May 2025

Teratogenicity: Are seizure medications safe in pregnancy? Antiepileptic Drugs in Women With Epilepsy During Pregnancy – Drkharkar

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This is an article from the Safe Pregnancy in Epilepsy patient guide. Seizure medications can cause birth defects. It is important to choose one of the seizure medications safe in pregnancy. The safest antiepileptic in pregnancy needs to be carefully selected for each woman. It needs to minimize both seizures and birth defects. Valproate has the highest risk of causing birth defects. In terms of lowest risk of birth defects, Lamotrigine and Levetiracetam are the antiepileptics safest in pregnancy. Which is the safest antiepileptic in pregnancy? There are two goals of epilepsy management during pregnancy: Prevent birth defects (teratogenicity) Prevent seizures In terms of preventing birth defects, Lamotrigine & Levetiracetam are the safest antiepileptics in pregnancy. But to select the safest antileptic for you, we need to make sure your seizures are controlled. So, your doctor may advise you to take a different medication. What is “Teratogenicity”? When the sperm and egg unite, a single cell is created. Like a miracle, this single cell divides & forms arms, legs, heart, brain and other organs. Here is a video of this process: https://youtu.be/fKyljukBE70Let us quickly summarize: First 3 months – Basic organs develop. The basic spinal cord forms within 2 months. 3-6 months – The brain, spinal cord and heart start becoming more complex. 6-9 months: All organs and the baby itself rapidly increases in size! Seizure medications can cause birth defects such as a small head, or improperly formed lips. “Teratogenicity” it the medical term for this problem. We want to minimize this problem. Is there a medication labelled the “safest antiepileptic in pregnancy”? Let’s read more. What structural problems can seizure medications cause? Seizure medications can produce many kinds of structural problems. But the most common ones are: Incorrect formation of the heart – For example: an incorrect hole (ASD, VSD) etc Incorrect formation of the lips and mouth – Cleft lip Incorrect formation of the spinal cord – Spina Bifida Incorrect formation of the brain – e.g. too small – microcephaly Other problems such as kidney problems are less common. The very important things to realize are: Problems with the brain and spinal cord are more serious. Even more serious than heart problems (most heart problems are fixable). The first 3 months are a critical period of spinal cord and brain formation. So, start taking steps to reduce this risk BEFORE YOU GET PREGNANT. How can you reduce risk to the baby? There are less safe seizure medications, and there are – relatively speaking – seizures medications safe in pregnancy. Newer medications like levetiracetam top the list of seizure medications safe in pregnancy. When it comes to avoiding birth defects, Levetiracetam (along with lamotrigine) is probably the safest antiepileptic in pregnancy. Please realize one critical thing: If you have a big generalized convulsion then both your and your baby’s life are at risk. Therefore, you HAVE to keep taking seizure medications during pregnancy. You need to plan your pregnancy properly (see below). Unplanned pregnancies in Epilepsy are common. Seizure medications can make oral contraceptives ineffective. Therefore, use condoms to prevent pregnancy. Meet your doctor at least 1 year before you get pregnant. Ask him/her the following 6 questions: How likely am I to get seizures while pregnant? Can I change to a seizure medication that is safer for the baby? Can I take a lower dose of my seizure medication? Can I take fewer seizure medications? Should I start taking folic acid supplements? Do I need more frequent ultrasound or blood tests? Let us talk about each of these questions. How likely am I to get seizures while pregnant? If you are seizure-free before pregnancy, you are unlikely to have seizures during pregnancy. Ideally, you should be seizure-free for one year before getting pregnant. This also means that if your seizures are not controlled then you may want to delay your pregnancy. Give your doctor time to control them, before getting pregnant. Can I change to one of the seizure medications safe in pregnancy? Some medications are not in the list of seizure medications safe in pregnancy. These tend to be the older seizure medications. Of the seizure medications safe in pregnancy, levetiracetam is the most commonly used one. As far as avoiding birth defects is concerned – Levetiracetam is (along with lamotrigine) the safest antiepileptic in pregnancy. But here is a critical point. When you select seizure medications safe in pregnancy, the one you choose has to control your seizures AND minimize risk to the baby. For you, that is the safest antiepileptic in pregnancy. Let us look at this table:Least safe Less safe Valproate Phenobarbital Carbamazepine Phenytoin Carbamazepine Oxcarbazepine And this one: More safeSafety not clearly knownLevetiracetam LamotrigineZonisamide (probably safe) Lacosamide (probably safe) Gabapentin (proabbly safe) Clobazam & clonazepam (probably slightly unsafe) Out of all these medications, Valproate is the least safe seizure medication in pregnancy. Valproate causes malformations in about 10% of babies. The flip-side of course is that (even with this medication) ~90% of babies have no such problems. Talk to your doctor if you are taking medications in the “least safe” column. Ask your doctor whether you can try one of the “More safe” medications instead. Often, such a switch is reasonable to attempt. Sometimes, the answer may be “No, there would be a very high risk of seizures”.  Remember: When you select a seizure medications safe in pregnancy, the one you choose has to control your seizures AND minimize risk to the baby. This answer can depend on the type of your Epilepsy. For example:Let’s consider JME, a common type of epilepsy. In JME, switching from Valproate (Least safe) to Levetiracetam (More safe) is usually possible. Remember: After a switch, be seizure-free for 1 year before getting pregnant. Should you change to seizure medications safe in pregnancy AFTER getting pregnant? Almost always, the answer to this question is No. Once you get pregnant, it is usually best to continue with your current medication. The American Academy of Neurology (AAN) guidelines discuss this problem. Switching seizure medications after getting pregnant is usually not a good idea because: You could lose control of your seizures. While changing from one medication to another, the baby

