Wednesday, July 30, 2014

What can I do to make my embryos stick ?

English: 8-cell human embryo, day 3
Patients who have failed an IVF cycle are often understandably desperate . It can be hard to come to terms with this failure, because most were very sure they would get pregnant in their very first attempt ( few patients would have the courage to start an IVF cycle if they did not secretly believe in their heart of hearts that it would work for them !) They start hunting for solutions to increase their chances of success in their next IVF cycle.

Most will have had good embryos and an easy embryo transfer . When the cycle fails, it’s obvious that the reason for the failure is that the embryos did not implant – what is grandly called – “ failed implantation”. The logical solution is then to do something to get them to stick – perhaps some kind of embryo glue which will make sure the embryos don’t fall out after they are transferred ?

Sophisticated patients and doctors might find it amusing when the patients expresses her desires in these simple terms. This is because many people  still have lots of misconceptions and myths about the entire process of what happens to the embryo once it is transferred into the uterus.

The truth is that most good looking embryos do not implant, and we know that the commonest reason for failed implantation is that there is a genetic problem in the embryo . This is often not something which we can diagnose, even with today's advanced genetic technology , which uses whole genome testing, array CGH and next generation sequencing ( NGS) .  This is because embryos which appear are normal on genetic testing may still have lethal genetic anomalies which we cannot pick up. Our genetic tests are still fairly crude, and only allow us to count the number of chromosomes. We still cannot analyse individual genes.

Embryo implantation is a complex process which depends on many variables. Along with the embryo, the uterine lining plays a key role as well , and this is affect by multiple complex variables, including: the blood supply to the endometrium ; the hormone receptors on the endometrium ; and the complex crosstalk between the embryo and the endometrium.

The problem is that most patients don't understand a lot of this , and doctors don't bother to explain this to the patient . This is why many patients jump to the conclusion  that the reason their cycle failed  even though  the doctor carefully deposited their beautiful embryos inside the uterus with the help of ultrasound guidance , was  that they must have done something wrong which caused embryo to get dislodged . Perhaps they put too much pressure on the uterus by lifting a bucket ? or did going through that big pothole cause the embryos to fall out ?  was their diet too hot ? or did they not rest enough ? Hundreds of doubts plague them, and it’s hard to find straight answers. They are very reluctant to ask their doctor their questions, because they feel these are “stupid”. Also, bulletin boards are full of misinformation and myths.

We need to keep on reminding women that medical science has its own limitations , and we don’t know why embryos do not implant.  , some doctors try to distort the truth by saying – “ I made perfect embryos for you. The failure suggests there is something wrong with your body . Perhaps it is rejecting the embryo , because you have some kind of immune dysfunction “. This “explanation” makes sense to the patient, even thought it is completely false !

They will then spend lots of money and time and energy on testing for these immune dysfunction problems , and even " treating " them . All of this might seem extremely medically sophisticated , but these tests are just as useless as thinking that the embryo got dislodged because the patient coughed or sneezed after the embryo transfer.

The honest doctor will tell the patient that once we have transferred the embryos into the uterus, this is now a “ black box “ area  - a non-man's land.  While we do our best to facilitate implantation ( for example, by providing luteal phase support with estrogen and progesterone), we still cannot control biological processes . This is often a matter of luck , but  patients don't want doctors to use terms like fate or chance or destiny. They crave certainty and  when a doctor tells them the unvarnished truth , they get upset and go hunting for another doctor , who will pacify them by providing them with a pseudoscientific explanation for the failure by invoking scientific garbage such as the presence of a .”pregnancy destroying factor” in their body which needs to be “ treated “ !

Not sure why your IVF cycle failed ? Want an honest second opinion ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Tuesday, July 29, 2014

Meet The Doctor Who Is Empowering Patients And Bridging The Doctor-Patient Gap


A doctor’s duty doesn’t end with just treating the patient’s symptoms. The anxiety, fear and vulnerability of the patient and his family need to be addressed too. As the blame game between patients and hospitals continues, Dr. Malpani has come up with an idea to empower patients and make every one’s task simpler. Read more to know how he is bringing both of them together on the same page.

http://www.thebetterindia.com/12671/meet-doctor-empowering-patients/

Monday, July 28, 2014

Doctors polish soft skills to deliver tough news

The Times of India has a great article on how physicians and surgeons in India are attending creative and communication workshops to help increase their patience towards patients. 
http://timesofindia.indiatimes.com/india/Doctors-polish-soft-skills-to-deliver-tough-news/articleshow/39085240.cms
Doctors can learn how to be patient from their patients ! 

