We travel, initially, to lose ourselves; and we travel, next, to find ourselves. We travel to open our hearts and eyes and learn more about the world than our newspapers will accommodate. We travel to bring what little we can, in our ignorance and knowledge, to those parts of the globe whose riches are differently dispersed. And we travel, in essence, to become young fools again—to slow time down and get taken in, and fall in love once more.
-Pico Iyer
The age of the hill station mirrored the period when seaside resorts, spas and the great mountain lodges were built in Europe and the United States. In some case, the style and atmosphere of these European or American mountain retreats were consciously copied in the colonies. The Adirondacks influenced a planner of Baguio, in the Philippines for example. But in colonial Asia, the relatively high altitude hill station, usually at 5,000 to 8,000 feet above sea level, always had to be more than just a resort. The hill station was also a genteel fantasyland, a retreat from reality where the homesick colonial could be cosseted by the atmosphere of a European hometown, down to its familiar institutions: the club, the library, the village church. The hill station at its homiest was and is a phenomenon most often associated with the British in India, but the French, the Americans, and to some extent the Dutch also endowed them with similar properties. As Indians, we must now take pride in announcing to the world a completely made by Indians – Hill-station!
If you’re looking for an exotic winter vacation with clouds in your hair and memorable nature trails, Lavasa as a hill-station is hard to beat. Citrus Citrus has pulled together some ideas for adventurous types more interested in exploring the rain forests of Lavasa or the rappelling off Ekaant than hanging out in the shopping malls of cities such as Tokyo, Seoul, Hong Kong, or Singapore. Even so, the Lavasa resort selections offer all the amenities one finds in major urban centers. Here’s a sampling of what Lavasa has to offer this winter vacation season.
The best time of the year for water-sports activities is now! Lavasa is turning out to be the water-sports capital of the country – with personal water jets, speed-boats, pontoon boats, inflatable dinghies and a water-obstacle floating dock! Again the winter months will be the best time to see the almost-extinct fresh-water crabs & the fruit-bats of Lavasa. For the trekking enthusiasts, the nature trails are full of flowers & butterflies the next 4 months! For the adventurous types, go rappelling with the official adventure co of Lavasa – Z-bac! I can bet my last penny that someone who steps foot into Lavasa for the first time will skip a heart-beat! It is a mini-Switzerland in Maharashtra! Its not only tourism that is being promoted – the Lavasa Corporation is also supporting traditional crafts of the villagers around and the first cooperative for bamboo weaving is called Bamboosa!
By now all of us have heard (too often) the old Proust line about how the real voyage of discovery consists not in seeing new places but in seeing with new eyes. Yet one of the subtler beauties of travel is that it enables you to bring new eyes to the people you encounter. Thus even as holidays help you appreciate your own home more—not least by seeing it through a distant admirer’s eyes—they help you bring newly appreciative—distant—eyes to the places you visit. You can teach them what they have to celebrate as much as you celebrate what they have to teach. This, I think, is how tourism, which so obviously destroys cultures, can also resuscitate or revive them, how it has created new “traditional” handicraft outlets, and caused craftsmen in villages around Lavasa to pay new attention to their works. If the first thing we can bring the Indians is a real and balanced sense of what contemporary Lavasa is like, the second—and perhaps more important—thing we can bring them is a fresh and renewed sense of how special are the warmth and beauty of this town or hill-station, for those who can compare it with other places around the globe.
Thus travel spins us round in two ways at once: It shows us the sights and values and issues that we might ordinarily ignore; but it also, and more deeply, shows us all the parts of ourselves that might otherwise grow rusty. For in traveling to a new place, we inevitably travel to moods and states of mind and hidden inward passages that we’d otherwise seldom have cause to visit. The beauty of this whole process was best described, perhaps, before people even took to frequent flying, by George Santayana in his lapidary essay, “The Philosophy of Travel.” We “need sometimes,” the Harvard philosopher wrote, “to escape into open solitudes, into aimlessness, into the moral holiday of running some pure hazard, in order to sharpen the edge of life, to taste hardship, and to be compelled to work desperately for a moment at no matter what.”
Welcome to Lavasa!

“Liberty and justice for all?”

Will Phillips doesn’t believe that describes America for its gay and lesbian citizens. He’s a 10-year-old at West Fork Elementary School in Arkansas, about three hours east of Oklahoma City. Given his beliefs, he refused to recite the Pledge of Allegiance, specifically because that one phrase, “liberty and justice for all,” he says, does not truly apply to all.

That did not go over well with the substitute teacher in his fifth-grade classroom.

The Arkansas Times reports that he started refusing to say the pledge Mon., Oct. 5. By Thursday, the substitute was steamed. She told Will she knew his mother and grandmother and they would want him to recite the pledge.

Will told the Times the substitute got more and more upset. She raised her voice. By this point, Will told the newspaper, he started losing his cool too, adding: “After a few minutes, I said, ‘With all due respect ma’am, go jump off a bridge.’”

That got him sent to the principal’s office. The principal made him look up information about the flag and what it represents. Meanwhile, there was the inevitable call to his mother.

