Wednesday, May 17, 2017

The many hats I wear


For most of my patients, I am just their IVF specialist.

However, I do wear lots of other hats as well - and if you are interested in what I do, you can follow my LinkedIn posts at https://www.linkedin.com/in/aniruddhamalpani/recent-activity/posts/, where I try to share what I am learning with the rest of the world !

Reducing IVF anxiety



Lots of patients are very scared of doing IVF. This is partly because they've heard lots of horror stories about how IVF babies are abnormal, or that the hormones will make them fat, or that if they grow too many eggs, they will either get menopausal sooner, or start getting ovarian cancer as they grow older. And, they've heard lots of horror stories from some of their friends, who've done IVF, about how painful the injections can be, or how many mood swings it causes, or the fact that you need bed rest or that there are lots of complications, or that the risk of miscarriage is higher after IVF.

There are lots of myths and misconceptions, and these obviously add to the patient's anxiety, because of the fear of the unknown, that you end up spending so much time, money and energy, and even after doing all that, not only may you not end up getting a baby, you may actually be worse off because of all the side effects you've put yourself through.

Somehow a lot of IVF seems very artificial and unnatural today, because patients think that you're doing stuff in the laboratory, you're manipulating things, you're doing stuff, which nature wasn't designed to do, as a result of which there are likely to be problems. They often don't trust doctors, and we tell them there won't be problems because most doctors will always try to reassure patients and their concern is that we're not aware of some of these long term side effects, or that we're trying to sell our treatment just because it's more profitable for us.

I think the only way of getting over all this anxiety and fear of unknown, is what I call information therapy. Patients need to read up about IVF from reliable websites so they understand what the truth is, and they can separate the myths, which are so prevalent and they don't get carried away by old wives tales, because otherwise they will end up depriving themselves of the best chance of getting pregnant, and regret this once they get older, and time doesn't come back.

You will find the free resources , which include an e-learning course at www.ivfindia.com very helpful !

You can download our IVF Comic Book free at www.slideshare.net/malpani/ivf-comic-book

Need more information about IVF Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !




Monday, May 15, 2017

हिन्दी में आईवीएफ जानकारी


भारत में स्मार्ट फोन सस्ता हो गए हैं, और 4 जी व्यापक और सस्ती हो गई है। आधे से अधिक भारतीय आबादी अब ऑनलाइन है, और जब उनमें से ज्यादातर मनोरंजन के लिए स्मार्टफोन का उपयोग, वे भी जानकारी के लिए शिकार के लिए उपयोग शुरू कर दिया है। जबकि आम कारण सस्ते दामों पर और सौदों के लिए देखने के लिए है, उनमें से बहुत कुछ इंटरनेट का उपयोग कर रहे चिकित्सा समस्याओं के बारे में जानकारी खोजने के लिए। 

बांझपन आम चिकित्सा समस्या है जो 25 और 45 की उम्र के बीच लोग बुरा असर है - और इस समूह जो ऑनलाइन अपने समय के सबसे खर्च कर रहा है अब है। वे सख्त बांझपन और आईवीएफ के बारे में जानकारी के लिए देख रहे हैं। 

अच्छी खबर यह है कि हम कम से समझने के लिए हमारी वेबसाइट पर विभिन्न भारतीय क्षेत्रीय भाषाओं में, विश्वसनीय जानकारी आसान के 500 से अधिक पृष्ठों प्रदान करना है www.drmalpani.com , गूगल ट्रांसलेट का शुक्रिया। जबकि अनुवाद की गुणवत्ता अभी भी एक बहुत होना बाकी है, इस बांझ दंपतियों के लिए खुद को हिंदी में सूचना थेरेपी के साथ सशक्त बनाने शुरू करने के लिए के लिए एक महान शुरुआती बिंदु है, तो वे खुद के लिए सबसे अच्छा आईवीएफ क्लिनिक पा सकते हैं!

