Why Are Indians Facing More Fertility Problems Than Ever? | Dr. Sulbha Arora x Dr. Pal

When we see Western celebrities conceiving naturally in their 40s, there is a racial difference. We have an ovarian reserve five to six years less than the ovarian reserve of Caucasian women. So the chances they have of conceiving at 40, we have at 34. What are the other lifestyle thing that women should do? So there have actually been studies in late night shift workers. And they found that the incidence of endometriosis, difficulty conceiving, miscarriages were higher in this category. Sometimes we have a condition called azospermia. The man doesn't have any sperm or all. No. In such cases, we have to do something called a. Hello guys, welcome to another episode of our podcast series Gut Feeling with Dr. Pal. In this video, we talk with Dr. Shulba. She's an IVF. She's a specialist at NOVA IVF Center, an expert in reproductive physiology. In this podcast, we discussed about what is the right time to get pregnant, what are all the infertility issues and why is it increasingly common and what you can do about this. Let's dive deep into it. Thank you so much for being in the podcast, ma'am. Thank you so much for having me. It's a pleasure to be here. Thank you, ma'am. So right off the bat, I want to ask you, fertility issues are becoming more common. Yes. Is it more common now because of whatever's happening in the last 10 years in the environment? Or is it that we're picking up a lot? It's both actually, and it's multifactorial. We are also picking it up more because people are now slowly getting over the stigma surrounding fertility issues and coming forward to get the help they much needed. Whereas back in the day, it was more common for them to continue suffering in silence. But the incidence is also on the rise. The incidence is rising because of multiple reasons. But what I feel the commonality. The commonality of this being lifestyle and environment. With lifestyle, you know, the single most important determinant of a couple's chances of conceiving is the age of the female partner. Because when we are born, unfortunately, we are born with a limited number of eggs. So you're saying age does matter? Of course it matters. It's the single most important thing that matters. When a woman is born, she's born with about 20 lakh eggs in both her ovaries combined. And that's it. After that, she can't make a single. She can't make a single new egg. In fact, it's like being born with a fully charged battery, a 100% charged battery, but the charger is not given to us. So right from birth, that battery is going to start reducing. This is what happens to the quantity and quality of eggs. By the time the girl gets her first period from 20 lakhs, this is already down to 4 lakhs. 20 lakh eggs is when they start menarche. When they are born. When they're born. When menarche happens, it's already reduced to 4 lakhs without getting a single period. In the first 10 to 12 years of life, it goes down from 20 lakhs to 4 lakhs. When the girl is in her 20s, 20 to 30 is the age of peak fertility because the quantity of eggs is good. The quality of eggs is good. Chances of conceiving are high. After 30, there is a more rapid decline. So an accelerated decline starts in quantity and quality. As we are approaching near to 40, we are left with our last few eggs, most of which may be too weak to give. We may rise to a pregnancy. That's why as we get older, our chances of conceiving keep dropping. Now what happens is that, you asked me, the incidence is rising. If we ask our mothers how old they were when they had their first child, most are going to say 20, 21, 22. Back in the day, probably even 25 was considered too late. But nobody is getting married that early and having babies now. For the women of today, and maybe rightfully so, there are so many competing priorities. Education and career are just as important for the girls as they are for the boys. And sometimes you just haven't found the right partner yet. So those peak fertility years go by very quickly before you even thought about starting a family. And now when people get married, very often in the early 30s, sometimes late 30s, sometimes early 40s, the biological clock has already slowed down for the women. See, in one generation itself, we have gone from trying to conceive to having a baby. We have gone from trying to conceive in the early 20s to trying to conceive now in the late 30s for most couples. But evolution doesn't change in one generation. It takes millions of years to realize that it needs to catch up. So we are still aging the way our mothers were aging. But we are not conceiving at the time when they were planning their first child. So age is one of the most important factors why more and more couples are struggling to conceive now. Choosing the right partner is the problem here. In many cases, people say arranged marriages were better, but not anymore. We are thinking that there is a lot of school of thought. It's better to have the right partner rather than having a family with the wrong partner. Absolutely. So it is difficult to choose the right partner in the first 20 to 25 years of age or even 25 to 30. Yes. And then when the. Let's say they find the right partner and then they go into 32. Can you tell me in numbers in terms of how many eggs they may have and what is the risk that they are taking if that is what they want to do? So what we say in scientific terms and then let me explain that to you in simple terms as well is that the rate of oocyte apoptosis varies between individuals. Oocyte is the egg. Apoptosis is disintegration. Yes. So the biological age does not always correlate with the chronological age. Now to put this simply, what this means is that some girls in the late 20s or early 30s itself could have a very low ovarian reserve because their ovaries