Monday, September 22, 2014

The abuse , misuse and overuse of surrogacy

 I was counseling a patient who had failed many IVF cycles . She was completely fed up and wanted me to do surrogacy for her. We have an active surrogacy program , and it's very profitable for me to offer surrogacy because it’s far more expensive than a regular IVF cycle . However, it’s my personal opinion than surrogacy is a treatment which is best reserved for patients whose uterus is absent or damaged .

For most women with the distressing problem of repeated failed implantation , the probability that there is a problem with their uterine receptivity is very low , especially when we have checked that their uterus is normal ( with the help of a transvaginal ultrasound scan which shows they have a thick, trilaminar endometrium).

This is why the uterus using a gestational surrogate makes no logical sense because it cannot increase pregnancy rates .

To use an agricultural metaphor, the seed has a far more active role to play as compared to the soil. We know based on extensive research that the reason for failed IVF cycles and recurrent miscarriages is far more likely to be a defective embryo because of a lethal genetic defect, rather than an endometrial problem.  Sadly, we still don’t have the technological ability to be able to document these genetic defects, and this leads to a lot of confusion. Thus, if an embryo fails to implant after PGS/CCS has shown it to be normal, patients jump to the flawed conclusion that the problem is with their uterus, which is “rejecting” the embryo. The reason this is erroneous is that PGS/CCS only allows us to count the number of chromosomes – it cannot test the normality of all the genes !

However, most doctors are quite happy to offer surrogacy as a solution , and this makes a lot of logical of sense to the patient. They feel that if the doctor transferred good looking embryos into my uterus and they still failed to get pregnant, this proves that their uterus is defective and is rejecting the embryos.

Their belief is strengthened by all the rubbish which floats around on the internet about immunological dysfunction causing recurrent implantation failure .

It’s often hard for me to explain to them why surrogacy's actually not the right solution for them , and why they would actually be better off considering donor egg IVF or embryo adoption . Patients come to doctors with preconceived notions , and they don't really want to engage in a debate with the doctor. Most would much rather find a doctor who was happy to do whatever they wanted . After all, they are willing to pay for the treatment , so why should the doctor object ?

The problem with surrogacy is that it deprives the patient the joy of experiencing pregnancy herself. The unfortunate women who are born without a uterus don’t have a choice in the matter, but it’s sad that they deprive themselves of this unique experience simply because of preconceived misconceptions.

I think my role is not merely just that of being a technician . I am a professional , so that I need to offer my personal opinion . I may not always agree with the patient, and some of them get upset when I do this. They would rather find another clinic who accedes to their requests . Of course, it’s much easier for me to do this as well, and by educating my patients , I am aware that I'm actually turning away income ! However, I think that it’s in their best long-term interests that they understand their alternatives , and then choose the option which is correct for them .

Sadly , I find a lot of patients want to do surrogacy simply because they are fed up of going through the ups and downs of IVF cycles. They can no longer emotionally cope with this kind of roller coaster ride , and would much rather just outsource the entire pregnancy to someone else.

What they fail to realize is that the implantation rate in a surrogate is not 100% either – and just because they are an arm’s length away does not  make the IVF treatment for them any easier . In fact, it can sometimes be scarier, because they are never sure what the surrogate is doing, and whether she is taking as good care of their baby as they would !  The fact that they have unrealistic expectations of the success rate of the surrogacy treatment cycle causes lots of heartburn when the cycle fails , especially when they have spent so much money , and done it with such high hopes and expectations.

Is your doctor pushing you to do surrogacy ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Sunday, September 21, 2014

Free IVF app to plan your IVF calendar

IVF treatment can be complex and time consuming  and patients have to juggle lots of stuff - doctor's appointments, medications, shots, blood tests, ultrasound monitoring, leave, home, travel, finances....

We have refined and polished our IVF app , My Fertility Diary, which runs on android smartphones , to help IVF patients manage their IVF treatment in a more organised fashion.

We are now looking for volunteers who are willing to be beta testers for this new version. We would like you to provide us with feedback so we can fix any bugs; and provide additional features to help IVF patients reduce their stress during their treatment.

If you are interested, please email me at so I can send you the beta version of the app.

Why do some embryos arrest ?

