Polycystic Ovary Syndrome: Lessons learnt from Atkins Diet & Alternative Medicine

PCOS is a common condition that affects up to 10% of all women of reproductive age. It is characterized by enlargement of the ovaries, irregular menstrual cycle, failure to ovulate, obesity, high levels of insulin in the blood and insulin resistance, excessive hair growth (due to increased testosterone), and infertility. More than 50% of all women with PCOS have high insulin levels, which may be a risk factor for diabetes, high blood pressure, blood clots, and heart disease.
Simply following a low carbohydrate diet can offer effective relief from distressing symptoms. In a report to the Endocrine Society 2005 meeting, Dr James Hays demonstrated that polycystic ovary syndrome (PCOS) is linked to a phenomenon called insulin resistance, which can be successfully reversed by reducing carbohydrate intake. Continually eating high carbohydrate meals and snacks can make your body's cells become less sensitive to insulin, so that more and more is required to do the job. Having a high level of insulin in your bloodstream eventually makes your ovaries and adrenal glands over-produce male sex hormones. These high levels of male hormones can cause the symptoms of extra body hair, acne and moodiness and increase your risk of heart disease. They also interfere with the normal release of hormones from the pituitary gland in your brain, which regulate the process of ovulation and the production of female sex hormones in your ovaries. This can cause absent or irregular periods and infertility.
The first step one should take to relieve symptoms of polycystic ovary syndrome (PCOS) should involve cutting down on carbohydrates. Doing so will mean that your insulin levels will naturally fall and other hormones in your body will gradually begin to balance out again. In his book, Dr Atkins' New Diet Revolution, Dr Atkins identifies a low carbohydrate diet as being central to the natural treatment of polycystic ovary syndrome (PCOS). He says, "It all goes back to lesson one in don't cause your metabolism to struggle incessantly with high insulin levels, weight gain and looming health tragedies". So remove all refined sugar products from your diet, such as cakes, confectionery, sweet drinks, honey and starchy foods such as bread, pasta, rice and potatoes. The good news is that you won't feel hungry since you can eat all the chicken, fish, seafood, omelettes, rich creamy sauces, crisp salads and green vegetables you want. Just make sure that you drink at least 2 liters of water a day, to flush away harmful toxins that will be released as your body breaks down fat. Dr Atkins also views nutritional supplements as an essential part of his diet plan, particularly in the treatment of polycystic ovary syndrome (PCOS). One that has recently proved its worth is N-acetyl cysteine, or NAC. Women with polycystic ovary syndrome (PCOS) and high insulin levels who took between 1.8 and 3 grams of NAC a day for five to six weeks, were found to have a significant reduction in their insulin levels and improved insulin sensitivity (Fertility and Sterility 2002; 77: 1128-35). Dr Atkins also recommends the amino-acid glutamine to prevent sugar cravings. Animal studies have shown that it helps combat insulin resistance too. Researchers at Vanderbilt University in the US found that glutamine improved blood sugar control so dramatically that they concluded "glutamine has potential benefit as a nutrient adjuvant during clinical situations associated with insulin resistance" (J. Nutr. 1996; 126: 273-79). A daily dose of 500mg is recommended. Chromium is a very important mineral if you have polycystic ovary syndrome (PCOS), since it encourages your liver to produce a substance called glucose tolerance factor (GTF), which increases the effectiveness of insulin. Chromium deficiency has been shown to produce symptoms of insulin resistance and diabetes (Health and Nutrition Breakthroughs, Sept 1998). In one study, chromium supplements combined with an exercise program reduced insulin and cholesterol levels (J Nutr Biochem 1998; 9: 471-475). Take 200mg to 400mg of chromium picolinate a day. The B vitamins are also important in helping to correct the symptoms of polycystic ovary syndrome (PCOS). B3 is a component of glucose tolerance factor (mentioned above), B5 helps to control fat metabolism and B6 balances hormone levels. A relative of the B vitamins, called d-chiro-inositol, increases the effectiveness of insulin in patients with polycystic ovary syndrome (PCOS), reduces male hormone levels and restores normal periods (NEJM 1999; 340: 1314-20). This compound is not available yet in the west as a nutritional supplement, but it is present in soya lecithin. Dr Atkins advises patients to take a B-complex supplement and one tablespoon of lecithin granules a day. In India, a traditional Indian ayurvedic drug being advocated for hyperinsulinemia in PCOS called Hyponiid (Charak Pharmaceuticals, India) also contains large amounts of D-chiro-inositol and could be used as a supplement.
