Third industrial visit on CIMAR Cochin

Introduction:

CIMAR Cochin is a fertility clinic that is committed to perfecting the technological

advances in healthcare and fertility management services. They update the professional skills of
their team through a process of continuous training and reviews. A multi-disciplinary team of
experienced fertility doctors, nurses and other supporting staff at CIMAR will make the fertility
treatment personalised and their skill and experience achieves the best possible outcome for
customers (or patients). Wherever the patients are, they make the fertility treatment easy. The
fertility clinics at four different locations make it convenient for the patients.
CIMAR Cochin is a more peaceful and comforting experience. They have chosen the
banks of Cheranellore River as one of the location for our fertility clinic. The strategic location
of this fertility clinic is easily accessible from the city of Kochi and at the same time, provides a
retreat-like experience. The quietness of the place is calming and refreshing and adds immense
value. We reached the hospital by 2:00 PM, and was greeted by the HR manager with a tour of
all the facilities of the organisations. The purpose of the visit was to understand the working of a
service industry which was different from the other two industrial visits which was on
production based firms.
CIMAR Fertility Centre has been accredited with the highest recognition for quality of
care and patient safety. CIMAR Cochin hospital is the first fertility hospital in India to be
graded in the HCO (Health Care Organisation) category by the National Accreditation Board
for Hospitals and Healthcare Providers (NABH). It was earlier recognised as the second IVF
hospital in India, accredited in the SHCO (Small Health Care Organisation) category. The
accreditation provides access to reliable and certified information on CIMAR’s world-class
facilities, modern infrastructure and level of patient care.
SHCO category requires the hospital to focus highly on critical aspects regarding the
patient safety. The recognition is expected to encourage SHCOs to continuously adapt quality
initiatives and attain full accreditation later on. According to NABH, patients are the biggest
beneficiaries among all stakeholders as the accreditation results in high quality of care and
patient safety. The patients are serviced by credential medical staff besides their rights are
respected and protected and patient satisfaction is regularly evaluated. Accreditation to the HCO
status seeks to stimulate a continuous improvement all around, according to NABH. It enables a
hospital to adhere to high quality care. It raises the confidence of the community in the services
provided by the hospital. It is also a great opportunity for the hospital to be benchmarked with
the best. Staff in an accredited HCO gets sustained learning, good working environment,
leadership and above all ownership of clinical processes. It improves the overall professional
development of clinicians and para Medical Staff. Finally, the accreditation provides an
objective system of empanelment by insurance companies and other third parties.
NABH is a constituent board of the Quality Council of India (QCI), set up to establish
and operate accreditation programme for health care organizations. It has been established with
the objective of enhancing health system & promoting continuous quality improvement and
patient safety. The board while being supported by all stakeholders, including industry,
consumers, government, has full functional autonomy in its operation. It is equivalent to JCI
and other International standards including HAS (Haute Authorite de Sante), Australian Council
on Healthcare Standards, Japan Council for Quality in Health Care, and the National Committee
for Quality Assurance in the United States. Its standards have been accredited by ISQUA the
apex body accrediting the accreditations hence making NABH accreditation at par with the
world’s most leading hospital accreditation.

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The first in vitro fertilisation centre (IVF) and fertility clinic of northern Kerala was
launched in September 1996 as a project of Edappal Hospitals (P) Ltd, Edappal. In fact, it was
the Infertility Division of the Obstetrics and Gynaecology department of this hospital who did
pioneering work in endoscopy and related fields which was transformed into CIMAR, when the
IVF facilities were added. Naturally CIMAR became the leader in infertility treatment in
northern Kerala. CIMAR provides the following services to its customers,

1. Infertility clinic:

Infertility is not a disease but a condition where, a particular couple is not able to conceive.
Infertility problems in a couple can be due to either the woman or the man, or it can be even due
to problems in both partners. A couple is considered to be infertile if,
 The female is under the age of 34 and the couple has not conceived after 12 months of
contraceptive-free intercourse. 12 months has been used as the lower reference limit for Time
to Pregnancy (TTP) by the World Health Organization.
 The female is over the age of 35 and the couple has not conceived after 6 months of
contraceptive-free intercourse. The declining egg quality of females over the age of 35yrs is
the reason for the age-based discrepancy as when to seek medical intervention.