have aged faster. And some in the late 30s can still have a larger ovarian reserve. So sometimes when girls come to me and I check their ovarian reserve and I find that it is low. They may be surprised that I'm only 28 or I'm only 31. How can I already have a low AMH or a low ovarian reserve? What I explain to them is that this is an aspect of aging. And just like any other aspect of aging, it differs from person to person. For example, white hair. It's a part of the aging process. But some people have white hair as young as 30, 35. Yes. Some don't have any white hair till 45, 50. Correct. Because it's different for everyone. So similarly, though the ovarian reserve by 32 should still be, you know, reasonably good. But in a lot of cases, that is not the case. So you mentioned about AMH. Yes. Is that a blood test? It is a blood test. Which can give you a sign of the ovarian reserve. Yes. So there are two main tests for ovarian reserve. One is the serum AMH. This is a blood test. It tells us if the value is two or more nanograms per ml. That is considered a good value. Less than two means now it has started rapidly declining. Very low values, less than 0.5, usually indicate a severely diminished reserve. AMH is not the only test we go by. We also do something called an antral follicle count, which we check on transverse ovarian reserve. So this is the antral follicle count. We check on transvaginal ultrasound scan. So we take a look at the ovaries and we count how many follicles we can see. What do you mean by follicle? Yes. Coming to that. So follicles are eggs which are present on the surface of the ovaries. You cannot see the whole reserve. But each month from the reserve, our body recruits a group of eggs and brings them to the surface. These can be seen and these can be counted and these are called your antral follicles. So as the reserve inside shrinks, the number visible on the surface keeps reducing. When we see a total antral follicle count of 10 or 12 or more, we are happy. It indicates a good reserve. When this number starts dropping to below 10, we have entered the stage now where the reserve is rapidly reducing. So apart from AMH, this is the other test that we do. Important to keep in mind is that any test you do is a test for your body. Any test you do is a test for quantity. Unfortunately, there are no reliable tests for the quality of eggs and that also declines as we get older. So two things happen at the quality level. One is oocyte senescence. That means aging eggs. It's like you can expect a 25-year-old to run a marathon but a 90-year-old won't have that kind of energy. So eggs from women who are in their 20s are much more likely to lead to hair loss. It's likely to lead to healthy embryos and live births. But the eggs from women who are in their late 30s or early 40s may not have that much energy. The other thing which is even more significant is something called aneuploidy. That means chromosomal abnormalities. Not every human egg is chromosomally normal. Some human eggs have chromosomal defects. When we are in our 20s, the majority of eggs are euploid. That means chromosomally normal eggs. In the 30s, this ratio starts increasing. By the time we are reaching 40, out of every 10 eggs coming out of our ovaries, in all likelihood, 7 or 8 have chromosomal defects. So even the percentage of chromosomal defects, abnormal eggs increases. So even if you see a 38 or a 40 year old who has a good AMH or a good antral follicle count, how many of these eggs would actually be able to give rise to a live birth? If the egg has a chromosomal defect, four things may happen. One, because it is chromosomally abnormal, it may not fertilize with the sperm and become an embryo at all. Two, it may become an embryo and then fail to implant, so fail to give rise to a pregnancy. Three, it might implant, so a pregnancy may take place, but then it ends in an early miscarriage. So the commonest cause of people not conceiving or having early miscarriages, especially as we grow older, is the increasing incidence of chromosomal abnormalities in the eggs. This is a protective mechanism that nature has in place because it will increase the number of eggs that are born. So if the egg has a chromosomal defect, it will try its level best to stop an abnormal embryo from becoming an abnormal baby. So either it doesn't lead to a pregnancy or even after conceiving, it doesn't grow. The person listening to this podcast, let's say they are 32 years old and then they are listening to this. Let's say they want to check their ovarian reserve. They go to a gynecologist and then get their blood test. They have a serum AMH and then they get an ultrasound of the ovaries and count the number of antral follicles. And let's say that they are good. Okay. But still, they need some more time to settle down. Is there where the egg freezing technique comes in? And what is your opinion on that? Yes, depends on how much more time they want. If they are reasonably sure that in spite of having a good ovarian reserve, at least for the next couple of years, they are not going to be planning a pregnancy. Then by the age of 18, they are going to be planning a pregnancy. 