At first, mom Laura Phillips told the Times, the principal talked about Will telling a substitute to jump off a bridge. When pressed, the principal admitted the whole incident was sparked by the boy exercising his constitutional right not to recite the Pledge of Allegiance.

Phillips suggested an apology was in order — from the teacher. When the principal said that wasn’t necessary, Will’s mother started venting to friends via Twitter. Those friends, in turn, told the news media. And what would have been a minor classroom incident has people throughout Arkansas and beyond choosing sides.

As for Will, he continues to exercise his right to remain silent. It can be rough at times, he and his family admit. He has his share of supporters, however, his critics are louder and nastier — especially because he took his stand to defend gay rights.

“In the lunchroom and in the hallway, they’ve been making comments and doing pranks, calling me gay,” he told the Times. “It’s always the same people, walking up and calling me a gaywad.”

Nonetheless, Will told the paper, he is sticking to his convictions. A reporter for the paper asked Will — with all this talk about patriotism and the pledge — what he thinks it means to be an American.

“Freedom of speech,” he responded. “The freedom to disagree. That’s what I think pretty much being an American represents.”

His mother is proud.

“He’s probably more aware of the meaning of the pledge that a lot of adults,” Phillips told the Times.

Watch the CNN interview at http://us.cnn.com/video/?/video/us/2009/11/16/am.boy.no.pledge.cnn

by Tom Henderson (Subscribe to Tom Henderson’s posts)

The MOGS Live Surgical Workshop on the Cutting Edge in Gyneacological Oncology was held on 14 November 2009. Cases were performed at the Tata Memorial Hospital, Parel and relayed live to the ITC Grand Grand Central, Parel, Mumbai. In the morning session, there was a demonstration on Radical hysterectomy for carcinoma cervix by Dr.Rajendra Kerkar.During the course of surgery he especially highlighted the nuances of surgical anatomy with respect to the pelvic vasculature and lymph nodes. This was followed by a demonstration of laparotomy for a large pelvic mass. It turned out to be large degenerating fibroid. This challenging case was skillfully dealt with by the invited Israeli onco-surgeons Dr.Jacob Korach and Prof.Gilad Ben-Baruch.

The next case demonstrated was that of groin node dissection for positive groin nodes in a case of Ca Vulva, which was operated upon by the invited onco-surgeons from Israel. There was healthy interaction between the faculty in the Operation Theatre and the chairpersons and audience at the ITC.

In the afternoon session, the Israeli team demonstrated two cases of laparotomy for ovarian masses. In the first case the performed a debulking/cytoreductive surgery for a cystic ovarian tumor. The procedure was carried out very smoothly and it was much appreciated

This was followed by a secondary cytoreductive procedure. Prof.Jacob Korach and Dr.Gilad Ben-Baruch demonstrated the technique of omentectomy and interacted with the audience about their approach, their surgical technique and their experience in Israel. The operation theatre at the Tata Memorial Hospital was coordinated by Dr Rajendra Kerkar. The sessions were chaired by Dr Belvi, Dr Sanjanwala and Dr Madhvi Pandya in the morning and Dr Reshma Rao and Dr Aparna Prabhu in the afternoon. The workshop was attended by over 100 delegates not only form Mumbai but also from all over the country.

The MOGS Conference on the Cutting Edge in Gynecological Oncology was held on the 15^th November 2009 at the ITC Grand Central, Parel, Mumbai. There were 127 registrations for this event. There were 35 delegates from outside Mumbai attending the Conference.The opening session was an Invited Video Session. The faculty demonstrated a variety of open and laparoscopic techniques for the entire gamut of gynecological cancers. Dr Shailesh Puntambekar, one of the invited faculty from Pune, has been recently awarded the Golden Laparoscope Award from the AAGL. As a last minute request, he shared with the audience his award winning video on laparoscopic posterior exenteration.

The Conference was then officially inaugurated. Appreciation plaques were awarded to Dr Rajendra Badwe, Director, Tata Medical Center and Dr Rajendra Kerkar. The Israeli faculty members, Professor Gilad Ben-Baruch and Dr Jacob Korach were thanked for their efforts at the Workshop yesterday and for their visit to India. Dr Puntambekar was felicitated for his recent achievements.

The next session of invited lectures featured dilemmas in borderline tumors by Dr Anita Borges, a celebrated name in the field of cancer pathology. Dr Jacob Korach from Israel gave a balanced view on treating gynecological cancer in the geriatric patient. The concept of cytoreduction for ovarian cancers was expounded by Dr Hemant Tongaonkar.

Before lunch, Dr Amish Dalal conducted a well-planned and informative panel discussion on controversies in gynecological oncology. The panel comprised of surgeons (Dr Jacob Korach, Dr Amita Maheshwari and Dr Murad Lala), radiation oncologists (Dr V Kannan and Dr U Mahantshetty) and medical oncologists (Dr H Menon and Dr Kumar Prabhas). The discussion was fruitful and had -important take-home messages for the delegates.