It’s extremely frustrating for patients when the clinic calls them with the information that what was a beautiful 4-cell embryo on Day 2 has arrested on Day 3 and remained a 4-cell embryo, instead of dividing further to become a 8-cell embryo.

Why do some embryos arrest in vitro ? And why do so many good looking embryos fail to implant after transfer ? And why do some of the ones which do implant end up in a heart-breaking miscarriage, rather than a beautiful baby ? The amount of inefficiency which riddles human reproduction is mind-boggling. ( In fact , it seems to start right from the fact that men need to produce millions of sperm in order for one of them to be able to fertilise the egg ! )

One way of making sense of this is to hypothesize that each embryo’s life expectancy is encoded in its DNA . This is a concept we are familiar with when we consider life and death after birth. We know that there will be some people who live upto the age of 100 – but lots will die at the age of 70 – and a few unfortunate ones will die at the age of 2.  While doctors have to write down a medical cause of death on the death certificate, and we are distraught when learning of the death of a friend’s child at the age of 10 because of leukemia, the fact remains that life expectancy seems to be a random lottery , and we cannot control this.

While we use terms such as lifestyle risk factor and heredity to explain this, a far more useful concept is the term heredity, coined by Dr Manu Kothari. This means that in a “herd” ( a population , for example, a group of children), their life expectancy can be plotted on a bell-shaped curve. Where an individual will figure on this curve is still not something we can determine, but this rule of thumb is a useful way of understanding this randomness. You could try plotting the life span of your father’s classmates, for example, or that of your family members, to see how true this is.

This means that in a given group of people ( and the larger the sample size, the better this rule works),
a certain proportion will keep on dying off at a particular age , because of their genetic predisposition to do so, no matter what we do.

If this is true after birth, then isn't it logical to expect exactly the same kind of variation before birth as well, in the embryonic stage ? Just like there will be some babies who will die at the age of two hours , and some at the age of two years , similarly there will be some embryos which arrest ( die) at the age of 48 hours, while some will arrest on Day 4.

We need to think of this as a continuum , starting from the point of fertilization . This means that the embryo’s life expectancy is hardwired into its DNA , and because this is such a random process , that particular embryo could die within 24 hours ; or after 25 years ; or may live upto the age of 85. Of course, the relationship is complex, and in some cases a bad lab can kill off good embryos ( just like too much smoking can reduce life expectancy).

We still haven't been able to tease apart exactly what affects life expectancy ( though we do know that the length of the telomeres on the chromosomes correlates with aging ).  Once we understand some of this randomness , we would have a better appreciation of the fact that human reproduction is not a very efficient enterprise , and this is why IVF still does not have a success rate of 100%, even when everything seems to be perfect. Our fate seems to be hardwired in our genes , and there's precious little we can do about it at present.

Saturday, September 20, 2014

Why do doctors continue using intramuscular progesterone ?

All IVF clinics routinely provide luteal phase support after the embryo transfer. This consists of a combination of both estrogen and progesterone , which are used to prepare the endometrium for embryo implantation .

In the past , progesterone was given in the form of intramuscular injections. Progesterone is an oily preparation , and needs to be given deep intramuscularly, with a fat needle. Not only is the injection painful, because the absorption is poor, the shots will often leave tender lumps in the muscles  , and these take many days to resolve. Often the butt is so sore that the poor patient cannot even sit down anymore.

Many patients who have been given intramuscular progesterone will refuse to do a second IVF cycle, simply because the progesterone shots have left them so miserable . Often, the thought of taking the injections again is far more painful than the idea of having to cope with a failed IVF cycle. This is true for the poor husband has well, who hates having to give his wife these excruciatingly painful injections. Many of them feel it’s not worth having a baby if they have to put their wife through that kind of pain.

Fortunately , thanks to technology , we now have far better preparations for progesterone . This includes micronized progesterone , which can be administered vaginally, in the form of either a gel or a suppository . These formulations have been  available for over 20 years, and we stopped  using intramuscular progesterone in our clinic 20 years ago.

