rates between the two treatments resulted in their conclusion that CC/IUI should be the primary treatment. These data were presented at the 2014 ASRM Annual Meeting and have yet to be published.

Other studies have consistently provided evidence against the routine use of gonadotropins and IUI for the treatment of unexplained infertility.

If we consider success rates, this con-

cept contradicts widely perceived notions about the success of gonadotropin/IUI treatment.

Historically, it was thought that gonadotropin/IUI treatment resulted in 15 – 20%/cycle success. These figures came from case series and retrospective cohort studies which also included unacceptable rates of multiple births, especially high order multiple births. Essentially every RCT that has compared gonadotropin/IUI, when gonadotropins are given in standard doses of 150 IU/ day, has demonstrated success rates that approximate 10% per cycle. The Dutch study that compared COS to expectant management demonstrated no improvement in success when mild stimulation protocols were used of gonadotropins and combined with IUI. The NIH FASTT Trial compared 2 treatment paradigms in 500 couples with unexplained infertility that had never previously had treatment.

These couples were randomized to Conventional Therapy (receiving up to 3 cycles of clomiphene/IUI, if not pregnant then 3 cycles of gonadotropin/IUI and if not pregnant up to 6 cycles of IVF) to a Fast Track Therapy (after 3 cycles of clomiphene/IUI they proceeded immediately to IVF). This study demonstrated that the time to pregnancy was statistically shorter and at an estimated $10,000 savings per pregnancy when gonadotropin/IUI was omitted from treatment. Also, the success rates for CC/IUI and gonadotropins/IUI were similar at 8 and 10%/ cycle, respectively. Once the results of the NIH Reproductive Medicine Network RCT of CC/IUI vs. gonadotropins/IUI vs Letrozole/IUI are published, there should be little room for doubt about omitting gonadotropin/IUI therapy from treatment for unexplained infertility in

References

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Guzick DS, Carson SA, Coutifaris C, Overstreet JW, Factor-Litvak P, et al. Efficacy of superovulation and intrauterine insemination in the treatment of infertility. N Engl J Med 1999;340:177-183.

Steures P, van der Steeg JW, Hompes PG, Hobbema JD, Eijkemans MJ, et al. Intrauterine insemination with controlled ovarian hyperstimulation versus expectant management for couples with unexplained subfertility and an intermediate prognosis: a

couples, the female partner who is under the age of 40 years.

Clomiphene/IUI is far less expensive than gonadotropin/IUI and has a far lower risk for multiple births, especially high order multiple births, and for ovarian hyperstimulation syndrome. If IUI is timed based on LH kits and not routine ultrasound studies (no studies have demonstrated better success rates when US studies are used), then the treatment becomes much more patient friendly.

The literature thus supports beginning treatment with 3 – 6 cycles of CC/IUI in couples where the female partner is under the age of 40 years and if not pregnant moving to IVF. The challenge is that while the literature supports CC, the success rates, although better than no treatment, are still relatively low at 8% per cycle live births. What is really needed is a treatment between CC/IUI and the jump to IVF where success rates are at least 40% per cycle for the same couples. At first blush one might think that treatment would be CC + gonadotropins with IUI. The challenge with this concept is that even when gonadotropins are used with doses of 150 IU/day, the success rates are still only 2% better than clomiphene and IUI. Low doses of gonadotropins with IUI have been shown to be no better than no treatment and increasing the doses increases only the high order multiple births. Perhaps that cost effective treatment with success intermediate between CC/IUI and IVF will be a low cost strategy for IVF that is clomiphene based. Clomiphene previously received bad press when used for IVF, but let us remember that those were the very early days of IVF when our laboratories did not produce excellent embryos they do today. With laboratory techniques

randomized clinical trial. Lancet 2006;368:216-221.

Dankert T, Kremer JAM, Cohlen BJ, Hamilton CJCM, Pasker-de Jong PCM, et al. A randomized clinical trial of clomiphene citrate versus low dose recombinant FSH for ovarian hyperstimulation in intrauterine insemination cycles for unexplained and male subfertility. Hum Reprod 2007;22:792797.

Reindollar RH, Regan MM, Neumann PJ, Levine B-S, Thornton

today, it is hard to imagine that the pregnancy rates aren’t improved.

A recent NIH study, the FORT-T Trial, compared 3 treatment paradigms for couples with unexplained infertility, the female partner 38 – 43rd birthday with normal ovarian reserve by clomiphene challenge test. These couples were randomized to receive either: (1) 2 cycles of CC/IUI then up to 4 cycles IVF; (2) 2 cycles gonadotropins/IUI then up to 4 cycles IVF; or (3) Immediate IVF up to 4 cycles. This study demonstrated that live birth rates were similar between the two IUI groups and combined live birth rates were 5% per cycle after the first two cycles of treatment with either CC/IUI or gonadotropins/IUI. These rates were statistically lower than liver birth rates for couples who began with immediate IVF. For all couples, no matter which treatment was initiated (COS/IUI or IVF), there was a similar proportion of them with a live birth after they completed up to 4 cycles of IVF (approximately 46%).

This makes sense given that all couples ultimately were able to have the same 4 cycles of IVF if needed. However, whether the couples began treatment first with COS/IUI or immediate IVF, 84% of all babies born in the study were from IVF. This study is very convincing that the most efficacious treatment for unexplained infertility the female partner being over 38 years of age with normal ovarian reserve is immediate IVF. However, it should be pointed out that not all couples will agree to IVF even if they can afford it. For them, a limited number of COS/IUI cycles would be reasonable, but only with CC/IUI since in this age group the live born pregnancy rates are essentially the same whether clomiphene or gonadotropins are used with IUI.

KL, et al. A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) Trial. Fertil Steril 2101;94:888-899.

Goldman MB, Thornton KL, Ryley D, Alper MA, Fung JL, Hornstein MD, Reindollar RH. A randomized clinical trial to determine optimal infertility treatment in older couples: the Forty and Over Treatment Trial (FORT-T). Fertil Steril 2014;101:1574-81.

Trouble Shooting and Risk Management in ART Dr. Richard Kennedy

INTRODUCTION: Risk is ever present in healthcare. Infertility and ART is no exception. It has been estimated that up to 10% of healthcare episodes have a complication . This of course can vary dramatically in severity from no harm to fatal consequence. In ART there are several sources of risk which may have disastrous consequences for the couple or woman undergoing treatment. In the laboratory environment there is the potential for gamete or embryo mix ups through an error in sample or patient identification. For the woman undergoing ART the main risks are Ovarian Hyperstimulation Syndrome (OHSS) and multiple pregnancies.

Aside from these “headline” risks many other problems can arise in what is a complex process . The consequences of errors and complications, whilst most acutely suffered by the patient and her partner also have an impact on the provider in terms of time, cost and reputation. We also have a responsibility for the offspring.

The adverse consequences of multiple pregnancies are well known but the evidence for adverse outcomes of singleton pregnancies resulting from ART is increasing. It is therefore essential that we have processes in place to ensure the patient journey is as trouble free as possible. These

processes collectively amount to Clinical Risk Management.

To better understand the origins of risk and how to minimise it we have to understand the theory of risk. James Reason wrote the seminal paper on risk in healthcare and his “swiss cheese” model is the basis of current understanding . The concept is that each hole in the cheese is a failure in the variety of barriers that prevent accidents. The barriers may be latent or active; system or individual but when the holes line up disaster strikes.

This paper gives a brief overview of the principles of clinical risk management and some of the significant areas of risk which impact on our daily practice of ART. 1.QUALITY AND SAFETY ISSUES IN INFERTILITY PRACTICE Designing systems to manage risk re-

quires an understanding of the risk which is present. There are two main ways of doing this. The reactive process principally arises from the monitoring of adverse incidents. This will enable us to assimilate the various points of failure in our system and apply fixes. When an incident causes harm it requires an effective investigative process. It is often easier to blame an individual for an error when in fact it may well be a system

ABOUT THE AUTHOR Dr. Richard Kennedy is the Executive Director for Women’s and Newborn Services at the Royal Brisbane and Women’s Hospital, Queensland, Australia and an obstetrician and gynaecologist and specialist in reproductive medicine. He has set up and directed the Centre for Reproductive Medicine, Coventry, UK,& has been an advisor and inspector for the Human Fertilisation and Embryology Authority. He was for five years Medical Director at the University Hospital, Coventry, one of the largest NHS Hospitals in England with responsibility for clinical standards, patient safety and practitioner performance.He is Associate Professor at University of Queensland School of Medicine and chairs the Standards and Practice Committee of the IFFS. Dr Kennedy is the President of the British Fertility Society and President Elect of the International Federation of Fertility Societies.

failure which caused the incident.

Only through a thorough investigation will the root cause enable corrective measures to be put in place .

Proactive assessment of risk requires a detailed understanding of the processes that give rise to risk. This necessitates mapping of the pathways involved and if we consider the “end to end” process of a patient being referred for infertility and going through IVF, the complexities are evident with multiple opportunity for error. This enables the implementation of effective “barriers” to prevent mistakes and minimise risk. This proactive approach lends itself to the new paradigms of lean processing

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coupled with risk management and logical status enables safe treatment SEIPS model. Regardless of the effec- planning, handling of gametes and embryos and advice to the couple about their future health and the potential risks to their offspring. It is also helpful to advise the woman of precautions that may be necessary in caring for a new born child. To this end it is recommended that all couples are screened for HIV, Hepatitis B & C before infertility treatment begins.

The impact of the presence of blood born virus is uncertain but the evidence suggests impairment of semen quality for men who are carriers, an association with tubal infertility in women who are carriers and a possitiveness of our proactive processes in- ble adverse impact on ART outcome. cidents will happen and effective Management in these cases requires monitoring is required. a multidisciplinary approach and Effective management of risk requires communication with the obstetric a whole system approach. Engage- team if pregnancy results. ment of the whole team is necessary For couples in whom the male partin understanding the process and im- ner is HIV positive and female partner plementing the barriers to realise the HIV negative management is deterbenefits. An effective system is not mined by viral load. In these couples complex in concept but its design timed natural intercourse (IC) carries needs to be relevant to the process for a low risk of horizontal infection which the risk is being managed. Put when the viral load is low and the simply it involves monitoring, analy- male is using HAART. Alternatively, sis, change and re-monitoring -the IUI with washed sperm should be classic audit cycle. Inherent in a safe considered. IVF / ICSI appears to be system are education, training, ex- safe although there are theoretical plicit procedures or guidelines and concerns of horizontal or vertical benchmarking. The whole package is transmission. For discordant, HIV feknown as a quality management sys- male positive couples, management tem. The ISO accreditation scheme revolves round exclusion of female provides a framework for such a sys- factors, pre-pregnancy control of viral tem. The adoption of effective risk load and minimisation of the risk of management does not guarantee vertical transmission. freedom from risk but it will certainly Hepatitis B and C carriers are comimprove the safety of patients, the mon and endemic in some countries. quality of the product and ultimately In discordant male positive discorbe more efficient. dant couples management revolves around effective vaccination strate2. BLOOD BORN VIRUSES – gies. There is no contraindication to CLINICAL AND LABORATORY ART. Management of couples in IMPLICATIONS IN ART whom either partner is Hepatitis C Blood virus infection is a global prob- positive will depend on the presence lem with endemic proportions is of HCV mRNA in which case for dissome geographical regions. The ma- cordant male positive patients the use jority of infections affect men and of sperm washing reduces the risk of women in the reproductive age horizontal transmission and for disgroup. The presence of blood born cordant female positive carriers virus has implications for the couple HAART may be indicated to reduce undergoing treatment, the clinical vertical transmission. and laboratory team providing the Protection of staff and prevention of treatment and the child that results cross contamination are the main from treatment. areas of risk management in the labPre-treatment knowledge of the sero- oratory management of ART. Couples

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in whom it is known that one is a carrier of a blood born virus require special handling of gametes and embryos with appropriate containment facilities and isolation of potentially infected material. The risk of cross contamination during cryostorage is likely to be vanishingly small. Protocols vary but prior knowledge will allow quarantine procedures of specimens resulting from known carriers.