A couple that has tried unsuccessfully to have a child for a year or more is said to be sub-
fertile meaning less fertile than a typical couple. The couple’s fecund ability rate is
approximately 3-5%. Many of its causes are the same as those of infertility. Such causes could
be endometriosis or polycystic ovarian syndrome. Basically infertility is classified into two
categories; Primary and Secondary Infertility. Couples with primary infertility are the ones who
have never been able to get pregnant. Whereas, secondary infertility is defined as the difficulty
in conceiving after already having conceived (and either carried the pregnancy to term, or had a
miscarriage). Technically, secondary infertility cannot be considered, if there has been a change
of partners. The infertility clinic in CIMAR COCHIN provides the following services,
1. Infertility & Embryology
2. Donor Treatment & Surrogacy Procedure
3. Fertility Preservation Program

2. Fetomaternal Medicine:

Maternal-fetal medicine specialist is the specialist within the field of obstetrics. They deal
with pre-conception counselling, especially in anticipated high risk cases both maternal and
fetal point of view, offer prenatal tests (invasive and non-invasive), provide treatments,
and perform surgeries. They act both as a consult during lower-risk pregnancies, and as the
primary obstetrician in, especially, high-risk pregnancies. The perinatologist may work closely
with paediatricians or neonatologists after the birth. Primatologists assist with pre-existing
health concerns, as well as the complications caused in the pregnancy of the expectant mother.
Maternal-fetal medicine specialist, in addition to a degree in obstetrics have training in obstetric
ultrasound, doing invasive prenatal diagnostic techniques like amniocentesis, chorionic villus

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sampling, fetal blood sampling and the management of high-risk pregnancies. Some are further
trained in the field of fetal diagnosis and prenatal therapy where they become competent in
advanced procedures such as targeted fetal assessment using ultrasound and Doppler, fetal
blood sampling and transfusion, fetoscopy and open surgery for fetal.
Maternal-fetal medicine (MFM), also known as perinatology is a branch of science. It
focuses on managing health concerns of the mother and foetus before, during and shortly
after pregnancy and delivery. They take care of pregnant women who have (e.g. heart or kidney
disease, hypertension, diabetes, and thrombophilia), pregnant women who are at risk for
pregnancy-related complications (e.g. preterm labour, pre-eclampsia, and twin or triplet
pregnancies), and pregnant women with foetuses at risk. Foetuses may be at risk due
to chromosomal or congenital abnormalities, maternal disease, infections, genetic diseases
and growth restriction.
For mothers, pre-existing health conditions, such as high blood pressure, drug use during
or before pregnancy, or a diagnosed medical condition, may require consultation with a
maternal-fetal specialist. In addition, women who have recurrent pregnancy loss may be
referred to a maternal-fetal specialist for assistance. During pregnancy, a variety
of complications of pregnancy can arise. Depending on the severity and the complication, a
maternal-fetal specialist may meet with the patient frequently and may become the primary
obstetrician for the pregnancy. Post-partum, maternal-fetal specialists may follow up with a
patient and monitor any medical complications that may arise. The Society for Maternal-fetal
medicine (SMFM) is an association of specialists who works to improve the maternal and child
outcomes by standards of prevention, diagnosis and treatment through research, education and
training.

What makes maternal-fetal medicine department at CIMAR different in

handling high risk pregnancies?

Complications arising during the pregnancy, you may visit maternal-fetal medicine
specialist as soon as the complication is suspected. The specialist will diagnose and confirm the
management of the situation at the earliest. Remember “a stitch in time saves nine”. It would
ensure the management according to the best available protocols. These strict protocols
followed by the management makes the Fetomaternal medicine department at CIMAR different
in high risk pregnancies. These protocols allow in the successful execution of the following
facilities in the Fetomaternal medicine department of CIMAR,
1. Planning the labour and delivery
2. Preterm birth
3. Hypertension and timing of delivery
4. Placenta praevia
5. Placenta abruption
6. Person with known heart disease and pregnancy planning
7. Obesity – antenatal and postnatal complications
8. Endocrinological disorders
9. Blood disorders
10. Autoimmune disorder patients and pregnancy
11. Infectious Disorders
12. Pregnancy of cancer survivor
13. Birth defects or anomalies and scanning

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14. Pregnancy and fetal complications

15. Fetal growth disorders in pregnancy
16. Intrauterine fetal demise
17. Alloimmunisation and blood transfusion
18. Antepartum fetal monitoring
19. Amniotic fluid
20. Fetal blood sampling
21. Advanced fetal treatment at CIMAR
22. Fetoscopic laser

3. Endoscopic Surgery
Laparoscopy or endoscopy procedure means looking inside and typically refers to looking
inside the body for medical reasons using an endoscope, an instrument used to examine the
interior of a hollow organ or cavity of the body.
 