30 or 32 maximum is the ideal time to consider fertility preservation, though it can be done sooner or later as well. For Indian women, the average age of menopause is now 46.1. And an accelerated atresia or decline in the eggs is said to start 13 years prior to menopause, which for Indian women is around 33. Also interesting to know is that we have an ovarian reserve 5 to 6 years less than the ovarian reserve of Caucasian women. So when we see Western celebrities conceiving so easily, naturally in their 40s, it's not necessary that we have the same capacity. It's different for us. There is a racial difference. So coming to your 32 year old, if she's not yet going to be planning at least for a couple of years, yes, she can consider fertility preservation. For single girls, it's egg freezing. For married couples, they have the option. Embryo freezing is preferred. Embryos are sturdier. So egg freezing is aspirating that egg from the women and then freezing it. Nothing happens in the quality? Nothing happens in the quality because the newer vitrification techniques are very, very efficient. See, the egg cell is the largest cell in the human body, because of which it has a large amount of water content. Earlier, about 10 or 15 years back, the new vitrification techniques didn't exist. We had something called slow freezing. Because of slow freezing to go from room temperature to the ideal freezing temperature of minus 196 degrees, the embryo or the egg had to spend a very long time in the chilling zone where ice crystal formation occurs and damages the cell. With the new vitrification technique, it goes from room temperature to minus 196 in a fraction of a second. So it doesn't get time for ice crystal formation or damage to occur. So when you freeze the egg, it's basically it's in a refrigerator kind of analogy. Yes. And then you can take it how long? Five years, 10 years after? Well, the law currently allows up to 10 years for eggs or embryos to be frozen. Law in India? Yes, the law in India. But medically speaking, there is no, there's no deadline to how long it can be kept frozen. So a person listening to this podcast, let's say they're 23 year old or 25 year old, can they freeze it at that age and then don't worry about at all? They can if they wish to. What the trend that I'm seeing is that about 10 years back, I mostly had women in the 40s coming to me for egg freezing. But that is too late. Too late. But now we do have a lot of awareness and the average age group coming to me now is 28 to 32. Sorry for interrupting the podcast flow, but let me take one minute to tell you about something I have passionately put together, the NuMe Lifestyle Medicine Clinic. If you're struggling with diabetes, hypertension, fatty liver, obesity or any other chronic lifestyle conditions, NuMe Lifestyle Medicine is designed to help you build long lasting habits and not just give you a diet chart, a detailed evaluation with a doctor, a clinical health coach. I personally review your profile and based on your medical needs, we create a three or a six month plan for you. Our doctors follow up with you regularly while clinical health coaches personally trained by me guide you through nutrition and sustainable habit change. But health is not just about food and NuMe, we also bring together movement through our virtual online gym. You could just log in anywhere from any time. Physiotherapy support were required, stress relaxation techniques and access to mental health therapies. This is what I believe healthcare should be, not just treating the disease, but helping you prevent and manage it through sustainable lifestyle change. If that sounds like the support you need, visit DrPalsNuMe.com and check out the program link in the description. See, I had a psychologist for the podcast. And then what she is saying is that, you know, I think it is high time, that you trust your partner, you take time to choose a partner. You know, we don't want any broken marriages because that is going to give a strain on the kids. Okay. And now you are coming and saying, oh, that's a wonderful opportunity that if you are thinking along those lines, why don't you freeze the eggs at age 25? For me, it sounds like a no brainer to me. It is because the process is simple and straightforward. It is, it's very safe. But as a consumer, I may, what if it increases? The risk of chromosomal abnormalities or babies born from this kind of technique will have the same lifestyle or yeah, but it has not been shown to increase that risk. We have enough number of years of data now. See IVF as such, also the first IVF baby was born in 1978. These procedures are not new. We've been doing them from almost half a century now. And she's grown up and had naturally conceived children of her own. So in all these so many years and how many millions of babies have born through IVF across the world, we have enough data that has put our minds at ease as far as outcomes are concerned. Babies born through IVF are no different than babies who were conceived naturally. It hasn't, though theoretically we had that speculation, but the, what the studies have shown in practice is that there is no difference. There is no higher risk of any sort to the babies conceived through IVF. So is the awareness about egg freezing is there or seeing more now? It is increasing. We are happy to see that. What has helped is that celebrities who have gone through it are now coming up and speaking about it. As long as there was silence around this, people were reluctant. They were hesitant. Any celebrity that you know, or can you say this? Have they openly said that we have done this? A lot of them have in my clinic as well. Just a month back, I had one of the celebrities who came to me, word of mouth, and she asked me even before coming, is it okay with you if I bring my camera crew along? I would like to document this. And I was very happy when she said that because I said it would be wonderful because it would create so much awareness. Of course. It would inspire other young girls when they see you. And she's decided to do a vlog about this. So as she's going through the journey, she's just yesterday, she's put up the first YouTube link of the very first consultation she had with me, her antral follicle count, how she has. Oh, it's in the YouTube already? Yes, yesterday. Then you could say the name. What's the name of the celebrity then? Urfi Javed. Urfi Javed? Yeah. You should go and check out that blog. Right? Yeah, you should because she has spoken about it very well. She