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Parkinson’s Plus Syndromes [5 important mimics]

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What are the Parkinson’s Plus Syndromes? It is best to think of the Parkinson’s Plus syndromes as the sisters of Parkinson’s disease. Although many diseases are similar to Parkinson’s disease, the changes they produce and their symptoms are slightly different. It’s why we think of these diseases as the sisters of Parkinson’s disease. Another name for them is the “Parkinson’s Plus” syndromes.Another name for them is the “Parkinson’s Plus” syndromes. PSP, MSA, CBD, and other “Parkinson’s Plus” diseases are like the sisters of Parkinson’s disease. There are three common Parkinson’s Plus syndromes. Parkinson’s Plus Syndromes 1. Progresive Supranuclear Palsy (PSP) 2. Multiple System Atrophy (MSA) 3. Cortico Basal Degeneration (CBD) Ideally, the specific Parkinson’s Plus Syndrome should be identified correctly before the start of treatment. But in the early stages of the disease, this may be difficult, and sometimes impossible. You ca read more here [external link: Frontiers in Neurology]. Because it is sometimes impossible to tell PSP, MSA, and CBD apart, doctors sometimes diagnose the patient as having a “Parkinson’s Plus” syndrome without noting the specific disease. As the years go by, the appearance of characteristic features (such as eye movement problems in PSP) may enable your doctor to make a more precise diagnosis. Which Symptoms May Indicate a Parkinson’s Plus Syndrome? If you have any of the following features, you may have a Parkinson’s Plus syndrome. These features are called “red flags”. This means that if you have one of these symptoms, your doctor is supposed to pause and think. Red flag. Your doctor will be extra careful if you have any of the following symptoms. ‘Red Flags’ suggesting that you may have a Parkinson’s Plus Syndrome 1. Lack of response to Levodopa. 2. Frequently falling down, especially backwards. 3. Severe talking or swallowing problems. 4. Problems with eye movement. 5. Impotence. 6. Blurring of vision. 7. Blacking out when rising from a seated position. 8. Problems with thinking or memory loss. 9. Personality changes. 10. Symptoms only in the legs while the arms and hands are completely normal. 11. Rapid progression of the disease. What is the Treatment for a Parkinson’s Plus Syndrome? The treatment for a Parkinson’s Plus syndrome is the same as the treatment for Parkinson’s disease itself. Many patients respond to Levodopa. However, what’s challenging is that sometimes Levodopa does not have a dramatic effect. It may also happen that this effect may not last for many years. Therefore, the response to levodopa is somewhat unpredictable. Once it enters the brain, Levdoopa is converted into Dopamine. That being said, a significant proportion of patients with Parkinson’s Plus syndromes respond positively to a comprehensive treatment effort. This effort should include the treatment of special problems associated with each syndrome. Therefore, it is crucial to figure out which kind of Parkinson’s Plus syndrome early you have so that these specific problems can be treated. For example: In PSP, the patient frequently falls backwards because the areas of the brain responsible for balance are not functioning well. In this case, balance training can help. In MSA, the patient can fall because of a drop in blood pressure when they get up. In this case, they should drink enough water and try to get up slowly to prevent falls. Some medications can also prevent falls. What is Progressive Supranuclear Palsy (PSP)? PSP is the most common of the “Parkinson’s Plus” syndromes. Patients with PSP frequently fall backwards. To know more about PSP, click here: [PSP patient guide] What is Multiple System Atrophy (MSA)? MSA is the second most common of the “Parkinson’s Plus” syndromes. Patients with MSA have trouble with a part of their nervous system that controls blood pressure, heart rate, sweating and sexual function. To know more about MSA, click here: [MSA in detail] What are Other Types of Parkinson’s Plus Syndromes? There are many other Parkinson’s Plus Syndromes. Since it’s not possible to describe each of these in detail here, I will mention their names and certain key characteristics. Corticobasal Degeneration: Characterized by difficulty using automatic movements of an arm or hand. Dementia with Lewy Bodies: Characterized by hallucinations & disorganized behaviour. Frontotemporal dementia (“Pick’s disease”): Characterized by personality changes, including impulsivity and dis-inhibition. Here is a nice review of many Parkinson’s Plus Syndromes. It is very nicely written, but a bit detailed: [McFarland et al 2016, Neurology Continuum]. PSP patient guide 1. What are the Parkinson’s Plus syndromes?2. What is PSP?3. 30+ Mimics of Parkinson’s & PSP 4. PSP treatment & new research:   (a) Do we have a miracle cure for PSP?   (b) Levodopa – actions & side-effects   (c) Amantadine – actions & side-effects 5. How to avoid aspiration6. How to avoid falling7. Avoid these medications!8. Get updates by email Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

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DBS for Parkinson’s Disease – Realistic expectations.

