The Lowly Gynaecologist

“ A Physician works at cerebral level, a Surgeon at spinal level and a Gynaecologist at Lumbrical level”

This was the sneering statement made by a Physician while we were in training.
For the non medical people, it implies that a Physician [post graduate in internal medicine] uses his brain, a surgeon his inherent skill, while a gynaecologist merely uses her hands without thinking or talent- the Lumbricals being muscles in the hand.
This patronising attitude towards us gynaecologists continues through our working lives.

With the Nobel prize for medicine being awarded this year to Professor Robert Edwards, the originator of the test tube baby and the first gynaecologist to win the award, all of us gynaecologists feel vindicated. It was balm on our bruised egos.
Thinking back, Gynaecologists have given several firsts to the world of medicine-

Professor Ian Donald, first thought of holding an ultrasound probe over the adbdomen of a pregnant woman and got images of the baby, thus starting the whole new field of sonography-which is indispensable in  diagnosis in almost every branch of medicine and even used in therapy.

Professor Kurt Semm also a gynaecologist, removed an appendix laparoscopically and then started doing hysterectomies setting the trend for endoscopic surgery. The surgeons followed with Laparoscopic cholecystectomies etc.

Prof. Camran Nezhat again a gynaecologist first used an endovision camera and monitor to do laparoscopic surgery while looking at a screen and not peeping through the telescope with one eye shut. Today extensive cancer surgeries are possible because of this one small step /giant leap.

Then there was the test tube baby- Louise Brown the brain child of Sir Robert Edwards and Patrick Steptoe. Gynaecologists all over the world adopted their methods successfully –leading to a whole new field of assisted reproduction. With this came advances in culture media, incubators, operative microscopes, sterile environments and led to development of stem cell research, tissue preservation and even cloning.

Prof Charles Koh, started doing endoscopic tuboplasty [for repair of the fallopian tubes] and opened up the field endoscopic microsurgery –useful even to cardio-vascular surgeons.

Besides these landmark developments by Gynaecologists, I feel a 'Doctor for Ladies' is different from other consultants in many ways-She has to be both Physician to treat various diseases in pregnancy, taking into account the effects on the mother and the baby; and Surgeon to operate on various pathologies of women. Besides gynaecologists need to have a fair knowledge of endocrinology, oncology and breast diseases. Plus she has to know about and use psychotherapy and also step in to sort out the social problems of her patients. Women she has delivered look to her for baby care tips and a basic knowledge of paediatrics is also in her domain. She also has to educate- girls starting puberty, women getting married, or trying to have a baby, sort out physical marital problems and help women age in comfort.

Gynaecologists are often primary care physicians for pregnant women and for those who are too embarrassed to see a male family doctor for an ailment of a personal nature.

To all derisive statements made towards us by doctors of other specialities, I would like to say we are not only your equal, we are first among equals.

Congratulations to Sir Robert Edwards for getting the highest honour for his work. Sir, you do us all proud.

Treatment by halves

" Sonny, send your worst cases to your enemy"-An old Gynaecology Professor to his assistant.

At the Wadia Maternity and Gynaecological Hospital in Mumbai that is exactly what we get. Women who have undergone multiple surgeries that have failed, multiple cycles for infertility treatment and have exhausted their resources but not hope, have lost a number of babies and are taking that one final chance, mothers carrying babies with severe growth restriction or anomalies where the gynaecologist doesn't want to break the bad news, ART practitioners who want their patients to undergo laparoscopy cheaply and save money for IVF and so on.
I speak from hind sight and a review of cases that I have managed and here are some of my observations-
ART practitioners, seem to jump too soon into IUI and then IVF cycles and further ICSI if all fails.
Several patients have a simple problem like lack of knowledge of fertile period, insufficient frequency of coitus, use of lubricants or douches, washing off the ejaculate, pain during intercourse from infection or inadequate relaxation and just advising couples on these basic techniques works for them.

The cervical factor is another neglected area. Most IVF clinics do a transvaginal scan and a simple per speculum or per vaginal check is skipped. Cervical erosions, ulcers, small polyps chronic cervicitis contributing to her infertility are missed. The first time the cervix is looked at is during an IUI by which time its too late to treat and the doctor proceeds with the procedure-which is likely to fail if the infection has tracked into the uterus or results in an abortion should a pregnancy occur. A simple procedure like a cryo or thermo cauterisation cure the erosion and several patients conceive spontaneously after.

Sometimes the cervical canal is tortuous or stenosed or there are large cysts [Nabothian]-obstructing passage of sperms and causing infertility. A generous dilatation, rupturing the cysts, removing the polyps and lysing the adhesions cures the infertility or makes the IUI or Embryo transfer much smoother and bloodless and hence more likely to be successful.

Uterine polyps are treated by most gynaecologists by simply pulling it or curetting it out-increasing chances of recurrence. If done at hysteroscopy taking care to cut the base, the polyp is unlikely to recurr and the patient has better chances of pregnancy -spontaneously or assisted.