IVF information in Hindi


Smart phones in India have become cheaper, and 4G has become pervasive and affordable. More than half the Indian population is now online, and while most of them use the smartphone for entertainment, they have also started using it for hunting for information. While the commonest reason is to look for bargains and deals, lot of them are using the internet to find information about medical problems.

Infertility is the commonest medical problem which afflicts people between the ages of 25 and 45 - and this is the group which is spending most of its time online now. They are desperately looking for information on infertility and IVF .

The good news is that we provide over 500 pages of easy to understand, reliable information in various Indian regional languages on our website at www.drmalpani.com,  thanks to Google translate. While the quality of the translation still  leaves a lot to be desired, this is a great starting point for infertile couples to start empowering themselves with Information Therapy in Hindi, so they can find the best IVF clinic for themselves !

Why do IVF doctors abandon their patients?


Most IVF patients are mature enough to realize that the success rate in an IVF cycle is never going to be a 100%. No matter how perfect your embryos are; how good your doctor is; and how easy the transfer is , we still have no control over implantation, and cannot predict which embryos will become  a babies.  Patients come to terms with the risk of failure, because they know that doctors are not gods. 
However, they find that while the doctor can be extremely persuasive and charming when they go for their first consultation  ( because they are in sell mode and want the patient to sign up for the IVF treatment), when their IVF treatment fails, they often feel abandoned . They are desperately seeking answers, but they find no one is willing to provide them. 

When they reach out to the clinic, often the doctor's simply not available . When they try to meet him, they find  it's very difficult to get an appointment . Even when they finally get a chance to talk to him, they find he's very evasive, and refuses to provide any clear answers as to why the IVF cycle failed.  Even though patients understand that we can't always answer all their questions, they want to hear the truth from the doctor's mouth. The trouble is that doctors start equivocating, and come up with all kinds of flimsy answers which patients know are not truthful. 

The doctor who was very optimistic and hopeful at the time of the embryo transfer because he told you that they had created perfect top quality embryos for you, starts singing  a completely different tune when your cycle fails . He now claims that the reason for your failure is that " Your embryos weren't very good because your eggs weren't very good" and "Perhaps we should consider doing donor egg IVF for you, or surrogacy in your next cycle". Sadly, you don't have any photos of your embryos, and this advice comes as a bolt out of the blue . Patients are understandably upset, because the doctor is not being consistent and congruent.

This is why they start losing confidence in the doctor , and feel that they've been cheated .
When an IVF cycle fails, a good doctor realises you are hurting, and will proactively reach out to support you. He will invite you back , so you can analyse the cycle together, and  create a  plan of action for the future, based on what went right, and what needs to be tweaked.

Can't understand what your doctor is saying ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion and I will be happy to help you !


Sunday, April 30, 2017

Surrogacy ? or donor egg ?

I just received this email from a patient

My date of birth : 24/7/73 (43 years old)
My partner date of birth : 11/3/76 (41 years old)
Trying to conceive 4 years, since May 2013
One previous pregnancy in June 2013, first month of trying, ended in early miscarriage at 5.5 weeks.

Started IVF in September 2014 and have had 7 failed cycles to date.  Details below:

Cycle 1: October 2014

Gonal F - 600 units
4 eggs retrieved
1 fertilised with icsi
1 top grade 8 cell embryo (no fragmentation) was transferred on Day 3
No pregnancy

Cycle 2: April 2015

Fostimon - 600 units
Early ovulation before egg collection meant I lost at least 1 mature egg, but they still managed to collect 2 eggs
Both fertilised with IVF (we dropped ICSI on Dr's advice as sperm was good quality)
2 top grade embryos were frozen on Day 2 due to my progesterone levels being too high for fresh transfer as a result of early ovulation

FET Cycle: July 2015
The 2 embryos from the above cycle were transferred, both survived the thaw
No pregnancy

Cycle 3: August 2015

Due to early ovulation last time and poor response to stimulation, we opted for a mild/natural cycle
Fostimon/Merional - varied between 75-300 units daily
2 eggs retrieved, fertilised with IVF
2 top grade embryos transferred on Day 2
No pregnancy