What amazes me is why some clinics continue to inflict so much unnecessary pain on their patients by insisting that they continue taking intramuscular progesterone. If IM ( intramuscular) progesterone were proven to improve IVF pregnancy rates because it’s more effective than vaginal progesterone, I would have understood. However, the truth is that it is no better – and this has been proven in many clinical trials. This is because the absorption from the intramuscular route is much worse . Also, when the progesterone gets absorbed into the bloodstream , it is metabolized in the liver, which breaks it down, as a result of which the levels of progesterone which reach the target organ – the uterus - are reduced.

In contrast, when we deliver the progesterone vaginally, it is directly absorbed and much higher levels reach the uterus – which is where we want it to act ! Some clinics measure blood levels of progesterone, but this is quite pointless, as we are interested in the tissue levels of progesterone in the endometrium – not the blood levels.

Ironically, some patients seem to prefer the IM route . They seem to have a medieval hangover which leans them to conclude that if it is painful, it must be more effective ! 

I cannot understand why doctors continue to inflict unnecessary pain on their patients by prescribing IM progesterone ! Is it just because this is what they have been used to doing, and therefore plan to continue doing it, no matter what the clinical evidence is ? Or is it that because most IVF doctors are men , they are blissfully unaware of how unkind they are being, and fail to understand how much damage they are inadvertently inflicting on their poor patients ? Patients expect injections to be painful, and will rarely complain about this to their doctors, because they feel they cannot afford to trouble their doctor with such trifles.

If I were an IVF patient , I would never take intramuscular progesterone - I would insist that it be given vaginally. I see no reason why we should subject our poor patients to unnecessary pain !

Not happy that your doctor is still prescribing IM progesterone shots ?
Please send me your medical details by filling in the form at so I can guide you sensibly ?

Friday, September 19, 2014

Managing your Doctor

Even in this day and age, where the medical profession seems to be vilified almost daily by the media, most patients still trust and respect their personal doctor. They see them as being professionals with medical expertise , which they can tap when they are ill and want to get better . They are usually quite passive and are happy to do whatever the doctor advises. This means in effect that it is the doctor who sets the agenda for the consultation .

This works well, especially for most bread and butter problems, where both doctor and patient are on the same page , and have the same expectations . The problem , of course , is that doctors are not mind readers , and if there is a difference between what you expect from the doctor and what the doctor is willing to provide , both doctor and patient are likely to be extremely unhappy with the consultation.

However,  unless you express your displeasure , there is no way that the doctor will know that he has not done a good job . Part of the problem is that patients do not provide feedback and when they are unhappy with the doctor’s treatment plan, they usually keep quiet and don’t tell him this. They nod their head, and the doctor is pleased that they are going to follow his advise when they walk out of his clinic. However, they have no intention of doing so, and this can be frustrating , not just for the patient ( who feels the doctor does not understand him ) but for doctors as well.

Noncompliance is a big issue , and doctors feel that if the patient was not going to follow their advise, then why did he waste their listening silently to him and not speaking up ? If the patient has concerns, the doctor can explain his perspective and clear the patient’s doubts. However, he can do this only if the patient speaks up. This can allow him to modify his treatment plan so it’s easier for the patient to follow.

However, most patients are scared to talk back to their doctor. They are scared that the doctor may take offense, which is why they bottle up their fears and worries. This is a shame, because it represents a waste of both the patient’s time and the doctor’s time as well.

Patients need to learn how to manage their doctor. Some doctors are extremely well organized and efficient , and sometimes the doctor-patient chemistry is so good that there are no issues as well. However, we don't all live in a perfect world , and  sometimes we need to do step up and do what is needed to help the doctor to help us. Patients cannot afford to leave everything up to the doctor. It’s best to assume positive intent, and the more the patient applies his mind and uses his own skill set in order to improve the consultation , the happier both doctor and patient will be . Remember that happy patients make for happy doctors !

Need to know how to manage your IVF doctor more effectively ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Thursday, September 18, 2014

The exception which proves the rule in IVF

It’s true that medicine is a complex biological system , and this is especially true of IVF . However , there are certain rules of thumb ( also called heuristics) which are extremely useful when we practice reproductive medicine .

Thus, we know that if the patients embryos fail to implant, 90% of the time the problem is with the embryo rather than with the endometrium . Similarly, when we encounter the distressing problem of failed fertilization after IVF, the problem is because of sperm dysfunction, rather than an egg problem. WE also know that the patient’s embryos are all of poor quality in a good IVF lab, the problem is much more likely to be with her eggs rather than with her sperm.