Management using donor gametes requires absolute certainty of the carrier status of the donor and in the case of sperm or oocyte a quarantine period to allow retesting of infected donors who have not sero-converted at the time of donation.

3. REDUCTION OF MULTIPLE PREGNANCY AND ELECTIVE SINGLE EMBRYO TRANSFER Multiple pregnancies is the most common significant complication of assisted conception. This statement should be uncontroversial to all who practice obstetrics as well as gynaecology. Twin pregnancies worldwide occur in 20% of pregnancies resulting from IVF/ICSI. Given a 25% live birth rate some 50000 sets of twins are produced each year. Conservatively 25% will be born with significant prematurely and 10% of these will suffer from cerebral palsy. Added to this is the 2x risk of congenital abnormality, the long term respiratory morbidity and the increased risk of antenatal

and intrapartum complications. The burden of cost this places on families and society is consequential. As ART practitioners we have a crucial role in supporting couples through treatment not only to have the best chance of success but also to have a healthy baby. This goal is best achieved through a singleton delivery although there is increasing evidence that even singleton pregnancies do less well

after ART than do those conceived naturally.

The only sure way of avoiding a multiple pregnancy is to replace a single embryo. However, this results in reduction in the live birth rate. In order to mitigate this reduction strategies are adopted to maximise implantation. These include morphokinetic assessment and extended embryo culture. Recent evidence suggests that blastocyst culture and transfer has a higher risk of preterm labour and birth defect compared to cleavage stage transfer. Further research is necessary to confirm the potential of time lapse assessment and PGS is both costly and currently not applicable to general use. Recent developments in cryopreservation have improved the pregnancy rates with cryotransfer. This provides us with the opportunity of sequential single embryo transfer giving the same chance of pregnancy from one stimulated cycle compared to replacing two fresh embryos. Furthermore if the embryos are replaced at cleavage stage the evidence suggests more embryos will be available for cryopreservation thus simplifying the embryology and reducing the potential hazards of prolonged culture. The paradigm

therefore is one plus one or one fresh embryo followed, if no pregnancy results, by the replacement of one frozen embryo. Further appropriately powered randomised controlled trials are needed to address the question whether one fresh cleavage or one fresh blastocyst followed by one frozen cleavage or blastocyst pro-

duces the better outcome. However it is clear both from national data and large single data that it is possible to have high single embryo transfer rates, low twin pregnancy rates and maintain acceptable live birth rates per cycle.

4. CRYOPRESERVATION: SAFETY, SECURITY AND MINIMISING RISK Cryopreservation is a core part of the ART process. Liquid Nitrogen is the base agent required to enable embryos and gametes to be frozen. Nitrogen is stored in its liquified form at -196° degrees C. This chemical has properties which impact of the safety of personnel handling it. For example it evaporate rapidly and has an expansion ratio of 1:683 to the volume of the source liquid, causing a white vapour to form which displaces Oxygen. Each year fatalities occur due to asphyxiation resulting from liquid nitrogen spillage and the resulting displacement of Oxygen leading to asphyxia. It is therefore essential to consider lab design to ensure adequate ventilation is provided.

Other aspects to consider are how liquid nitrogen is accessed within the lab, what type of alarm system is used for low oxygen in the lab and low levels of nitrogen in the Dewars and the correct use of personal protective equipment.

As well as staff safety all samples must be stored in a safe environment. Consideration should be taken to minimise risk of viral transmission and the UK policy for screening patients is offers one approach. Comprehensive risk assessments should be undertaken to ensure no harm comes to either stored samples or staff in the cryopreservation facility.

When this results in massive ovarian enlargement, ascitis and hydrothorax it is a potentially life-threatening condition. Deaths occur and the mortality rate from this condition has been calculated at 3 per 100,000 cycles of ART. This equates to 30 deaths per year worldwide from OHSS. These are avoidable deaths.

The trigger for OHSS is hCG and is thought to be due in part to its significantly longer half life when exogenously administered. Risk factors for OHSS are well known and include PCOS, younger age in the female partner, obesity, increased dose of stimulation and previous OHSS. If hCG is avoided the risk of OHSS is all but eliminated however hCG is necessary for final egg maturation and is therefore routinely administered in IVF/ICSI cycles to ensure treatment success. Alternate strategies for minimising the risk of OHSS include early identification and appropriate management in women known to be at increased risk, cycle coasting, elective embryo freezing, reduced dose of HCG, Bromocryptine and the use of albumin all have limited value and none avoid the possibility of OHSS. Stimulation regimes in women known to be at risk of OHSS should include GnRH Antagonist down regulation. This is known to reduce but not eliminate the risk of OHSS. The question is can the use of hCG be avoided. One possible solution is the use of GnRH analogue as a trigger for final oocyte maturation. Research has shown that this will avoid the risk of OHSS but results in a lower pregnancy rate because of reduced luteal phase support. This problem has yet to be resolved satisfactorily. To date the optimum strategy to avoid the risk of OHSS is to stimulate with a GnRH Antagonist, trigger ovulation with GnRH Analogue and perform a freeze all.

5. OHSS – MINIMISING THE RISK In many countries ART accounts for between 1and 5% of all conceptions.

In Europe and the US some 600,000 cycles of IVF/ICSI are carried out each year. Virtually all of these involve gonadotrophin ovarian stimulation.

Ovarian hyperstimulation syndrome (OHSS) is a major iatrogenic complication of ovarian stimulation and occurs in up to 5% of all stimulation cycles. 1-2%of women are hospitalized with severe or moderately severe OHSS. This equates to 6000 women 6.EVIDENCE BASED PRACTICE each year in Europe and the US. AND THE USE OF CLINICAL

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GUIDELINES IN INFERTILITY PRACTICE Evidence-based medicine advocates that to the greatest extent possible, decisions and policies should be based on evidence, not just on the beliefs of practitioners, experts, or administrators.

Examples of a reliance on "the way it was always done" can be found in almost every profession, even when those practices are contradicted by new and better information. Evidence-based practice is a philosophical approach that is in opposition to rules of thumb, folklore and tradition and involves complex and conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences. It recognizes that care is individualized and ever changing and involves uncertainties and probabilities.

The main component of evidence based medicine is the acquisition and interpretation of information usually produced through scientific research.

The quality of this evidence is determined by the methodology of the research. The Randomised Controlled Trial (RCT) produces the most reliable information and best quality evidence. However the process by which the RCT has been carried out either REFERENCES: A framework to guiding clinical teams in improving safety Vincent 2013 http://qualitysafety.bmj.com/content/23/8/670.full.pdf+ html HFEA report on adverse events in UK IVF centres 2014 http://www.hfea.gov.uk/docs/Adverse_incidents_in_fertility_clinics_2010-2012__lessons_to_learn.pdf Human error models and management: Reason 2000 http://www.bmj.com/content/320/7237/768.full.pdf+html Root Cause Analysis Toolshttp://www.nrls.npsa.nhs.uk/resources/?entryid45=59847 Human Factors implementation http://www.patientsafetyfirst.nhs.uk/ashx/A sset.ashx?path=/Interventionsupport/Human%20Factors%20Howto%20Guide%20v1.2.pdf Risk assessment tools http://www.nrls.npsa.nhs.uk/resources/?entryid45=59813&q=0%C2%ACrisk+management%C2%AC&p=2

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adds weight to or detracts from the quality of the evidence. Parameters which are considered to be important in determining the quality of the RCT include a sample size large enough to produce a statistically significant result of the primary outcome measure, the validity of the method of randomisation and the blinding of the study.

Meta analysis is a technique which has developed in recent years and collates the outcomes of more than one randomised controlled trial . This aims to improve the significance of the finding of each individual study by combining the data and increasing the number of patients subjected to the intervention of interest. The Cochrane collaboration has played a major role in improving the science and practice of this form of evidence through the application of a standardised methodology. The Forest plot is the typical representation of the included studies, their individual effect size and confidence limits and the cumulative result. The use of this approach has increased dramatically and it is important to look critically at the methodology applied. It is not unusual for only two studies to be included and this severely limits the usefulness of the result .

Clinical guidelines help support the

application of evidence based medicine by “guiding” clinicians and scientists towards the application of the safest and most effective treatment.

Guidelines achieve this by using the available evidence and synthesising statements to inform clinical practice.

Typically a guideline’s strength is based on the quality of the available evidence. Thus a high quality appropriately powered RCT will enable a strong guideline to be produced. In Reproductive Medicine there are a number of high quality guidelines informing clinicians across a range of practice and there use should form the mainstay of practice .

Kato O, Kawasaki N, Bodri D, Kuroda T, Kawachiya S, Kato K, Takehara Y.Neonatal outcome and birth defects in 6623 singletons born following minimal ovarian stimulation and vitrified versus fresh single embryo transfer.Eur J Obstet Gynecol Reprod Biol.

2012 Mar;161(1):46-50

story in Québec.Reprod Biomed Online. 2011 Oct;23(4):500-4.

Practice Committee of Society for Assisted Reproductive Technology; and Practice Committee of American Society for Reproductive Medicine.Elective single-embryo transfer.Fertil Steril. 2012 Apr;97(4):835-42.

One at a time Policy http://www.oneatatime.org.uk/211.htm BFS Statement http://www.fertility.org.uk/news/pressrelease/08_09-SingleEmbyoGuidelines.html Kresowik JD, Stegmann BJ, Sparks AE, Ryan GL, van Voorhis BJ.Five-years of a mandatory single-embryo transfer (mSET) policy dramatically reduces twinning rate without lowering pregnancy rates.Fertil Steril. 2011 Dec;96(6):1367-9 Bissonnette F, Phillips SJ, Gunby J, Holzer H, Mahutte N, St-Michel P, Kadoch IJ.Working to eliminate multiple pregnancies: a success

CONCLUSION Risk is ever present in healthcare and assisted conception is no exception.