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1) It is not magic DBS is not a magic solution or a miracle cure. 2) Expected benefits It leads to increased ON-time (4-6 hours on average) and decreased severity of symptoms during the OFF time. However, even after DBS many patients will still experience fluctuations and OFF-times. 3) Non-motor benefits DBS may also cause improvements in non-motor symptoms such as improving the quality of your sleep. 4) Some symptoms do not improve DBS does not improve all symptoms of Parkinson’s disease. Some symptoms, such as unsteadiness do not respond to DBS treatment. Other symptoms such as freezing while walking, may show variable improvement. 5) You will need to keep taking medications You will need to take some medications even after DBS. The doses of medications after GPi-DBS may remain the same, or may even increase. Medication doses can be reduced after STN-DBS, but this is done carefully and gradually over 3-6 months. 6) DBS programming takes some time DBS Programming can take many months to complete. During this time, you can expect a gradual recovery of motor function. However, finding the optimum parameters for the maximal benefit can take up to 6 months. 7) Few people may not improve Most patients improve after DBS surgery. Some patients do not show adequate improvement even if the electrode is properly positioned, and the programming is done correctly. This lack of response in some patients happens in all institutions throughout the world. Some, but not all, of these patients may show improvement after advanced programming techniques. The exact reason why some people do not respond adequately is not known. Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor’s permission.

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Seizures: Always prevent seizures during pregnancy! Can Epilepsy Patient Get Pregnant – drkharkar

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This is an article from the Safe Pregnancy in Epilepsy patient guide. Women with Epilepsy can have seizures during pregnancy. Having seizures while pregnant can hurt the baby & mother. It is incorrect to say that pregnancy triggers seizures. But seizures can increase due to 5 important causes of seizures in pregnancy. It is imporant to know these causes of seizures in pregnancy. Taking simple precautions can prevent seizures while pregnant. Can I have seizures during pregnancy? Yes. For example: 1/3rd of women with Epilepsy who get pregnant have breakthrough seizures. This data comes from a research group from Europe. They studied 3500 pregnancies. Can pregnancy trigger seizures? The same European study found two other things: They found that 15% of women had worsening of seizures during pregnancy. Surprisingly, 12% of women have decreased seizures during pregnancy. So, it is too simplistic to say that pregnancy can trigger seizures in patients with Epilepsy. If that were the case, none of the women would have decreased seizures during pregnancy. Why do some women have decreased seizures while pregnant? Epilepsy is not a static condition. It’s intensity waxes and wanes, like the waves in the ocean. You may have noticed this if you have uncontrolled epilepsy. On some months, you get more seizures but cannot pinpoint why. On other months, you stop getting seizures and you don’t know why. Some researchers strongly believe that this is the cause. That increased seizures during pregnancy are just caused by the waxing & waning nature of Epilepsy. But this is not the complete story. Based on research, and in my experience – there are 5 important causes of seizures in pregnancy. To prevent seizures during pregnancy, you need to pay heed to these… 5 causes of seizures in pregnancy: Of these 5 causes of seizures in pregnancy, 4 are more common in Epilepsy patients. The last is equally common in women with epilepsy, and those without epilepsy. (1) Uncontrolled Epilepsy before getting pregnant This one is obvious. Of all the causes of seizures in pregnancy, this is the best predictor of seizures. In some people, Epilepsy is difficult to control. If you were having breakthrough seizures even before