The laparoscopy operation is a surgical procedure that involves making one, two, or three
very small cuts in the abdomen, through which the doctor inserts a laparoscope and specialized
surgical instruments. A laparoscope is a thin, fibre-optic tube, fitted with a light and camera.
Laparoscopy in gynaecology allows your doctor to see the abdominal organs and sometimes
make repairs, without making a larger incision that can require a longer recovery time and
hospital stay.  

Some causes of infertility, like endometriosis, can only be diagnosed through laparoscopy.
Laparoscopy allows your doctor to not only see what’s inside your abdomen, but also biopsy
suspicious growths or cysts. Also, laparoscopic surgery can treat some causes of infertility,
allowing the patients a better chance at getting pregnant either naturally or with fertility
treatments. Laparoscopy can be used to remove the scar tissue that’s causes pain.
 
Process:

Laparoscopy is performed in a hospital, under general anaesthesia. The doctor will give
the patient instructions on how to prepare for surgery beforehand. She will be probably be told
not to eat or drink for 8 or more hours before the scheduled surgery, and they may be instructed
to take antibiotics. She will receive an IV, through which fluids and medication to help you
relax will be delivered. The anaesthesiologist will place a mask over the face, and after
breathing a sweet smelling gas for a few minutes, the patient will fall asleep. Once the
anaesthesia has taken effect, the doctor will make a small cut around the belly button. Through
this cut carbon dioxide gas will be used to fill the abdomen. This provides room for the doctor
to see the organs and move the surgical instruments. Once the abdomen is filled with gas, the
surgeon will then place the laparoscope through the cut to look around at the pelvic organs. The
surgeon may also biopsy tissue for testing. Sometimes two or three more small cuts are made,
so that other thin surgical instruments can be used to make repairs or move the organs around
for a better view.
 

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After surgery, the doctor will explain what are the options are for getting pregnant. If she had
fibroids removed or a fallopian tube repaired, she may be able to try to get pregnant without
help. Depending on the findings during laparoscopy, your doctor may recommend fertility
treatments.
 
Advantages of laparoscopy in infertility treatment:

It will allow the diagnosis of infertility problems that would otherwise be missed in the
absence of laparoscopy. A problem that can only be identified through surgery are pelvic
adhesions. Also known as scar tissue, adhesions cannot be seen with ultrasound, x-rays or CT
scans. Adhesions can interfere with the ability to conceive if they make it more difficult for the
egg to get into the fallopian tube at the time of ovulation.
Many people view laparoscopy as a less invasive surgery than traditional surgery.
Traditional surgery requires making an incision in the abdomen which is several centimetres
long. This in turn means that the patient has to spend two to three nights in the hospital.
Laparoscopy utilizes one to three smaller incisions. Each incision may be one half a centimetre
to a full centimetre in length. Most often, patients who have had a laparoscopy will be able to go
home the same day as the surgery. In other words, a hospital stay is not usually required. Some
people believed that laparoscopy would result in less adhesions being formed after reproductive
surgery. However, this does not appear to be true.
 
Disadvantages of laparoscopy in infertility treatment:

Laparoscopy requires a different set of skills compared to traditional surgery. In many

cases, it can be more challenging to complete a procedure. A good fertility doctor will know
when laparoscopy is an advantage and when it is a liability.
 
Generally, laparoscopy should be reserved for couples who have already completed a
more basic infertility evaluation including assessing for ovulation, ovarian reserve, ultrasound
and hysterosalpingogram for the female and semen analysis for the male. Some couples may
elect to skip laparoscopy in favour of proceeding to other fertility treatments such as
superovulation with fertility medications combined with intrauterine insemination or in vitro
fertilization. There may be instances in which the fertility doctor may have a high suspicion for
finding problems with laparoscopy. For instance, if a woman had a history of a severe pelvic
infection or a ruptured appendix, this would increase the likelihood that she may have pelvic
adhesions and therefore more likely to benefit from laparoscopy.
 
