Wednesday, August 24, 2016

Why is it so easy to fool IVF patients?



I just did a consultation with a patient who had done three IUI cycles at a local clinic. She'd got pregnant in each and every IUI cycle, but had apparently miscarried. Now this seemed a little fishy to me - after all, it sounded too good to be true. An IUI cycle has a pregnancy rate of only 10% per cycle, so how come her doctor managed to get got pregnant in every cycle ? And how come she miscarried every time? Something smelled wrong.

When I reviewed the results , I realized that when she said she got pregnant, this meant her beta HCG blood test was positive, as was her urine pregnancy test. Now this was only because she did the tests after her doctor gave her an HCG injection ! The doctor would give all her IUI patients a HCG injection to induce ovulation, and would continue giving the HCG injections every 3-4 days during the luteal phase. The mystery was finally solved - this was why her HCG results were always positive. The doctor would give her a HCG injection , and then draw the blood test for checking her HCG level the next day. This is why she had so many false positives - her doctor was just taking her for a ride.

To add insult to injury, the doctor would repeat the HCG injection after the first HCG blood test was positive, as a result of which her periods kept on getting delayed , and she kept on hoping that she was pregnant each time.  Even worse, her doctor told her, " I am getting you pregnant, which means my treatment is 100 % effective. You are miscarrying every time , and we need to test you for what the reason for your recurrent pregnancy losses are." This doctor kept on fooling this patient - who was a highly educated intelligent software professional with a B.Tech degree.

So why is it so easy for doctors to fool IVF patients ?  Part of it is because they're desperate. If anyone tells them that they can get them pregnant, they suspend their intelligence, and are happy to clutch at straws.  Patients have been taught to trust their doctors, which is why they don't bother to come to counter check what the doctor's telling them . This emotional vulnerability means that their common sense often takes a back seat.  Even worse, there are lots of doctors who are willing to take advantage of the gullibility of these patients, therefore will mercilessly cheat them left, right and center.

In fact, this doctor then went on to do an IVF cycle for this poor patient using exactly the same tricks. She told her, " Congrats -  your HCG's positive and you're pregnant, but you have miscarried again, which means you now need donor egg surrogacy in order to get pregnant ! Given how many doctors prey on the infertile patient's desperation, it's hardly surprising that patients don't trust doctors any more !



Tuesday, August 23, 2016

Sex, the infertile couple , and the doctor


We all know that infertility and sexuality are closely linked  and this connection has multiple relationships. Thus, having sex infrequently will obviously affect fertility, and this is a surprisingly common problem in today's day and age in metropolises like Mumbai , where many young couples are too stressed out and too tired to be able to have sex. Job pressures , cramped houses with no privacy, and long commutes contribute to this.  Perhaps the only occasion when they can carve out time for themselves in order to have baby-making sex is during a weekend, and obviously ovulation is not always that obliging. This contributes to their infertility , which means this is often social , because of their work pressures, rather than because of medical reasons.

Infertility also affects sexuality. Often a woman who is labelled as being infertile doesn't feel like having sex; and the husband who feels that he's forced to have sex on demand just in order to make a baby is going to find his libido takes a beating. Often  a woman who has been told that her tubes are blocked or that she has endometriosis has poor self-esteem, and this kills her sexual desire, because she feels that her reproductive system is "defective".

The big problem is that even though sexuality is the elephant in the room , it's something which is never discussed. Often, this is because the husband is ashamed - for example, because he has erectile dysfunction. This affects the wife as well, who starts feeling that she's contributing to the problem because the lack of an erection means that her  husband doesn't find her sexually desirable, and this causes an inferiority complex .

Doctors also contribute to the problem. They are very busy, and during the consultation they are more focussed on the medical details, which means they don't even either bother to take a sexual history; or when they do so , they do it extremely perfunctorily . This often means that they will just mindlessly check off a box on a form which says - Frequency of sexual intercourse ? Thrice a week. This is the standard answer which most couples will give , even when they know that it's not true, because they don't want to admit that they're just not having sex frequently . They know that this could be one of the reasons for their infertility , but they're ashamed to discuss this openly in front of a doctor, especially in the first visit.

In order to get over this problem, I think a simple question every infertility doctor should ask is: When did you have sex last? Now, this is not such a threatening question, and it's much easier for people to answer. If you see that the couple looks embarrassedly at each other , or is sheepish about the fact that they haven't had sex for the last two or three weeks, then this at least gives them permission to discuss what their problem is , so that you can provide solutions. For example, you could prescribe medication to help the erectile dysfunction ; or advise them to use sexual toys such as vibrators ; or tell them to use liquid paraffin to reduce pain during sex because of vaginal dryness.

The important thing is to be able to discuss the topic openly and freely, and this is a very useful question which can help the doctor to get the ball rolling. You will be quite surprised with the range of answers you will get , if you learn to ask this question !

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !






Saturday, August 20, 2016

How to protect yourself from medical errors


Medical errors can be a nightmare - both for patients, and for doctors.
However, this is one of those topics which we prefer to sweep under the carpet, because it can be so emotionally charged.

This is the first book from India on this important topic, and provides a holistic overview of medical errors from multiple perspectives.

Doctors, nurses, pharmacists, other healthcare providers, pharmaceutical companies, insurers and  patients all need to work together to promote patient safety.