ART practice with technical boundaries pushed to the limit in an environment of fiscal or commercial pressure and ever rising demand for access all confront the practitioner with additional risk. Paramount above all other considerations is the need to ensure the safety of both patient and staff. This can be achieved by effective management of risk delivered through teamwork, attention to detail and a no compromise approach to safety.

www.gassafeconsultants.co.uk Devroey P, Polyzos NP, Blockheel C. OHSS Free clinic Devroey Hum Reprod (2011) 26 (10) 2593-2597 Agonist vs HCG triggering Cochrane review 2011 http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD008046.pub3/pdf/standard Pharmaceutical options for ovulation trigger http://www.hindawi.com/journals/bmri/201 4/580171/ Meta-analysis – what they can and cannot do http://www.smw.ch/content/smw-201213518/ IUI Cochrane Review http://onlinelibrary.wiley.com/doi/10.1002/ 14651858.CD001838.pub4/pdf/standard NICE Fertility Guideline 2013 http://www.nice.org.uk/guidance/cg156/resources/guidance-fertility-pdf

First Yuva NatioNal CoNFereNCe oF Indian Society for Assisted Reproduction 26th & 27th July 2014, Jodhpur, rajasthan, iNDia

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he First Yuva annual conference of Indian Society for Assisted Reproduction was organized by ISAR, Rajasthan Chapter from 26th July 2014 to 27 July 2014.

There were 3 Pre congress workshops on 26th July 2014 which were attended by a large number of people & had good interaction with the faculty. The two workshops were conducted in Hotel Indiana and a Live Surgery Workshop was held at Vasundhara Hospital & Fertility Research Centre, Jodhpur.

A brief of Pre Congress Workshops is as follows: LIVE HYSTEROSCOPY WORKSHOP: Which was conducted in Vasundhara Hospital & Fertility Research Centre, the Hysteroscopic surgeries, performed during the workshop were telecasted live in the Vasundhara Hospital Auditorium, where a number of delegates witnessed the surgeries. Dr Osama Shawki (Egypt), Dr Rahul Manchanda (Delhi), Dr Narendra Gupta (Jaipur) and Dr Parul Kotdawala (Ahemdabad) were the operating faculties. Dr B.S. Jodha and Dr Vinod Shaily were the conveners for the workshop.

Male infertility & IUI: Dr. Anuradha Khar form Bangalore discussed about Donor IUI: Natural Cycle v/s Stimulated while Dr Parasuram Gopinath from Kochi discussed Sperm retrieval techniques. Dr Kapil Kocher from Delhi explained about the Evolving role of evidence based micronutrient in management of Male sub fertility. Dr Ajit Saxena from Indore - Male Sexual dysfunction: a root cause of

male sub fertility. Dr Parth Bavishi from Ahemdabad and Dr Aditi Dani from Mumbai discussed about sperm preparation technique and IUI insemination technique, respectively.

Dr Seema Bebu Pandey and Dr Sapan Kaswan were the conveners for the workshop.

RECURRENT IMPLANTATION FAILURE: This workshop discussed about Implantation in Assisted Reproductive: look at Endometrial Receptivity, Immunological testing and intervention for Reproductive failure, Hydrosalphinges & IVF, RIF gamete & embryo factor. Dr Priya Bhave & Dr Ranjana Desai were the conveners for the workshop.

The Pre congress workshops successfully came to an end after a highly stimulating and insightful exchange with experts.

THE MAIN CONFERENCE of Indian Society for Assisted Reproduction, YUVA ISAR 2014, started on 26th July in Indana Hotel, Jodhpur.

There were more than 60 lectures, multiple discussions, 28 free paper presentations and various orations. The Presidential Oration was on Improving ICSI result by ISAR President Dr. H.D. Pai. The sessions were chaired by Dr. Sanjay Makwana (Vice President Rajasthan Chapter) Jodhpur, Dr. Dhiraj Gada, Indore .

The congress was followed by ISAR executive meeting and inaugural function. Shree Gajendra Singh Shekhawat, Member of Parliament, inaugurated the program and Dr Arvind Mathur, Principal and Controller, Dr. SN Medical College was the Guest of Honour.

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On this occasion Dr Sadhana Desai, Dr Dhiraj Gada & Dr Sudha Prasad were felicitated.

Dr Osama Shawki (Egypt) was the key attraction & his motivational talk was appreciated by everyone.

Dr Reena Bhansali moderated the program and Dr Sanjay Makwana welcomed the faculties and delegates.

The conference concluded with the valedictory function. Dr Renu Makwana gave the thanks speech.

The YUVA ISAR 2014 not only shaped up their skills but also witnessed the Mega Ramp Show, wherein all the young beautiful, graceful medical professionals walked the ramp and made this gala event in historical place like suncity created lot of enthusiasm amongst the audience.

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By Dr. Kanthi Bansal

Overview of Fertility & Its Management in INDIA

HISTORY According to Hindu Mythology, Assisted DR KANTHI Reproductive Technology (ART) is not new but has BANSAL existed for several thousand years. Mahabharata MD, DGO, portrays many such issues where the probability of a FICOG is a child born from other than the marriage route is renowned involved. The first example is of Karan who was the Gynaecologist, Infertil- adopted son of Radha and her charioteer husband Adiratha, but later Karan was presented with the ity & IVF Specialist practising in facts that Kunti a queen of much higher status was Ahmedabad, India. She can her genetic mother. It is believed that Karna was be contacted at born to Queen Kunti by the deity Surya, before her kanthibansal@gmail.com marriage to King Pandu 1, 2. Second example is that of

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Courtesy: www.isconpune.in

About the AuthoR

the Pandavas brother who were five in number and their brothers Kuarvas who were one thousand in number. This huge number of offsprings can be only answered when we relate it to assisted reproductive technology. India has a number of messengers who were divinely conceived and one of them bore the name “Krishna the saviour”. Now Krishna was born of a chaste virgin called Devaki, who on account of her purity was selected to become the mother of God. Buddha was considered and believed by his followers to have been begotten of God and born of a virgin whose name was Maya. Long before the Christian era, we read of how the divine power called the “Holy Ghost” descended upon virgin Maya. So there is a high probability regarding such a technology or similar to it, existing during that era.

ABOUT INDIA India is the 7th largest country by area, 2nd most populated country with a population of over 1.2 billion and the most populous democracy in the world. It is in South Asia and shares it’s boundary with Pakistan, Nepal, Bangladesh, Sri Lanka, China and Bhutan 3.

India boasts of having the highest birth rate with 100,000 births very month in one part of Uttar Pradesh alone. It is indeed sad to know that this country has significant poverty, high infant mortality and at the same time in contrast there is high class facilities provided by Fertility Clinics and Private Hospitals.

Medical tourism is having a good market as far as

reproductive health and its prevention and appropriate treatment, where feasible, are essential.

Infertility also carries the burden of social stigma and a feeling of personal failure. It deprives the couple of personal happiness, the feeling of parenthood and old age security and inflicts distressing trauma on the individual.

Even if the cause of infertility is in the male, the female partner always considers herself more guilty and responsible for the problem in India. Women feel that infertility is the worst thing to happen to them as parents, neighbours, relatives and even the entire community is concerned and anxious about her infertile status.

It is estimated that around 15-20 million couples suffer from infertility in India. These numbers are huge and calls for an urgent solution and treatment of infertility. In this modern era of assisted reproductive technology, infertile couples have a golden chance to conceive. Before the birth of the first IVF baby, Louise Brown, there was no option for women with bilateral, blocked tube to conceive 4.

RULES AND REGULATION FOR FERTILITY TREATMENT IN INDIA In India, clinics are well established with high standards, relaxed regulations; allow treatments for women up to 55, for singles and same sex couples and even surrogacy is available which makes India a popular destination for fertility treatment internationally.

AVAILABILITY India accepts the open policy for the treatment of single and lesbian’s women. Women in the age group of up to 55 years can be treated using donor eggs and surrogacy and it is legal.

Donor anonymity The identity of donors is not released to prospective parents and they remain anonymous. Only a court order allows the release of identity in exceptional circumstances.

fertility clinics are concerned due to the cost effectiveness provided.

INTRODUCTION TO INFERTILITY Reproductive health involves all aspects of physical, mental and social well-being relating to the function and processes of reproductive system. It also implies that individuals have the capacity to reproduce and have a satisfying and safe sex life.

Infertility, therefore, is a basic component of

Donor offspring limits Donor women can donate eggs only up to six times regardless of the number of offspring born as a result.

Embryo transfer policies Maximum three embryos are transferred in women under 30. For older women a maximum of 4 embryos can be transferred.

Embryo storage rules The regulations of the UK’s Human Fertilisation and Embryology Authority is followed in India, which

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Techniques like in vitro For erectile fertilization & embryo problems and transfer (IVF-ET) & premature intracytoplasmic sperm ejaculation, medicines and Causes & Diagnosis of Infertility injection (ICSI) have counselling helps Infertility is a stressful condition which prevents superseded older to improve reproduction at the reproductive age of a couple.

Infertility could be primary, not conceived even once, fertility. Even therapies, and in some infertility caused or secondary, where the woman has conceived once cases have provided a but is not able to conceive again for two or more years. by hormonal backup when all other imbalance can be WHO says that about 5% of infertility is due to treated with anatomical, endocrinological, genetic or therapeutic options fail. medicines. immunological problems. The rest is due to In women with preventable conditions such as parasitic diseases, PCO, medications sexually transmitted diseases (STDs), unsafe like clomiphene abortions, harmful health care practices and policies citrate & and exposure to potentially toxic substances 5.

In women causes may include ovulatory dysfunction, gonadotropins are given for ovulation.

II.SURGICAL TREATMENTS tubal disease, endometriosis, sexual dysfunction, 1) Fallopian tubes - surgery in few cases where tubes immunological factors, congenital abnormalities, endocrine factors or unexplained infertility. Infertility are blocked or scarred from a previous disease, infection, or previous surgery. Also, applicable where can often be a result of chronic pelvic inflammatory the tubes are blocked due to previous tubal disease caused by infections including STDs sterilisation. Surgery to the Fallopian tubes is done by (gonorrhoea, and Chlamydia infections), abdominal Laparoscopic method known as laparoscopic tuberculosis, post-partum and post-abortion microsurgery. infections6.

2) Endometriosis- a condition where surgery in some Even the endocrine causes such as an ovulatory cases helps to improve fertility. Cases of oligomenorrhoea, amenorrhoea with normal or low Endometrioma or Chocolate Cysts of Ovary are best endogenous gonadal and pituitary hormones, and treated by Laparoscopic surgery. ovulation and irregular cycles were the second most 3) Polycystic ovary syndrome- is mainly treated by common cause (38%) of female infertility 6. medical line of treatment but in few selected cases, In males, the causes for infertility are not laparoscopic surgery helps in conceiving. This demonstrable in half the cases by common diagnosis procedure is known as ovarian drilling or ovarian due to lack of knowledge of male reproductive diathermy. physiology.