During laparoscopic surgery, the patient will be under the effects of general anaesthesia, so they
would not feel any pain, nor remember the procedure. When they wake up, they may have a
sore throat, caused by a tube that is placed there that help to breath during surgery (but is
removed before they wake-up). It is said to be normal for the area around the cuts to feel sore,
and the abdomen may feel tender, especially if the doctor removes a lot of scar tissue. They may
feel bloated from the carbon dioxide gas, and may experience sharp pains in the shoulder. This
should go away in a few days. They patient should plan on taking it easy for at least one or two
days. They may need a week or two to recover if many repairs were made. She may also be
prescribed pain medication and antibiotics.
 

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A hysteroscopy may be recommended for evaluation for abnormal uterine bleeding, recurrent
pregnancy loss, or recurrent abortions are also evaluated by hysteroscopy abnormal findings on
a hysterosalpingogram, ultrasound, or pelvic exam may also require a hysteroscopy for further
evaluation. Uterine fibroids, polyps and septums [divisions] are evaluated as well as treated
hysteroscopically. It is mainly conducted as two types, diagnostic and operative hysteroscopy.
Diagnostic hysteroscopy can be performed with a smaller instrument. This procedure is
generally shorter and can be done under mild sedation or short general anaesthesia for better
comfort the procedure is quick and inexpensive. Whereas Operative hysteroscopy is performed
under general anaesthesia. This will allow the physician to both diagnose and treat most
findings, which are encountered at the time of the procedure. The Operative Hysteroscope has
ports, which allow the physician to insert operating tools, such as, scissors, cautery devices or a
laser fibre. These may be used to resect or cauterize specific abnormalities under direct
visualization.
The Hysteroscope is also valuable in treating some forms of tubal occlusion. Many
patients with a blockage in the fallopian tube may have an obstruction at the junction between
the uterus and fallopian tube. The Hysteroscope is used to pass a small catheter through this
contracted area under direct visualization. Occasionally, scar tissue can be disrupted and allow
passage of sperm as the result of the procedure. A physician will be able to evaluate the cervical
canal, the contour of the uterus, and the quality of the endometrial lining. The tubal Ostia are the
openings of the fallopian tube into the uterine cavity. They should be easily seen with the
Hysteroscope.

4. High Risk Pregnancy

Pregnancy is one of the most exciting and happy phase of women’s life. But for some,
especially those with chronic medical conditions or who are expecting multiples, pregnancy
management can be a time of intense fear and uncertainty. It is in those circumstances that we
need to provide specialized care for both mother and child to ensure good health for both of
them. It is only in less than ten percent of pregnancies, which will have some kind of
complication that can affect the health of the mother or the child. These are called as high risk
pregnancy. When babies are born pre-term, they have a higher risk of having serious health
problems. If these high risk pregnancy can be identified and the pregnancy managed
accordingly, they will be able to achieve a favourable outcome and they can have a comfortable
pregnancy. In fact, many risk factors can be identified even before conception occurs. For all
this they will require a comprehensive approach to their medical condition and pregnancy care
along with a strong support system.
The Common Risk Factors that lead to a High Risk Pregnancy are,
 Advanced Maternal Age
 Chronic medical conditions, such as cancer, diabetes, high blood pressure or arthritis
 Systemic complications in pregnancy
 Heart disease
 Renal disease
 Respiratory disorders
 Hepatobiliary dysfunction
 Haematological problems
 Family history of mental retardation or birth defects

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 Women who have experienced miscarriages, pre-term deliveries, stillbirths, etc…

The department of obstetrics and gynecology along with the feto-maternal unit provides

comprehensive care for high risk expectant mothers and their unborn babies. The department
provides a hospital based outpatient program that follows a multidisciplinary team approach. At
CIMAR, a team of experienced healthcare professionals is dedicated to offering comprehensive,
compassionate care that includes,
 Diagnosing potential pregnancy complications and fetal development issues in their
early stages
 Providing top-of-the-line medical treatments to both mothers and infants
 Being compassionate and offering emotional support during trying times

A team of experienced healthcare professionals is dedicated to offering comprehensive,

compassionate care that includes
 Preconception and genetic counselling
 Prenatal testing and diagnosis
 High risk pregnancy consultation and maternity services
 Comprehensive 2-D, 4-D & Doppler ultrasound
 Diabetes education and nutritional counselling
 Lactation support and consultation
 Psychosocial assessment and lifestyle management
 Patient and family education classes and support groups