The book is online at www.safetyforpatients.in

It can also be downloaded free at http://www.slideshare.net/malpani/patient-safety-protect-yourself-from-medical-errors

Please do send me feedback so we can improve it !

Friday, August 19, 2016

Dr.Farokh Udwadia: Medical Errors: Improving Doctor Patient Trust

Dr.Sunil Pandya: Medical Errors -How do you Gain a Patient's Confidence ...



When the patient's course takes a downhill turn, family members will often suspect that the doctor made an error. This causes doctors to become defensive, and this widens the rift between the doctor and patient even more. Dr Pandya describes what doctors need to to do earn the patient's confidence, so they can bridge the gap.

PGS for recurrent pregnancy loss: forget it! Human Reproduction journal article



The latest issue of Human Reproduction, the world's most reputed journal on assisted reproductive technology, has an article by Dr Gayathree Murugappan and colleagues from Stanford and Seattle , which shows that preimplantation genetic screening (PGS) does not improve live birth rates as compared to expectant management ( = do nothing) in patients with recurrent pregnancy loss (RPL). 

Not only does  PGS not improve their chances of conceiving, it also does not help them to conceive any quicker. For these patients, masterly inactivity ( = reassurance) is the best option.

However, as the authors point out, " counseling patients with unexplained RPL to pursue expectant management presents several challenges. These couples often feel an urgency to conceive , and expectant management can feel like a passive and time-consuming approach to conception. In addition, patients often carry a significant amount of guilt and grief in association with miscarriage. Attempting spontaneous conception can feel emotionally vulnerable; despite reassurance of good prognosis, patients doubt that a subsequent pregnancy will be successful ."

This is why  IVF clinics have been promoting preimplantation genetic screening (PGS) for treating patients with RPL with the goal of increasing live birth rates.  It's also very profitable for the IVF clinic to offer this high-tech treatment option. However, the truth is that this does not help, as proven by this research study.

You can read the article, Intent to treat analysis of in vitro fertilization and preimplantation genetic screening versus expectant management in patients with recurrent pregnancy loss  at http://humrep.oxfordjournals.org/content/early/2016/06/07/humrep.dew135.full

Wednesday, August 17, 2016

Our IVF pregnancy rates for July 2016



We did a total of 30 transfers, and 20 patients got pregnant.

Two caveats. These are small numbers, which means it's hard to extrapolate these to the entire year ; also, these are pregnancy rates, and not live birth rates.

All the donor egg cycles were with frozen eggs, which were thawed, and then the fresh embryos transferred to the recipient.

All the embryo transfers are Day 5 blastocysts; and we never transfer more than 2 blastocysts.

Tough decisions about embryo transfer



It can often be very confusing for a patient to make decisions about their embryo transfer. For example, how many embryos should you transfer ? Do you transfer in a fresh cycle or in a  frozen cycle ? Do you transfer on day 3 or a day 5.

Here are some rules of thumb which I have found helpful.

For one thing, the pregnancy rates with day 5 embryos are definitely better than with day 3. That's pretty much a no-brainer. You should optimally opt for a clinic which routinely does day 5 transfers.

As far as how many embryos to transfer, I think one is the perfect number. If it implants, it gives you a singleton pregnancy , which has the lowest risk of pregnancy complications. Two is fine too, specially if you don't have any babies, and you're getting fed up and frustrated, because the chance of getting pregnant with two blastocysts is definitely better than with one. Even if you end up with twins, the pregnancy can be managed well with good obstetric care. For lots of infertile couples, twins are a bonus because they now have an instant family . Many are happy that their kids will have a sibling , and they don't have to go through an IVF cycle again.

Let's look at a patient who on day 5 has one blastocyst and one morula. She now actually has a surprising number of options which she didn't in the past, when we would be forced to  go ahead and transfer whatever embryos we had, as we didn't want to waste any precious embryos.

Here are some of the options we can offer her. We can still transfer both the embryos. Some people worry about transferring a morula on day 5, but they need to understand that just because the morula is growing slowly, doesn't mean that if it implants, the baby will be abnormal. It just means that the probability of a morula implanting is lesser than that of a blastocyst. However, if it does implant, the baby will be completely healthy.

Also, the morula will not interfere with the blastocyst implantation, because each of these are in separate shells ( zonae) . They don't interact or affect one another, so you don't need to worry about reducing your chances just because you're transferring a slow growing embryo.

The other option is that we could freeze all her embryos , and then transfer in a frozen cycle, after thawing them and culturing them for 24 hours in vitro before the transfer. This has now become our preferred option, specially for patients who live in India, because the pregnancy rates with frozen embryos are much better than with fresh transfers. Of course, patients need to factor in the additional cost ; the inconvenience ; and the fact that it takes more time because they need to come back again for the transfer.

The other option we could offer her was to transfer the fresh blast and freeze the morula after waiting to see if it becomes a blastocyst on day 6. If it does, then this way she has her  cake and can eat it too. The good news is because we are a full-service clinic with a full-time expert embryologist, we can offer lots of choices to our patients in order to maximise their chances of success. We have the flexibility and the  resources to be able to customise and personalise our treatment, according their needs. This sometimes leaves patients confused, but it's always better to have options !

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !





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