4) Fibroids- Surgery is compulsory in submucous Male pathogentic factors like defective fibroids. In case of intramural fibroids, surgery is spermatogenesis due to pituitary disorders, defective optional. Operative laparoscopy is preferred for sperm production, sperm dysfunction and other factors like genetic factors, germ cell aplasia, testicular surgery of fibriods.The suberous fibroids do not require surgery 8. cancer, environmental and therapeutic factors, 5) Male infertility- A block produced by an varicocele, immunological, infective, neurogenic or abnormality in the epididymis in the testis, surgery is psychological factors all this can lead to infertility 7.

And the underlying causes of infertility are due to the indicated. Varicoceles that are grade II or III will give socio-economic status of people, and may also satisfactory results when operated. Infection of depend on the geographical location 7. Induced reproductive tract can be treated with antibiotics but infertility is profoundly high in less educated people only fewer cases restore fertility. For erectile problems with low economic status. In individuals of higher and premature ejaculation, medicines and socio- economic status, gentical, anatomical or counselling helps to improve fertility. Infertility caused endocrinological are the main reason for infertility. by hormonal imbalance is treated with medical line of treatment by giving hormones.

MANAGEMENT OPTIONS B. Treating Infertility with Assisted Reproductive A. Treating infertility without Assisted Reproductive Technology: Technology: With the advancements in reproductive medicine and I. MEDICINES TO IMPROVE FERTILITY the experiences gained through the specialised Infection of reproductive tract can be treated with infertility management clinics a wider range of antibiotics but only in few cases fertility is restored. diagnostic and treatment options have become stipulates that couples have to give consent for storage. The embryos can then be stored for 5 years, and this can be extended to 10 years.

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Initially, IVF-ET was applied successfully in patients with fallopian tube block. Even in certain conditions where infertility can be treated by specific management e.g. hormonal and surgical treatments for endometriosis, specific therapies to induce ovulation in an ovulatory woman and tubal microsurgery to correct mechanical pelvic disorders, most cases will benefit by ovarian stimulation accompanied by one or other of the gamete manipulation procedures.

LATEST TECHNOLOGIES AVAILABLE IN INDIA • Sperm DNA-damage tests • Intracytoplasmic morphologically selected sperm available to infertile couple. injection Techniques like in vitro fertilization and embryo • Amino acid and metabolomics profiling transfer (IVF-ET) 9 and intracytoplasmic sperm • Preimplantation genetic screening injection (ICSI) 10 have superseded older therapies, • Time-lapse imaging and in some cases have provided a backup when all • Artificial gametes other therapeutic options fail.

• Ovarian transplantation ART is proving increasingly effective for the management of male infertility. The technique of ICSI, • Gene therapy which uses one single spermatozoa recovered from CONCLUSION the testes or epididymis, or picked up from the ejaculate of normal or deficient spermatogenesis, has India has remained impervious with the advancement almost replaced the other treatment modalities and is in the treatment of infertility and techniques like ART. India was second in the world to produce test tube adequate to fertilize the egg. baby in 1986. ART increases the average rate of take The ICSI technique is used in following conditions: home baby to around 30% per cycle. ART gives a (i) Normal sperm parameters but either less number golden opportunity for the infertile couple to have a of oocytes or oocyte defects, cryopreserved semen. baby. (ii) Abnormal sperm parameters such as There are many private sectors in India which offer ART oligoasthenoteratozoospermia, azoospermia, services for infertility management. The treatment immotile spermatozoa, cryptozoospermia, involves the infrastructure, equipments, drugs, oligozoospermia, testicular cancer and following its disposibles, media and maintenance which make the treatment, genetic defects in males. treatment expensive. Therefore, the advances of fertility (iii) Ejaculatory dysfunction. management in the form of ART are limited for (iv) Antisperm antibodies. The obstetric outcome in wealthier community in India. A lot of efforts are ICSI pregnancies as a whole is similar to that of required to decrease these expenses so that people with conventional IVF-ET pregnancies 11, 12. low income bracket can also take advantage of these ART has equally proved increasingly effective in higher technologies & have take home babies. treating female infertility.

REFERENCES 1 Mahabharata, Book 1: Adi Parva, Sambhava Parva, Section CXI 2 Bheel Mahabharata: Kunti and the Birth of the Sun God’s Child by Satya Chaitanya, 2006-04-02, retrieved 201308-01.

3 National Symbols of India, Know India (National Informatics Centre, Government of India), retrieved, 27 September 2009 4 Need and feasibility of providing Assisted Technologies for Infertility management in resource-poor settings, ICMR bulletin, Vol. 30, No. 6-7 June-July, 2000.

5 World Health Organization, The World Health Report, WHO, Geneva, p 12, 1996.

6 Rowe, P. J. and Farley, T.M.M., The standardized investigation of the infertile couple. In : Diagnosis and Treatment of Infertility. Eds. P.J. Rowe and E.M. Vikhlyaeva. Hans Huber Publishers, Toronto, Stuttgart, p 55, 1988.

7 Farley, T.M.M. and Belsey, F.H. The prevalence and etiology of infertility. In : Biological Components of Fertility.Proceedings of the African Population Conference, Dakar,Senegal.

International Union for the Scientific Study of Population, 1:2.1.15, 1988 8 Gab Kovas, International Medical Director, Australia, IVF Preceptorship: The state of the ART, 2-3 August 2013, Serono Symposia International Foundation, Sao Paulo, Brazil.

9 Steptoe, P.C. and Edwards, R.G. Birth

after the re-implantation of a human embryo. Lancet ii : 366, 1978.

10 Palermo, G., Joris, H., Devroey, P. and Van Steirteghem, A.C.Pregnancies after intracytoplasmic injection of a single spermatozoon into an oocyte. Lancet 340 : 17,1992.

11 Van Steirteghem, A.C., Nagy, Z., Joris, H., Liu, J., Staessen,C., Smitz, J., Wisanto, A., and Devroey, P. High fertilization and implantation rates after intracytoplasmic sperm injection.Hum Reprod 8 : 1061, 1993.

12 Payne, D., Flaherty, S.P., Jefferey, R., Warnes, G.M. and Mathews, D. Successful treatment of severe male factor infertility in 100 consecutive cycles using intracytoplasmic sperm injection.

Hum Reprod 8: 2051, 1993.

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By Dr Haroon Latif

Overview of Fertility & Its Management in PAKISTAN

About the AuthoR DR HAROON LATIF MCE(Aus), FECSM is a renowned embryologist of Pakistan. He is the CEO of LIFE (Pvt) Ltd & Director, Hameed Latif Hospital, Lahore, Pakistan. He can be contacted at haroon@lifepakistan.com

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“The intense desire for something coupled with the inability to fulfill that desire is life’s most painful combination”. This quote from an unknown author aptly describes infertility. Unfruitfulness is not only a medical problem but also a social one. Our socio-cultural customs and religious beliefs often influence how we address childlessness.

DEFINITIONS OF INFERTILITY WHO has defined infertility in three groupings; clinical, demographic and epidemiological. According to World Health Organization infertility is clinically defined as, “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse”[1].

fertility is prevalent in 3.5% and 18.4% secondary infertility [6]. This translates to about one fifth of the total population. These figures are comparable with world statistics of developing countries.

estimate of magnitude of the involuntary infertile Demographic deďŹ nition -5 years of childlessness despite actively trying. (in developing countries minus China, data up to year 2000) Infertility is not only a disease of the reproductive system but also considered a disability by WHO. This means that there is impairment of function and needs to be addressed because more than 34 million women alone suffer from infertility. Majority of these belong to the developing nations [2].

DEMOGRAPHICS OF PAKISTAN Pakistan has an estimated population of about 200 million. This stands Pakistan as the 6th largest populous country of the world [3]. Its population increases seven fold in urban areas and 4 fold overall increase. A higher population growth rate in the urban areas is probably due to the urbanization process which leads to development of megacities [4].

With such a large populous country, it faces multiple problems. Health issues are not usually on the same priority list of government agencies. It is predicted by Department of Economic and Social Affairs, the population division of United Nations that the population of Pakistan will rank 6 until 2050 [5].Thus our problems will remain and probably increase if not addressed.

Infertility statistics are not officially available. Individual establishments have certain estimates. Prof.

Rashid Latif Khan, Pioneer of In-vitro fertilization in Pakistan, has a logical estimate of 22%. Male causes contribute about 40% while women as well seem to contribute equally. The remaining 20% causes are equally divided between unexplained and both male and female infertility. In addition, infertility seems to be on the rise. Conjointly, more couples in the recent past are presenting with male factor infertility. Despite having a high fertility rate of close to 2%, primary inwww.arifmemorialhospital.com prof. rashid latif Khan is the pioneer of ivF in pakistan. rashid latif Medical College (rlMC), lahore, is named after him. the Medical College is attached with two teaching hospitals, on-campus arif Memorial teaching Hospital (400 beds) and Hameed latif Hospital (250 beds).

Hameed latif Hospital is also recognized for post Graduate training by the College of physicians & surgeons of pakistan (Cpsp) in the disciplines of Gynaecology & obstetrics and Neonatology & anaesthesiology.

200 180 168 160 140 120 100 80 60 40 20

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secondary infertility

(Source:Rutstein, and Sha, DHS Comparative Reports, no. 9, 2004)[7] CAUSES OF INFERTILITY IN PAKISTAN Common causes of Infertility in Pakistani Population can be seen in the following table: Causes of infertility among the studied couples (n=534) [6].