5. Obstetrics and Gynaecology

Being a world class fertility centre, it is needless to say that they also offer excellent
obstetrics & gynaecology care services ranging from routine to high risk ante-natal care. With a
good back up from the maternal-fetal medicine experts in India and neonatology departments,
they are able to assure a safe transit for the baby from the womb to the world outside so that the
patient can relax and enjoy their pregnancy, delivery and post delivery period. The common
gynaecological problems they cater to include adolescent gynaec problems (PCOD, irregular
bleeding), abnormal uterine bleeding, ovarian cysts, fibroid, endometriosis, pelvic infections,
prolapse uterus, urinary problems like incontinence, menopausal & postmenopausal complaints.
Obstetrics & Gynaecology department also provides a Women Wellness Clinic.

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6. Neonatology
A neonatal intensive care unit (NICU) is a specialised unit for care of ill or premature
newborn infant needs intensive care. The NICU combines advanced technology and skilled
health care professionals to provide specialized care for babies. NICUs may also specialised
areas for babies who are not as sick but do need specialized nursing care. In NICU newborn
will stay for days, weeks, or possibly longer, depending on the baby’s degree of prematurity and
severity of illness.

Different levels of NICU

1. A Level 1 NICU or Level 1 Nursery:

It is defined by two different sources as follows: “Level 1 nurseries care for
healthy, full-term babies. They are able to stabilize babies born near term to get them
ready to transfer to facilities that offer special care.”
2. Level 2, or specialty care nurseries:
In addition to providing basic care, can provide care to infants who are
moderately ill with problems that are expected to resolve rapidly or who are recovering
from serious illness treated in a level 3 (subspecialty) NICU.
3. Level 3 NICU,
It is a neonatal intensive care unit that is capable of caring for very small or very
sick newborn babies. Level 3 NICUs have a wide variety of staff on site, including
neonatologists, neonatal nurses, and respiratory therapists who are available 24 hours a
day. Baby’s condition requiring special care, whether it is premature or critically ill,
NICU is the right place for the baby care.

Most babies admitted to the NICU are premature (born before 37 weeks of pregnancy),
have low birth weight (less than 2500 gm), or have a medical condition that requires special
care. Twins, triplets, and other multiples often are admitted to the NICU, as they tend to be born
earlier and smaller than single birth babies.
The following are some factors that can place a baby at high risk and increases the chances of
being admitted to the NICU. However, each baby must be evaluated individually to determine
the need for admission. High-risk factors include the following:

Maternal factors:
 Age younger than 16 or older than 40 years.
 Drug or alcohol exposure.
 Diabetes

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 Hypertension (high blood pressure)

 Bleeding
 Sexually transmitted diseases.
 Multiple pregnancy (twins, triplets, or more)

Delivery factors:
 Foetal distress/birth asphyxia (changes in organ systems due to lack of oxygen)
 Breech delivery presentation (buttocks delivered first) or other abnormal presentation
 Meconium stained amniotic fluid / meconium aspiration
 Nuchal cord (cord around the baby’s neck)
 Forceps or caesarean delivery.

Baby factors:
 Pre or post term deliveries (less than 37 weeks or more than 42 weeks).
 Birth weight less than 2,500 grams or over 4,000 grams.
 Small for gestational age.
 Medication or resuscitation in the delivery room.
 Birth defects
 Respiratory distress including rapid breathing, grunting, or apnea (stopping breathing)
 Infection such as herpes, group B streptococcus, Chlamydia.
 Seizures
 Hypoglycemia (low blood sugar)
 Need for extra oxygen or monitoring, intravenous (IV) therapy, or medications.
 Requiring blood transfusion

The baby will be cared for by a team of well-trained, diversely skilled staff members any of
whom will be glad to answer any questions at any time. Doctors like Neonatologist,
Paediatrician, Staff nurses, Nurse in charge and other healthcare professionals like Pharmacist,
Developmental team, Audiologist, Ophthalmologist, etc…

The CIMAR hospital neonatal unit (NICU) has adequate space, controlled access,
nominated sterile areas, uninterrupted power supply, efficient medical gas distribution systems
and modern medical infrastructure in an environment that is sensitive to the needs of the baby
and the family. Facilities exists in the unit for providing the safest critical care to the premature
babies including the ELBWs (extremely low birth weight babies weighing less than 1000
grams) and those new-borns with a wide variety of complex medical, cardiac and surgical
problems.