Why do infertile women spend so much time on the net ?


Lots of infertile women spend hours on the Internet , hunting for information and looking for treatment options and the best possible doctor. This is especially true when they have failed an IVF cycle and are trying to find what they can do differently the next time , in order to improve their chances of success.

Infertile women need lots of emotional support , which is why they often glued to the PC, reading posts on bulletin boards ; searching for nuggets of information on blogs  ; and posting information about their problem and looking for solutions from other infertile women .

This is because husbands are quite poor at providing emotional support – and doctors are even worse. An online community , which can provide support ; and which is anonymous and instantly available can be so comforting for them . It gives them a chance to network with other women , who have been there,  done . These expert patients can provide wise counsel, which is not contaminated by commercial influences, which means that it’s trustworthy.

A lot of husbands get irritated by the amount of time which their wife spends on the Internet . They feel that the Internet has become an obsession with them , and believe that it adds to their stress levels. Because they spend so much time and energy trying to find out stuff , they feel this time is wasted. Their belief is that the doctor is the expert, and they should trust him. They are worried that a little knowledge can be dangerous , and that their wife has become an infertility net junkie.

Many women also get frustrated , because so much of the online information is untrustworthy . Viewpoints and opinions on many websites are exactly the diametrical opposite of what other sites claim – and women get confused because they don't know which sites to trust . They are not sure what their next action step should be, and often get paralysed into inaction.

When they ask their doctor for help, he often gets irritated by “internet-positive” patients who bring pages and pages of Internet printouts to them. They will often be dismissive of these website, and will say – “ Don’t waste your time hunting for information on the Internet . I am your doctor and I will  provide you with the right solutions . You just need to trust me !

I don't think this is a very constructive approach . We need to acknowledge that infertile women are hungry for reliable information, and the Internet is a great source of potentially valuable information. However, patients need to be taught how to use the net intelligently , so that they can then access reliable sites , rather than waste time on dodgy commercial sites, which are out to peddle their wares and cheat patients of their hard earned money by making false promises and ridiculous claims ( for example, the Clear Passage Therapy website).

Banning infertile women from going online will just result in throwing out the baby with the bath water ! Doctors need to help their patients identify reliable websites , so that they can use Information Therapy to maximize their chances of getting pregnant .

Confused by all the information you are finding online ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?





Friday, July 25, 2014

More patient complaints and compliments for Malpani Infertility Clinic


Patient Compliments for Malpani Infertility Clinic 2013  

We understand it's hard for patients to judge how good or bad an IVF clinic is based on just their website. After all, most websites looks very similar ! 
This is why we have included excerpts from our Complaints and Compliments book at our clinic, so you can read the unvarnished truth, as to what our patients think about the care we provide them.

Wednesday, July 23, 2014

Patient Compliments and Complaints for Malpani Clinic

Why IVF patients are treated as guinea pigs


I am very critical about the overtesting which is so rampant in IVF today. This leads to overtreatment , and ends up wasting a lot of time and money , because no one really knows how clinically useful a lot of these test results are. Just because tests make logical sense on paper doesn't mean that this logic always translates into clinical benefits.

The sad fact is that real life can be quite messy , and what sounds very sensible in theory often does not work out well in practice .

I recently saw a patient who had failed multiple ICSI cycles. His doctor had told him that this was because of his high sperm DNA fragmentation, and that we would need to use donor sperm.

I have a very low opinion of these sperm DNA fragmentation tests . They are of very limited utility , and have not been validated in clinic practice, because of the huge problem with false positives they suffer from.

He challenged me. Doctor, if you are so skeptical about these latest and newest cutting-edge tests, then how will medicine possibly advance ? Don’t we need to run tests to find the “root cause” of the problem ? Don’t we need to know the answer to the question – Why did the cycle fail, so we can improve our chances with the next attempt ?

I have nothing against new tests. Our IVF clinic is state of the art and we offer all the latest technology, including blastocyst transfer, vitrification, laser hatching,  and PGD using CGH. However, we don’t offer tests simply because of their novelty value ! I'm not a Luddite and I'm not old-fashioned . My point is that while some of these tests may be extremely useful in a research setting , they cannot be blindly applied in a clinical setting . Just because a test works in a mouse lab doesn’t mean it will work in real life for human patients . We cannot afford to get carried away by marketing pressures and technological jargon.