has even spoken about the fact that whatever lifestyle choices she has made, she has been doing it for a long time. And she's been doing it for a long time. is i don't trust men i might as well do something for myself you know so yeah because it is an easy process fairly it's not complicated what it does is that it takes the pressure off it gives you more autonomy over your life's choices otherwise the way we've been biologically designed it's the woman who needs to compromise either on the career front or on the childbearing front in this time besides age what are the other lifestyle thing that a woman should do or a couple should do in case they are going through infertility issues so there is a huge impact of environment and lifestyle on our general as well as reproductive health for both partners actually fertility is not just a female issue in almost 50 percent of cases there is a sperm factor involved as well 50 percent wow which they may not be able to do in the future so i think it's a very important thing to do and i think it's a very important thing to do and i think it's a very important thing to do and i think it's a very important thing to do and i think it's a very important thing to do not be aware about but usually women are being blamed a lot more in your practice yes that's sadly what is still happening men are sometimes reluctant even to get a semen analysis done but we are seeing that changing now there are times when we've even had men single men come and say i'm about to get married i'd like to check my semen quality first yeah that's refreshing to see that kind of is it right it is right yeah so they want to so we can assess the quality of the semen as well we can do a semen analysis for them so instead of astrology they should do this before marriage they should right they should check the ovarian reserve they should check the semen analysis there are so many tests that they should be doing well astrology i'm not going to dismiss it completely but this is equally important as well and we'll come to the genetic issues in a bit but yes we're talking about the lifestyle and the environment first of all what i feel unfortunately obesity is becoming like a pandemic so obesity plays a role in infertility it plays a very big role when the bmi is too low or too high too high is what we find more commonly too low is a little rare uh it impacts egg quality and sperm quality it reduces the chances of implantation it creates hormonal imbalances so it's very important to try and achieve a normal bmi which is between 20 and 25 kilograms per minute and it's very important to try and achieve a normal bmi which is between 20 and 25 kilograms per minute and it's very important to try and achieve a normal bmi which is between 20 and 25 kilograms per minute and it's not always possible to achieve that especially for people who have a very high bmi but at least they need to make a start somewhere even if they lose five to ten percent of their current body weight it shows a significant improvement in their chances so sometimes what we do with couples who are of a very high bmi and we know the clock is ticking we tell them do the embryo freezing focus on your weight loss and then do the embryo transfer so you're at least conceiving at a time when you are in a much healthier state and then we always try to emphasize that this normal bmi they have to try and achieve with the help of both exercise and diet exercise is so lacking in our generation a lot of the health problems are due to what we call a sedentary lifestyle right what makes it worse is the misconception that couples have that when they are trying to conceive they should not be working out they just stop working out women just stop working out oh because they're not working out they're not working out because it may interfere with they quit their jobs they start sitting at home they start taking bed rest but they're reducing their physical activity even further what i tell them is that if you see our grandparents generation they were so much more physically active than us most of them stayed in rural areas they went walking they did everything manually washing clothes filling water from wells so in our grandparents generation it was very common to have large families four children six children some had eight in our parents generation my mother is 73 she goes grocery shopping walking every day she goes to the dry cleaner walking every day she doesn't miss her morning walk evening walk so our parents generation was fairly active as well they also conceived without much difficulty two or three kids most of them had we blink it we don't even go we don't go anywhere we sit in our chair and we take an app and we go to the bathroom and we go to the bathroom and we take an app swiggy or blink it and we order our groceries our day-to-day activity has become so limited that what nature designed our bodies for the level of physical activity that we were designed for we're not even doing a small fraction of it that's why it's very important to in your day-to-day activity if you can increase you know your step count etc it's great but also work out it's very important to work out you cannot skip exercising even if your bmi is normal you should not skip exercising even if you look if you look normal even if you look normal how does exercise helps in ivf outcomes first of all exercise is the most underrated stress buster it releases endorphins it makes you feel good it gives you a sense of accomplishment you start your day with a good one hour workout it sets the pace for your day and we know that stress levels are high that's another factor that's contributing to couples having difficulty conceiving so exercise is great for your general physical health and your mental health both so even people who have a normal bmi should still be exercising so but what is