After lunch, we opened up the newer vistas of minimal access surgery in gynecological oncology. Dr Neeta Warty dealt with the suspicious adnexal mass. Dr Puntambekar spoke about complications and the videos on the problems one can face were engrossing. Interestingly, most of the complications were treated laparoscopically as well. Dr Rajendra Kerkar gave a detailed account of minimal access surgery and future directions in gynecological cancers.The next session was a sponsored session on prevention of cervical cancer. Dr Ashwini Bhalerao Gandhi and Dr Bhaskar Pal from Kolkata spoke on this subject and this was followed by an audience interaction.

The last session was the Indo Israeli Keynote Address. Professor Gilad Ben-Baruch brought with him his immense experience on the subject of his interest, organ preservation and conservatism in gynecological oncology. His talk was peppered with case notes and personal insights which enthralled the audience.On the whole, the scientific content was of high quality. The program ran on schedule with adequate time for the audience to participate. The venue was well-appointed with a sumptuous lunch buffet. The hotel staff extended a great deal of co-operation to make the program a pleasure to attend and organize.

Organizing Secretaries: Sulbha Arora, Parikshit Tank, Rajendra Kerkar

Joint Organizing Secretaries: Rajendra Nagarkatti, Vipin Checker, SN Agrawal

President: Gautam Allahbadia

Secretary: Ashwini Bhalerao Gandhi

Report submitted by: Parikshit Tank

Of all the prospective parents conceiving through assisted reproduction, those in surrogacy arrangements often face the most difficult legal issues. The surrogate and usually also her husband will be treated as the child’s legal parents at birth, leaving the commissioning parents with no legal connection with their child whatsoever, even where both are the biological parents.

There is a special remedy available called a parental order. This is an order made by the family courts which reassigns parenthood after surrogacy, extinguishing the responsibility of the surrogate parents and transferring it to the commissioning couple. The process takes place post-birth: the application must be made within the first six months of the child’s life (though the surrogate’s consent is ineffective until after the first six weeks) and typically takes many months to be processed by the courts. At present, only married couples can apply, but as from 6 April 2010, unmarried and same sex couples will also be eligible.

The Department of Health (DH) is currently consulting on new draft regulations which prescribe the detail of this court process, and which will replace existing regulations that have been in place since 1994. The consultation closes on 23 November.

What is in the draft regulations?

Like the existing regulations, the proposed revised regulations apply provisions of adoption law to the parental order application process, setting out court procedure and giving a surrogate child broadly the same legal status as an adopted child. Adoption law has itself been overhauled substantially in recent years, and this is reflected in the wording of the new regulations. However, as part of the general updating, there are some important revisions being made to the existing parental order system which need to be looked at carefully.

For example, a court considering whether to grant an adoption order now has to first consider the ‘welfare checklist’, a prescriptive list of considerations which includes ascertaining the child’s wishes and feelings and considering his or her relationship with the birth family. The new parental order regulations incorporate this checklist into the parental order process. However, it does not seem appropriate for the court to have to address all these issues in surrogacy cases, given that the child will inevitably be less than six months old, and will be already living with the applicants (at least one of whom is his or her biological parent).

Importing the new adoption law without amendment fails to adequately take account of the special nature of surrogacy arrangements, and there may be a risk that this could make the process of applying for a parental order even more onerous than before. While a parental order is similar to an adoption order (in the sense that it transfers legal parenthood from one person to another), surrogacy is very different from adoption. Because a surrogate child (or at least those to which parental orders can apply) is biologically connected to at least one of the commissioning parents and is almost invariably in their care from birth, the dynamic of the family is perhaps closer to donor conception than to adoption. Adapting adoption law is therefore a difficult task, and one which we think could be handled more carefully by the regulations.

The parental order system

Even though a more fundamental review may not be within the power of these regulations, it seems impossible to look at any legislation relating to parental orders without making the point that the whole system is problematic. Parental orders were introduced as a late amendment to the Human Fertilisation and Embryology Act 1990 in response to a specific surrogacy case. At the time, surrogacy was viewed as very rare and something which occurred largely on the fringes of the law and ethical acceptability. The 1990 rules on legal parenthood clearly prioritised donor conception (making the carrying mother the legal mother, and her husband the legal father), and parental orders were designed as a limited remedy – a ’sticking plaster’ – in respect of the awkward application of legal parenthood rules in surrogacy situations.

As all those working in this field know, things have changed radically since then. Surrogacy as a form of fertility treatment has blossomed, both in the UK and abroad, and no longer affects just a small number of altruistic inter-family arrangements. Indeed, the Human Fertilisation and Embryology Act 2008 itself has endorsed this, by legalising non-profit making surrogacy agencies like Surrogacy UK and COTS and extending the categories of couples eligible to apply for parental orders. We are also seeing growing numbers of fertility patients travelling abroad for surrogacy, which brings even more complex legal challenges.

The current system, which came about by historical accident rather than a concerted policy decision, fails to meet this increased demand, and is inadequate from almost every perspective. The surrogate and her husband (who, in the vast majority of cases do wish to surrender the child) remain legally and financially responsible for the child for up to a year after the birth, and may have no legal redress against intended parents who refuse to assume responsibility. The intended parents often have no status in respect of their child for many months, including no right to make decisions or to consent to immunisations, no right to transmit inheritance or citizenship rights automatically and the intending mother has no rights to maternity leave (though this is the subject of another current campaign), leaving children very vulnerable during the early months of their lives.

