Tuesday, September 02, 2014

What are my chances of getting pregnant

Patients often ask me - What are my chances of getting pregnant if I do IVF ? The honest answer to that question really is - I don't know ; and it really doesn't matter . Let me explain why .

There is a difference between short-term thinking and long-term thinking . No one can predict the chances of success for an individual patient in a single cycle. While we can tell you what the success rate in our clinic is, we cannot reliably extrapolate these figures to individual patients.

Patients need to accept the fact that we are not fortunetellers , and they need to learn to be able to live with this uncertainty . The quality of our answer will improve once we have done a treatment cycle for you, because we can then see how well you respond and how good the quality of your embryos is. The better the data we have, the better the quality of our answers.

The reason it doesn't matter is that while we cannot predict what the outcome of a single cycle will be , for the individual patient our ability to be able to tell them what their chances of pregnant over 3-4 cycle is much better. We are able to provide a much more accurate estimate when we have more data. This is a fundamental law which is true in any biological system .

There is another reason why it doesn't matter . Whether I quote a figure of 20% or 60% , this guesstimate is completely immaterial and irrelevant for the individual patient. If she doesn’t get pregnant , her success rate is 0% ; and if she gets pregnant , it's 100% ( or even 200% if she has
twins !)

Finally, the reason it doesn't matter is that if she chooses to do nothing ( her default option) , her chances of getting pregnant would be far less as compared to her doing IVF . The one certainty is that doing IVF will improve her chances of having a baby , no matter whether that increase is 5% or
40% .

Patients need to be sophisticated enough to understand the limitations of our answers. When asked what their chances of success are, most IVF doctors are  happy to pull out an arbitrary figure out of their hat, in order to keep their patients happy – and the higher this number, the happier the patient, even though the number has no bearing with reality. This is why clinics plays so many games with their success rates , in order to keep their patients happy. However, the truth is that Garbage in – Garbage Out, and these figures have no relevance to the honest answer to your specific question which is – what are my chances of getting pregnant  ?

Inaccurate figures can be harmful to your health ! While quoting a number can provide a false sense of security to the patient, this number means very little for the individual patient. The overall clinic’s IVF success rate is a useful metric to use when comparing clinics, but it is of limited predicting value for the individual patient.

Need help ? 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 ?

Monday, September 01, 2014

Bed rest after IVF is harmful

Most gynecologists in India continue to routinely prescribed bedrest after the embryo transfer . They scare them that if they do not rest, their embryo will fall out of their uterus ! Some of them insist that the patient not get out of bed even to go to the bathroom; while others tell the patient to put a pillow under her hips, so that her embryos remains safe and secure within her uterus.

We know this is complete rubbish , and IVF clinics all over the world now allow patients to resume normal activity immediately after the embryo transfer . Once the embryos is inside the uterus, it cannot fall outside, whether the patient coughs, sneezes , strains or goes bungee-jumping ! This is true whether the embryos reaches the uterus through the fallopian tube ( as it does when couples have sex in  their bedroom); or whether we transfer it through he cervix using an embryo transfer catheter

The embryo does not care if it spends three days in the fallopian tube , or three days in the test tube ! This makes absolutely no difference to embryo implantation , and there is no way physical activity can dislodge the embryo from the uterus.

So why do doctors continue giving such bad advice to their patients .

I think some of these are old-fashioned doctors , and often when they really don’t have anything else to offer patients , they advise them to rest in bed !  This is a historical hangover , and is the standard advise obstetricians have given when ever the pregnancy was complicated.

It’s easy for doctors to advise bed rest – it  doesn't cost them anything to do so. However, the adverse consequences for the poor patient are enormous ! It must be dais in their defense that many doctors don’t even realize the unwitting harm they cause by giving such poor advise. Not only does bed rest disrupt the household; it causes lots of physical problems for the poor patient ( back pain ; an increased risk of DVT; and muscle weakness and atrophy). The emotional price bed rest exacts is huge. It adds to her stress levels, because when she is stuck in bed, all she thinks about all day along is what is happening to her embryos and whether the cycle will work or not. The 2ww lasts for much longer when you have to spend it in bed. At least, when a patient is working, her mind is distracted, and she has other things to worry about.

Even worse, if the patient doesn’t get pregnant , she blames herself by feeling that it’s because I did not rest properly that my embryos fell out. Even if she is mature enough not to beat up on herself, her mother in law will often “blame” her for the failure by saying she did not follow medical advise and did not rest properly.

Bedrest after IVF intuitively makes a lot of sense .This is why many women ( and their mothers and mother-in-laws) will impose this on themselves, even if the doctor doesn’t advise this.