These heuristics are extremely useful when counseling patients when things don't go well. They help us to plan our next action steps , and we can be confident that we are providing good advice , even though we don't have specific evidence for that particular patient . These rules are based on experience with many other patients , and empirical evidence is quite reliable since medical science has so much experience with IVF today.

However , there will always be exceptions to these rules. The problem arises because doctors love these exceptions . They are fascinated by complicated cases – by patients who are outliers. This is because doctors get bored by the routine, run-of-the-mill problems. They are always on the lookout for the new and the unusual – something who can challenge their curiosity and perhaps results in a paper they can publish !

They believe that not only can they learn a lot more from these exceptions, they can use this knowledge to advance medical science- after all, how much more can you learn from the ordinary case ? They treasure their exceptions, and this is why doctors are fascinated by zebras !

However , as regards patients , it's much more important for them to know what the rules are , because their problem is much more likely to be what occurs commonly , rather than something which is extremely rare . Unless patients are willing to be guinea pigs, they should assume that their problems are similar to everyone else’s.

Because doctors are fascinated by what is uncommon , they love ordering extensive tests, in order to pinpoint the particular problem for that individual patient . This is especially true for clinicians who are also research scientists. While this may be acceptable in a university setting, or during a trial, this is inappropriate in a clinical setting. It often represents a waste of time and a drain of that patient’s resources, because these tests are exotic and expensive . Infertile patients can’t afford to go to doctors who enjoy chasing red herrings to satisfy their intellectual itch !

Not only is this wasteful, it does not help the patient either , because it doesn't usually change her treatment options . Hunting for zebras is an intellectual challenge for doctors. They love playing a game of one-upmanship and treasure these war stories to show how much better informed they are than their colleagues. However , this may not always be in your best interests !

Not sure if your problem is the exception which tests the rules ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Wednesday, September 17, 2014

HELP is looking for a social entrepreneur !

JOB TITLE: Chief Operating Officer

REPORT TO: Medical Directors

PURPOSE: To empower Indian patients by promoting Information Therapy


Your mission will be to market, disseminate and promote the use of Information Therapy tools in India.  Community Health Research Program is a NGO which is the Indian licensee for the Healthwise Knowledgebase in India.  Healthwise is a non-profit organisation in the USA, where it is the market leader in developing patient educational content .  You will head a small team and will be responsible for making sure things get done ! You need to develop and implement a business model which is sustainable and scaleable.

You are a social entrepreneur who wants to heal a sick healthcare system by improving doctor-patient communication. You understand the need to put patients first, and have to ensure that it makes business sense for health insurers and hospitals to do this, so that the model is sustainable and scaleable.

1.  Medical Graduate - MBBS
2.  Masters in Business Administration
3.  Proven marketing , sales and networking skills

Please send  me your resume at :

You can learn more about HELP at our website,

Check out the Healthwise Knowledgebase at !

Healthcare Achievers Awards

New India Assurance presents the Healthcare Achievers Awards, an initiative with The Times of India, to celebrate the achievements of the Indian Healthcare industry. The award aims to bring together key stakeholders of the Healthcare industry on a common platform, ignite ideas through healthy discussions by way of sharing best practices and inspire innovation in this field.

There is a panel discussion on "Enabling Patient Centric Healthcare" 22th September 2014. The panel will discuss having a patient focus approach in today's cost and technology driven times. This hi-profile panel comprises of distinguished panelists from government, industry dignitaries, reputed doctors, and renowned subject matter experts.

I am very excited that  a leading health insurer has taken this initiative ! It makes business sense for health insurers to invest in patient education, as this reduces overtesting and overtreatment . By highlighting the efforts of good doctors and hospitals, the medical industry can learn to emulate good practises which Put Patients First. 

The IVF coverup

I just saw a couple who had done IVF earlier at another clinic. They were told that their cycle failed because their embryos were of poor quality - and that the reason for the poor quality of their embryos was either that their eggs were not good enough, or that the sperm had a lot of abnormalities.

They were advised that they need to use either donor eggs or donor sperm. The moment the doctor blames abnormal sperm as being the reason for poor quality embryos, this should raise a red flag that you are getting poor quality advise . The fact of the matter is that no matter how poor the quality of the sperm, if ICSI is being done in a high quality lab by a skilled embryologist, you should good quality embryos.