happening right now it's a vicious cycle where the couple is having infertility issues they are stressed out and for stress they are staying at home thinking that the infertility will get better if i don't do any any workout or also actual work and then they end up eating more then they put on more weight it's a vicious cycle it is a vicious cycle so exercise is one aspect diet is the other and typically when people are stressed out they reach for comfort foods when you're stressed out you're not going to think okay let me have a salad when you're stressed out you want to have your french fries or your parathas or you know whatever gives you happiness happiness which is okay sometimes but if your lifestyle contains mostly food which is not giving you proper nutrition is healthy calories then the food becomes a factor as well and not just that because a lot of people are now working late nights eating at erratic hours the circadian rhythm is disrupted which is another very big factor so sleeping for seven to eight hours is very important but from the correct time to the correct time sleeping at 3 a.m and waking up at 11 a.m doesn't count as good sleep hygiene so i'm a big promoter of circadian rhythm yes i say eight by seven p.m sleep by 10 p.m yeah but can you tell me how the circadian rhythm sleep exercise stress is affecting the actual ovarian pathophysiology so maybe if i can explain that to the layman person then maybe they'll be able to connect both together because our hormones respond to the circadian rhythm so estrogen progesterone melatonin melatonin so there have actually been studies in late night shift and they found that the incidence of irregular periods pcos endometriosis difficulty conceiving miscarriages were higher in this category so of course there is an impact in some professions maybe there isn't much that they can do about it but at least for people who don't have those kind of work commitments where they have to work all night they can try and reduce too many late nights and like you said eat in time sleep on time there's so you're saying when you do this when you're aligning with circadian rhythm the quality of the hormones are much better hormones are more balanced balanced yeah and because infertility is a hormonal issue it is a everything is a hormonal issue as far as fertility is concerned if your hormones are balanced it's like an orchestra you know with it's so many different hormones that play it's a simple symphony it's a symphony yes it's multiple micro molecules are being engaged yes and every molecule has its own circadian rhythm that's the beauty of it yes and what is good is that the awareness of the impact of all these lifestyle factors amongst medical practitioners is increasing and so we are able to educate our patients better about it as well it's not just take this tablet or take this injection it starts with lifestyle modification you cannot skip that so we talk a lot about stress so stress increases cortisol cortisol decreases the quality of estrogen and progesterone through these multiple interactions and that hormone needs the ovaries to produce this a good quality ovum it is not there infertility stress again which is like yes so stress plays a role in many indirect ways as well the direct connection in fact has not scientifically been conclusively proven but when couples are stressed out you just imagine a couple that has got you know very difficult job high stress levels a lot of times they're not even able to have relations at the time of population they're just too tired or one is tired one is not their marital life is taking it becomes a chore it becomes a chore and as I mentioned when they are stressed out they're more likely to eat at erratic hours eat the wrong things and also reach out for that extra cup of coffee coffee for that one glass. of whiskey or alcohol just to calm them down smoking so which then again comes down to our lifestyle factors where all these things are concerned smoking even one cigarette is going to hamper your egg quality and your sperm quality everyone knows smoking causes cancer how many people know that it causes reduced egg quality reduce sperm quality increased incidence of IUGR babies miscarriages importance alcohol in moderation doesn't have as much of an impact as smoking does but in moderation in excess of course it will similarly caffeine in moderation is not harmful but everything has to be in moderation smoking has to be not at all smoking in your practice as women is also in absolutely is it right that's something new because I went to us in 2006 at that point of time women smoking was not common it is becoming common now because of you know the corporate offices the men stepped down for a cigarette break the women stepped down with them as well so it just it's not necessarily only the men anymore there's an equal number of women smokers depends also where you practice where I practice in Mumbai and Andheri it's fairly common to see both men and women smoking so after listening to this podcast let's say that people understand okay so lifestyle plays a role in your infertility treatment so I'm going to sleep on time eat on time I'll do meditation I'll do stress relaxation techniques I'll do physical activity I'll work on it I'm saying this so frequently because this is what I tell in my online new me clinic repeatedly on a daily basis but as a matter of fact any patients with infertility when when I treat them with a lifestyle the outcome is significant of course because the impact is the impact is significant significant it's very clear very clear it takes time it takes six weeks to three months but it's not going to be overnight but it's a step in the right direction when they quit smoking in the next one year the adverse effects of smoking have been reversed already so it takes time but then they need so one