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The unit is constructed scientifically as per the current recommendations and follows open care
system with state of the art radiant warmers for the babies. The unit has bed strength of 23 as
detailed below:
 Level III Neonatal Intensive Care Unit (NICU) – 4 ventilated beds
 Level IIB Special Care Baby Unit- intermediate dependency care – 14
 Level IIA Special Care Baby Unit – low dependency care – 5

7. Mind Body Medicine

Happy and successful marriages are based on mutual respect, understanding, love, care and
healthy sexual life. It is all the more important that these problems be solved in the context of
the stress and strain of modern life. In CIMAR, the focus on the total wellbeing of mind and
body is achieved by the hard work of the team of expert counselling and therapy, such as,
 Counselling for patients undergoing infertility treatment
 Specialized counselling and therapy for sexual dysfunctions and disorders
 Family/Marital counselling
 Premarital counselling and sex education
 Relaxation therapies
 Psychotherapy

They provide treatments for Common sexual problems such as Erectile Dysfunction, Premature
or delayed ejaculation, Fear of Sexual Intercourse, Non-consummated marriages, Lack/Loss of
sexual desire, orgasmic disorder, arousal disorders, general break down in a couple’s
relationship, etc…

8. Genetics
Cytogenetics is a branch of genetics. Every individual has 46 chromosomes with XX sex
chromosomes in females and XY in males. These chromosomes are carriers of the genetic
material that encodes for all genetic information. Thus any abnormality in the chromosome
number or structure leads to a genetic condition with mild to severe clinical presentation
depending on the type of chromosomal abnormality.
Chromosomal abnormalities can happen in any cell in the body when egg and sperm cells
are being made, during early fetal development, or after birth. A routine cytogenetic analysis
involves evaluating 15 to 20 cells to determine their modal chromosome number and assessing
the structural integrity of each chromosome in the complement. Thus, cytogenetics has a direct
effect on the diagnosis, management, and prevention of many disorders that are caused by
chromosome aberrations. The cytogenetics department at CIMAR has the best cytogenetics lab
that work together with maternal-fetal medicine department and infertility department. The
cytogenetics testing involves prenatal diagnosis, neonatal and paediatric investigations for
recognised syndromes, investigation of developmental delay, learning difficulties, multiple

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congenital abnormalities (dysmorphism), investigation of infertility and reproductive disorders

in adults. In conjunction with collaborating laboratories, we also undertake specialist
cytogenetics testing for rarer genetic syndromes. CIMAR cytogenetics lab offers the following
services:
 Genetic Counselling
 Premarital Counselling
 Antenatal counselling
 Work up of the Index Child

Conclusion

CIMAR Cochin provides its patients with world class ambience and facilities it can put any
patient at ease and make every visit pleasant and memorable. Located along the picturesque
Cheranellore River, which spares the din and bustle of the city. A Great amount of time, effort,
and detailing has gone into ensuring optimum patient care and comfort while setting up the
centre and going beyond the conventional approach that dictates hospital architecture, they have
tried to present their patients with totally a new feel in terms of service and comfort. They have
intentionally kept their total bed capacity under 50 in order to ensure very high levels of
personal attention to their patients. Speaking of their rooms and quality of service may be more
in line with luxury hotels. Along with their designer they carried out motion study while
implementing the finer details of the layout to give the utmost hospital experience. They offer
rooms, suites and wards to cater to all categories of patients.
The staff have been a major contribution to their success. While being treated like
family members, it is ensured that there is proper discipline and training provided to boost their
morale. The staff comes with experience ranging from over 40yrs in the field of being head of
Departments, research facilities. The nurses and office staff are trained to make the patients feel
at home while they undergo various procedures. At CIMAR, care does not end at patients, but
extends to the environment also. Their water treatment plant meets the highest standards of
pollution control and can handle in excess of five times the maximum consumption in full
occupancy. There has been every effort to provide maximum natural lighting in the building to
cut down the use of artificial lighting. The entire garden is being watered with treated water and
all the common toilets are set with sensors to control water flow and prevent wastage. They
have also made wide use of energy saving LED and CFL lamps.
 

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