CAUSES NO. OF CASES Male factor 117 Ovulatory failure 118 Sexual dysfunction 30 Mucus hostility 9 Normal pelvis 141 Tubal blockage 77 Tubal blockage and Tubo-ovarian masses 7 Endometriosis 35

PERCENTAGE 21.91 22.09 5.61 1.68 26.40 14.41 1.31 6.55

There are many factors that affect the ability of a couple to conceive. Some causes are reversible such as

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lifestyle and infrequent intercourse. Other factors are more complex and require treatment. Sometimes symptoms may be nebulous and addressed when no resolve is possible. An example for this is premature ovarian failure. In conclusion early intervention will yield positive results.

personnel. Pakistan is one of the pioneers of ART in the region. The 1st IVF Center of the country was established in 1985 just six years after the birth of Louise Brown (the first IVF baby of the world). The inception of this state of the art facility took place under the guidance of Prof. Rashid Latif Khan and his team. The center has been running successfully for the past three TREATMENT OPTIONS AVAILABLE IN PAKISTAN decades keeping abreast with latest developments and Infertility is not only a med- technologies. Today the country has about 15 ART faical condition but also plays cilities which offer basic diagnostic facilities to high havoc as a disability. It is tech treatments such as ICSI & PGD. The total number emotionally and financially of ART cycles performed per year in the country is taxing. In our society it is 2000-2500. The number is very small keeping in view the desire of almost every the demand. The country needs atleast 150 more clincouple to have children. If ics to cater the demand. However the main reason for conception does not take this acute shortage is that ART is not covered by the place within a few months, government or any of the health insurance compaimmediate family members nies. Hence the treatment which costs around $3000 concern raises. As the to $4000 is out of financial means of most of the coumonths pass and no conples seeking help although it is cheaper than most of ception takes place, presthe developed countries. sure mounts on the couple. All ART facilities are in the private sector. The governThus, infertility also bement with its limited resources is focused on other comes a disability [8]. acute health care problems keeping subfertility on the Pakistan is a very densely populated country with a back burner. Hence this trend of private ART clinics is large population facing problems in achieving connot likely to change in the near future. A lot of work ception.The country does not have the infrastructure and dedication is required at the government level to to deal with high demands. Hence subfertility is being establish these facilities. treated at multiple levels. Care givers involved in the treatment include both qualified and unqualified per- CONCLUSION sonnel.Unfortunately a large population base gets Infertility is a painful and lonely path and not every their treatment from hakeem’s, quacks and charlatans. couple seeking treatment will be successful. By creatThese self-claimed specialists offer traditional home ing awareness and developing compassion for such made remedies with a touch of spirituality. This has a couples as health providers we can bridge the gaps in huge negative impact on the infertile couple. They not fertility treatment. Development of more establishonly end up with medical complications but also face ments along with a data system to support the work is a financial & emotional burden. Eventually by the time the need of the moment. We further need to develop they seek help from a doctor it is already too late tools for education and create awareness in the public Assisted Reproductive Technique (ART) in Pakistan and private sector. Lastly efforts should be made to reThere are multiple state of the art facilities which deal duce the cost of the treatment so that it becomes afwith subfertility under the guidance of highly qualified fordable for larger population base.

REFERENCES: 1. (Internet) WHO-ICMART revised glossary, (cited 2014 October 25) available from: http://www.icmartivf.org/ivf-glossary.html 2. (Internet) Infecundity, infertility, and childlessness in developing countries. Demographic and Health Surveys (DHS) Comparative reports No. 9 (cited 2014 October 25) available at: http://www.who.int/reproductivehealth/publications/infertility/DHS_9/en/ 3.Maya N. Mascarenhas, Seth R. Flaxman, National, regional, and global trends in infertility: a systematic analysis of 277 health surveys, Dec. 2012 PLoS Med 9(12): e1001356.

4. (Internet) Dr. S. Van Der Poel, focal point for Infertility,Prevalence of Infertility. (cited 2014 October 25) available from: http://www.gfmer.ch/infertility/pdf/Preva-

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lence-infertility-Vanderpoel-2012.pdf 5. (Internet) Pakistan Population,(cited 2014 October 25) available from: http://www.worldometers.info/world-population/pakistan-population/ 6. RiffatShaheen, FazliSubhan, Sikandar Sultan, Prevalence of Infertility in a Cross Section of Pakistani Population, Pakistan J. Zool., vol. 42(4), pp. 389-393, 2010 7. Estimate of magnitude of the involuntary infertile Demographic definition -5 years of childlessness despite actively trying. (in developing countries minus China, data up to year 2000). Source: Rutstein, and Sha ,DHS Comparative Reports, no. 9, 2004 8. (Internet) Infertility definitions and terminology, (cited 2014 October 25)available from: http://www.who.int/reproductivehealth/topics/infertility/definitions/en/

THIRD PARTY

REPRODUCTION Assisted Reproduction Technologies involving a third party in the treatment of infertile patients has definitely helped to fulfill the dreams of many a childless couples. Dr Nayana Patel explains how...

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Patients who require donor oocyte occur in two maingroups :DR NAYANA PATEL Women with nonfunctioning ovaries M.D. (OBST.& GYNAEC) 1) Premature ovarian failure – Idiopathic, Genetic like is a renowned Gynaecologist, InferTurner’s syndrome, Immunological, Auto immune, Iatility, IVF & Third Party Reproductrogenic including Surgical oophorectomy, tion Specialist practising in Anand, chemotherapy and radiotherapy.

Gujarat, India. She can be con2) Ovarian agenesis tacted at nayana@ivf-surrogate.com 3) Menopause After the birth of Louise Brown, new manipulation 4) Resistant ovary syndrome techniques have been developed to bring the gametes Women with functioning ovaries together, facilitating fertilization and the achievement 1) Carriers of genetic disease or chromosomal abnorof pregnancy. With the advent of new technologies, malities. the role of a third party being involved in helping the 2) Repeated IVF failures due to poor response to suinfertile couple to achieve their goal became possible. perovulation, failure of oocyte recovery, failure of ferInvolvement of a third party can be in the form of : tilization due to poor oocyte quality and repeated implantation failure of apparently normal embryos.

• SPERM DONATION 3) Inaccessible ovaries.

• OOCYTE DONATION 4) Older women : - with reduced ovarian reserve or • EMBRYO DONATION poor quality oocyte • SURROGACY SOURCE OF OOCYTE DONORS SPERM DONATION A major challenge to oocyte donation programme is to Intrauterine insemination with donor sperms has find an adequate number of women willing to donate been a routine clinical treatment for male infertility eggs. Broadly speaking egg can be sourced from: for many years. But use of donor sperms in IVF is (a) Known donors: Some recipients seek their own mainly indicated when along with the male factor like donor, either a close friend or a relative.

Non Obstructive Azoospermia and Risk of transmit(b) Volunteers: Some women are willing to undergo ting hereditary disease, the female partner has: ovarian stimulation and egg donation • Bilateral tubal block altruistically to anonymous recipients.

• Severe endometriosis (c) Spare oocytes: Some infertile patients undergoing • Advanced age IVF may volunteer to donate their excess eggs to an• Repeated failures with Intrauterine insemination of nomymous recipient. Using spare oocytes has its addonor sperms vantages, some of them are: i) Donor does not have to suffer additional risk.

OOCYTE DONATION ii) Egg sharing reduces the cost of treatment.

Oocyte donation has now beHowever the disadvantages come feasible with the advent are: of in-vitro-fertilization (IVF). i) Donation from infertile Acceptance of gametes from women is less successful than another individual for procre- from fertile women. ation is understandably a diffi- ii) When the best oocytes are cult decision for any couple. used for the donor, the out Alan trounson However, situations do exist come for the subsequent rewhen this option should be considered and many cipient may be suboptimum. clinical, scientific and ethical issues addressed. (d) Professional oocyte In 1983, Trounson and colleagues reported the first donors: These donors give pregnancy after transfer of a donated oocyte fertilized their oocytes against payin vitro to a cyclic recipient. The world’s first pregment. nancy resulting from the transfer of an in vitro fertilGiven the paucity of donors, ized single embryo from a 42 year old donor to a 39 alternative sources of donor year old recipient resulted in a spontaneous abortion, oocytes need to be explored. but the same group subsequently achieved an invitro Technology however has fertilized donor pregnancy reaching full term (Lutjen opened numerous avenues et al 1984). like: • In-Vitro Maturation of eggs INDICATIONS FOR DONOR OOCYTE • Cryopreservation of oocytes

About the AuthoR

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• The use of cadaver ovaries, and fetal ovarian tissue • Human embryo twinning

• Counseling regarding the procedure • It is advisable not to allow the donor to donate oocytes for more than 6 times.

CYCLE MANAGEMENT Firstly the cycle of the donor & the recipient should be synchronized followed by stimulation of the donor & endometrial preparation of the recipient.

Treatment of the donor: The donor is stimulated with a combination of GnRh analog, FSH and hMG after a proper Day 2/3 hormonal workup and baseline ultrasound scanning.

The donor will be treated with a period of long downparameters: regulation with the GnRh analog, luperolide or • Upper age limit ideally should be 45 years, subject to buserelin for upto 2 weeks, after which the serum levthe health of the recipient. els of LH, Progesterone and Estradiol are measured.

• Detailed family history, medical history, Once the baseline stimulation been achieved, follicu• Pelvic examination and ultra - sound scanning to ex- lar stimulation with gonadotropins can begin. Recomclude pelvic pathology and to assess the uterine size binant FSH 150 i.u. or 225 i.u. daily is given. and endometrium.

Monitoring starts after 5 days of stimulation and the • Routine blood work up. stimulation is continued until two leading follicles • Laboratory Studies – Blood chemistry, Blood group- reach atleast 18 mm in mean diameter and serum ing, hematological profile, thyroid profile, Rubella An- estradiol level are commensurate with the number tibody titer, screening for venereal diseases, HbsAg, and size of follicles. Human chorionic gonadotropin HIV, Pap smear and diabetes. (hCG) 10,000 i.u. is given 34-36 hrs. before the in• Office Hystreroscopy to evaluate the endometrial tended time of oocytes recovery. cavity.

Oocytes and sperms are incubated, Embryos are kept • Mock endometrial preparation cycle to assess the frozen for a minimum of 3 months. During the last endometrial adequacy. month, the host mother is further counselled, the ge• Male partner should have a semen analysis and netic parents both have a further test for HIV and physical examination if indicated. when the result is confirmed negative, the host’s re• Proper counseling becomes the first step of the placement cycle is started. Fresh embryos are transscreening procedure. They should be given a detailed ferred when the recipient wants it but with informed explanation of the procedure and legal, moral and consent. ethical implications.

Treatment of the host mother Thus, potential recipients should be evaluated by a se- Majority of the medical and psychological assessment lection criteria that includes appropriate medical indi- is already done. If the host mother is on the oral concations for oocyte donation and ascertainment of the traceptive pill, then it is recommended that this be woman’s ability to tolerate pregnancy, labor and deliv- discontinued one or two cycle before the treatment ery both physically and psychologically. cycle and barrier methods of contraception used.

The host may be treated with either frozen-thawed SELECTION AND SCREENING OF POTENTIAL embryos, or fresh embryos OOCYTE DONOR from ‘quarantined sperms.’

Selection of the right oocyte donor is essential for pos- Replacement in a natural cycle itive outcomes. Ideally the following points should be This method is suitable for women, who have been carefully looked into before selecting a donor: sterilized or whose husbands have had a vasectomy.

• Age- 21 – 35 years.

The host is monitored daily from about day 8 of the • Family History, Medical History. cycle until natural LH is detected. Embryos are thawed • Endocrine profile – FSH, LH, Estradiol, TSH, Proafter 24 hrs and transferred after another 24 hrs. lactin, Progesterone Replacement in a hormone controlled cycle • Ultrasound examination Control of the host’s replacement cycle is recom• Complete blood count, Blood sugar, Blood group mended if: and Rh typing.

• If the menstrual cycle is irregular, anovulatory or if • Exclude infectious diseases like HIV, Hepatitis B, luteal phase insufficiencies is detected.

Syphilis, Chlamydia, Gonorrhea.

• If the host is fertile and has to rely on barrier contra• Written consent ception.