Cycle 4: October 2015

Mild/natural cycle
Fostimon/Merional - 75/150 units daily
1 egg retrieved, fertilised with IVF
1 top grade embryo transferred on Day 2
No pregnancy

Cycle 5: February 2016

Mild/natural cycle
Fostimon/Merional - 75/150 units daily
2 eggs retrieved, fertilised with IVF
Both were frozen on day 2 as I wanted to try another cycle in order to batch together 3 or 4 embryos

Cycle 6: August 2016

Mild/natural cycle
Fostimon/Merional - 75/150 units daily
1 egg retrieved, fertilised with IVF
Top grade embryo, was transferred along with the 2 frozen embryos from the previous cycle (1 of these looked very weak after the thaw, but the other looked good, but they still transferred all 3)
No pregnancy

Cycle 7: December 2016

Fostimon/Merional - 600 units
4 eggs retrieved
1 fertilised normally with IVF
1 top grade embryo transferred on Day 3
No pregnancy

I then embarked on a 3-cycle package with a view to freezing and batching any embryos

Cycle 8 : March 2017

Fostimon/Merional - 450/600 units
4 eggs retrieved
3 fertilised with IVF
2, top quality embryos made it to Day 3 and were frozen 
(SO I now have one 7 and one 9 cell Day 3 embryos in the freezer)

Cycle 9: April 2017

Fostimon/Merional - 600 units
6 eggs retrieved
5 fertilised with IVF
5 made it to Day 3 (4 top quality, one lower as it has 50% + fragmentation) and we have for the first time ever decided to try to take them to Day 5 and see if I can produce any blastocysts.
As of today, these embryos are :  3 x 6 cells and 2 x 8 cells (one of the 8 cells is the one with the fragmentation which she thinks is likely to stop growing, and one of the 6 cells is a little elongated in shape but she said it still looks normal)

This brings you up to date as this last cycle is still active - we will know whether they make it to Day 5 by Tuesday.

Over laying all of the above I have had various immune work as I have ulcerative colitis, an auto immune disease, and so have been tested for NK cells/cytokines.

I have tried : Humira, Prednisolone, Intralipids, LIT treatment and also take clexane and aspirin in addition to the progesterone post transfer.

I hope this gives you a lot more information.  As you can see, we have few eggs/embryos per cycle but a very high fertilisation rate, with high grade embryos, but still none of them have led to a pregnancy. 

I am baffled as to whether this is an egg quality issue (I have been told this is probably the case due to my age - but I have been trying since age 39 and am a very fit and healthy person), or if it is a receptivity issue.  That's what makes it difficult to decide whether it's donor eggs (we are not keen on this) or surrogacy with my own eggs that we should be exploring or keep going with my own eggs/womb...any advice you can give is very much appreciated as we are desperate to have a family.
-------------------------------------------------------------------------------------------------------------------------

This is a very common dilemma many patients face, and they are very confused if they should change the uterus ( surrogacy) or change the eggs ( donor egg)

This was my answer.

 I am worried about your advanced age. This suggests you have diminished ovarian reserve, and this would explain your early miscarriage; as well as your repeated failed IVF cycles. Being fit or healthy does not translate into  having genetically fit eggs . As a woman grows older , her eggs accumulate genetic defects, because she does not produce any new eggs.

You can read more about this at http://www.drmalpani.com/knowledge-center/the-infertile-woman/oopause

Surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus, or whose uterus has been irreparably damaged. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem. The soil is passive - it is the seed which is active and is responsible for growth


I agree donor egg IVF is a very hard option to come to terms with, but this would maximise your chances of having a baby

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 !




Monday, April 24, 2017

Do doctors charge too much ?