•  It seems logical: after all, won’t standing up allow gravity cause the embryo to drop out of the uterus ?
•It feels better to “ prescribe “ bed rest than to tell a patient, “we really don’t have anything to offer you to improve your chances of embryo implantation”
•Women on bed rest are doing something, which for them feels a whole lot better than doing nothing.
•If bed rest isn’t recommended, and the patient fails to get pregnant, they will always blame the doctor because they may believe that bed rest would have changed the outcome.

Some doctors advise bed rest because they have a vested interest. In case the cycle fails, they can always blame the patient for the failure.  Another reason doctors advise bed rest is because they do not want their patients to go to another center for their IVF treatment.  The leading clinics in India are in the large cities, and because doctors in small towns who do IVF want to hang on to their patients, they scare them by saying that it you travel to Mumbai for your IVF, your embryo will fall out when you travel back, and you will never get pregnant.  This is rubbish , but it's very easy to take ignorant patients for a ride, especially when there are already so many myths and misconceptions about bedrest during pregnancy .

Getting conflicting advise ? 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 ?

Saturday, August 30, 2014

The problem with IVF supplements

Prescription placebos used in research and pra...

Lots of infertile patients take supplements in the hope that these will increase their chances of getting pregnant . Lots of doctors also prescribe these supplements, for many reasons. Some are designed to improve egg quality; others to improve endometrial receptivity; while others are supposed to boost sperm quality.

Most of these supplements are “natural products” which is why doctors are quite liberal about prescribing them . Also, the FDA does not need the manufacturer of these nutraceuticals and supplements to prove their efficacy. Most doctors and patients believe that since these are natural herbs, they are unlikely to do much harm, so why not go ahead and prescribe them. At least the patient is happy that “something is being done”, even if there is no proof that they help.

The problem is that some of these are extremely expensive . While they many not cost much on a daily basis, since the “course of treatment” lasts for many months, the costs add up very quickly !

Even worse, practically none of them have been proven to work. While it’s true that some patients will get pregnant after taking the supplement, this could very well be a placebo effect – and prescribing expensive placebos is hardly good medial practice !

No controlled clinical trials have ever been carried out to check the efficacy of these supplements . They are actively promoted by flashy websites , which do a great job of marketing by playing on the emotions of infertile couples. Many articulate women on bulletin boards will inadvertently promote these supplements by describing how they got pregnant after taking them.

The problem is that one swallow doesn't make a summer – and just because a supplement works for someone doesn't mean it will work for everyone.

The problem is that when women take supplements , they don't take just one – they take an entire box full, to cover all their bases ! It’s impossible to make out what worked and why, which means we do not learn anything useful from all these N=1 clinical trials women are carrying out on themselves.

The big danger is that anything which has helpful effects can also have harmful effects  ! This means that these supplements can actually reduce a patient's fertility , rather than increase it . We are seeing this in our practice. Thus, myoinositol is being actively promoted for treating patients with PCOD, where it has been shown to be effective. However, because it is being marketed under clever brand names such as Oosure, many doctors are mindlessly prescribing it for all patients who have ovulatory dysfunction – including those with poor ovarian reserve ! If doctors are confused as to which supplements to prescribe when, you can imagine the plight of the poor patients !

Patients get confused. When the doctor prescribes them with supplements such as DHEA to be taken for 6- 12  weeks prior to starting their IVF cycle in order to improve their ovarian reserve , they feel that if these supplements can improve IVF success rates, they may be able to help them to conceive naturally as well. They end up wasting a lot of time and money taking these supplements, and then get fed up and frustrated when they do not work.

This causes them to lose precious time – and the risk is that the false hope these supplements create may actually end up reducing the patient’s chances of having a baby.

Confused as to whether your supplements are helping you or harming you ? 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, August 29, 2014

Hindi language content for patient education

This is slowly changing. The launch of Devanagari script web addresses on Sunday, allowing people to use  .भारत domain names, was another step in the slow effort to bring about a multilingual Web. Already, Indian languages like Hindi – one of the most commonly-spoken languages on Earth – lag far behind. The move gels well with the new government’s effort to promote the use of Hindi, and its push to increase digital services available to all citizens. The next few years could well see a spurt in vernacular content online.


Health is one of the commonest topics people search for information on. The government should take the initiative and  publish reliable, trustworthy updated information on health and illness for patients in local Indian languages, so they can take better care of their own health.

This would be a great way of ensuring that patients are well-informed; and this will help them to ensure that their doctors are providing them with the right medical treatment.

When IVF patients have unrealistic expectations

One of the major problems we have to deal with in IVF is the unrealistic expectations which many patients have about IVF success rates. 