The system is not an effective guardian of public policy against commercial surrogacy, since the check on payments comes at the end the process (by which time any payments have already been made) and the only sanction available to the court is a refusal to grant an order, which is almost impossible to enforce since this would prejudice the welfare of a newborn child. And, most importantly of all, these problems mean that surrogate children lack even basic protection. The problems are highlighted most starkly in foreign surrogacy cases. For example, in the landmark case of Re X and Y (foreign surrogacy) [2008], the law left surrogate twins born abroad to a British couple stateless and parentless. Such children risk being abandoned to foreign state care in the absence of complex and expensive legal intervention – surely this is an outcome which the law has an obligation to avoid at all costs.

We need a better and more planned approach to surrogacy. Of course, there are difficult and sensitive issues to be handled in creating new law. Surrogacy arrangements are among the most ethically and humanly complex in assisted reproduction, with three or even four adults involved throughout the process of conception, pregnancy and birth, and possibly third party gamete donors as well. The respective interests, protection and independence from exploitation of all these adults and, most importantly, the resulting child, need to be adequately balanced and protected by the law.
It is disappointing that such issues were not properly addressed during the government’s overhaul of assisted reproduction law last year. Although the Minister indicated that surrogacy was a sensitive issue which would be looked at separately, no firm commitment for this review, or a date, has yet been set – and it seems, given the current ’status’ of surrogacy – odd to continue treating it separately. In order to ensure that our law can cope with the demands of modern surrogacy practice, and to ensure that vulnerable children are protected, we urge the government to take a fresh look, not only at the regulations, but at the law itself.

By Natalie Gamble and Louisa Ghevaert
Partners with specialist fertility law firm Gamble and Ghevaert LLP

The MOGS FPAI Dr Avabai Wadia Memorial Workshop on Contraception was held on 26 September 2009. Cases were conducted at the Lokmanya Tilak Municipal General Hospital, Sion and relayed live to the Regus Convention Center, Bandra Kurla Complex, Mumbai.

There was healthy interaction between the faculty in the Operation Theatre and the chairpersons and audience at the Convention Center. The operation theatre was coordinated by Dr Niranjan Chavan and Dr Shailesh Kore. The sessions were chaired by Dr V D Patkar, Dr Mukesh Gupta and Dr Abha Bhat in the morning and Dr Asha Dalal and Dr Vipin Checker in the afternoon. The organizing secretaries were Dr Sulbha Arora, Dr Raju Nagarkatti, Dr Vipin Checker and Dr Parikshit Tank.

The MOGS – FPAI Avabai Wadia Conference on Contraception was held on the 27^th of September 2009 at ITC Grand Central, Parel. There were 100 delegates for this event including 12 postgraduate students. The Israeli Faculty included Dr Asher Shushan and Dr Motti Hallak. Dr Gautam Allahbadia, MOGS President welcomed the Israeli Faculty, the MOGS members and delegates from all over India. The national anthems of both the countries ie India and Israel were played to commemorate the MOGS Indo-Israeli year of Academic Exchange. Dr Usha Krishna, President FPAI and Dr Anjali Sen, Regional Director International Planned Parenthood Federation, addressed the audience. The program began with the Avabai Wadia Video Film Festival on Reproductive Health Technologies, where 8-minute videos were presented on Tubal Ligation and its reversal, Vasectomy and its reversal, Manual Vacuum Aspiration and Hysteroscopic Permanent Sterilization. This was followed by a Panel Discussion on Repositioning Family Planning Leading to Population Stabilization. The panel was expertly moderated by Dr Usha Krishna. The panelists included the Israeli Faculty as well as renowned doctors & family planning practitioners from India. The Indian Demographic scenario, the role of the Government & NGOs, factors having positive & negative influence, and advantages / disadvantages of the available methods were discussed. The Avabai Wadia Memorial Oration was delivered by Prof RP Soonawala on The Indian Contraception Story: Lessons Learnt and Future Challenges. The wonderful talk outlining the evolution of contraception over the last 3000 years with fascinating stories and personal experiences was enjoyed by all. Post Lunch we had four sessions of Invited Lectures on four different aspects of Family Planning. The Hormonal Contraception Session was sponsored by Wyeth, and covered lectures on Low Dose Oral Contraception, Modern Trends in Contraception and Injectable Contraception. The MTP Session included Medical Methods, Implications and Amendments of the MTP Act and Emerging Trends in Second Trimester MTP. The session on Surgical Approach covered the areas of Non Scalpel Vasectomy, Trials & Tribulations of Female Sterilization and Hysteroscopic Sterilization. Lastly we had a session on Contraception in Special Groups such as Adolescents, the HIV Positive and women with Medical Disorders. The day concluded with the MOGS Dr Bhanuben Mahendra Nanavati Golden Jubilee Oration, which was delivered by Prof Suneeta Mittal from New Delhi on Contraception Acceptance: Gaps and Promises. This excellent oration was founded on years of experience, data, images and personal insights. The tireless efforts of the Organizing Committee ensured that the conference was a success in all aspects – the acquisition of knowledge, free exchange of ideas with audience interaction and experts’ opinion on all aspects of family planning.