Fibroids not only distend the uterine cavity, make the endometrium inflamed and hostile to implantation, they may mechanically obstruct passage of sperm if they are close to the cervix or the fallopian tubes. They also make an IUI / ET a bit more difficult. With modern laparoscopic techniques, it is possible to have few or no adhesions after myomectomy and often patients conceive after the myomectomy.

Poly cystic ovaries or indeed any ovarian cyst needs to be diagnosed and ovarian drilling removes large unruptured follicles that mechanically obstruct newer ones, changes the hormonal environment, and these patients come back pregnant much to their surprise. If they are on treatment, ovarian drilling makes them sensitive to drugs like clomiphene to which they were hitherto resistant, reduces their requirement of gonadotropins and chances of Ovarian Hyperstimulation. However one needs to do just 4-5 punctures, with a minimum current for just a few seconds and copiously irrigate the ovary to avoid thermal damage to other eggs.

Endometriotic cysts are often punctured and left to nature by gynos not sufficiently confident of endoscopy-removing the cyst wall is essential to prevent recurrence of these cysts.

Tiny patches of endometriosis are also left untouched-these release several factors that inhibit ovulation, alter tubal and uterine peristalsis and interfere with conception. Removal of all endometriosis, makes a patient better responsive to ovulation induction and increases her chances of pregnancy.

If there is a problem in sperm count or motility, the male partner is sent to an andrologist who may rule out hernias, hydrocoeles, varicocoeles and undescended testes but rarely bothers to do his sugars, thyroid function tests and take a history of exposure to high temperature or stress, do a semen culture and treat the infection. An exhorbitant nutritional supplement is prescribed that most men stop after a month because of the cost. It is so easy and cost effective to test and take a history to get at the real problem before jumping to do an IUI where the few poorly motile sperms will also be lost and then to ICSI. The chances of successful ART  are also increased by taking care of these other common problems.

Finally, many women have multiple cervical dilatations for various procedures and often have an incompetent os on top of a multiple gestation. Good idea to look out for this prior to infertility treatment and continue to look for it from 3 months onwards with a sonography[ most sonologists never comment on the cervix] and take a stitch if required, preventing a precious pregnancy aborting.

Male gynaecologists avoid proper exam of the patients breasts which is left to nurses. they often miss galactorrhoea and though the prolactin levels are normal, correction of the galactorrhoea does often restore normal cycles and fertility.

Thyroid disorders are missed if the tests are not done at a good laboratory-so looking for signs of thyroid disturbance and sending these patients blood to a good [although expensive] lab may be worth it.

So lets 'Look at the patient not just the disease'. Lets not be in a hurry to start an ART cycle. Lets take care of everything we possibly can-this would help our infertile patients get pregnant at minimum cost and carry their babies to term which is the final aim of both the patient and the doctor.

The new age in women's surgery

When my mother needed a hysterectomy 25 years ago, she had her abdomen cut, her uterus removed and things stitched back.

My aunt got her uterus removed vaginally.

Both went through pain, prolonged recovery periods, bed rest, put on weight due to bed rest, had to stay home from work and were miserable.

A revolution in surgery started with a German gynaecologist Kurt Semm who did a hysterectomy using a telescope, thin instruments put in through fine metal tubes and coagulating protein in tissues using electrical energy and even stitching up through those tubes.

Endoscopy was adopted by all surgeons-general surgeons now remove appendices and gall bladders laparoscopically, gynaecologists remove uterii, fibroids, ovarian tumors and even repair hernias [prolapsed uterii]  and orthopaedic surgeons to repair joints and even neurosurgeons are reaching remote areas of the brain endoscopically.

When my son needed a major joint surgery, all he needed were 3 puncture wounds round his shoulder, was home in one day and doing everything himself in two days.

This is the new magical world of endoscopy. We look into the patient's abdomen with a telescope-the image magnified several times and coagulate and cut tissues precisely using excellent instruments and electrical power or ultrasound waves. The tissue to be removed is cut with a rotating blade and removed in strips through a small puncture wound. Essential suturing is done. The cavity is washed with saline and every fine bleeding point is taken care of. 

The patient recovery is amazing. She sits up and drinks on the same day and goes home the next.

A week later, her sutures are removed and the scars are invisible in a few months.

Like any surgery, these operations have their complications but in experienced hands with good instruments, the complications are negligible.

At my hospital, where two patients who underwent the same surgery but one with a cut on her abdomen and the other laparoscopically, were lying side by side and comparing notes.

The Laparoscopic one went home in a day and the one who had open surgery started crying and quarreling with the doctors for not doing a laparoscopic surgery on her. Yes. There is such a degree of difference in the two routes.

However, lack of good training, poor instruments, lack of experience and hurry and greed on part of doctors are giving this surgery a bad name.

Further, senior renowned doctors are not familiar with these techniques and in an attempt to keep their patients, malign laparoscopy.

No matter, this is the future and it is here to stay.