SELECTION AND SCREENING OF RECIPIENT It is imperative to have a proper selection and screening process in place for optimal outcomes. Special consideration should be given on the following

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RESULT OF OOCYTE DONATION TREATMENT Pregnancy rates following oocyte donation are excellent in comparison with those achieved after the transfer of the patient’s own oocytes. Interestingly transfer of fresh embryos has a higher pregnancy rate than that of frozen embryos. It is also observed that neither the age of the recipient nor the diagnosis play a substantial role in the success of oocyte donation However the age of the donor is an important factor in achieving good pregnancy rate and pregnancy rates are directly related to the number of embryos transferred.

Reasons for higher success rate are lack of hyperstimulation, no risk of hyperestrogenism, no specific cause for underlying infertility, no premature luteinization, and better control of window receptivity.

The risk of pregnancy for women increases considerably with increasing maternal age and there are no reports of increased risk of fetal abnormality following oocyte donation. Agonadal women have breast-fed their infants normally after oocyte donation.

EMBRYO DONATION Embryo donation is a well established and successful form of assisted conception treatment where both partners are subfertile.

Indications for embryo donation • Menopausal and perimenopausal woman and subfertile partner.

• Recurrent IVF failures.

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• Carriers of genetic disease or chromosomal abnormalities.

Need for embryo donation Whenever there are spare embryos in an IVF cycle, there are four choices of what to do with them – discard, donate to research, donate to infertile couples or cryopreserve for future use.

Couples, who have created embryos as part of their own IVF treatment, especially if they have completed their families, are often willing to donate excess embryos to infertile couples.

The advantages of embryo donation are good use of excess embryos. Also the recipient bears the child and hence the bonding with it is the advantage over adoption. This is relatively a simple procedure, cheaper treatment compared to oocyte donation or IVF and fewer medical complications.

• Selection, screening & counseling of embryo donors & recipients is essentially the same as oocyte & sperm donors.

• Data about the outcome of embryo donation is scarce. Asch reported 13 pregnancies in 17 embryo recipients (77% pregnancy rate per patient) which was higher than oocyte donation.

SURROGACY Surrogacy has been an accepted form of treatment for certain group of infertile couples, yet not very prevalent in India.

Before the advent of modern assisted conception techniques, ‘Natural surrogacy’ was the only means of helping certain barren women to have children.

Later, artificial insemination became more acceptable than the natural way. When assisted conception methods such as IVF (in vitro fertilization) became available, it was a natural step to use the eggs of the woman wanting the baby and, with the sperm of her husband, to create their own embryos in vitro and transfer these to a suitable host.

The earliest mention is in the Old Testament of Bible. Ishmael was born to Abram and Sarai by the way of natural surrogacy, with the help of the maid.

DEFINITIONS: ‘Genetic Couple’ ‘Commissioning Couple’ ‘Intended parent’: the couple who provide both sets of gametes.

www.snowder.com

By down regulating the host and controlling the cycle with a gonadotrophin releasing analog and then replacing estrogen in increasing doses, creating an artificial proliferative phase, the chance of implantation of the embryo is increased if the host tends to have inefficient cycles. Also, by taking control of the cycle, natural conception with the host’s partner is prevented.

This control is achieved by the administration of luperolid or buserelin subcutaneously, from the previous cycle day 21 until day 2 of the next menstrual period, when serum LH, progesterone and Estrogen are checked and development of the endometrium and ovaries is monitored by ultrasound. If down-regulation has been achieved, oral estradial valerate (Progynova) is given in increasing daily doses from 2 to 6 mg. Progesterone in the form of natural micronized Injectable 50mg daily intramuscularly, is given from day 15. The embryos are replaced on day 17 of the artificial cycle. Progynova 6 mg orally daily and micronized vag. pessary 400 mg twice daily or Injectable progesterone 100 mg intramuscularly daily are continued, until the result of pregnancy test is known. If it is positive, then both are continued until 12-14 weeks gestation, by which time endogenous sources of both hormones are sufficient to maintain the pregnancy.

‘Surrogate Host’ or ‘Host’: The woman receiving the embryos created from the gametes of the genetic couple.

‘Natural Surrogacy’, ‘Traditional Surrogacy or ‘Partial Surrogacy’: where the egg belongs to the female carrying the pregnancy, the intended host is inseminated with the semen of the husband of the genetic couple.

‘Gestational Surrogacy’ ‘IVF surrogacy’ or ‘Full surrogacy’: a treatment by which the gametes of the genetic couple or intended parents in a surrogacy arrangement are used to produce embryos and these embryos are subsequently transferred to a woman who agrees to act as a host for these embryos.

‘Commercial surrogacy’ arrangements: This is when the surrogate is paid over and above the necessary medical expenses.

‘Altruistic surrogacy’ arrangements: This is when the surrogate is paid only the necessary pregnancy related expenses and at times nothing at all.

INDICATIONS FOR TREATMENT Patients without uterus: • Women with congenital absence of the uterus, Mullerian Agenesis (Rokitansky – Kuster – Hauser Syndrome).

• Women who have had hysterectomy for various reasons like uterine fibroids, carcinoma, Ante-partum or Post-partum haemorrhage, uterine rupture, severe adenomyosis or ruptured uterus.

Patients with uterus: • Women who suffer repeated miscarriages.

• Repeated failures in IVF cycle – non-receptive uterus.

• Women with certain medical conditions, which make pregnancy life threatening – like severe heart disease or kidney disease.

• Women for whom the prospect of carrying a baby to term is deemed to be very remote.

• No women are considered for treatment by surrogacy who requests it for career or social reasons.

PATIENT SELECTION The genetic couples are usually first seen alone and indepth consultation and counseling of all the medical aspects of the treatment is conducted. If medically suitable for treatment, they are given some guidance on finding a host for themselves or take the help of a professional surrogate.

When the suitable host is found, she and her partner are interviewed and explained in detail of the implications of acting as a surrogate host.

SCREENING OF SURROGATE Some basic guidelines for screening of a surrogate mother are: • Age < 35 yrs. (preferably) • No severe medical disorders or personal habit like smoking, alcohol and drug abuse.

• See for hereditary disorders, infections diseases, haemoglobinnopathies • Psychological assessment especially possessiveness.

COUNSELING The role of counseling in surrogacy is to help to prepare all parties contemplating this last-resort treatment and to consider all the factors that will have an influence on the future lives of each of them. The counseling ensures that they be confident and comfortable with their decisions, and have trust in each other, so that no one party is felt to be taking advantage of the other. Both the couples should be counseled regarding the failure of the treatment, as it could have a profound effect on them and their families.

CONCLUSIONS Sperm donation oocyte donation, embryo donation and surrogacy are all an accepted form of assisted conception treatment.

In the past 3 decades, there has been a spectacular change in the field of reproductive technologies. Continuing research & advancement of the technology has given hope to many who are devastated when they cannot have children.

Assisted Reproduction technologies involving a third party in the treatment of infertile patients has definitely helped to fulfill the dreams of many a childless couples.

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ISAR 2014

MEGA MEMORABLE MAGICAL â&#x20AC;&#x153;The Price of success is hard work, dedication to the job at hand and the determination that whether we win or lose, we have applied the best of ourselves to the task at the endâ&#x20AC;?

T

he 19th annual conference of the Indian Society of Assisted Reproduction hosted by the Gujarat Chapter of ISAR held in Ahmedabad on 14th 15th and 16th February 2014 seems to be the most memorable event in recent years! The Gujarat Chapter ISAR won the bid to host the prestigious conference during the ISAR Conference held at Raipur 2012. The preparations for the mega event started immediately after returning from Raipur. In the first meeting a decision was made regarding the organising committees which consisted of Organising Chairperson Dr Manish Banker, Organising Vice Chairperson Dr Nayana Patel, Organising Secretaries Dr Kanthi Bansal and Dr C.B. Nagori, Treasurer Dr Tushar Shah, Jt.Treasurer Dr R.G.Patel.

The scientific committee chairpersons were late Dr Pravin Patel & Dr Sanjay Patel. There were several other sub committees. Thereafter regular meetings were held on a monthly basis for a year, once every 15 days for 6 months and every week for the next 6 months. The event management was by a local based company so that the day to day affairs could be handled smoothly.

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he scientific program was the first to be drafted and meticulous care was taken to see that all the topics pertaining to the theme of conference were included. The theme of the conference was “Basics, Recent and the future of Infertility management”. There were six Pre-Congress Workshops on various subjects like Endoscopy in Infertility, Ovulation Induction, Ultrasound in Infertility, ABC of ART, ISAR - ESHRE workshop on Advance Embryology, Workshop on ART for Paramedicals so that maximum number of delegates could get trained in the subject of their choice.

Paramedical workshop was a new entity which had new interesting aspects like ‘Mock IVF Drill’. There were a total of 1100 delegates for the workshops. All workshops had the same timings - 9am to 4pm. All halls were fully packed and the delegates were avidly concentrating on workshop proceedings and no delegate was seen in the lounge area or exhibition hall.

We had invited 23 International faculties. The International experts were well known for their expertise and publications.

Sufficient time was given in each workshop and all doubts of the delegates were cleared during the workshop. There were several meetings held consecutively during these three days like ISAR Managing Committee meeting, Gujarat Chapter ISAR GBM, ISAR Special General Body Meeting for constitutional amendment, IFFS 2016 LOC meeting, ISAR General Body Meeting and ISAR Managing Committee Meeting (New).

On 15th and 16th Feb, the main conference was in four halls.

Hall ‘A’ dealt with ‘Basics in Infertility’. Hall ‘B’ considered ‘Recent Trends in Infertility’ and Hall ‘C’ - ‘Future of Infertility Management’. Hall D was allotted for free papers. This was to encourage research papers from Clinicians and Embryologists.

We had a total number of 54 oral and 62 poster presentations.

Prizes were distributed to the 2 best papers and 2 best posters which were judged by esteemed judges. The selection of International and National faculties was based on their expertise, oration capability, publications etc. Every talk was allotted 20 minutes and 5 minutes discussion so that proper justice was given to every subject. There were a total number of 230 national faculties, moderators and chairpersons. Total number of delegates attending the conference was 2225.

The cultural program was the icing on the cake. On Friday we had a magical and spell binding performance by great danseuse Dr Mallika Sarabhai. Her performance put everyone in a trance. She gave an unforgettable performance and everybody got a golden chance to witness an entertainment

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program which was truly amazing.

The Inaugural function was held on 15th from 6pm to 7pm so that it did not disturb the scientific proceedings. To add more weightage to the evening we had our Honourable Chief Guest “Dr Amrita Patel “Chairman of the National Dairy Development Board (NDDB) and Founder and Chairman of the Foundation for Ecological Security (FES) and Guest of honour “Ms Diana Hayden” the former “Miss India and Miss World”.

Both their speeches were apt and to the point. It was very well organized inaugural program. Handing over of Presidentship from Dr Manish Banker to Dr Hrishikesh Pai was executed. The new President of ISAR, Dr Hrishikesh Pai is like an evergreen hero, liked by one & all, as popular as he is ever smiling, enigmatic & intellectual. Dr Hrishikesh Pai gave a spell binding speech which was powerful and peppered with his dreams and aspirations; he wants to complete much in his tenure. One of his greatest ideas was to start Yuva ISAR conferences.