Abnormal sperm morphology or high sperm DNA fragmentation are very rare causes of poor embryo quality, and if your doctor trots these out as the reason for your ICSI failure, then there is a high chance that a coverup of the truth is in progress.

While it is true that poor quality eggs can result in poor quality embryos , it is also equally true that often it’s poor IVF lab conditions which cause poor quality embryos , especially in a young woman with a normal AMH level, a good antral follicle count and a good ovarian response.

It’s possible that the embryologist is not experienced; or that the incubator doesn’t function properly ; or that the culture medium being used is substandard.  Unfortunately, many labs do not follow basic quality control standards, and most clinics are pretty much free to do what they like, since there is no regulation or supervision.

This is why, rather than be honest with the patient and frankly admit that the reason the embryos were of poor quality was because the lab was not good enough, IVF doctors need to be creative and manufacture reasons for why the embryos were of poor quality . They can get away with this because there is a complete lack of transparency about IVF treatment . Most doctors don't even bother to tell patients how many follicles are growing on the ultrasound scan ; what their sizes are; or how many eggs were retrieved. They hide even basic information, such as how many embryos were formed, or what their quality is, by refusing to give them photos of embryos .

This means patients are pretty much at a loss , and are pretty much forced to accept whatever their doctor chooses to tell them. When they have poor quality embryos and then hunt for a second opinion , they then find out that their doctor wasn’t forthright or straightforward. They are understandably  upset , but once they have lost confidence in one IVF doctor, their confidence levels in all IVF doctors goes for a toss and they are very reluctant to try another cycle.

This is why patients need to do their homework proactively and learn to ask high quality questions before starting the cycle. While the outcome is always uncertain , patients need to be sure that the IVF clinic they select is following the right processes properly and that they will share information with them proactively.

Many doctors refuse to answer the patient’s legitimate questions by airily dismissing them. “ You don’t need to worry about all these details. They are too complex, and you will not understand any of it, so why bother ? We doctors know exactly what we are doing, and you just need to trust us !”

Patients are overpromised success when they first attend the clinic, because the doctor wants them to sign up for an IVF cycle. However , when the cycle fails, the doctor becomes a completely different person. He often blames the patient’s eggs for the failure, and patients can't understand why the doctor is now saying something which is so diametrically different from what he did when they started the cycle . Because of these conflicting messages, they lose confidence in IVF clinics, and this is why IVF clinics end up getting a bad reputation.

It’s easy to understand why doctors are very reluctant to tell patients the truth when they think there has been a problem with the quality of care they provided . It’s hard to tell a patient – I am sorry, you didn't get pregnant because our IVF lab wasn't good enough !  However, patients are stupid, and doctors cannot fool all the patients all the time. They will check with other patients and with the clinic staff as to how many patients got pregnant, and when the doctor tries to cover up the truth , they can smell that something fishy is going on. When they do find out the truth, they are very resentful and angry that the doctor lied to them.

Are you worried that your IVF doctor is not being honest and open ? Please send me your medical details by filling in the form at so I can guide you sensibly.

Abnormal sperm are not a cause of miscarriages or IVF failure

Animation of the structure of a section of DNA...
Sperm DNA fragmentation index does not correlate with the sperm or embryo aneuploidy rate in recurrent miscarriage or implantation failure patients

This article is now available free online and is worth reading.

Lots of IVF labs now do sperm DNA fragmentation testing; and when the IVF cycle fails, they
" blame " the sperm for the implantation failure. This makes sense  to the patient - after all, doesn't the sperm contribute 50% of the genes to the embryo ? And if the sperm's DNA is abnormal, then doesn't it logically follow that the embryo created by these sperm is also likely to have abnormal DNA , which means it's more likely to result in implantation failure ?

This paper shows that this reasoning is flawed - and that there is no correlation between abnormal DNA in the sperm and IVF failure.

Here's the abstract - and you can read the full text as well. Please share this with your doctor !