getting pregnant, you could have seizures while pregnant. For example: A study in Australia studied almost 1000 pregnancies. Women who were seizure free for at least one year were 4 times less likely to have seizures during pregnancy. Here are the exact chances per that study: If you are seizure-free for 1 year, less than 20% chance of having seizures during pregnancy. If you are not seizure-free, 75% chance that you will have seizures during pregnancy. Another study done in the US (the MONEAD study), had similar findings. So, to prevent seizures during pregnancy – make sure you are seizure-free for at least 1 year before getting pregnant. (2) Stopping seizure medications Some women stop seizure medications when they realize they are pregnant. They are trying to prevent harm to the baby (Teratogenicity). This is a bad choice. This is a easily preventable cause of seizures in pregnancy. Having seizures while pregnant can be dangerous for you and your baby. Please don’t stop seizure medications by yourself, ever. You can and should talk to your doctor about all options. He/she will most likely advise you not to stop medications. In most cases, it is just too risky. Taking your medications regularly is critical to prevent seizures during pregnancy. (3) Changing seizure medications after becoming pregnant Some seizure medications are more likely to harm the baby. Other seizure medications are safer for the baby. You can consider switching the safer medications before pregnancy. What about after you get pregnant? Would taking the safer medications instead be better? This seems more reasonable than stopping seizure medications entirely. Perhaps it is. But: Usually, this too is not a good choice. This, too, is an easily preventable cause of seizures in prengnacy. The 1998 American Academy of Neurology guidelines advise against this. They also superbly explain why: You could have uncontrolled seizures. If you change medications, the baby is exposed to two different medications. This ,may be more dangerous than any one medication. Patients go to a neurologist several weeks after becoming pregnant. By that time, there is limited advantage to change. (4) Decreased levels of seizure medications during pregnancy Many of the causes of seizures in pregnancy discussed so far are obvious. But many patients and caregivers are not aware of decreased levels of seizure medications. During pregnancy, the liver and kidney go into over-drive. The liver inactivates medications more quickly. The kidneys throw medications out of the body more quickly than usual. Also during pregnancy, the volume of your blood increases. The medications you are taking get diluted. Thus, the concentration of seizure medications decreases. There are other ways in which the levels of seizure medications can decrease. These include frequent vomiting, decreased absorption, decreased binding to proteins in the blood etc… Ultimately, your brain gets less seizure medication. This can lead to breakthrough seizures. To prevent seizures during pregnancy, it is critical to ensure adequate blood levels. This may mean that you need to increase the dose of epilepsy medications. Which seizure medications are affected? Almost all seizure medication levels decrease in pregnancy. But some seizure medications are more severely affected. The table below shows data from a recent paper (Arfman 2020). Marked drop in levels Lamotrigine (50%) Levetiracetam (50%) Oxcarbazepine Phenyotin* Valproate* Topiramate* Marked drop in levels Carbamazepine Unknown Lacosamide Clobazam Gabapentin Perampanel *Phenytoin, Valproate & Topiramate should be avoided in pregnancy anyway, due to the risk of teratogenicity. Prevent seizures during pregnancy due to reduced levels: First of course, you should aim for good seizure control before becoming pregnant. Then, before getting pregnant, your doctor will check a blood level. This is the “baseline blood level”. This is the level at which your brain is happy, at which it stops having seizures. Some people suggest doing this twice before pregnancy to get the best possible estimate. During pregnancy, your doctor may regularly check the blood level