The cultural program on 16th was once again a big hit with playback singer Kunal Ganjawala who gave his best to the listeners. All the delegates were dancing and singing to his tunes. It was a great treat for all the delegates and a fitting finale to the grand success of the Conference.

We had Intas Pharma as the Platinum sponsor, there were three Gold sponsors - Sun, Bharat Serums & Vaccines Ltd & Merck.

There were six Silver sponsors - Cook Medical, Shivani Scientific, Trivector, MSD, Ferring Pharmaceuticals & GE Wipro.

Large number of Pharma as well as Instruments, Media companies & Medical Publishers participated with enthusiasm & had taken up stalls.

The valedictory program was the most important as the hard work done by everyone making this event a mega conference was appreciated. The inaugural and valedictory function were important and carried out in a sophisticated manner. The prime time was not compromised and conducted only in the evening so that the delegates did not lose out on their educational event, which was the main focus of the conference.

ISAR 2014 is an example of what a good team can do. It’s uplifting to get compliments lauding it as one of the best conferences so far & comparable to International standards.

The food was delicious, luscious and mouth watering and it was arranged in such a manner that it satisfied the sensory buds of the populace who gathered for the conference and there were no complaints. The conference was indeed a great success and fruitful due to the amalgamation of the right people who worked day and night and managed the entire show, good speakers and an august audience.

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...& an evening to remember

kudos... the following are few of the mails which we got describing the success of conference: It was a grand success and I congratulate all the team members. Some of the delegates have expressed their view, that it was as good as ESHRE conference. Thanks.

Dr Rajesh Goraisa

Kudos to team ISAR 2014 for excellent organization of this national conference We congratulate you for excellent organization, scientific feast, venue management, hospitality and very nice audio-visuals.

We appreciate the sheer hard work put on by the whole team. Again congratulations and thanking you.

Dr Gayatri Thaker

Congratulations on an excellently executed conference of high academic standards, warm hospitality and entertainment par excellence! All the best for all your future endeavours.

Warm regards, Duru Shah Thank you. It was an honour to be a speaker.

Rebecca Z. Sokol Please accept my hearty congratulations for best ever organized ISAR conference at Ahmedabad. The scientific Program, speaker’s selection, audience interaction and meetings all were excellent. Despite it being hi tech speciality deliberations were ground to earth and with clear messages.

I am very happy to be part of it and also owe special thanks for it.

Best wishes for all your future endeavours.

Warm Regards, Dr Sadhana Gupta “Success belongs only to those who are willing to work harder than anyone else” Dr Kanthi Bansal Organizing Secretary ISAR 2014 Joint Treasurer ISAR Chairperson Accreditation Committee ISAR Secretary Gujarat Chapter ISAR

Christopher Reeve

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“

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so many of our dreams at first seem impossible, then they seem improbable, and then, when we summon the will, they soon become inevitable.

FORTHCOMING CONFERENCES Knowledge has to be improved, challenged, and increased constantly, or it vanishes.

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20tH NatioNal CoNFereNCe isar Chennai 10th - 12th april 2015, Chennai trade Centre. www.isar2015.com

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Agra

• eShRe AnnuAl MeetIng: lisbon, portugal.

14th to 17th June 2015. www.eshre2015.eu • FeM ConFeRenCe: Hotel palladium, lower parel, Mumbai.

25th and 26th July 2015 . www.femconf2015.com • YuvA ISAR 2nd nAtIonAl ConFeRenCe: bhubaneshwar.

8th & 9th august 2015. www.yuvaisar2015.com • CogI 22nd WoRld CongReSS: budapest, Hungary.

17th to 20th september 2015. www.congressmed.com • eMbRYologY ISAR: Gurgaon, New Delhi.

4th and 5th september 2015. www.embryologyisar2015.com • FIgo 21St WoRld CongReSS: vancover.

4th to 9th october 2015. www.figo2015.org • ASRM AnnuAl ConFeRenCe: baltimore, Maryland.

17th to 21st october 2015. www.asrm.org • 59th AICog 2016: agra.

13th to 17th January 2016. www.aicog2016agra.com • IFFS 22nd WoRld CongReSS: New Delhi.

24th to 28th september 2016. www.iffs2016.com supporteD bY

ISARExprEss

69

The Indian

MULTINATIONAL

Intas Overview: Intas is a leading, vertically integrated, global pharmaceutical formulation development, manufacturing and marketing company headquartered in India.

Intas' success and incessant growth lies in clinical execution of successful and strategic moves made in the areas of manufacturing, R&D, biotechnology and global operations over three decades.

Intas - Indian Operations: Intas is now ranked as the 12th largest pharmaceutical company in the domestic market (as per IMS Health India, Secondary Stockiest Audit (SSA), April, 2014 MAT), having 2.51% market share with 13.2% growth rate.

In the domestic market, Intas is the 5th largest corporate in Indian Chronic Pharma Market with a market share of 4.85%. It also has a presence in cardiovascular system (CVS), diabetology, gynecology, infertility, respiratory care, gastroenterology, pain management as well as other therapeutic segments.

AICOD Besides a rapidly growing domestic prominence, Intas is also present in more than 70 countries worldwide with robust sales, marketing and distribution infrastructure in markets like North America, Europe, Central & Latin America, Africa, Australia, New Zealand, Asia Pacific as well as CIS and MENA countries.

Intas has made a substantial commitment to its Biologics Business Unit in terms of creating R&D, manufacturing and marketing capabilities for its biotech portfolio. As on date, Intas commercialized 11 biologic products and continues its R&D efforts in chronic disease areas such as Oncology (Cancer), Rheumatology, Auto-Immune, Nephrology, Ophthalmology and Plasma derived product based therapies.

Intas has made strategic investments in ten manufac-

turing facilities globally. Between them, these facilities have received approvals from various prominent international regulatory bodies, including U.S. Food and Drug Administration (FDA).

Intas operates through 33 exclusive and dedicated sales depots and has established relationships with over 4100 stockists in India. A dedicated sales representative team of 3000+ covers more than 1,50,000 doctors including specialists from different therapy areas. The company is set to enhance its presence in the market through its active progress in NDDS. Currently, Intas has launched 3 NDDS products in India using patented technology.

MILESTONES AT INTAS:

INTAS International Operations Overview: Intas' forte in delivering world-class products has earned it a reputable presence in over 70 countries on the International pharmaceutical horizon, with 3000+ live product registrations. It has successfully augmented its R&D and manufacturing competency to enter into product alliances and strategic tie-ups and build business efficiencies for its partner companies.

Three of Intasâ&#x20AC;&#x2122; biosimilar assets are already partnered for the EU, US, Canada, China and other markets. The first product for the regulated markets will be GCSF and is expected to be launched in Europe towards the mid of 2015 by the companyâ&#x20AC;&#x2122;s collaborator. Intas aims to be the first Indian company to have enabled a commercialization of an indigenously developed biosimilar product in the regulated market. Intasâ&#x20AC;&#x2122; biosimilar products are already commercialized in many emerging markets, through strategic marketing alliances. Several other biosimilar programs are at an advanced stage of development, and available for partnering discussions.

Intas is supported in its endeavours through its extensive network of branch offices and subsidiaries spanning USA, Canada, Europe, Central & Latin America, Africa, Asia-Pacific as well as CIS and MENA countries.

Manufacturing Facilities: Intas operates nine formulation manufacturing facilities, of which seven are located in India, one in the U.K. and one in Mexico. It also operates two API and intermediate manufacturing facilities, each of which complies with the regulatory requirements in the jurisdictions in which it operates. Between them, these facilities have received approvals from various prominent international regulatory bodies, including from U.S. Food and Drug Administration (FDA).

Each of Intas' manufacturing facilities is designed, equipped and operated to deliver high quality products within defined cost and delivery schedules. These manufacturing facilities have the flexibility to operate in various dosage forms and a wide range of batch sizes.

Intas' Oncology formulation facilities are world class containment facilities which operate under global regulatory and safety standards.

The Ahmedabad SEZ caters exclusively to the US, Europe and other regulated markets.

supported by

65

T

he scientific program was the first to be drafted and meticulous care was taken to see that all the topics pertaining to the theme of conference were included. The theme of the conference was “Basics, Recent and the future of Infertility management”. There were six Pre-Congress Workshops on various subjects like Endoscopy in Infertility, Ovulation Induction, Ultrasound in Infertility, ABC of ART, ISAR - ESHRE workshop on Advance Embryology, Workshop on ART for Paramedicals so that maximum number of delegates could get trained in the subject of their choice.

Paramedical workshop was a new entity which had new interesting aspects like ‘Mock IVF Drill’. There were a total of 1100 delegates for the workshops. All workshops had the same timings - 9am to 4pm. All halls were fully packed and the delegates were avidly concentrating on workshop proceedings and no delegate was seen in the lounge area or exhibition hall.

We had invited 23 International faculties. The International experts were well known for their expertise and publications.

Sufficient time was given in each workshop and all doubts of the delegates were cleared during the workshop. There were several meetings held consecutively during these three days like ISAR Managing Committee meeting, Gujarat Chapter ISAR GBM, ISAR Special General Body Meeting for constitutional amendment, IFFS 2016 LOC meeting, ISAR General Body Meeting and ISAR Managing Committee Meeting (New).

On 15th and 16th Feb, the main conference was in four halls.

Hall ‘A’ dealt with ‘Basics in Infertility’. Hall ‘B’ considered ‘Recent Trends in Infertility’ and Hall ‘C’ - ‘Future of Infertility Management’. Hall D was allotted for free papers. This was to encourage research papers from Clinicians and Embryologists.

We had a total number of 54 oral and 62 poster presentations.

Prizes were distributed to the 2 best papers and 2 best posters which were judged by esteemed judges. The selection of International and National faculties was based on their expertise, oration capability, publications etc. Every talk was allotted 20 minutes and 5 minutes discussion so that proper justice was given to every subject. There were a total number of 230 national faculties, moderators and chairpersons. Total number of delegates attending the conference was 2225.

The cultural program was the icing on the cake. On Friday we had a magical and spell binding performance by great danseuse Dr Mallika Sarabhai. Her performance put everyone in a trance. She gave an unforgettable performance and everybody got a golden chance to witness an entertainment

66

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program which was truly amazing.

The Inaugural function was held on 15th from 6pm to 7pm so that it did not disturb the scientific proceedings. To add more weightage to the evening we had our Honourable Chief Guest “Dr Amrita Patel “Chairman of the National Dairy Development Board (NDDB) and Founder and Chairman of the Foundation for Ecological Security (FES) and Guest of honour “Ms Diana Hayden” the former “Miss India and Miss World”.