There is no cure for PCOS, but doctors often recommend birth control pills, which help decrease the levels of testosterone, estrogen, and progesterone, thereby reducing hair growth and shrinking the cysts in the ovaries. However, birth control pills have not been shown to improve insulin resistance. N-acetyl cysteine may be useful in picking up where birth control pills leave off, by increasing insulin sensitivity. While it is possible that birth control pills and NAC could work in conjunction with one another, the interaction between the two treatments is unknown.
In this preliminary study, 31 women with PCOS were given 1.8 to 3 grams per day of NAC for five to six weeks. Blood measurements for glucose and insulin were taken before and after a glucose tolerance test, both at the start of the study and at the end of the treatment period. No dietary modifications were made during the study.
Initial measurements showed that 14 of the 31 women had normal insulin levels, while the remaining 17 had abnormally high levels of insulin. Women with high initial insulin levels who took NAC had a significant reduction in insulin levels following the glucose tolerance test and also showed improved insulin sensitivity. On the other hand, those with initially normal insulin levels had no improvement in any measurement. This suggests the benefit of NAC in women with PCOS may be restricted to only those women who already have high insulin levels to begin with.
NAC is an amino acid that has commonly been used as a treatment to break up mucus in the lungs. It is also a precursor to glutathione, a powerful antioxidant in the body, which has been shown in other studies to improve insulin sensitivity. Although glutathione levels were not measured in this study, the improvement in insulin resistance seen in the group taking NAC may have been due to increased amounts of glutathione; however, future studies will need to clarify this issue.
Some physicians recommend taking NAC on an empty stomach, so it does not compete with other amino acids in food for absorption. People taking single amino acids should also make sure they eat adequate amounts of protein, to prevent upsetting the balance of amino acids in the body. In addition, some doctors recommend that long-term supplementation of NAC (more than a few weeks) be accompanied by 15 mg of zinc and 2 mg of copper per day, because preliminary evidence suggests that NAC might deplete these minerals.
N-Acetyl Cysteine (NAC), an antioxidant with insulin-sensitizing properties, may boost the effectiveness of other pharmaceutical treatments for polycystic ovary syndrome (PCOS), according to a new placebo-controlled, double-blind, randomized trial (Fertil Steril. 2005 Feb;83(2):367-70). Researchers studied 150 women who suffered from PCOS that was resistant to clomiphene citrate, one of the drugs used to treat this condition. The subjects, ages 18-39 years, were all undergoing therapy for infertility. The researchers randomly assigned the patients to receive either 1.2 grams of NAC per day or a placebo. Each of the two groups also consumed 100 mg per day of clomiphene citrate for 5 days starting at day 3 of the cycle. The combination of clomiphene citrate and NAC significantly increased both ovulation rate and the pregnancy rate in women with clomiphene citrate-resistant PCOS. The NAC-treated subjects experienced a 49.3% increase in ovulation compared to only a 1.3% increase in placebo-treated subjects. The NAC treated subjects also experienced a 21.3% pregnancy rate whereas none of the placebo-treated subjects were able to conceive. Two of the NAC-treated patients who were able to conceive, however, did eventually miscarry. Although agents that stimulate the ovaries sometimes cause ovarian hyperstimulation syndrome (OHSS), a serious condition that causes pain and potentially life-threatening consequences, no cases of ovarian hyperstimulation syndrome were reported in the NAC group. The researchers concluded that NAC is safe and well tolerated.
Even in the West & the rest of the developed world, researchers & doctors & health authorities are looking at alternative medicine with an open mind. Dr HS Palep is presently lecturing American Universities on the benefits of Ayurveda. I wonder why such draconian laws have been passed in a country like India against Gynecologists using traditional Indian medicine!