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Deep Brain Stimulation Cost in India [Reduce DBS cost!] – DBS Surgery in India – Drkharkar

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Deep Brain Stimulation cost in India varies between Rs.12 lakh to Rs. 16 lakh. Most of the cost variation is based on the DBS device used. A rough breakup of the minimum cost is as follows: Expense Approximate cost (INR) Approximate cost (USD) Pre-operative evaluation Rs. 50,000 $ 680 DBS Device (Activa-PC) Rs. 7.6 lakh $ 10166 Operation charges (Hospital) Rs. 1 lakh $ 1337 Doctor’s charges (Neurologist, Neurosurgeon etc) Rs. 1.5 lakh $ 2006 Hospital stay including medications Rs. 1.5 lakh $ 2006 TOTAL (Minimum cost of DBS in India – For example, at Nanavati Hospital) Rs. 12.1 lakh $ 16,195 On the whole, this is the minimum DBS cost in India, or rather the DBS cost in Mumbai. This is the typical DBS cost for Parkinson’s in Mumbai, when my team at Nanavati hospital, Mumbai treats a patient with DBS. This cost of Deep Brain Stimulation in India may vary with time and location. It is very reasonable to get a firm, clear estimate from the hospital before making a decision. You should know a few critical things: DBS cost in Charitable/Governmental Indian institutes Some semi-charitable hospitals in India also perform this procedure. For example, the Nizam’s institute of medical sciences in Hyderabad performs a large number of DBS surgeries. Another option is the Sree Chitra Insitute in Thiruvantapuram, Kerala. A third option is AIIMS, in New Delhi. The All India Institute of Medical Sciences (AIIMS) is one of the Governmental organizations providing phenomenal services to Indians, including DBS. The DBS cost at these Governmental institutions may be even lower. They may also be able to acquire the DBS device at lower cost from the companies. But logistically, getting a DBS at charitable institutes in India may be a bit difficult. These institutes deliver really admirable, yeoman service with excellent outcomes to a very large number of people. For example, the wait periods for getting DBS are frequently very long, sometimes many years. Scheduling appointments may be difficult. If you are particular about convenience, timings, accessibility, personalized attention & counselling etc you may want to follow-up at a private hospital instead. DBS cost with non-US DBS devices Two manufacturers in China have now started manufacturing DBS devices. Here are the links to the 2 Chinese companies manufacturing DBS: PINS Medical SceneRay Medical  Two chinese companies have started producing DBS devices. These are cheaper, but less well-proven as compared to the US devices. Just to remind you, there are 3 US manufacturers of DBS devices. You can read all about the American DBS devices by reading this article on my website. Here are the links to the company websites. Medronic ‘s Activa System Abbot’s Vercise System St. Jude’s Inifinity system. The cost of Chinese DBS devices is expected to be much lower than the US-made devices. There are three issues to consider: These devices have not been specifically approved by the Indian FDA yet. The effectiveness of these devices is not as well established as US devices. The very long term reliability of the hardware is not known. Long term service (e.g. battery replacements & availability of DBS programming devices) is a concern. This is a developing situation. China makes reliable cell phones and other electronic devices. However, their expertise in manufacturing medical electronics is not as established as the US. At this point, this appears to be an unreliable option to reduce DBS cost in India. But as more information becomes available, this might be one avenue through which Deep Brain Stimulation Cost in India may be reduced. If the cost is lower, is DBS surgery in India inferior to USA/UK/Europe? No. India is one of the best countries in the world to get tertiary level care. The level of care given by my team at Nanavati hospital, Mumbai is excellent & comparable to any other hospital in World. Almost all members of our team at Nanavati hospital, Mumbai – including myself – are internationally trained. Surgeon experience: Having worked in many systems throughout the world, I can confidently state that the expertise of Neurosurgeons in India is second to none. The stereotactic procedure used to insert the wire into a precise position may seem like magic. Thankfully, it is used in many other brain procedures, particularly brain biopsy. As a result, many neurosurgeons in India have excellent results with the procedure. Surgical Equipment: At this time, much of the neurosurgical equipment is imported. For example: The Frame used to guide wire insertion is imported from the USA or Europe. Many places use the Leksell system from Sweden, which is one of the most popular systems internationally. The MRI and CT machines are usually from one of 3 manufacturers – Philips, Seimens or GE (USA). Much of the surgical equipment used for DBS in India is imported from the US / Europe.DBS devices used in India Lastly, regarding the DBS devices, the US devices are marketed by the same companies in India, who also provide the after-surgery services.  Amongst all DBS systems, the price of Medtronic’s Activa system is the lowest in India. Therefore, it is the most commonly used DBS device in this country. Why do some DBS surgeries cost up to Rs. 16 lakh or even more? The higher cost of surgery is mainly based on the type of DBS device used. Should you select a more expensive device? The DBS devices which are rechargeable are costlier than the non-rechargeable devices. They last longer. So, battery changes are not required often. The newer devices from Abbot (Vercise) and St. Jude (Infinity) offer technologically advanced features like current steering. But they are also very expensive. Here is a video describing what the newer, more expensive devices can do: https://www.youtube.com/watch?v=nVLWauTKfPo You can read more about DBS device selection here. But let me quickly summarize the important points. The advanced programming offered by the more expensive devices (Vercise & Infinitiy), may help in some cases. But these advanced features are rarely required. The regular devices offer just as much improvement, in almost all cases. Should you select an expensive DBS device? If you can afford it, it is worthwhile to consider rechargeable & advanced devices. But if

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Fertility: Can a man or woman with epilepsy have a baby?