A doctor's income seems to have become an extremely sore issue in this day and age. Lots of people, right from the average citizen to the PM , feel that doctors charge way too much. Their belief is that medicine is supposed to be a noble profession,  and doctors should not allow their minds to be contaminated by base commercial considerations .  After all, doctors are highly educated professionals, and they should take delight in helping their patients to get better, rather than trying to maximize their income.
Lots of people believe that doctors have become too commercial and uncaring, and that their primary focus is on earning more, rather than providing good clinical care. This is why we are now seeing a backlash against doctors. They are getting beaten up by angry patients; the judiciary as well as the media are happy to criticise them; and  politicians are happy to pander to the masses by putting a price cap on procedures and medical equipment, so that they can make healthcare more affordable.
Doctors, on the other hand, feel very embittered that in spite of sacrificing the best years of their life burning the midnight oil in order to master medicine, they make a fraction of what corporate executives do. It burns them up that hot shot lawyers charge over 10 lakhs for making an appearance in court, irrespective of whether they open their mouth or not. They are knowledge workers, just as lawyers are, and yet people grudge them their fees. They can't understand why society uses such double standards when dealing with doctors. All a lawyer does is win a case, whereas a doctor can actually save your life - and how can anyone measure the worth of a life ? Doctors hare the fact that when a doctor messes up, judges are quick to  fine them crores of rupees, but when they perform life saving surgery, patients are reluctant to pay even a few thousand. Where's the justice in this ?
The problem is that we can't put a price on saving human life, which is why we expect doctors to be satisfied with compliments and gratitude. While these are great for enhancing a doctor's emotional income, how do they expect a doctor to survive on these ?
While an emotional income can be personally satisfying, how can the doctor use this to make a living ? He needs to pay money to buy a house to live in ; and send his children to school. Even if we wants to run a clinic to treat his patients, he still needs to buy the office space , the medical equipment, and pay the electricity bill.
The divide between doctors and patients is progressively widening. A doctor feels he gets grossly underpaid . No matter how many hours he may have spent in the middle of the night, struggling to save his patient's life, when the patient gets better, all he gets is gratitude. However, when the patient doesn't do well ( often for no fault of his) he becomes the patsy who is at the receiving end of the patient's ire.  This is why doctors feel they are getting an extremely raw deal.
There is no correlation between the amount of effort and time which he has invested in his career , and the return which he is now getting. This causes a lot of heartburn, and this is one of the reasons why doctors no longer want their children to become doctors anymore. They feel that all those years of hard work they have put in are never adequately compensated. Now it's not that doctors are greedy  - if they were, they would have become bankers - they are intelligent enough to have got into any profession of their choice ! They don't expect to roll in wealth , but they do want to make enough to be able to live comfortably.
I think we need to stop grudging them their fees. I agree there are a few greedy doctors, but by being miserly and by underpaying doctors, we're harming everyone in the healthcare system. It's because doctors are not paid well that they to resort to all kinds of underhand means in order to increase their income levels.
I think this is one of the problems we are seeing an epidemic of medical corruption today. It would be far healthier if doctors were paid freely and fairly for their professional services, and were given the value and the respect which they deserve.  Unfortunately, in India , we don't seem to value advice.  Thus, while patients are willing to pay surgeons a fat fee for doing an operation, they are not willing to pay family physicians for the advice they give , even though the advice may be far more valuable because it helps to save them from unnecessary surgery. Underpaying doctors just increases medical corruption because doctors can't live  on love and fresh air.

Saturday, April 22, 2017

All doctors need to become patientologists


Doctors take pride in mastering the scientific minutiae of medicine . On the top of the medical hierarchy are the super specialists - the ones who have a lot of technical expertise in a very narrow slice of medicine. They're usually looked up to by other doctors because they're the doctor's doctors. They know practically everything there is to know about their personal area of interest, and because they attract a lot of referrals, their depth of knowledge in their domain is enormous.

However, all this super specialization comes with a price. Because they are so focused on the little segment of medicine  which is of special interest to them, they sometimes fail to see the big picture. This is something which makes a lot of their patients extremely unhappy because they feel that these specialists have lost the human touch.

Doctors need to remember that while it's great to specialize - to be an interventional  cardiologist or a pediatric pulmonologist, they all need to be patientologists as well. They all need to specialize in learning how to take care of their patient's emotional needs.

