Fertility Support for the South Asian Community with Dr. Nidhee Sachdev

Thank you for joining us on another episode of the Egg Whisperer Show. I’m so excited to have Dr. Nidhee Sachdev on today. She practices in Newport Beach, California in Orange County, as a part of OC Fertility. They are a part of the CCRM Network. She is joining me today to talk about fertility support for the South Asian community.

Dr. Aimee: Welcome back to the show, Nidhee. Can you tell us why today’s topic is so important to you?

Dr. Nidhee Sachdev: Well, I’m of Indian decent, so I grew up in a South Asian community. I think for many of us we identify strongly with the culture that we were raised in and grew up in. Fertility is such an important topic and there are certain aspects of the South Asian community that I think effect how we view fertility, how we talk about it, and how we’re treated. So, I thought it would be important to talk about it.

Dr. Aimee: What are common underlying health issues prevalent in the South Asian community that might affect their fertility?

Dr. Nidhee Sachdev: When talking about South Asians, the general term includes people who come from India, Pakistan, Sri Lanka, and Bangladesh, in that region.

People of South Asian decent have a higher rate of association with diabetes and underlying insulin resistance. That’s important particularly with fertility because there’s an association between insulin resistance and insulin sensitivity in something called Polycystic Ovarian Syndrome, or PCOS. That’s one that can affect our fertility and many people who are interested in fertility are aware of that syndrome.

Dr. Aimee: What other syndromes? Is it possible that also means that they might be at higher risk for diabetes and other things, maybe thyroid problems, too?

Dr. Nidhee Sachdev: Yes. Endocrine disorders in general are just more prevalent in the South Asian community. It’s important because having an underlying insulin resistance predisposes you to diabetes, and that’s important because that also predisposes our risk for cardiovascular diseases like heart attacks and having elevated blood pressure and elevated cholesterol levels.

Thyroid diseases are important because that can affect how our body metabolizes things. Particularly for the menstrual cycle that’s important because that can alter our menstrual cycle and have irregular cycles for us.

Dr. Aimee: If someone thinks that this might be an issue for them, what can they possibly do and how can they reduce the risk factors for developing the diseases that you just mentioned?

Dr. Nidhee Sachdev: Let’s break it down by disease. With cardiovascular disease and diabetes there are modifiable risk factors, which I think many of us are familiar with, but diet and lifestyle are really important. Increasing the amount of cardiovascular exercise by 30 minutes a day can really decrease our risk of cardiovascular disease and diabetes.

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Monitoring what we eat. The South Asian culture often will have foods that might be vegetarian, but they still are heavy in oil and carbohydrates. I think limiting the amount of rice that we eat or the type of rice that we eat, instead of white rice maybe brown rice. For many of us there are breads that are really good, like Roti and Naan, but trying to be cognizant of how much we’re eating and how often we’re eating, and if we can switch to ones that involve whole grains instead of other types of flours.

Dr. Aimee: If someone listening to us right now and they have a pencil or pen and paper, what tests should they write down that they could ask their doctor for?

Dr. Nidhee Sachdev: I think an important one is checking for diabetes, so hemoglobin A1C or an oral glucose tolerance test. The hemoglobin A1C is a blood test that is a marker of what our blood sugar levels are over the course of the last few months. By checking that we can assess are we in the prediabetes range, are we not in the prediabetes range, are we actually diabetic.

For anyone trying to conceive, that’s really key. If you actually are diabetic, you really want to make sure that you get that under control prior to conceiving. If you’re prediabetic, you want to make sure that doesn’t lead to diabetes, because that can be important too.

Other things that we want to have evaluated are to be evaluated for Polycystic Ovarian Syndrome (PCOS). PCOS manifests three main factors.

One is having irregular or longer menstrual cycles. Two is having excess of male hormones, like testosterone. That can manifest just based on our blood levels, or more commonly it can manifest as having signs of acne, hair loss, excess hair growth. In the South Asian culture, we just in general have darker more course hair that is more visible, so for many people they think it could be cultural, or it could be that you happen to have an excess amount of androgens leading to those symptoms. The third aspect is on ultrasound ovaries will have signs of cysts, leading to a polycystic nature.