year no smoking reversed almost yes almost reverses and then there's the environment as well because unfortunately we now live in an environment where we are exposed to the environment where we are exposed to the environment where we are exposed to more than 20,000 chemicals on a daily basis 800 of which have been proven to be toxic and we can do nothing about it but it is so you know it's so ingrained that people don't realize what kind of toxins they are exposed to everything is a chemical your toothpaste your so your shampoo they're all chemicals your detergents your floor disinfectants and as if that isn't enough if you see the way food is being prepared nowadays agriculture there is such rampant pesticide use where the only species that sprays our crops with poison so that other species don't eat it and then we eat it and nowadays as you know this mango season was going on rampant use of carbide injections to cause early ripening of mangoes that we don't realize when we are consuming the pesticides also spraying them wasn't enough now we've heard reports of them being injected into the roots so even if you try to correct your lifestyle but what do we do about this toxic environment it's in everything we breathe the drink and eat there's a very interesting book called our stolen future our stolen future it's our stolen future because of our own activities we are heading towards our own extinction the book tells about it was written in the 1970s or 80s but it's a very eye-opening book it's not a medical textbook it's for anyone to read it tells you about everything in our environment the endocrine disruptors the fact that plastics and certain other chemicals mimic estrogen and that's another reason why male babies right from the time when they are in the womb in utero are exposed to chemicals that mimic hormones and could be part of the reason why we are seeing an increased incidence of male infertility that book is very interesting it says that in all the parts of the ocean where the industrial toxins are dumped the whales have cancer if this is what we're doing to them isn't this why don't you feel that the incidence of cancer is higher than it was 40 years back 40 years back the average sperm count across the world was hundred million today the average sperm count across the world is 37 million even the WHO criteria for a normal sperm parameters they have had to keep revising and reducing because it is reducing another culprit is plastic which for so many days decades the you know the impact wasn't so well-known but now micro plastics have been found in breast milk micro plastics are found in follicular fluid in the ovaries there was a study I read recently where they compared the placenta of women who had preterm deliveries with the placenta of women who delivered at the full nine months the preterm deliveries the placenta had a higher concentration of micro plastics so at least that awareness is coming in if you go to most of the restaurants and hotels now they have replaced plastic mineral water bottles with glass bottles and this is something I encourage a lot of couples to do in their homes as well a lot of people have already when I tell them they say yes doctor we had we don't use plastic bottles anymore we use steel or we use glass so people are also becoming aware about this wow so I'm going to show you a reel and then I want you to react to it sure okay yeah right what do you think so I'll tell you it's not just about them being scared to give a sperm sample but sometimes we have a condition called azospermia where there is a zero sperm count in the ejaculate that the man doesn't have any sperm at all no and many of these cases but they can still ejaculate they can ejaculate but it's it's blank there's no sperms in it in many of these cases the testes are actually producing sperm but they're not coming out in such cases we have to do something called a TISA a testicular sperm retrieval to be able to get the sperm directly from the testes most of the times the husbands get so terrified when they hear this that they are just so reluctant not willing to do it and the reel that you just showed me with the size of the needle that aspirates the oocytes that is when I tell them this is the size of the needle that's going into your wife's ovaries through her vagina for a testicular aspiration it's a small 26 gauge needle even if something more is required it's a small 18 gauge only the ones used for blood collection and they are so tiny and they don't even go all the way into the abdomen so we do explain to them that the needle used for egg pickup is much larger and longer than the one we will use for a TISA that's a very tiny needle but yes we do see I I know that you know women were blamed and you know men were always patriarchal but now it is changing correct many people are even considering that you know we are also involved how much is a change in your practice quite a lot although we do still have that small person percentage of couples where they come and tell us the husband is not willing for the semen analysis it's interesting to see the demographics the socio- economic backgrounds of such couples because usually the more educated ones are more willing to get their semen analysis done we still find that in the lower socioeconomic strata with the less education or the slightly more underprivileged where they have a stigma even getting a semen test done hopefully with these podcast with these awareness maybe they'll be open to the idea that you know 50% yeah which is the reason we try and come on these platforms and talk about this because there is such a huge need to create an awareness to put reliable information out there to encourage people first of all to start the conversation it all begins with that if they are not going to be able to even speak about How are we going to help them?