Rotunda achieved its first pregnancy with Cryoshipped Vitrified embryos from USA and transferring them into a surrogate mother.

Till now, we have received frozen embryos from many countries and successfully transferred them into surrogate mothers at Rotunda. Most of these embryos were frozen by the slow freezing process. As vitrification is becoming popular as a method of choice for freezing gametes, we have started receiving vitrified embryos from world over. Our first case of cryoshipped, vitrified blastocyst transfer has resulted in a pregnancy.

A short history lesson:

In 1972 preimplantation mammalian embryos were first successfully cryopreserved. The method was very time consuming. Slow cooling was used (1 degree/min or less) to about -80 degrees Centigrade. Then the embryos were placed in liquid nitrogen.

The embryos also needed to be thawed slowly and a cryoprotectant added and removed in many gradual steps. This was a lot of work.

The first reported pregnancy in humans from frozen embryos was in 1983.

Most of the research has been done on mouse embryos. Development of frozen thawed mouse embryos, in vitro and in vivo, is not statistically reduced as compared to their nonfrozen counterparts.

Research continues in this area and human embryo freezing and thawing protocols have improved tremendously over the past 25 years. Hopefully, the newer vitrification technique will prove to have equivalent success rates with human blastocyst embryos transferred fresh or after freezing and thawing.

What is the difference between slow freezing and vitrification?

Patients who undergo IVF may have several eggs collected. The eggs are then fertilized with a sperm and checked for fertilization. Fertilized eggs are called embryos. A patient may have multiple high quality embryos eligible for embryo transfer back to the uterus. A certain number of embryos are chosen for embryo transfer, and the surplus of high quality embryos can be cryopreserved for future use.

Previously, embryos were cryopreserved using a slow freeze method. Embryos were run through different solutions of media todehydrate the cells of water and replace it with cryoprotectant. Then the cryoprotected embryos were individually labeled and stored in cryopreservation straws, which were put in special freezers. These freezers slowly (-0.3 degrees Celsius per minute), cooled the embryos to -35 degrees Celsius using liquid nitrogen. They were then stored in liquid nitrogen (-196 degrees Celsius). At that extremely cold temperature, cellular activity is essentially brought to a halt, allowing the embryos to remain viable indefinitely.

When patients decide to use their cryopreserved embryos to try for a pregnancy, the embryos are removed from the liquid nitrogen, warmed and run through solutions of media to remove the cryoprotectant and rehydrate the cells with water. During cryopreservation, the formation of intracellular ice crystals can damage the cells of the embryo, decreasing future viability. Therefore, new methods were developed to improve cryopreservation techniques.

Recent technical advancement in the field of cryobiology has opened up various options for freezing gametes and embryos at different developmental stages. The tendency of the IVF world to switch over to natural cycle IVF and to elective single-embryo transfer has put cryotechnology in the forefront of IVF. Vitrification method is gaining popularity as the method of choice for gamete/embryo cryopreservation.

Vitrification is a new process for cryopreserving embryos. Through vitrification, the water molecules in an embryo are removed and replaced with a higher concentration of cryoprotectant than in the slow freeze method. The embryos are then plunged directly into liquid nitrogen. This drastic (-12,000 degrees Celsius per minute) freezing creates a glass transition temperature, commonly called a “glass” state, and the embryos are vitrified. This quick freezing reduces the chance for intercellular ice crystals to be formed, thus decreasing the degeneration of cells upon thawing for embryo transfer.

In 1998, it was shown that vitrification using an EG-based vitrification solution (EFS40) (Kasai et al., 1990) with conventional cryo-straws was effective for human embryos at the 4- to 8-cell stage (Mukaida et al., 1998). The effectiveness of vitrification was confirmed for human embryos at the 8- to 16-cell stage (Saito et al., 2000) and the morula stage (Yokota et al., 2001b), also using EG-based solutions.

Many studies show survival rates of vitrified embryos to be far higher than survival rates of slow freeze embryos. Thus far at Rotunda, vitrification results are very encouraging, and we are excited to offer this cutting edge technology to our patients.

For more information about vitrification, ask to speak to the embryologist at your center.

Vitrification, a cutting edge technology for cryopreservation of embryos, is now available at Rotunda – Center for Human Reproduction.