We need to understand the limitations of these tests before incorporating them into clinical practice . A lot of pressure to overtest comes from the marketing departments of the companies who invent and discover these tests. Also, some of the itch to order tests comes from doctors themselves . Doctors will often indulge in a game of one upmanship ! They all want to be one better than someone else , and one way of doing this is by ordering the latest or the newest test .

This way the doctor. can position himself as being state-of-the-art , because he's better informed than the other “old fogeys” whom the patient saw earlier , and who did not have the sense to order the test. This goes to “ prove “ that he's much smarter and has much more expertise than the rest of them , because he read about this test in the latest issue of a medical journal; or saw a presentation at the recent global medical IVF conference.

Patients need to be extremely wary about this kind of cowboy approach if they do not want to be treated as unwilling guinea pigs. Sadly, many patients pressurize doctors to order some of these new-fangled tests, because they have read about them on a website or a bulletin board. New is not always better , and it requires a mature and experienced specialist to say - No further testing is needed ! It’s very profitable for the doctor to order these tests, but good doctors know that if the test has not been proven to improve IVF clinic outcomes, then they should desist from ordering them.

We take pride in the fact that we refuse to treat our patients as  guinea pigs !

Tuesday, July 22, 2014

To be or not to be ( pregnant !)


Why some doctors are scared of Information Therapy


I recently had an interesting conversation with a senior doctor who was quite skeptical about the
value of empowering patients with information. He felt this was a fad, and would just create
more problems. He believed medicine was a complex subject – after all, it takes years of full-time training to become a surgeon, so how can one expect patients to understand the nuances of their medical problems in a few minutes? Isn’t it far better for them to trust their doctor, who is the true
expert, and who can help them heal quickly?

The doctor was very critical of patients who came with pages and pages of Internet printouts about
their medical illnesses. He felt they were often very confused and ended wasting a lot of their own time and his by wanting to discuss options and alternatives that did not make any sense. He also felt
that second-guessing just caused patients to doubt their doctor, and this loss of faith and trust would end up harming patients and doctors as well.

In general, he was quite dismissive about “well-informed patients” who felt they had become “half-doctors” by reading and researching their medical problem online. He believed a little knowledge can be dangerous, and patients who think they know a lot about their disease often created more problems than they solved by challenging their doctor’s decisions.

He also highlighted the fact that doctors, not used to having patients disagree with them, can often end up getting upset and angry with “well-informed” patients, which makes doctor-patient relationships confrontational rather than cooperative.

While everything he pointed out was true, this doesn’t mean there is anything wrong with the idea of information therapy. Like anything else, information can either be used properly or misused and abused.

The key is that the information we provide needs to be reliable, updated, evidence-based and tailored to each patient’s needs. If every doctor prescribed information rather than forcing patients to
seek it out for themselves, this would create a win-win situation. The patient would trust this information since it was coming from his doctor and would not have to waste his time wading through pages of potential misinformation. The doctor would also be more confident that the patient was well informed and had realistic expectations of his medical treatment.

WHAT IS INFORMATION THERAPY ?

Information therapy can be defined as the prescription of the right information to the right person at the right time to help them make better health decisions.

The ‘right’ information is accurate because it is evidence-based, approved by experts, up to date, easy to read and understand, available in many different formats (including local languages and audiovisual formats) and referenced.

The ‘right’ person means this information needs to be delivered directly to the patient (and their
caregivers). This information is best dispensed to a patient by his or her own doctor – the person they trust the most when it comes to their health.

The ‘right’ time means the information should be provided when the patient needs it – that is, in time
to help them make the best possible medical decisions.

So, what is the ‘right’ information, and who decides what is right?

ON THE RIGHT PATH

There are several ways of delivering this powerful tool – it can be clinician prescribed, system-prescribed, or consumer-prescribed. At present, most patients get information through their own research, often online where plenty of unreliable and misleading information exists.
Unfortunately, patients are often not knowledgeable enough to conduct searches that yield valuable results. In an ideal world, all relevant information would be routinely handed over to patients by doctors.

It’s a fact that hospitals and medical centres that systematically implement information-therapy
applications will be in a better position to gain market share, profitability and prestige over those
that don’t. It actually makes good business sense in a world where healthcare is rapidly evolving
around the world. We now have empowered consumers (who demand time, information, control, and service), a new focus on quality (which promotes safer medical care and a move towards
pay for performance), and a new way of validating what does and does not work in medicine (the science of evidence-based medicine).

Thanks to the Internet, we are also equipped with the technology needed to reach out to consumers
– it connects anyone, anywhere, any time to quality information.