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This is an article from the Safe Pregnancy in Epilepsy patient guide. Epilepsy does not decrease fertility. But Epilepsy medications can affect fertility. Epilepsy medications can affect the reproductive system in women. Some medications like valproate can cause PCOD.  Epilepsy medications can cause temporary problems in getting pregnant. Some epilepsy medications can decrease sperm counts. However, epilepsy medications usually do not decrease fertility of males. Hello! I am Dr Siddharth Kharkar, a Neurologist in Thane, India and a Neurologist in Mumbai, India. I provide Parkinson’s treatment in India and am an Epilepsy specialist in India. I provide Epilepsy surgery in India at Mumbai & Parkinson’s surgery in India. Come, let’s learn about this important topic. I think knowing the facts will relieve your stress! Can a woman with Epilepsy have a baby? Yes! Certainly and definitely! A woman with Epilepsy can get pregnant. A woman with Epilepsy can have a baby. Many women with epilepsy have babies every year. So no, neither epilepsy nor epilepsy medications decrease fertility in women drastically! You need to be well informed about pregnancy in epilepsy. Also, there are some extra things to take care of. These articles cover almost everything you need to know about pregnancy in Epilepsy. Does Epilepsy affect the reproductive system? No. There is some controversy about this topic. But, recent research shows that Epilepsy does not affect fertility. For example:A recent US study looked at women who were trying to get pregnant. They studied both women with epilepsy, and women without epilepsy. Most women became pregnant in less than 1 year. Women with epilepsy were equally likely to become pregnant. So, what is the controversy? Older research shows that Epilepsy patients may have trouble getting pregnant. There is a simple reason for the difference between newer and older studies. Patients in earlier studies were on older medications like Phenobarbital. Older epilepsy medications can decrease fertility (see below). In summary, Epilepsy itself does not affect fertility. But in some cases, older epilepsy medications decrease fertility. Read more below. Do epilepsy medications affect fertility in women? Yes. Some medications can. Please note that these epilepsy medications decrease fertility. They do not abolish it. Many women get pregnant while taking these medications. Epilepsy medications decrease fertility in women in 2 different ways: (1) Valproate: Valproate is one of the older seizure medications. It can disrupt a female’s reproductive cycle. Valproate may cause a condition called Polycystic Ovarian Disease (PCOD). PCOD causes irregular cycles. PCOD can prevent the female’s eggs from developing normally. As a result, patients with PCOD find it more difficult to become pregnant. (2) “Enzyme Inducing seizure medications”: The liver gradually inactivates hormones floating in the blood. This gives the hormones some time to act on various body parts. Some seizure medications are called “Enzyme Inducers“. They can cause your liver to go into overdrive. It starts inactivating hormones rapidly! The hormones include estrogen & progesterone. These sexual hormones are important for becoming pregnant. These “Enzyme Inducing” medications include: – Phenobarbital – Phenytoin – Carbamazepine – Oxcarbazepine Phenobarbital really pushes the liver into overdrive! This decimates hormones. Thus, phenobarbital may produce temporary infertility. The other medications push the liver less hard. But according to some studies, in some cases these epilepsy medications decrease fertility. In my own practice, I find this to be uncommon. These medications may also disturb child growth during pregnancy. This problem is called teratogenicity. It is described in another article (see below). Can a man with Epilepsy have a baby? Yes! Certainly and defintely and quite easily! A man with Epilepsy can have a baby. Many men with Epilepsy have babies every year. Just like women, there are a few extra things to keep track of. Does epilepsy or epilepsy medications affect fertility in men? As explained below, epilepsy medications can decrease sperm count. But because men produce so much sperm, usually epilepsy medications do not affect fertility in males. There are very few described cases of epilespy medications causing infertility in males. These cases are temporary. After changing medications, sexual function, sperm count and sperm function all improve. Does Epilepsy affect sperm count? Epilepsy may decrease sperm production. But this usually does not affect chances of pregnancy. Usually, men produce a lot of sperm. Every time a male ejaculates, he releases about 40 million or more sperm! Epilepsy may produce mild hormonal changes in men, like it does in women. This may reduce sperm production and may cause slightly higher abnormal sperms. But due to the huge number of sperm produced, the net effect is usually insignificant. Do epilepsy medications affect sperm count? Yes. This effect is more significant. Both kinds of medications described above can have this effect. (1) Valproate: It is unclear how valproate reduces male fertility. It may cause hormonal changes. It may also decrease energy production in the testes (mitochondrial dysfunction). Males treated with Valproate produce fewer sperm. They can get a low sperm count. They also produce higher numbers of abnormal sperm. Higher doses of Valproate are more likely to produce male infertility. The problem is less marked at lower doses. (2) “Enzyme inducing seizure medications” As listed before, these medications include: – Phenobarbital – Phenytoin – Carbamazepine – Oxcarbazepine As explained before, these medications put the liver into overdrive. In males, this causes the liver to decrease testosterone in the blood. This can lead to reduced and less speedy sperms. This effect is less dramatic than the effect of valproate. In my practice, decreased male fertility due to these medications is uncommon. Newer epilepsy medications are less likely to affect male fertility. For example: Levetiracetam is a newer seizure medication. It does not affect sex hormone levels and decreases sperm count only by 10-20%. So the chance that levetiracetam and newer epilepsy medications decrease fertility in males is very small. Can epilepsy medications cause impotence? Yes. Some epilepsy medications may decrease sexual hormones. This may decrease your sexual desire (libido). This is one obvious way in which epilepsy medications decrease fertility. Decreased sex certainly decreases the chances of you becoming pregnant.

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DBS surgery risks & Deep Brain Stimulation side effects, Side Effects of DBS For Essential Tremor – Drkharkar