Shalom & Namaskaar! The MOGS Indo-Israeli Year is well on its way with the second clinical meeting creating waves in the Ob-Gyn community in India. We had a star-studded faculty from both India & Israel. Prof Israel Shapiro is the President of the Israel Society of Ultrasound in Obstetrics & Gynecology. He is the Coordinator of the Scientific Meetings of the Society. He is also the Chairman of the Academic School of Ultrasound in Obstetrics & Gynecology. He is attached to the Department of Obstetrics & Gynecology at the Bnai-Zion Medical Center, Haifa. He has vast experience in Industrial Counseling and is currently the Consultant of General Electric (GE Healthcare) in developing ultrasound equipment.In fact, he developed the first transvaginal probe prototype with Elscint in Israel eons ago!Prof Shlomo Lipitz was awarded his MD degree in 1984 from The Hebrew University, Jerusalem and thereafter completed a Clinical Fellowship at The Fetal Medicine Unit, Department of Obstetrics & Gynecology, University College Hospital, London. He is now the Director of The Fetal Medicine Unit at The Sheba Medical Center, Israel. His areas of interest are Amniocentesis, Chorion Villus and Fetal Blood Sampling, Intrauterine Fetal Blood Transfusions, Shunts, Multifetal Pregnancy Reductions, Laser Therapy in Twin-Twin Transfusion Syndrome and Bipolar Coagulation in Monochorionic Twins.Prof Reuven Achiron is the Director of the Ultrasound Unit at the Department of Obstetrics & Gynecology at the Chaim Sheba Medical Center, Tel Hashomer. He has been invited to the World Congress of Ultrasound in Obstetrics & Gynecology thirteen times. He is a Member of the International Ultrasound Society and has been on the Editorial Board of the journal Ultrasound in Obstetrics & Gynecology. He has published six monographs and over 130 original articles on Obstetric Ultrasound & Fetal Diagnosis.Dr Chander Lulla is one of the pioneers of ultrasound in India and is the most-sought after interventional sonologist in this part of the world. He is affiliated to the Nowrosjee Wadia Maternity General Hospital as well as to the Jaslok Hospital in Mumbai. The formidable four were all set to showcase their skills to an eager audience sitting in two different auditoriums; the PG students in the Main Lecture Theatre at KEM hospital & the practicing gynecologists at the ITC Grand Central which is a kilometer away.

The Indo-Israeli workshop on fetal diagnosis and intervention organized by the Mumbai Obstetric and Gynecological Society and Seth G.S. Medical College, KEM hospital (Department of Obstetrics & Gynecology) was held on 6th June 2009 in the department of Obstetrics & Gynecology, KEM hospital. The workshop equipment was provided by Wipro GE Healthcare. Prof Reuven Achiron , Prof Shlomo Lipitz and Dr. C.P. Lulla demonstrated live 2-D and 3-D fetal ultrasound all through the day from 9am to 5pm with a short Lunch break! Live scanning of eleven cases was performed with detailed interaction with the audience. Normal first, second and third trimester ultrasounds, malformation scans, 3-D ultrasound and an interventional procedure of placental biopsy as a prenatal diagnostic technique in a case of thalassemia were demonstrated. Various congenital malformations including cranial, cardiac, pulmonary, renal, skeletal and gastrointestinal were demonstrated. The correct methodology for anomaly detection and the management protocols were discussed. The postgraduate students and the delegates at ITC Grand Central found the workshop very informative and useful for clinical practice.
.
The Conference on Fetal Diagnosis and Intervention was held the next day -the 7th June 2009, Sunday at the ITC Grand Central, Parel, Mumbai. There were 145 registrations for this event. The opening session was on free communications. Dr Shailesh Kore was awarded the prize for the best paper. His subject was prediction of preeclampsia by placental laterality. This was followed by a session on the journey of a fetus from the womb to the pediatric operation theatre. It was a collaborative effort by Dr Nitin Chaubal and Dr Sanjay Oak.The Israeli Faculty were thoroughly impressed with this presentation & congratulated both the speakers (see video). Prior to the Key-note addresses, we played the National Anthems of both countries. This was a truly emotional moment for our invited guests. The international faculty presented the Keynote Addresses on Applications of current ultrasound in fetal medicine (Professor Reuven Achiron) and Diagnosis and treatment of complications of monochorionic twins (Professor Shlomo Lipitz).

The post lunch session was a visual treat with twelve videos from invited faculty.Prof. Shapiro’s video was the run away winner of this Video film session (see video). This was followed by invited lectures by Dr C P Lulla, Dr Aniruddha Badade and Dr Sameer Dikshit.

The Dr M Y Raval Oration was delivered by Professor Israel Shapiro on the subject of “Three Dimensional Ultrasound: Gimmick or Breakthrough”. This 100 minute oration was founded on years of experience, data, images and personal insights. It was laced with the right dose of humor and received a standing ovation from the audience (see video).

The chairpersons ensured that the sessions were interactive and kept the program running on schedule. The venue was well-appointed and hospitable. Once again, on behalf of MOGS we would like to express our thanks to the superlative Banqueting team at the ITC Grand Central. I would also like to mention that the success of this meeting was shaped in a large way with the untiring efforts of the hands-on conveners Dr Sulbha Arora & Dr Parikshit Tank. The MOGS office staff ensured that the Registration Desk & other admin formalities purred on smoothly like a BMW engine! Thank you delegates – We had delegates from Arunachal, Bihar, Haryana, Gujarat, Maharashtra & Sri Lanka too! I am still receiving positive feedback on this meeting from doctors who were not present , but have heard about this meeting from registered delegates. This is really heartening & we look forward to the Late Dr Avabai Wadia Workshop & Conference on Contraception in September 2009. Before I pen off, I would like to express my gratitude to the supporters of MOGS who were present in the exhibition hall on both days. Thank you Danny for making our Indo-Israeli dream a reality. Lakhaim!