These drivers create a compelling case for information therapy, which revolves around an expanded patient role. As healthcare evolves, the following should occur:
• Every clinic visit, medical test and surgery is preceded or followed by information-therapy prescriptions.
• Information prescriptions sent between in-person visits will extend the continuity of care.
• Patients will play an active role in shaping how they want information to be delivered to them.

Information therapy is a very cost-effective solution that allows a doctor to put each patient at the heart of the care he or she provides. As the renowned poet and writer Kahlil Gibran once said, ‘Progress lies not in enhancing what is, but in advancing toward what will be’.

In the delivery of excellent patient care, you and every one of the doctors in your practice should be prescribing information to each and every patient.


BACK TO BASICS

It’s important to remember here that the word doctor is derived from the Latin word docere, which means to teach or instruct. When doctors don’t do so, we are abdicating our responsibility and forsaking our patients, who feel lost and are then forced to fend for themselves.

The solution is simple – doctors need to guide their patients, and prescribing information therapy is a simple way of doing so. This must be curated, reliable information that both doctors and patients trust, thus ensuring they are on the same page and are active partners in a healing relationship.


This article first appeared in the Autumn issue of the Private Practice Magazine, which is published in Australia.


Monday, July 21, 2014

The difference between follicles and ovarian cysts

  Cyst ? Or follicle ?

A patient just sent me this query

I am 29 and trying to conceive for past 4 years.I have irregular cycles. My doctor prescribed me Injection recagon 100units for 6 days from 12-May-2014. On 11th day of cycle during follicle study I got dominant follicles on both ovaries and doctor prescribed to take orgamed capsules for 14 days This month I didn’t get my periods and HPT is negative and even checked with doctor , it is negative again and she prescribed me regestrone tablets for 10 days I have a clarification . If I got dominant follicles on both ovaries, where the follicles would have gone? As per my assumption it should be either fertilized or I should have started periods . I'm so confused. Please guide me

It’s very common for infertile women to be confused about reproductive basics. They often do not understand the relationship between menstrual cycle and ovulation; or the difference between follicles and eggs; or how follicles are different from cysts.

We need to go back to basics, to make sure there is clarity going forward. Otherwise this poor patient will keep on going round and round in circles, cycle after cycle !

This was my answer.

The reason your periods are irregular is because you Do not ovulate. This is called anovulation. Read more at www.drmalpani.com/articles/anovulation.htm.

 This maybe because you have PCOD ( polycystic ovarian disease). You can read more about this at www.drmalpani.com/articles/pcod.htm.

 You need the following medical tests.
1.    Blood tests for you for the following reproductive hormones – FSH ( follicle-stimulating hormone),LH ( luteinizing hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone)
( to check the quality of your eggs). Do this from a reliable lab such as SRL ( www.srl.in);
2.     A vaginal ultrasound scan which should check for the following.
a.    Ovarian volume
b.    B. antral follicle count
c.    C. uterus morphology
d.    D. endometrial thickness and texture

Please send me the detailed test results and medical reports . You can scan them in as a single Word file and email them to me. Patients with PCOD will typically have a high AMH level; a high LH:FSH ratio; increased ovarian stroma; and many small cysts arranged around the periphery of the ovary.

 So what’s the difference between a follicle and cyst ?  A cyst is basically a follicle which does not contain an egg.  They both appear as hollow dark spherical objects in the ovary on ultrasound scans.  Since we cannot make out if the structure we see on scanning contains an egg, this creates a lot of confusion in the patient’s minds .

To make matters worse, doctors often loosely refer to the follicles seen on ultrasound scanning as eggs. In reality, eggs are microscopic, and can only be seen in the IVF lab when the follicular fluid is examined under the microscope by the embryologist. While there are many kinds of cysts, the commonest kind we see is called a functional cyst, which looks exactly like a follicle , except that it’s larger.

Thus, when a mature follicle ( which contains an egg) fails to rupture at the time of ovulation, it collects fluid and becomes larger. This is called LUF syndrome. Read more at http://www.drmalpani.com/articles/luteinized-unruptured-follicle-syndrome-LUF-infertility.htm

A functional cyst ( so called because it is functioning and produces hormones) will often result in the period being delayed, as a result of the hormones it produces. This is why it may cause the period to be delayed. It’s possible to make this diagnosis by doing an ultrasound scan. The period can be induced with medications . These cysts will usually resolve on their own.


Have a query you are scared to ask your doctor because he is too busy ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly!







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