If you’re thinking about conceiving and you have any kind of symptoms that you think might fall into that category, seeing a fertility specialist or an OBGYN to just talk about the possibility of that is really key because there are things that you can do to improve your chances of conceiving naturally if you do have PCOS.

Dr. Aimee: How far ahead of time should someone be seeing that specialist before they start planning a pregnancy?

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Dr. Nidhee Sachdev: I think it depends. If you have underlying issues, you want to think about seeing someone six months to a year beforehand. If you don’t feel like you’re having any issues, I would say I think it makes sense to have a preconception counseling appointment at least three to four months prior to conceiving so that you can make sure there are no underlying issues.

Particularly, whether you’re South Asian or not, you want to make sure your immune to all the things you should be immune to prior to getting pregnant, and you want to have your hormone levels and everything of that sort checked out, so that when you are ready to conceive you don’t have any setbacks.

Dr. Aimee: I know I’m stating the obvious right now, but you need to have sex to have a baby. Right? Unless you come here, and we take it out of the bedroom and it’s clearly not as romantic in our offices as it is at home. For some people, sexual dysfunction is, unfortunately, part of the marriage, and sometimes it’s really hard to talk to a doctor about that.

What cultural aspects might play a role when planning a pregnancy for South Asian women and men?

Dr. Nidhee Sachdev: Sexual dysfunction happens to men and women, I would say equally, across multiple different ethnicities. I think the more common theme in the South Asian community is that sex and sexual dysfunction isn’t always as talked about in our culture. Not just about sex, but about our reproductive system in general, our menstrual cycles. Even though we see sexual dysfunction in all sorts of cultures, sometimes in the South Asian community because it’s not as often talked about or addressed earlier on in life, it becomes prevalent that couple then is trying to conceive.

For the South Asians couples, sometimes we’ll see that there could be discomfort with intercourse, which could be for a myriad of reasons. On the male side, there could be difficulty with maintained an erection or ejaculating. I think the key is if there are issues that you identify, maybe seeking out care and finding a provider that you feel comfortable to talk to about that to identify what things we can do to help with those issues.

Dr. Aimee: Do you have any tips for a patient who might be nervous about bringing this up with their doctor? How can they do that?

Dr. Nidhee Sachdev: I think the key is finding a provider that you feel comfortable with. Oftentimes, as a fertility specialist, I ask patients questions that allow them to answer in a more comfortable manner. For some patients, if I didn’t ask, they may not feel comfortable enough to tell me. It’s a routine part of the evaluation to ask how long you’ve been trying, is there any pain or discomfort while trying, and again on the male side, any issues of maintaining an erection or ejaculating.

Regardless of who you are, when you’re trying to conceive, the pressure to conceive at the right time can cause a lot of stress and discomfort, so it’s actually quite common to see signs of sexual dysfunction across all ethnicities.

Dr. Aimee: Right. I just say, “Tell me about your sex life,” and if I start hearing crickets, I know it’s an issue and then I can start asking more questions. I’m sure you do the same thing.

Dr. Nidhee Sachdev: Totally. Yes. I think for the South Asian culture it’s important because there are things that for many that they just aren’t educated about, like use of a tampon. Again, just because you’re South Asian doesn’t mean that happens.

There are variations across cultures and across families, but for some they’ve never had the conversation about how to use a tampon, how to insert a tampon, or about sex. If maybe that was done earlier on, they may have identified certain issues and they could have possibly sought treatment. For many, they think about sex as a way to procreate, so it doesn’t come up until the time that they’re trying to conceive.

Dr. Aimee: Right. What are some available treatments that a couple could seek?

Dr. Nidhee Sachdev: Pain with intercourse on the female side can happen for a myriad of reasons. I think a lot of times people think it’s psychological, but oftentimes it’s biological or physiological.

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What people don’t understand is that our female pelvis is actually made up of a bunch of muscles. When people are having pain with intercourse, it could be due to an issue with some of those muscles. Oftentimes I’ll refer to pelvic floor physical therapists that help by doing exercises and treatments that might help improve that.