For many couples, being infertile no longer means having to go through life without children. Modern science and continued research in this direction has helped millions of couples all over the world become parents to a healthy child. Even issues that were once thought to make it impossible to conceive a child can now be overcome. One such female fertility problem is having a lack of eggs available for fertilisation.

What is Egg Donation

So what is a woman to do if her eggs have been found to be of poor quality or low quantity? Using an egg donor can significantly increase your chances of pregnancy. Compared to a your own eggs, using donor eggs are typically a better option when you do not have a very good ovarian reserve.

Ovarian reserve is the quantity and quality of eggs present in a woman’s body and this number differs for from every woman. In some cases, in spite of a high number of follicles, a woman may not have her eggs mature due to issues like premature ovarian failure. Other women may have eggs that are incapable of being fertilised or implanting on the uterine wall due to structural defects.

On the whole, donor eggs may be a better option when:

- Premature ovarian failure due to genetic or auto-immune disorders has been diagnosed or has occurred due to radiation therapy or artificial removal of the ovaries

- A woman is over 40 and is going through or has already gone through menopause

- There has been no response to fertility drugs

- There is a high level of FSH in the blood (FSH is a hormone that stimulates follicles to mature into eggs. If its level is too high in the blood, it signifies fewer eggs present in the body.)

- A woman cannot conceive in spite of repeated IVF cycles

- There is a risk of transferring genetic disease, like haemophilia, to the child from the mother

Physical Considerations

Doctors recommend that if a couple is opting for donor eggs, the mother should undergo a detailed medical analysis to check whether her body is suitable for pregnancy or if she is at a health risk. This particularly becomes important for women aged 40 years or more.

The uterus is also checked for deformations such as fibroids and scarred tissues that may not allow the egg to implant.

Psychological Considerations

The decision of using an egg that is not yours is a difficult one. The choice of the donor, her being known or anonymous, the ethical or religious aspects, the choice of telling the child, the involvement of relatives and friends and most importantly the parents’ firm will to use donor eggs are some aspects of the issue that have to be dealt with.

Psychological counseling can be very helpful for couples in this regard to make a concrete decision.

Selection of Donor

Choosing a donor is a crucial aspect. She might be a family friend, relative or a person known to you. There are also many organisations and online sites that provide a list of donors who are willing to donate eggs. If you are already attending a fertility clinic, they too may have a pool of egg donors from which you can choose. Some couples have also successfully advertised for donors, though this may not be a safe approach, as the person’s background cannot be sufficiently verified.

Depending on how you locate your donor, the donor may remain anonymous. For instance, if your infertility clinic offers an egg donor program, you will likely be able to read about a donor’s health history, physical traits, education level, possibly profession and other general information. However, you will not learn the donors name, address or any other information that will allow you to identify them.

In general, women between the ages of 18 and 35 who are physically healthy, non-smokers, with no hereditary or sexually transmitted diseases and who are psychologically fit are most suited to become donors.

Donor’s Check-Up

In order to ensure that a donor is physically, genetically and psychologically healthy for the donation, she has to undergo a number of tests. These may include:

- Blood tests to know the blood group, blood count and check for any infectious diseases might be passed on to the child

- HIV tests

- Hepatitis B and C tests

- Test for syphilis

- Medical history of the donor and her family to ensure that no hereditary problems are present

- The level of hormones present to know how fertile she is and whether her eggs are healthy enough

Psychological counseling is also advised to know her better as well as prepare her for the process.

The Procedure

Once you have decided to use donor eggs, the first step involves consultation with a physician or an organisation providing the donors. This helps in identifying your needs better and also answers any queries you might have regarding the procedure. The consultant also tries to find out your physical characteristics, likes, and dislikes to best match you with a donor.

After the selection of the donor comes the evaluation cycle phase.

Egg Donation Cycle

When the process of pregnancy takes place naturally, the uterus of the mother prepares itself by thickening the lining of the inner wall, while the body automatically produces an increase of hormones, like estrogen and progesterone, for the conception. But in the case of pregnancy with donor eggs, a mother’s body is not prepared for pregnancy and therefore the hormones have to be artificially induced.

A prospective mother will undergo an evaluation to determine the correct amount of estrogen and other hormonal supplements to be administered prior to transferring a fertilised donor egg. This is done by measuring your blood estrogen level and through ultrasound check ups to observe the uterine lining. The doctor may also give oral or estrogen injections to raise your hormone levels, which you may continue to take for a period of 10 to 14 days.

Then, the donor and the mother’s cycle are synchronized with the help of birth control pills. Once this has been done, the donor is given fertility drugs to promote a greater number of eggs being matured during her cycle. Meanwhile, you are given the appropriate dose of estrogen to prepare your uterus for the embryo.

A day before your donor under goes egg retrieval, you are given progestrone vaginally or with an injection. When the donors egg are retrieved, your partner will provide a semen sample that day so that his sperm can be combined that day with the freshly retrieved eggs. After 3 to 5 days, once the embryos have formed, two to three embryos will be transferred to your uterus as it normally would during an IVF procedure.