Infertile couples will move heaven and earth in order to maximize their chances of having a baby. They try to cover all their bases by finding the best possible doctor and going to temples and churches to seek divine intercession.

Because there is so much riding on the outcome of the IVF cycle, they are understandably  distraught when the cycle fails. They let their emotions colour their logic, and start looking for alternative options.

Aggressive patients , who naively believe that medical technology can solve all problems , will look for more “ advanced “ and technically sophisticated solutions, such as PGD using CCS or NGS . Others who are more spiritual will go on fasts in the hope that their next cycle will result in a deeply longed for baby.

However , these are unrealistic expectations . There are no guarantees in life , and human reproduction remains inefficient , no matter whether it's done in an IVF lab , or in the bedroom . It’s important that patients learn to have realistic expectations , and understand that while we can control the process , we cannot control the outcome.

In a good clinic, we can ensure that the quality of care provided is of the highest level . However, the outcome is always uncertain . Even though Sachin Tendulkar was a great batsman, this didn’t mean that he always scored a century every time he went out to bat.

The problem with IVF is that it is fill of complex biological variables which we still don't have a good handle . A far more realistic and sensible approach is to focus on the process , and accept the fact that once you've done your homework and performed the process properly, you have no control over the final outcome . This is true for patients and for doctors as well , and once we learn to be humble , it's easier to deal with the ups and downs of an IVF cycle.

The problem is that patients are very vulnerable and they don’t want to listen to the truth. They want guarantees, and it’s very easy for unethical doctors to exploit these hopes by overpromising, so that they sign up for the IVF treatment.

Want an honest opinion about your chances of IVF success ? 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 ?

Thursday, August 28, 2014

Heparin Does Not Reduce Pregnancy Complications, and May Create Some

For the past 20 years pregnant women with an increased risk of developing blood clots have often been prescribed a common blood thinner to prevent serious complications from the clots, including preeclampsia (high blood pressure in the mother), disruption of the placenta, low birth weight and loss of the fetus. The largest randomized clinical trial to examine the therapy finds that the drug—low-molecular-weight heparin—is not effective. The find, reported in The Lancet, is the result of a dozen years of analysis of patients across five countries.

Doctors are very happy to overtreat - and here's an excellent example of how they often end up doing harm rather than good.

Lots of IVF specialists have also started treating patients who have failed IVF cycles with LMWH ( low molecular weight heparin), claiming that this helps to improve the chances of implantation by improving blood flow to the uterus ( presumably by reducing the clotting tendency of the blood). Sadly, this has never been proven, and is used as empiric therapy, only because it makes logical sense.  The injections are painful - and expensive , and are best avoided , in my opinion.

What makes some IVF clinics better than others

For most surgical operations, the outcome of treatment is pretty much the same , no matter who the doctor is, and which hospital you select. Thus, most competent surgeons will perform routine operations such as appendectomy and tonsillectomy perfectly adequately , and patients will go home without any problems .

However , the situation seems to be completely different with IVF. This is because IVF is such a complicated treatment , which involves not only clinical expertise , but sophisticated IVF lab services as well. Because of the many biological variables involved in IVF treatment, the success rate amongst IVF clinics varies widely . In fact, the success rates in the best clinic can be upto four times as high as the worst.

There are lots of reasons for this wide variation .

The experience and the expertise of the IVF doctor makes a world of a difference. Good doctors have mastered the art of superovulating patients.IVF  success rates depend on the quality of embryos , and this in turn depends on the quality of the eggs which the patient grows. Expert doctors can coax even the failing ovaries of older patients to yield good quality eggs.

The expertise of the doctor may not make much difference for most young patients , who will grow eggs well, no matter which protocol is used. However, for difficult patients - for example , those with polycystic ovarian disease or those with poor ovarian reserve, the superovulation protocol the doctor uses can make the difference between failure and success .

The IVF lab has an extremely important role to play . Unfortunately , this is an area where lots of IVF clinics take shortcuts . Many don't even have a full-time embryologist ! Their equipment is often of poor quality and routine quality control measures ( for example, checking the temperature and CO2 level in the incubator ; and the pH of the culture medium) are never performed.

Many embryologists do not have the expertise to do ICSI properly – and lots do not have the confidence of being able to grow embryos to the blastocyst stage. Sadly, it’s easy to take ignorant patients for a ride, and these clinics take advantage of the patient’s gullibility.

The poor patients suffer, and end up failing multiple cycles , when all they need is to take treatment at a good clinic which has a good IVF lab , which can generate good-quality embryos for them.