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DBS surgery risks & Deep Brain Stimulation side effects are relatively low. It is very easy to think only about the risks of the surgery itself. But the DBS surgery risk is relatively minor, and described below. A few weeks after the DBS surgery, the DBS electrical current is switched on. The current decreases Parkinson’s Disease symptoms. But sometimes, Deep Brain Stimulation side effects are seen. Stimulation can increase certain symptoms such as depression, thinking problems and rarely, falling. There is a small risk of DBS failure as well (10-15%). Although not a DBS risk as such, it is worthwhile to discuss it here. Let us learn more. What are the DBS surgery risks (risk of the actual DBS surgery)? Although this is surgery on the brain, as compared to other surgeries, it is relatively minor. Therefore the DBS surgery risks are low. But they are not non-existent. The DBS surgery takes a few hours but is quite safe. Let us look at one of the largest studies on this topic, to know the DBS surgery risk. A group of German researchers studied 1,183 patients who had Deep Brain Stimulation (DBS) surgery. This series included patients with Parkinson’s disease as well as with other diseases. These were their findings. The risk of death was less than 1%.  About 2% of patients had bleeding inside their head that caused weakness on one side of the body. In many patients, this weakness resolved by itself within 30 days. A few patients (0.6%) had uncommon problems such as infection. A few patients (0.6%) had somewhat unrelated problems such as pneumonia. In short: More than 95% of patients did not have any complications. The risk of death or permanent problems was minimal (about 1%). Overall, as previously mentioned DBS surgery risks are modest. They are on the lower side of those expected from a major surgery. Perhaps more important is to consider the long-term side effects of the electrical stimulation itself. [Click here for the entire study] What is the risk of long-term Deep Brain Stimulation Side-effects? A few weeks after the surgery is done, the DBS current (stimulation) is switched on. Most people have marked relief from their Parkinson’s symptoms at this time. Many people do not have any Deep Brain Stimulation side effects. But sometimes, the stimulation can cause some characteristic problems. A few weeks after surgery, the DBS device is switched on. This may cause worsening of some side effects. Deep Brain Stimulation side effects include possible worsening of 3 symptoms of Parkinson’s disease: It can worsen Depression, if you already have uncontrollable depression. It can worsen Thinking & Memory problems, especially if you already have them. It can worsen falling, if your falling is caused mostly due to instability. Depression and Memory: The first two problems usually happen only if you have these problems before DBS as well. This risks can be reduced by making sure you are a good DBS candidate. [Read “Am I a good DBS candidate?”] If you have uncontrolled deprssion or thinking/memory problems, these need to be controlled before you can have DBS. Also your doctor may recommend DBS of a different brain part called GPi. [Read about DBS targets]. A few weeks after surgery, the DBS device is switched on. This may cause worsening of some side effects. Instability and rarely, falling Let us think about two things that can cause you to fall if you have Parkinson’s: Imbalance – increases in 1/3rd of patients after DBS. Freezing – decrease in most patients after DBS. Overall, the beneficial effects outweigh the increased imbalance. So, usually patients fall less often after DBS.  But if the most important reason for you falling is that you are unstable, you should pause. And think. You should ask your doctor these 3 questions, BEFORE DBS. Why am I falling? Is it because of Freezing or Instability? Do I have a “Parkinson’s Plus Syndrome”? Is another problem (for example, B12 deficiency) causing my falls? If instability is the cause of your falls, proceed only after understanding the pros & cons. If you have a Parkinson’s plus syndrome, consider not getting DBS. If you are falling very often, you need to stop and think BEFORE you have DBS. In summary DBS improves most symptoms of Parkinson’s disease. But it may worsen three symptoms: 1. Falling: If you are falling because of instability. 2. Thinking/memory: If you already have these problems. 3. Depression: If you already have uncontrollable depression. No one is perfect. Most patients with Parkinson’s have these symptoms, in greater or lesser severity. This does not mean nobody can get DBS. But if you have very severe/uncontrollable problems with any of these three symptoms, you should discuss the pros/cons of DBS in detail with your doctor before proceeding. What is the risk of DBS failure? 10-15% Few patients do not get any benefit after DBS. Proper selection of the DBS candidate helps to reduce this risk. But, even if you don’t improve initially after DBS surgery, there is still hope. A initial DBS failure can be converted into a success. For example, the University of Florida & Harvard university studied patients who had not improved after DBS. This study included both Parkinson’s patients and some patients with other diseases. The most common reasons for failure were: Misdiagnosis. [read more] Incorrectly placed electrode. [read more] Incorrect DBS programming. (the DBS settings needed to be changed) Improper medication adjustment With optimized care such as changing medication doses and reprogramming the DBS, more than half these patients improved.  Therefore the DBS risk of failure can be lowered. You can click here for the entire study. In summary, DBS surgery risks are low. Deep Brain Stimulation side effects are uncommon, provided the evaluation is done carefully, BEFORE DBS. Ont the other hand, the chances of DBS success are very high. They are described in another article. Keywords – best hospital for dbs surgery, deep brain stimulation cost, long term side effects of dbs, life after dbs surgery, how long does deep brain stimulation last, deep brain stimulation dystonia success rate, deep brain stimulation surgery, side effects of dbs for essential tremor Caution:

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What is the Deep Brain Stimulation Success rate for Parkinson’s? – Deep Brain Stimulation for Parkinson’s Disease – Drkharkar