You will continue to receive estrogen and progestrone doses to help encourage a pregnancy. 10 to 11 days after the embryo transfer, a pregnancy test is carried out to check the success of the procedure.

Benefits

There are a number of benefits to using donor eggs:

- A donor egg from a younger woman increases the chances of conception to 50% as compared to 15% to 18% with your own eggs. This is because donor eggs are of better quality and there are more numbers of eggs available for fertilisation.

- As the donor egg provides a better chance of fertilisation, you may not have to undergo as many IVF cycles thereby saving yourself from the physical, mental, and financial anxieties associated with each cycle.

- Donor eggs provide an opportunity to conceive a child whose genetic make up resembles one of the parents.

- You are able to experience the process of giving birth when the fertilised egg is placed inside your uterus, which is not possible with an adopted child.

Risk Factors

A common fear of parents is that their child will be born with a genetic defect. Donors, however, are usually extensively checked for any signs of physical and genetic abnormalities. As a result, the chances of your child being affected by genetic problems caused by a donor are significantly reduced. However, they cannot be completely eliminated.

Unlike donor sperm, which is frozen and quarantined for at least six months, donor eggs are not frozen. This is because the freezing technique for eggs has yet to be perfected; in fact, freezing eggs typically damages the egg making it unusable. Therefore, fresh eggs must be used when you opt for donor eggs. Some infections, like HIV, may not produce a positive result until months after the infection, which means, although a donor may be tested, there is still a chance that she, and her eggs, could have a serious infection.

Other risks associated with this procedure include those associated with the IVF process itself as well as the chance of miscarriage if your body does not respond to the embryo. Furthermore, because two to three embryos are transferred, your risk of a multiple pregnancy occurring is increased.

Success Rate

Research has shown that there is about a 48% to 50% chance of conceiving using donor eggs. For women above the age of 40, who in general have a lower quality and quantity of eggs, the chances of conceiving with a donor egg is 5 times more than with their own eggs.

A major new trial recently published in the journal Fertility and Sterility shows that for couples beginning infertility treatments, an accelerated path to in-vitro fertilization (IVF) can offer a shorter time to pregnancy, cost savings of nearly $10,000, and a lowered risk of multiple births.

For the first time, these results demonstrate that the long held treatment combining fertility injections with insemination (IUI) does not have a place in infertility treatments today. This study also demonstrates that today’s infertility treatments are very successful. When fertility care is covered by insurance (or alternatively when couples can afford all needed treatment), the vast majority will have a baby, and the quickest way to get pregnant is to follow this new shortened protocol.

Elizabeth Ginsburg, President of the Society for Assisted Reproductive Technology, commented, “This is a very important study that will likely influence physicians to reduce the number of stimulated inseminations for patients with unexplained infertility. Adoption of such an accelerated course of treatment could result in many patients conceiving in less time with less expense.”

Lord Winston, emeritus Professor of Fertility Studies at Imperial College London and pioneer of IVF, has criticized fertility clinics for over-hyping egg freezing services. In an interview with the Daily Mail newspaper he accuses providers of creating false optimism in the effectiveness of the procedure particularly where signing up patients for purely ’social’ reasons. Before use of egg freezing grows further he calls for more research into both the effects of egg freezing on the ability to later conceive and into the long-term health implications for those born
from frozen eggs.
The comments come in response to calls, made at last week’s European Society for Human Reproduction and Embryology (ESHRE) annual conference, for greater availability of egg freezing as an option for women who are postponing pregnancy until later in their lives. Lord Winston’s comments partially mirror a joint statement made in February by the UK’s Royal College of Obstetricians and Gynaecologists and the British Fertility
Society (BFS) which also called for women not to freeze eggs for social reasons.
Lord Winston noted that the production of six to ten eggs for freezing involves both the risk of ovarian hyperstimulation syndrome for the woman and an increased likelihood of chromosome defects in the eggs produced. Producing such a quantity of eggs he sees as dangerous yet also inadequate to ensure a viable embryo is produced. The BFS has stated that the average chance of success for any individual frozen egg is six per cent and only four children have been born from frozen eggs in the UK to date.
Additionally, the lack of data on the long term health effects – the first children conceived with frozen eggs are only now five – is provided as reason enough for adopting a cautious approach towards increasing availability of egg freezing and makes encouraging those without a pressing need (such as impending cancer treatment) all the more dubious. Lord Winston states, in unequivocal terms, ‘in my view it is irresponsible [for clinics] to egg freeze until long-term animal research has been done’. The most detailed research to date is due to be published next month.
Describing the procedure as a ‘quick fix’, Lord Winston sees the best path forward for prolonging the ability to have a child, for social reasons, is to attempt to develop better means of postponing the menopause. Though the procedure can be justified for those with serious medical conditions it is not be encouraged as a means of delaying motherhood. The provision of egg freezing for social reasons, available for between £2,500 and £5,000 at 45 clinics in the UK, is in his view simply an ‘undesirable commercial activity’ and should not be encouraged.