Unfortunately, this key skill is often lacking. It's not as it doctors are not empathetic, it's just that this valuable trait is not emphasized during their training. In fact, residency can be very dehumanising, because the poor junior doctor is often made to work under conditions where he feels he is being treated like an animal. He is often sleep deprived, hungry, stressed, and subject to bullying by his seniors. It's high time we brought humanity back into the medical profession, and the first step in this direction is to handle young doctors more kindly, so that in turn, they also learn to treat their patients with tender loving care!

Thursday, April 20, 2017

Generic drugs vs branded debate



The recent move by the Modi government to make prescribing of generics compulsory has raised a lot of hackles. The objections have been pretty predictable. Obviously, the pharma companies are up in arms because they make most of their money from selling branded drugs. If this option is taken away from them, they're going to have to look for alternative means of generating revenue, and having to change a highly profitable business model is not easy for large corporates. Once the law gets teeth, it will no longer be business as usual, which is why they're upset. They are worried that their business will get commoditised and their margins will shrink. Since pharma CEOs are powerful , lots of observers are understandably cynical about the prospects of these new rules being implemented . Their belief is that they will be diluted so much that they will remain a toothless tiger.

Since the pharma companies guys can't complain directly that they are upset because this is going to eat into their profits, they are using doctors as their puppets. Doctors are upset with this move because they see this as an encroachment on their professional autonomy. They've been writing brand names for many years, and they don't see what they need to change an engrained habit. Yes, brand names are easier to remember, but the truth is that many of them get incentivized to prescribe a particular brand. They are obviously reluctant to say goodbye to this easy money. Also, they are worried that the locus of power has now shifted to the chemist, who will end up deciding which generic to dispense.

The general perception today seems to be that brands are of higher quality than generics. This is not true, since the active molecule in the drug remains the same - it's only the label which is slapped on it which changes. Yes, the government needs to make sure that the drugs are manufactured in a quality factory , and this is true for all drugs , whether or not they are generic or branded ! If you have a poor quality manufacturer, then whether he's marketing a generic molecule or a branded drug, its quality will remain equally poor . The FDA will have to become far more proactive , and as long as the medicines meet quality control standards, what the name on the box says makes no different at all to its therapeutic efficacy ! This is why private labels have become so popular in the FMCG industry - consumers are realizing that there is no point in spending extra on branding . This is as true for drugs as it is for FMCG products.

All pharmacology textbooks teach students and medical residents to prescribe generics. It's the active molecule which makes the drug effective, and this is what is drilled into the doctor's head during his training. The problem is that once a doctor starts practice, he forgets what his professors taught him, and gets influenced by the friendly medical representative, who is always welcomed because he comes bearing gifts.

There are many extraneous factors which come into play when a particular doctor chooses to prescribe a particular brand, but he never talks about this openly , because he's ashamed about the fact that he's not necessarily doing what's in the patients best interest. He needs to justify his actions, and the most convenient excuse is that brands are better than generics, even though he has no proof that this is true. He needs to salve his guilty conscience by bad-mouthing generics.

The healthcare industry needs to get back to basics . Pharma should focus on producing high-quality drugs at a reasonable cost, and stop wasting money on " marketing ". Once generics become mainstream, they will no longer need to employ an army of medical representatives to cajole and induce doctors to prescribe their brand - most of which are just "me-too" variants. This will help to reduce their marketing spends, because companies will not have to waste money on competing with other pharma companies for which particular brand the doctor chooses to prescribe. This is a step in the right direction , and we should all be pleased , because it'll make quality drugs more easily available to patients at an affordable cost. As with anything else, any time you change the status quo, some people are going to get upset, but over time this move will help to make sure that medicine is practiced more rationally and ethically in this country.

Pharmaceutical companies will now focus on improving the quality in their manufacturing plants, rather than wasting money on branding and marketing. Also, since they will no longer have to spend on cajoling doctors to prescribe their brands, they will be able to deploy this towards educating patients, so that patients are better informed about what medicines they are taking, and why.

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