The Tata Indicom Apathy

This might be just the place to put out a scam that seems to be prevalent in the Bandra area. In the second week of December 2006, some Tata Indicom marketing executive slipped some Tata Indicom Broadband promotional literature under our main door. On checking with the building manager, he said that the Tata Indicom people had distributed such pamphlets to all flats not only in our building but in the entire area. There were two mobile numbers on the pamphlet alongwith an illegible small rubber stamp of some agency on the reverse page of the pamphlet. I needed the internet connection and called one of the two cell numbers namely- 9821774463. One Mr Sameer Ahmad answered the cell and promptly came over to my consulting room the next evening(19.12.2006). He helped me select the appropriate internet plan & I gave him a "crossed" cheque favoring "Tata". I specifically asked him if I need to complete the Payee name as Tata Indicom or Tata
Broadband, but this gentleman insisted that they are collecting all checks as only favoring Tata. I gave him a check for Rs. 4580 favoring Tata drawn on State Bank of India(Carter Road Branch) bearing Number 476910 dated 19.12.2006. He assured me that my internet connection would be connected within a week. After 10 days of this man collecting the check, we started chasing him on the two cell numbers we had. He would not take any calls & most of the times the number would be unavailable. In January first week, we realized the numbers have been disconnected & in a few days more the numbers were apparently re-allocated to some new customers. Next we called the Tata Indicom helpline & were told that my name was no-where on their records. We confirmed our bank statement that clearly showed that this crossed cheque was cleared on 20.12.2006 itself. We had a mini-struggle to try and trace out the account where this check was encashed. My receptionist followed up with one Mr Salvi at the SBI, Carter Road Branch persistently till he traced out the beneficiary of this check who had an account with UTI bank in Marol. We asked Mr Salvi to get us a copy of my issued check. I could finally get hold of this copy only in April 2007 and to my horror, my check was forged (over-written) to read the payee as Tofail Ahmad Siddiqui. Tata was touched up with a pen to read as Tofail. I personally called up the customer service helplines of Tata Indicom to complain about this scam. The tele-executives were polite but said they could do nothing about my complaint. I pleaded with them on more than one occasion that this group might have collected lakhs of rupees in this way from one locality, but they were helpless. They even took my cell number upon my insistence and request to ask one of
their senior managers to talk to me, but no one ever called. I wrote to customer service but received no reply. Finally, I went personally to the VSNL headquarters in Fort & the receptionist there directed me to the Tata Indicom Prabhadevi office. I bumped into an old friend Mr Rashid Baba who is now a senior officer with Tata Indicom & handed over the following set of documents to him:
1.My Email correspondence with Mr Rajesh Chathnath of Tata Indicom
2.My Tata Indicom Broadband Receipt No 0980657 dated 19.12.2006
3.My SBI Passbook copy showing that the amount was debited from my savings account on 20.12.2006
4.Copy of the encashed check upon which forgery was performed.
He assured me someone from the vigilance team would get back to me. I was hoping that the vigilance Department of Tata Indicom takes up this matter seriously because it is a big slur to their image, with their own agents running such a scam. I have become disheartened with the Tata Indicom response to my complaints & have also approached my local police station. The Police station was another story. No one was ready to register the complaint & a kind soul suggested that since the culprit was traced by my clinic to Marol, we must register the police complaint at Marol Police Station. Felt like doing the RDB dance there. I got frustrated and sent a copy of my complaint to Office of the Addl. Commissioner Police-Economic Offences Wing, Mumbai. On two subsequent occasions after December, I have seen this man carrying some folders/papers on Hill Road. Probably, this group is still active & ruining the Tata image completely. But no-body is bothered. Life goes on.
Just when I thought nothing is ever going to happen, I received a letter from the Office of the Addl. Commissioner Police-Economic Offences Wing, Mumbai asking me to go and meet the Sr. Inspector of Police, Bandra Police Station who might investigate the complaint. I will go there on the coming Monday.
I ask myself why am I going the distance. Why dont I just forget the 4K & concentrate on my patients. I don't know... maybe I want to make a difference to my city, my country. Hope someone gets the culprits to book. I promise to give it my best shot.
Jai Maharashtra. Jai Hind.