I wish my mother had had a laparoscopy and not suffered any pain, or been invalid.

I'm glad we now live in the age where no pain or disfigurement needs to be suffered even for a supramajor cancer surgery.

In future, with robots endoscopy will become even more accepted and done remotely.-Yes a surgeon in Bangalore will soon be able to operate on a patient in Bhatinda.

Driving in Bombay

India has the highest number of road accidents in the world-13 an hour. And the figure is only going to go up.

A motorist in Bombay truly suffers- from traffic jams, naka bandis, dug up roads, construction of flyovers or monorail, pot-holed roads, flooded roads,lack of parking places, towing away of your car, obstruction by tourist buses, BEST buses, taxis, rickshaws, hand carts, bullock carts, dogs, cows, garbage bins, garbage trucks, jaywalkers and even policemen who stand in the middle of the road or stop a passing truck.

Our pavements are either dug up or have debris lying on them for months, hutments, toilets for the hutment dwellers, STD booths, milk booths, Jhunka-bhakar stalls which sell everything but, extensions of shops or hotels, fencing off for growing plants, hawkers, cows, Municipal contractor's offices, police chowkies, dust bins, cars parked, basket makers, ganapati pandals, temples, offices of political parties and many more obstructions to their real use which is for pedestrians to walk on. 

The people of Bombay are forced to walk on the causeway exposing them to accidents by vehicles.

If rickshaws are not allowed on main roads, how come hand carts and bullock carts are allowed  completely blocking the flow of traffic? Is this a village?Isn't there a law against it? If so, why is it not being enforced? Rickshaw drivers and two wheelers have the worst manners and will go at snail pace in the fast lanes, cut lanes, stop in the middle of the road, disrespect signals, overtake from the left and generally make life hell for motorists

Taxis park any and everywhere, not at designated parking areas. even double park. thereby completely blocking roads.

The police carry out naka bandis without a thought for the huge snarls they might cause-not taking into account dug up roads, nor making an effort to allow smooth movement of traffic.

It is an open secret that politicians make huge amounts of money from any construction. Hence before an election, all major roads undergo some work leading to an impossible traffic situation-this could easily be done in a phased manner helping smooth flow of traffic.

Can't the BEST narrower buses that don't occupy half the road? and get rid of some that run empty? Further the BEST drivers are the worst road-hogs, cutting lanes, never stopping close to a pavement but right in the middle of the road, pushing other cars out-severe penalties should be laid on them and they should be taught some etiquette. garbage trucks are even worse-and dangerous too as is evident from the number of deaths caused by them.

Our pavements need to be freed of all the encroachments if people are to get some place to walk on. so that cars get some place to drive on. so that there is less road rage. and fewer accidents.

Maternity hospitals of Mumbai

Mumbai has a multitude of nursing homes. And several five star hospitals. And several government run hospitals. These are not at all appropriate in today's age and time.

If a middle class woman wants to have a baby, she can hardly afford Breach candy, Leelavati, Jaslok, Bombay hospital, Hiranandani, Wockhardt unless she can shell out Rs.40,000 or more for a normal delivery with a private room and an experienced gynaecologist. and these may be too far from her residence. If she needs a caesarean then it may go to Rs.75,000 to a lakh and a half-which is the main deterrent. She can hardly expect to be comfortable and rested if she shares a room with one to three other women in these hospitals if she needs or wants a hospital delivery but can't afford a single room.

Nor can she go to a municipal hospital or semi aided hospital for worries about overcrowding and infection.

So, she settles for a nursing home.-a mom and pop kind of place. where it may take up precious time if she needs a caesarean, blood, neonatologist, physician, surgeon or intensive care.

similar is the case for all middle class people even if they have insurance, but can't afford hospitals and have to settle for nursing homes.

Doctors too find this 'nursing home' set up restrictive. they cannot treat all the cases they may be qualified for and may not get an attachment to a large hospital due to lack of the right connections. it is also outright dangerous in some instances.

So what is the solution? simple. 'Cluster development'. instead of four nursing homes and path labs and bloods banks in four streets, have them in one place. with quarters for nurses, resident doctors, anaesthetists etc., an intensive care unit, a blood bank-the works. this is the logic behind co-operative farming.

The government should also step in and help such hospitals to develop-allotting land and giving permission for water, electricity etc. this will greatly benefit ordinary people and doctors. and solve a major problem we face in Mumbai today. This is how medicine is practised all over the world. Doctors are attached to hospitals-one in every locality.

Even small towns in India have large hospitals because real estate is affordable. not so in Mumbai. Hence Mumbai lags behind.

Everyone talks of rural health forgetting that we need an urban health policy that helps the middle class.

people are talking of 'fortune at the bottom of the pyramid'. This is a huge market waiting to be tapped in Mumbai.-a reasonably priced, multispeciality hospital in your locality with the best doctors of the area. And above all they should not neglect expectant mothers just because it is considered a risky business or not very lucrative like most of the newer hospitals in Mumbai.