Both their speeches were apt and to the point. It was very well organized inaugural program. Handing over of Presidentship from Dr Manish Banker to Dr Hrishikesh Pai was executed. The new President of ISAR, Dr Hrishikesh Pai is like an evergreen hero, liked by one & all, as popular as he is ever smiling, enigmatic & intellectual. Dr Hrishikesh Pai gave a spell binding speech which was powerful and peppered with his dreams and aspirations; he wants to complete much in his tenure. One of his greatest ideas was to start Yuva ISAR conferences.

The cultural program on 16th was once again a big hit with playback singer Kunal Ganjawala who gave his best to the listeners. All the delegates were dancing and singing to his tunes. It was a great treat for all the delegates and a fitting finale to the grand success of the Conference.

We had Intas Pharma as the Platinum sponsor, there were three Gold sponsors - Sun, Bharat Serums & Vaccines Ltd & Merck.

There were six Silver sponsors - Cook Medical, Shivani Scientific, Trivector, MSD, Ferring Pharmaceuticals & GE Wipro.

Large number of Pharma as well as Instruments, Media companies & Medical Publishers participated with enthusiasm & had taken up stalls.

The valedictory program was the most important as the hard work done by everyone making this event a mega conference was appreciated. The inaugural and valedictory function were important and carried out in a sophisticated manner. The prime time was not compromised and conducted only in the evening so that the delegates did not lose out on their educational event, which was the main focus of the conference.

ISAR 2014 is an example of what a good team can do. It’s uplifting to get compliments lauding it as one of the best conferences so far & comparable to International standards.

The food was delicious, luscious and mouth watering and it was arranged in such a manner that it satisfied the sensory buds of the populace who gathered for the conference and there were no complaints. The conference was indeed a great success and fruitful due to the amalgamation of the right people who worked day and night and managed the entire show, good speakers and an august audience.

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...& an evening to remember

kudos...

The following are few of the mails which we got describing the success of conference: It was a grand success and I congratulate all the team members. Some of the delegates have expressed their view, that it was as good as ESHRE conference. Thanks.

Dr Rajesh Goraisa

Kudos to team ISAR 2014 for excellent organization of this national conference We congratulate you for excellent organization, scientific feast, venue management, hospitality and very nice audio-visuals.

We appreciate the sheer hard work put on by the whole team. Again congratulations and thanking you.

Dr Gayatri Thaker

Congratulations on an excellently executed conference of high academic standards, warm hospitality and entertainment par excellence! All the best for all your future endeavours.

Warm regards, Duru Shah Thank you. It was an honour to be a speaker.

Rebecca Z. Sokol Please accept my hearty congratulations for best ever organized ISAR conference at Ahmedabad. The scientific Program, speaker’s selection, audience interaction and meetings all were excellent. Despite it being hi tech speciality deliberations were ground to earth and with clear messages.

I am very happy to be part of it and also owe special thanks for it.

Best wishes for all your future endeavours.

Warm Regards, Dr Sadhana Gupta “Success belongs only to those who are willing to work harder than anyone else” Dr Kanthi Bansal Organizing Secretary ISAR 2014 Joint Treasurer ISAR Chairperson Accreditation Committee ISAR Secretary Gujarat Chapter ISAR

Christopher Reeve

68

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“

“

so many of our dreams at first seem impossible, then they seem improbable, and then, when we summon the will, they soon become inevitable.

FORTHCOMING CONFERENCES Knowledge has to be improved, challenged, and increased constantly, or it vanishes.

Peter Drucker

20th NatioNal CoNfereNCe isar Chennai 10th - 12th april 2015, Chennai trade Centre. www.isar2015.com

Lisbon

Bhubaneshwar

Baltimore

Agra

• ESHRE AnnuAl MEETing: lisbon, portugal.

14th to 17th June 2015. www.eshre2015.eu • FEM ConFEREnCE: hotel palladium, lower parel, Mumbai.

25th and 26th July 2015 . www.femconf2015.com • YuvA iSAR 2nd nATionAl ConFEREnCE: bhubaneshwar.

8th & 9th august 2015. www.yuvaisar2015.com • Cogi 22nd WoRld CongRESS: budapest, hungary.

17th to 20th september 2015. www.congressmed.com • EMbRYologY iSAR: Gurgaon, New delhi.

4th and 5th september 2015. www.embryologyisar2015.com • Figo 21ST WoRld CongRESS: Vancover.

4th to 9th october 2015. www.figo2015.org • ASRM AnnuAl ConFEREnCE: baltimore, Maryland.

17th to 21st october 2015. www.asrm.org • 59TH AiCog 2016: agra.

13th to 17th January 2016. www.aicog2016agra.com • iFFS 22nd WoRld CongRESS: New delhi.

24th to 28th september 2016. www.iffs2016.com supported by

ISARExprEss

69

The Indian

MULTINATIONAL

Intas Overview: Intas is a leading, vertically integrated, global pharmaceutical formulation development, manufacturing and marketing company headquartered in India.

Intas' success and incessant growth lies in clinical execution of successful and strategic moves made in the areas of manufacturing, R&D, biotechnology and global operations over three decades.

Intas - Indian Operations: Intas is now ranked as the 12th largest pharmaceutical company in the domestic market (as per IMS Health India, Secondary Stockiest Audit (SSA), April, 2014 MAT), having 2.51% market share with 13.2% growth rate.

In the domestic market, Intas is the 5th largest corporate in Indian Chronic Pharma Market with a market share of 4.85%. It also has a presence in cardiovascular system (CVS), diabetology, gynecology, infertility, respiratory care, gastroenterology, pain management as well as other therapeutic segments.

AICOD Besides a rapidly growing domestic prominence, Intas is also present in more than 70 countries worldwide with robust sales, marketing and distribution infrastructure in markets like North America, Europe, Central & Latin America, Africa, Australia, New Zealand, Asia Pacific as well as CIS and MENA countries.

Intas has made a substantial commitment to its Biologics Business Unit in terms of creating R&D, manufacturing and marketing capabilities for its biotech portfolio. As on date, Intas commercialized 11 biologic products and continues its R&D efforts in chronic disease areas such as Oncology (Cancer), Rheumatology, Auto-Immune, Nephrology, Ophthalmology and Plasma derived product based therapies.

Intas has made strategic investments in ten manufac-

turing facilities globally. Between them, these facilities have received approvals from various prominent international regulatory bodies, including U.S. Food and Drug Administration (FDA).

Intas operates through 33 exclusive and dedicated sales depots and has established relationships with over 4100 stockists in India. A dedicated sales representative team of 3000+ covers more than 1,50,000 doctors including specialists from different therapy areas. The company is set to enhance its presence in the market through its active progress in NDDS. Currently, Intas has launched 3 NDDS products in India using patented technology.

MILESTONES AT INTAS:

INTAS International Operations Overview: /5"4 '035& */ %&-*7&3*/( 803-% $-"44 130%6$54 )"4 &"3/&% *5 " 3&165"#-& 13&4 &/$& */ 07&3 $06/53*&4 0/ 5)& /5&3/"5*0/"- 1)"3."$&6 5*$"- )03*;0/ 8*5) -*7& 130%6$5 3&(*453"5*0/4 5 )"4 46$$&44'6--: "6(.&/5&% *54 "/% ."/6'"$563*/( $0.1&5&/$: 50 &/5&3 */50 130%6$5 "--*"/$&4 "/% 453"5& (*$ 5*& 614 "/% #6*-% #64* /&44 &''*$*&/$*&4 '03 *54 1"35/&3 $0.1"/*&4 )3&& 0' /5"4< #*04*.*-"3 "44&54 "3& "-3&"%: 1"35/&3&% '03 5)& "/"%" )*/" "/% 05)&3 ."3,&54 )& '*345 130%6$5 '03 5)& 3&(6-"5&% ."3,&54 8*-- #& "/% *4 &91&$5&% 50 #& -"6/$)&% */ 6301& 508"3%4 5)& .*% 0' #: 5)& $0.1"/:<4 $0--"#03"503 /5"4 "*.4 50 #& 5)& '*345 /%*"/ $0.1"/: 50 )"7& &/"#-&% " $0..&3$*"-*;" 5*0/ 0' "/ */%*(&/064-: %&7&-01&% #*04*.*-"3 130%6$5 */ 5)& 3&(6-"5&% ."3,&5 /5"4< #*04*.*-"3 130%6$54 "3& "3&"%: $0..&3$*"-*;&% */ ."/: &.&3(*/( ."3,&54 5)306() 453"5&(*$ ."3,&5*/( "--*"/$&4 &7&3"- 05)&3 #*04*.*-"3 130(3".4 "3& "5 "/ "%7"/$&% 45"(& 0' %&7&01.&/5 "/% "7"*-"#-& '03 1"35/&3*/( %*4$644*0/4 /5"4 *4 4611035&% */ *54 &/%&"70634 5)306() *54 &95&/ 4*7& /&5803, 0' #3"/$) 0''*$&4 "/% 46#4*%*"3*&4 41"//*/( "/"%" 6301& &/53""5*/ .&3*$" '3*$" 4*" "$*'*$ "4 8&-- "4 "/% $06/53*&4

Manufacturing Facilities: /5"4 01&3"5&4 /*/& '03.6-"5*0/ ."/6'"$563*/( '"$*-*5*&4 0' 8)*$) 4&7&/ "3& -0$"5&% */ /%*" 0/& */ 5)& "/% 0/& */ &9*$0 5 "-40 01&3"5&4 580 "/% */5&3.&%*"5& ."/6'"$ 563*/( '"$*-*5*&4 &"$) 0' 8)*$) $0.1-*&4 8*5) 5)& 3&(6-"503: 3& 26*3&.&/54 */ 5)& +63*4%*$5*0/4 */ 8)*$) *5 01&3"5&4 &58&&/ 5)&. 5)&4& '"$*-*5*&4 )"7& 3& $&*7&% "11307"-4 '30. 7"3*064 130.*/&/5 */5&3/"5*0/"3&(6-"503: #0%*&4 */$-6%*/( '30.

00% "/% 36( %.*/*453"5*0/ "$) 0' /5"4 ."/6'"$563*/( '"$*-*5*&4 *4 %&4*(/&% &26*11&% "/% 01&3"5&% 50 %&-*7&3 )*() 26"-*5: 130%6$54 8*5)*/ %&'*/&% $045 "/% %&-*7&3: 4$)&%6-&4 )&4& ."/ 6'"$563*/( '"$*-*5*&4 )"7& 5)& '-&9*#*-*5: 50 01&3"5& */ 7"3* 064 %04"(& '03.4 "/% " 8*%& 3"/(& 0' #"5$) 4*;&4 /5"4 /$0-0(: '03.6-"5*0/ '"$*-*5*&4 "3& 803-% $-"44 $0/5"*/.&/5 '"$*-*5*&4 8)*$) 01&3"5& 6/%&3 (-0#"- 3&(6 -"503: "/% 4"'&5: 45"/%"3%4 )& ).&%"#"% ! $"5&34 &9$-64*7&-: 50 5)& 6 301& "/% 05)&3 3&(6-"5&% ."3,&54