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Deep Brain Stimulation Success rate for Parkinson’s disease is excellent. According to Medtronic’s data, 85-90% of patients have significant improvement after DBS. DBS does not reduce all symptoms equally. It reduces some symptoms more than others. In most cases: DBS reduces the major symptoms of shaking, stiffness and slowness. Patients walk faster. However, DBS does not reduce imbalance. DBS reduces many non-motor symptoms of Parkinson’s disease. But it may worsen thinking problems & depression. So, we should discuss Deep Brain Stimulation Success rate under different headings. Please note that this is the average improvement after DBS. A few patients may not benefit. The reasons for DBS failure are also described below. Let us begin. Deep Brain Stimulation Success rate for Shaking, slowness and stiffness Shaking (Tremor) responds very well to DBS. In most cases, the severity of tremor decreases by more than half (>50%). In the future, customized DBS may reduce tremor by almost 90%. Customized DBS includes putting the wire into other targets (such as the zona inserta). Currently, we can use this data during programming to stimulate these areas as well. DBS is very successful in reducing uncontrolled shaking (Tremor). Tremor is the most noticeable symptom of Parkinson’s. But, most patients complain that stiffness and slowness are most disabling. DBS works great in reducing these symptoms as well. Both are reduced by more than half (>50%). Again, future customized DBS may be even more successful. Deep Brain Stimulation Success rate for Walking and imbalance As expected, patients with Parkinson’s walk slowly. They may also have episodes when they feel “stuck” to the ground. This is called “Freezing”. After DBS, patients walk much faster. Also, “Freezing” is reduced. DBS enables patients to walk faster. Also, they get fewer episodes of feeling “stuck” to the ground (Freezing). What is the problem? DBS does not improve balance. In about 1/3rd of patients, it may worsen balance. So are falls more common after DBS? No. Most studies indicate that falls decrease after DBS. For example, Dr. Karachi reported that falls reduced in 1/3rd of patients after DBS. You see, one of the major cause of falls is “Freezing” of gait. Reduction in “freezing” leads to a reduction in falls. Again, this is an average. If you are falling due to instability rather than freezing, you may fall more often after DBS (see box). If I fall often, should I get DBS? You should discuss 3 questions with your doctor: 1. Why am I falling? Is it because of Freezing or Instability? 2. Do I have a Parkinson’s Plus Syndrome? 3. Is another problem (for example, B12 deficiency) causing my falls? If instability is the cause of your falls, proceed only after understanding the pros & cons. If you have a Parkinson’s Plus Syndrome, consider not getting DBS. If you are falling down often, you should find out the reason why you are falling BEFORE you get DBS surgery. Deep Brain Stimulation Success rate for Non-Motor symptoms Patients with Parkinson’s disease have non-movement problems as well. These include sleep problems, constipation, pain and many others. You can find articles on these problems on the site. Thankfully, DBS decreases many of these non-motor problems. For example, sleep improves after DBS. I, along with my colleagues at Kings college, published a research paper on improvement in sleep after DBS in 2018. DBS improves sleep and many other non-motor symptoms of Parkinson’s. The effect of DBS on some non-motor symptoms is unknown. For example, we don’t know if DBS reduces excessive sweating and urinary problems. Unfortunately, DBS may worsen a few non-motor symptoms. If you already have thinking/memory problems, DBS may worsen them. If you already have severe depression, DBS may worsen it. This possible worsening is important to consider. Please read these two articles to know more: [Good DBS surgical candidate] [DBS risks]. Deep Brain Stimulation Success rate for Motor fluctuations Before going on, let us look at the simple terms “OFF” and “ON”. OFF is how a Parkinson’s patient is without symptoms – he/she has very severe symptoms. ON is how a patient is when his treatment is working well – he has few symptoms. In late Parkinson’s disease, medications effect becomes inconsistent. This causes “Motor fluctuations”. In late Parkinson’s disease, your day may seem like a roller coaster ride. You are ON during some hours, and OFF during other hours. These ups and downs are called “Motor Fluctuations”. Let us look at the 2 most common motor fluctuations: Some patients report that their medications stop working after a few hours. They become “OFF”. This is called “Predictable wearing-OFF”. Some patients complain that their body shakes a lot after taking medications. This is called “Dyskinesia”. DBS reduces these fluctuations. On average, patients get 4-5 hours of extra ON-time after DBS. This is the major success of DBS. Also: Even when patients are OFF, their symptoms are less severe. Dyskinesias improve. On average, Dyskinesias are reduced by more than 80%. Deep Brain Stimulation Success rate for Quality of life The goal of reducing your symptoms is to improve your quality of life. So, the ultimate measure of Deep Brain Stimulation Success rate is an improvement in Quality of Life (QOL). The distinction is crucial. For example, if your slowness decreases by 60-70%, your doctor would be happy. But are you satisfied? Has that enabled you to have a better life? DBS helps you become independent in your ADLs (Activities of Daily Living such as bathing, dressing, eating, etc.). Does a high Deep Brain Stimulation Success rate enable you to have a better life? Yes. The evidence behind this is quite robust. In multiple studies, patients have reported improved quality of life after DBS. For example, ADL means activities of daily living – bathing, dressing etc. Many patients can perform ADLs better after DBS. For all these symptoms, the progression of underlying Parkinson’s itself may worsen QOL and ADL in some patients. Improvement in movement (especially slowness) improves your quality of life. But, if your quality of life is low due to other symptoms such as depression, DBS may not improve it. These other factors

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