When talking about treatments, there are some goals. Is the goal to be able to tolerate a speculum exam so that you can have a pap smear and have an evaluation by a gynecologist? Is the goal to be able to tolerate intercourse to conceive? Or are you having lower back pain or tailbone pain that is secondary to these muscles that is also causing pain or discomfort and is that the goal? So, there are different avenues and treatments.

Ultimately, regardless of what the issue is, there are ways that we can circumvent that for you to still get pregnant.

Dr. Aimee: Right. There are pain meds, we can do procedures under anesthesia, you don’t have to have a pelvic ultrasound every time you come see us, we can do abdominal scans. Don’t be afraid to see one of us, especially to get the help that you need.

Dr. Nidhee Sachdev: Totally. There’s also inseminations, so if you’re having difficulty with intercourse then we can circumvent that. On the male side, if they’re having issues with producing a sample at the right time, you could freeze sperm so that when the time comes there is no stress. If they’re not able to produce, that’s okay, we have a frozen sample and we can do an insemination that way.

There are many ways to circumvent any issues with sexual dysfunction. I think the key is just being open with your healthcare provider. Even if you don’t feel comfortable being open with your partner about it, find a healthcare provider to be open with about it so that they can educate you about the treatment options, because that shouldn’t preclude you from starting a family, we have ways to help you with that.

Dr. Aimee: Absolutely. We don’t want people to be at home for years until they have enough courage to come see us. You do have enough courage. You’re listening to us right now. Go talk to a doctor.

What I want to talk about next are cultural stigmas related to fertility treatment. Are there any? If so, what are they?

Dr. Nidhee Sachdev: I would say within every culture there are some stigmas involved. I think the big one that’s a more prevalent theme in the South Asian community is just like I mentioned before, there’s not as much of a discussion around sex, which can lead to sexual dysfunction. There’s also this value placed on starting a family and the pressure to start a family.

For one, I think an important concept is egg freezing. Egg freezing is something that is becoming more popular, it’s something that we’re trying to empower women to educate them about what they can do to preserve their fertility for the future. I think for many when there might be societal pressures or internal pressures to get into a committed relationship and start a family that way, the thought of freezing your eggs is almost like for some they feel like they’re giving up on that future.

That may or may not be cultural, but I think just talking to my peers and some of my friends and family members, they feel that they don’t often as much support from the older generations in their family about freezing their eggs because they may feel as if it’s a sign that they are not going to lean towards a committed relationship.

I think the key for that is finding someone that you can confide in, having a friend, a family member, or even just a physician and coming in to talk about your options. I think regardless of how you feel or what kind of support you have, it’s important to understand your options and finding someone that you feel comfortable with that’s going to be able to talk to you about that.

Dr. Aimee: I agree. What if you have family member that is being critical? What suggestions do you have to deal with those types of criticisms that you might get from friends or family?

Dr. Nidhee Sachdev: That’s a good question. Honestly, it varies from person to person. I think the key is finding someone that you do feel comfortable with. Hearing and being respectful of other people’s opinions, understanding that’s their opinion and that might be secondary to their own cultural biases.

Even the South Asian culture is very different now than it was 30 years ago. How people were raised and what they thought 30 years ago is changing. I think it’s important to just understand that and be respectful of someone’s thoughts and feelings, but understand that you are independent and that we have this technology.

Think of it more as a medical procedure. If we had a way to preserve your coronary artery to keep it from getting blocked in the future, we would do that. I think of freezing our eggs as the same thing.

Dr. Aimee: I think I might be using that line in the future. Thank you for that. That’s a great one. I think that’s someone that everyone can relate to.

What we’re also seeing more and more across all culture is this; women are choosing the love of a child over the love of a man. We have a clock, that’s the reality. Women don’t produce healthy eggs our entire lives. Are there any stigmas around single parenthood? What options does a member of the South Asian community have to grow their family without a partner?

Dr. Nidhee Sachdev: South Asian or not South Asian, you have the same options that everybody has. I think for many cultures that we identify, South Asian or non, there might be a stigma associated with single parenthood. Just in general in America, I think there’s a stigma in general. But being a single parent is definitely an option. Especially if you’re a female, you have many options.