Corporate Hospitals & Mortal Doctors

Escorts & Naresh Trehan hogged all the TV channel headlines & print headlines for over a fortnight. I was remembering my own recent stint at a Corporate Hospital. This is just to reiterate that run-ins with Corporate hospitals can be damaging to your career. About three years ago I was offered a challenging portfolio in a Corporate hospital to set-up a state-of-the-art IVF unit. It was hard work but I enjoyed the challenge of getting the team together & the act together. We had to our credit India's first Trans-ethnic surrogate pregnancy recorded from this young unit. A Singaporean couple went home with a healthy baby boy who spent 9 months in an Indian mother's womb. The hospital Press - Release was as follows:
An overseas couple who are ethnically Chinese, had opted to undergo surrogacy at the Center for Human Reproduction in 2005. An Indian surrogate mother delivered a healthy baby boy on 19.05.06 at 3:30am. Both baby and mother are healthy and doing well. This is the first documented Trans-ethnic Surrogacy Pregnancy successfully delivered on the Indian sub-continent. The doctors who led this successful medical breakthrough are Dr.Gautam Allahbadia, Chief Consultant , Center for Human Reproduction and Dr. Yashodhara Mhatre, Consultant, Center for Human Reproduction. The team included Dr. Anita Soni, who was the Obstetrician who delivered the baby.
In 2007 March , I was shocked to read the Hospital Magazine released on their annual day. The Trans-ethnic surrogacy case was one of the three achievements of the hospital since inception. In the "Our Achievements" section, an entire color page was dedicated to this medical miracle with a one inch title credit. And to my surprise, the title credit carried only my erstwhile associate's name. What disheartened me most was that everyone connected with the hospital knew that I was the IVF team leader & had planned the protocol & done the Embryo Transfers. No one spoke up for me. Immediately there-after I was told I was not getting enough work to the Dept. & that I was travelling excessively & the hospital wanted a full-time doctor who would not practice outside the hospital. I left with a smile on my face & a tear in my eye. I loved the challenge of setting up a successful Dept.
Anyways destiny always takes care of its own children! I loved the place & continue to refer patients there. God Bless!

Are Indians Genetically Inferior?

I remember my first meeting with Prof. VN Shrikhande at the Bombay Hospital when I had joined as a visiting research fellow in 1992. The first topic we discussed in the Surgeon’s room was “Are Indians genetically inferior?” and “Why no Indian working in India has ever been awarded a Nobel prize ?”. Well, his theories were wonderful & ICMR should give him an oration on this topic? But it is a fact that India is the only country where cows stroll across runways & bullock carts cross National Highways with impunity☺
Once we understand why we have been backward, and why we still are backward, we should be on the way to success. In many areas of space technology, defence systems, nuclear engineering, telecommunications and the like, we are admittedly at the cutting edge of technology. At the same time, it is proper for us to enquire why we built temple halls with a thousand pillars a millennium after others had mastered the design of the arch. Or, consider why we built the great sundial in Jantar Mantar long after telescopes had become commonplace, and why even today we remain the only manufacturers of vintage cars. When Alexander bore down on us with his swift horses, we stood stuck in the mire with elephants. We learnt no lessons from our defeat at his hands. 1700 years later, we lost again to Babar because, in all those intervening centuries, we had remained loyal to elephants and further had nothing better than muskets to counter Babar's cannons. Even in 1962, the Chinese humiliated us because they had modern arms and we had none. Why do we stick to obsolete technology all the
time?

Let me illustrate the issue with a couple of stories. The first concerns a dhabha where, as is to be expected, the food was delightful. A guest after enjoying the meal, washed his hands and asked for a towel to dry them. The towel that was proffered was so filthy that he was driven to protest. The dhabha owner was perplexed. He replied "Saab! Hazaron log use kiye hain; abhi tak koi complaint kiye nai!". The second concerns a seller of gud in a mandi in Rajasthan. Noticing that the whole mound of gud was covered with flies, a young police officer asked the shopkeeper to do something about it. The shopkeeper was unperturbed. He said: "Wo kitna kha sakta hai, saab!" (How much can they eat, sir!) .
These anecdotes tell us a great deal about our culture. One, as in the case of the dirty towel, we are content with the barest minimum utility and have no concern for quality. Two, as in the case of flies, we measure what is irrelevant. We are backward in technology not because we do not have the materials, not because we do not have the talent, not because we do not have the money, not even because we cannot get the technology. We are backward because, as Sardar Vallabhbhai Patel has postulated, our culture makes us think poor.

Technology innovation is like a baby. As you know, a baby is defined as an alimentary canal with a loud voice at one end and no responsibility at the other! Likewise, technology innovation is a conduit for digesting natural resources - with environmental disturbance at one end and science at the other. Further, in the Indian tradition of caste, imparting knowledge to the undeserved is prohibited. So, textbooks are not written with the fear they may fall into wrong hands. Unfortunately, we were also taught that innovation requires intuition that comes out of a form of Immaculate Conception. That needs a miracle. Unfortunately, in the strict sense, technology permits no miracles. Instead, as Kuhn points out, revolution is actually the culmination of continuous evolution - it is always one last straw that breaks the camel's back. In our culture, in theory, we may question but as we do not experiment, we have no logical way of doing so. That is why we still manufacture cars exactly the way they were designed nearly half a century ago. In this respect, Indian intellectual culture is similar to that of ancient Greeks. They too felt that the best way to develop new ideas is to sit under a tree and think and think and think until realisation comes like a bolt of lightening.