BACKGROUND The aneuploidy rate is higher in poor-quality sperm samples, which also have higher DNA fragmentation index values. The aim of this study was to assess the relationship between sperm DNA fragmentation in samples from infertile men belonging to couples with recurrent miscarriage or implantation failure and the aneuploidy rate in spermatozoa as well as in embryos from patients.
METHODS This prospective study evaluated DNA damage and the aneuploidy rate in fresh and processed (density gradient centrifugation) ejaculated sperm as well as the aneuploidy rate in biopsied embryos from fertility cycles. 
RESULTS A total of 154 embryos were evaluated from 38 patients undergoing PGD cycles; 35.2% of the embryos were chromosomally normal. Analysis of the same sperm samples showed an increased DNA fragmentation after sperm preparation in 76% of the patients. There was no correlation between DNA fragmentation and the aneuploidy rate in embryos or in fresh or processed sperm samples.
CONCLUSIONS Sperm DNA fragmentation is not related to chromosomal anomalies in embryos from patients with recurrent miscarriage or implantation failure.

Tuesday, September 16, 2014

Panel on Impact of Social Media on Healthcare in Mumbai

What IVF patients can learn from Goldilocks

One of the hardest decisions an infertile patient needs to make is to decide which IVF clinic to select for their treatment . There is a bewildering array of choices , and patients are understandably confused .

Should they choose the clinic which is the closest to them ?
Or the one which is cheapest ?
Or the one which is the most expensive (after all , if it charges so much , it must be better ) ?
Should they go to the one their family doctor recommends ? Or is he referring you to a clinic because he has a vested interest in doing so ,as they give him the biggest kickback ?
Should they go to the one which is the biggest ?
Or the one with the best d├ęcor and ambience ?
Or the one which comes up No 1 on google or has the flashiest website ?
Should they choose the one which advertises heavily in magazines and on TV ?
Or one which they just read about in the newspaper ?

I'd like to make a simple suggestion. As with everything else in life, there is always a sweet spot with IVF clinics as well ! You don’t want one which is either too big or too small .  Like Goldilocks, you need to find the bed which is just right for you.
While a large clinic has the advantage that it has lots of people , expertise and equipment under one roof , it often becomes an impersonal assembly-line treatment factory, so that patients are often treated as being a number. These clinic are often very commercial , and are more focused on throughput and the number of patients they can see , in order to maximize their turnover , rather than on providing personalized hands-on patient care , customized to your special needs.

The danger with small clinics is because they don't see too many patients , they often don't have enough expertise to deal with rare problems over with complications .

Similarly, you want a doctor who adopts a conservative middle of the road philosophy. You don’t want someone who overtests and overtreats and offers the “latest” treatment, simply because it is the fashion of the month - you don’t want to be treated as a guinea pig, under the pretext of being provided with cutting-edge medical care . Not everything which is new is effective , and it takes time for science to realize what works , and what doesn't .

However, if your doctor wants to try out the latest stuff on you, you are the one who has to pay the price, because you may end up receiving lots of ineffective and very expensive treatment , just because it is new .

One the other hand , you don't want an old-fashioned doctor, who keeps on doing the same stuff he has been doing for the last 10 years, simply because he cannot be bothered to keep up . Thus if your doctor doesn’t routinely provide blastocyst transfer; vitrification; and embryo photos, you should worry a lot !

You need to find someone who has the right balance – someone who follows the Buddhist philosophy of the Middle Path.  Wise doctors understand that just because stuff is new doesn't make it better , but they are willing to keep up with the times , and provide his patients with the benefit of the latest advances after they’ve been scientifically proven and validated in lots of clinics all over the word .

They are not interested in being the first to do something , just because he wants a newspaper article - he just wants to be the best , and therefore provides evidence-based care , using proven well-established techniques .

Are patients sophisticated enough to be able to find the right clinic ? Here’s a simple short cut you can use to make sure your clinic is good !

Check to make sure they provide embryo photos routinely. This is something which is extremely simple to do - any IVF patient can easily ask for this. Good IVF clinics provide photos of the embryos to all their patients . This helps clinics to remain honest , and it encourages openness and transparency . Every good clinic does this as it allows them to document they have provided good quality care.

However, remember that this is a condition which is  necessary but not sufficient  ! This means that every good clinic does this routinely , but just doing this doesn't necessarily mean that this clinic is your best choice !

Need help in finding the right IVF clinic ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

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