We have an option to use donor sperm and do an insemination to get pregnant, or to create embryos. When someone comes to me and is talking about freezing their eggs, depending on their age, I also talk to them about the option of possibly using donor sperm to create embryos to increase your options. The key is that you have options to get pregnant on your own with a donor sperm, whether it’s doing insemination or with IVF and making embryos.

If you’re a single male, there are options as well. It’s just a little bit more involved. It might require an egg donor and a gestational carrier.

Dr. Aimee: And there are South Asian men who have donated sperm to sperm banks, so there are options.

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Dr. Nidhee Sachdev: Yes, totally.

Dr. Aimee: What about donor eggs? As a society, we’re all delaying childbearing, and sometimes it’s at a time when we run out of healthy eggs. What are donor egg options for South Asian men and women?

Dr. Nidhee Sachdev: A donor egg is basically when you have somebody else, either anonymous or known, that undergoes the process of egg freezing and donates those eggs for somebody else to purchase. They can be fresh or they can be frozen. Truthfully, the South Asian community, if they’re looking for a specific subsect of South Asian, it might be a little bit limited in how many donors they have, but there are South Asian donors out there.

I think when I talk to anybody, regardless of their ethnicity or culture, when looking for donor, I just say, “What’s important to you?” Is it physical characteristics? Is it religion? Is it eye color? If it’s just physical characteristics, oftentimes I will suggest to South Asian couples that maybe you don’t need to find someone South Asian. A Hispanic donor might look similar to somebody that is South Asian. Some people aren’t comfortable with that, and that’s totally okay, but other people say, “Actually, you’re right. What do I care about? Is it the physicality that the baby looks somewhat like me?”

Regardless of where you get the donor from, if you raise that baby, you’re living with that baby, that baby is likely to look somewhat like you, your facial expressions and your mannerisms. Identifying a donor egg for some people, if they’re focused on South Asian, occasionally it does take longer than it would if you were looking for a different ethnicity.

Dr. Aimee: Your patients are so lucky to have you. It’s nice that you talk through all of this stuff with them. For people who don’t necessarily have access to you, what are ways that they can get more emotional support if they’re not getting it from a physician like you?

Dr. Nidhee Sachdev: Well, that’s key. One, social media is a wonderful outlet. Even if you don’t want to share your stories, there are many other people sharing their stories. Whether you are just passively involved or you are actively involved, that is a way for people to hear other people’s stories and hear their voices.

There are other support groups. We’re really lucky locally in Orange County, there’s a really great support group that our patients are involved in. They’re able to meet — now virtually, because of our situation with COVID. They’ve basically formed like a sisterhood where you have another friend that is going through the same thing.

I think really what people don’t understand is that (South Asian or not) there are many people going through the same thing. Finding someone that you feel comfortable with to confide in and to talk to, if not that person, they might put you in touch with somebody else that has undergone the same thing. Just expanding your network and leaning on the support that you have. If not your clinic, if not your doctor, maybe some of the staff. Maybe they can refer you to a reproductive psychologist, we happen to have some in our network that patients have found supportive, or support groups. I think just finding anybody that you can converse and talk to.

Dr. Aimee: Absolutely. Your personal physician will have all the resources for you, they’ll send you links for all the folks in your community. Certainly, I’m sure you would be open to people reaching out to you, just like me, for resources around us here in Bay Area and in Orange County.

Dr. Nidhee Sachdev: Totally, yes.

Dr. Aimee: Cool. I’m wondering, I’ve had this question, and I answer questions by going to the literature, and I’m just wondering is this a myth or truth. Do South Asians have a lower IVF pregnancy rate or lower fertility treatment success rate in general?

Dr. Nidhee Sachdev: There have been a few studies, not a lot. There have been a few studies looking at it that suggested that the South Asian community has lower success in fertility treatments.