There is the story of Aristotle decreeing that women had less number of teeth than men. Such was Aristotle's reputation in the Western world that, for centuries, people did indeed believe that women had fewer teeth. They could have easily verified whether that was true or false by asking their wives to open their mouth. They did not because in those days they too did not believe in experiments. Eventually, they started experimentation, and progressed. We do not do so as yet. So, we remain stuck. Not many people are aware that the first rockets ever used in war were of Indian origin. Almost exactly two hundred years ago, Tipu Sultan stuck terror among British troops with his rockets. Unfortunately, his rockets were so primitive and so uncontrollable that they devastated Tipu's own troops as often as they hurt the enemy. So, Tipu Sultan abandoned his rockets instead of trying to improve them. (As a matter of curiosity, the only sample of Tipu's missiles is not in India, but in the British War Museum.) The moral of the story is, generating ideas is not the same as converting ideas into usable products. The latter needs patience, time, determination and above all empathy.

Many of us have been fascinated by the extraordinary progress of East Asian countries. As Lawrence Summers has explained, the East Asian success is attributable less to technology innovation and more to higher application of capital. East Asian countries operate with technologies that are available for sale, not with innovations of their own. However, a large country like India cannot become rich by selling TV sets and notebook computers based on somebody else's design. Then, what can we, who missed the bus of post-war expansion, do? The story of drug industry indicates the way out. Drug prices often fall to less than a tenth the moment their patents expire. That is an indication of the power of technology innovation. Monopolies are always profitable. However, in that respect no commercial monopoly can hold a candle to technology monopoly. That is, what India needs most is technology of her own. India can become rich not by exploiting labour, not by borrowing capital but only through technical innovation.

As it has been said, it is better to be approximately right than to be precisely wrong. Let me give one example. It is said that Howard Hughes the self-made billionaire of yester years approached a banker for a loan to build an aeroplane. According to the story, the banker refused to lend him the precisely calculated amount the gawky youngster wanted. He insisted on lending him a lot more because a new venture is always uncertain, and there will always be unexpected demands. Compare that banker's wisdom with the way our bureaucrats and the government lending agencies operate. Our administrators pare down financial support to the barest minimum in the expectation the returns will then become maximum. As we know, more often than not, our bankers and our government lose everything. In contrast, Hughes's banker not only saved all his investment, he made millions for himself and for Hughes too. Once again, precise answers are wrong, approximate ones are right! Our country will march forward in technology only when our managers stop insisting on assured returns, and prepare to gamble to lose all --- or win the jackpot!

Then, there is the even more startling case of the Xerox Corporation offering to sell to IBM the patents of the Xerox copier. In turn, IBM turned to Arthur D.Little, the famed management consultants, for advice. Those management experts calculated that even if the Xerox copier took away 100 percent of the existing market for carbon paper and for dittographs, it will not be financially viable. So, IBM turned down the offer. Against such advice, Xerox persisted. The rest is history. The flaw in the management approach of Arthur D. Little was, there is no way of conducting market research on a product that does not exist, a flaw nobody in India appreciates. As Schumpeter pointed out over eighty years ago, "innovations do not as a rule take place in such a way that first new wants arise spontaneously in consumers ... It is the producer who as a rule initiates economic change, and consumers ... are taught as it were to want new things.
It would be nice if our managers, whether in the government or in industry, ask of themselves every day, and day after day, "Am I using this technology because it is good, or is it because I am used to it?" As Robert Frost has written: Two roads diverged in a wood, and I took the one less travelled by, And that has made all the difference.

In one of the most evocative passages in our Upanishads we are given the advice:
Shraddhaya deyam, ashraddhaya adeyam. Hriya deyam, bhiya deyam, sriya deyam, samvida deyam. (Give with reverence; do not give disrespectfully. Give with humility, give with a sense of awe, give generously,give affectionately.)

We are not good at giving. That is why we ourselves get so little. Authority is exercised both when you say "Yes!" and when you say "No!" I can assure you, it is more joyful to exercise authority by saying "Yes!" than by saying "No"

Dare To Dream

According to scientists, it is the ability to think which distinguishes man from other animals. They say that the basis for everything that makes man unique is thinking, for other animals can run faster, swim and climb trees better, and can fly without the aid of flying machines. But while I am not going to argue this, I do not completely agree with it either. For I believe there is one more thing that makes man unique. It is my belief that man is the animal that thinks and dreams. I feel that the one major reason for man attaining the heights which he has today is because man dreams. It was because Columbus dreamed of finding a new way to the Orient that he discovered America. It was because man has had an endless dream to fly that the Wright Brothers invented the airplane. I could give an endless list of such discoveries and inventions which are the end result, whether through foresight or by chance, of man's dreaming but will refrain from doing so for the very reason that it is endless. But, it is because man dreams that "great leaps for mankind," as astronaut Neil Armstrong said when he stepped onto the surface of the moon, have been made. I believe this is what is wrong with society in India today. All , everybody is looking for is stability, few people have a dream to work towards. Many young people blame this on the so-called "Age of Apathy," which they claim is the present period. To me this claim ridiculous. Not having a dream or not working for something you believe in is not something which can blamed on others. The only one you can blame is yourself. It is you who have to do something, nobody is responsible for you. It is up to you to discover something to work for and it is up to you to bring forth the will power to reach that something. You may wonder how to go about creating a dream for yourself and how to achieve it. But this, too, is something no one can give you any help with. All I can say is that you ought to try to set up something big as your dream. Something which would call for all that you have in you, or perhaps more. Something which would demand that you give your total devotion, something which you believe you want to obtain most of all. This can be anything, it doesn't really matter how big it is as long as you believe you can devote yourself to it and are capable of achieving it. It can be something like wanting to perfect a surgery, to something as big as working towards the Nobel Prize. The importance lies not in what you are working for, but in the fact that you are working towards something. Nor does it really matter whether you succeed or not, as long as you believe you have given your utmost. Because through this process alone you are improving yourself and developing your capabilities. I can think of nothing more satisfying or important.
I was particularly impressed by one of President Ronald Reagan's memorable quotes: Aim for the top, Pray to God & Hope for the Best. That should be our philosophy & it should be our endeavor to strive for excellence in all aspects in our life. I would conclude with a story that applies to all of us in the medical profession. In ancient times there was a philosopher who had many disciples. One day a cynical young man decided to humiliate him by asking him a question he couldn't possibly answer correctly. The cynic put a recently hatched chick in the palm of his hand and asked the philosopher, in front of a large audience, whether what he had in his hand was dead or alive. His intention, if the philosopher said `alive,' was to crush the chick to death and show the master to be wrong. If the philosopher said `dead,' then he planned to let the chick live--to prove the great man wrong.
In response to the question, the philosopher looked the cynic in the eye, smiled, and calmly replied: `The answer, my son, lies in your hands. Well, like that young man, the future of our profession lies in our hands. Our actions over the next few years will determine whether allopathic medicine--as we know it today--will be alive with research. . . and will thrive. . . or only a memory. Education is simply the soul of a society as it passes from one generation to another. And scientific meetings such as our annual meetings (www.sisab.net/tubes2007) are soul keepers of the society.

My Teacher

"A teacher affects eternity; he can never tell where his influence stops."
--Henry Brooks Adams
I was remembering my days in Israel, where I had gone to fine-tune my skills in Assisted Reproduction. Those were the turbulent years in Tel Aviv with suicide bombers causing havoc. The spirit of the citizens was remarkable - that is one brave race. I was really lucky to work with the finest teachers in the subject. There are over 25,000 IVF cycles done every year in Israel with a population of 4 million. The State pays for IVF till every patient has completed her family with two kids. If she divorces and re-marries, she again has the support of the state to have two more children to complete her new family. As a result, the public IVF centers have huge volumes of patients and the trainees & junior specialists can hone endocrinological & surgical skills. The practical experience that these fertility physicians imbibe is unrivalled in any other country. I remember the tips & tricks handed down to me by Prof. Danny Seidman, Dr Ariel Weissman, Dr Adrian Shulman & Prof. Ilan Tur Kaspa. Even today, I feel at times that these buddies are right next to me guiding me along the most difficult of cases. The student-teacher relationships graduated into close friendships & even today I ask them for advice in complex situations or for trouble-shooting. Today, the relationship is on a more even keel and they turn to me for guidance on Medical Tourism & third party reproduction issues.