There was one study actually done by a friend of mine in the Bay Area which looked at the South Asian community versus the Caucasian community and specifically looked at IVF outcomes. It found that when you compared South Asians to the Caucasian community when undergoing fresh IVF that they had lower success rates, but when you looked at frozen outcomes, they actually had comparable. So, could there be that there’s some sort of underlying mechanism in our physiology that lends us to having greater success with the frozen?

It’s hard to tease out, but it does give us some insight that obviously every person is unique and different and that you do have to think about is their ethnicity possibly playing a role. It’s really hard to tease that out because there aren’t that many studies, but it gives us something to think about.

Dr. Aimee: What I would love for you to do now is share with us your golden rules. It can be for everyone, but specifically I’d love to hear what are your golden rules for people in the South Asian community, to prevent infertility.

Dr. Nidhee Sachdev: That’s a great question. One, I would say if you’re having any issues with what you believe might be sexual dysfunction, or inserting a tampon, or pain with intercourse, I would consider seeking evaluation. When it comes time to getting pregnant, the stress that comes with that is going to be a lot.

A lot of people don’t feel comfortable even talking to their really close friends or family about it, so finding a gynecologist that you feel comfortable with. I know for many who are in that situation, the idea of going to a gynecologist is daunting, because you think about having an internal procedure and that’s uncomfortable, but not every appointment with a gynecologist has to involve a speculum exam or a physical exam like that. I would say just reaching out to a gynecologist or a fertility specialist to talk about things is key.

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The other thing I would say is if there’s any sort of menstrual abnormalities that you’re noticing, to get evaluated. The other thing is to make sure that you’re educated about your menstrual cycle. I was reading an article about how tampon use in India is limited just because many women aren’t educated about the use of tampons or their menstrual cycle. I think that’s changing as technology is there and we’re becoming more evolved and women are becoming more educated.

I think just understanding your body, understanding the anatomy, and your own menstrual cycle is key. If you find that you’re having any menstrual irregularities, to seek out a gynecologist or a fertility doctor.

You particularly want to be screened for Polycystic Ovarian Syndrome. When trying to identify it, do you have excess hair growth? Which is sometimes hard for people to identify, because many people start grooming early. If you’ve been waxing or threading since you were 16, it’s hard to identify if you’re in that category where you have excess. If you’re not sure, seek evaluation.

I think the other issue is that if you’re having trouble getting pregnant, I would reach out to a fertility specialist. I think what people don’t understand is that the mental and emotional aspects of fertility treatment are hard. The longer that you wait, the more those feelings mount.

The other thing I would say is find somebody that you feel comfortable talking to. In many cultures, including ours, people don’t often talk about their problems. Maybe you came from a family that does talk about your problems, but then you marry into a family that doesn’t feel comfortable sharing about their problems.

Finding an outlet, whether it’s a friend, whether it’s social media listening, a doctor, a support group, I think it’s key because the goal of a fertility journey is to help you get pregnant, but it’s not to crush your spirit in the process. If you don’t have somebody that you can talk to or an outlet, it can make the whole situation daunting. I think finding someone that you identify with is key.

Dr. Aimee: I love that. The goal of infertility treatment is to help you get pregnant, not crush your spirit in the process.

Dr. Nidhee Sachdev: Yes. I think it’s key because people don’t get that the dropout rate for fertility treatment is so high. What I tell patients is that I want to get you to have a baby, but if the process to getting you to have a baby is so difficult that even if you want to have a second one you’re traumatized by that, I’ve directly changed the trajectory of your life, and not for the better. I have to help you get through it. Yes, we all want the end goal of a baby, but we have to do it in a thoughtful way.

Dr. Aimee: Wow. That’s very powerful. I love that. I want someone to make that into a t-shirt, maybe socks, something. Patients really need to remember that we cannot let their spirits be crushed.

Dr. Nidhee Sachdev: Yes. They need support. Whether it’s from us or from a friend, they need support.

Dr. Aimee: Yes. Thank you, Dr. Sachdev. I really appreciate you coming on today and spending your time with us, sharing with us your pearls of fertility wisdom. Thank you so much. Have a wonderful day.

Dr. Nidhee Sachdev: Thank you. You too. Good seeing you.

Dr. Aimee: Thanks. Bye. Thank you, everyone, for joining us.

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