Finally, the most important variable is proper patient selection . Some clinics will cherry pick patients, and treat only those who have a good prognosis, thus inflating their success rates. Others will treat everyone who comes to them, no matter how slim their chances of success, after counseling them , to make  sure they have realistic expectations . Finally, the worst ones will “ treat “ patients who have no chances of getting pregnant.  They go through the motions of doing IVF for them , just in order to generate money .

It can be hard for patients to make out which clinic is good and which clinic is bad . This is why it’s important for patients to educate themselves , so they can find out which clinic offers the facilities they need in order to maximize their chances of getting pregnant . This does require doing homework and putting in a certain amount of effort , but it's well worth it when the IVF cycle succeeds !

Need help in selecting the best IVF clinic ? 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 ?

Wednesday, August 27, 2014

When not to do IVF

Most infertile patients know that IVF is the treatment option which maximizes their chances of getting pregnant .

However, the problem seems to be that the pendulum has swung in the other direction , and lots of patients are being advised to do IVF, even though they do not need it. The truth is that there are many simpler treatment options available to treat infertility, and not every infertile couple needs IVF !

Thus, young patients with PCOD can easily be treated with medicines for ovulation induction. This is much less expensive than doing IVF – and it’s much more fun making babies in the bedroom than going to an IVF clinic.

It’s important that patients explore these simpler treatment options before moving on to IVF , which can be expensive .

The other group of patients who should not be doing IVF are the ones for whom the chances of success are extremely low . For these, treatment may be futile. Examples would include patients with Asherman syndrome , where the uterus has been completely damaged ; or patients with ovarian failure, who will not be able to grow eggs, no matter what we do.

These can be difficult patients to tackle . They are extremely desperate to have a baby , and are not willing to consider third-party options, such as donor eggs or surrogacy . So what is the poor doctor supposed to do ?

A good doctor will counsel patients that their chances of success are extremely poor. After doing so, if the patient has realistic expectations and still insists on going ahead , I think it's fine to do so, since the patient has provided informed consent . However, the danger is that often doctors are not very forthright, and they will hide this critical information from the patient . Some will go ahead with IVF treatment and transfer embryos into a uterus which such a poor lining, that the embryos do not have even the slightest chance of implanting.

Some IVF clinics will even transfer embryos which have arrested in the lab into the uterus, and thus fool the patient that they have received IVF treatment ! Others will go ahead with the treatment cycle, and then tell the patient at the last minute that since your embryos are of very poor quality, we need to use donor embryos in order to achieve a pregnancy. Because patients are so desperate at that point , they will go ahead and do whatever their doctor tells them to do, but this often results in long term unhappiness for the couple, who wasn’t mentally prepared to use donor embryos, and they may reject the child.

Tuesday, August 26, 2014

Is Malpani Infertility Clinic expensive ?

There are some patients who believe that we charge too much for IVF treatment . They compare the prices at Malpani Infertility Clinic with what their local clinic charges, and feel that we charge a premium. They feel this is unfair. After all, don’t all IVF clinics offer the same treatment ? Then how can we justify charging more ? Is it because we are greedy ?

While it is true that IVF treatment at a good clinic is expensive , it’s actually a bargain as compared to doing IVF in a bad clinic in order to save money .

There are many reasons why we believe our charges are cost effective. For one, they are open and transparent . Unlike the vast majority of Indian IVF clinic, we publish them in black and white on our website, which means patients do not suffer from sticker shock when they get the bill.

We pride ourselves in providing a high quality service, where patients come first. This means that our patients always have access directly to me, without having to go through assistants and juniors. We do not employ any assistants, and while this means we can provide care only to a limited number of patients, this also ensures that the quality of care is unsurpassed. This is also the reason we only have one clinic. We do not travel to any other clinic, and are always available in Mumbai for our patients.

How is the poor patient supposed to make out whether the IVF clinic they have chosen follows best practices ? After all, it’s very hard to judge the quality of medical services because they are intangible. Here’s a simple experiment you can try at your present clinic. Try to contact the head IVF doctor – the brand name doctor for whom you pay your fees, in order to get treatment from the best, and see how long it takes to get a reply.

In our clinic, we guarantee a reply directly from me within 24 hours. Isn't this confidence of always being able to get my advice invaluable? We store all your records electronically so we have instant access to them 24/7, and this ensures we can craft a personalized plan of action for you.

We have a highly qualified , experienced and full-time skilled embryologist ; and we use state-of-the-art equipment to provide cutting edge medical care. This combination allows us to provide high-tech high touch care to our patients. Because of our focus on quality , we ensure we provide personalized attention to all our patients, we don't cut corners .

Yes, it’s true that there are many clinics which charge less than what we do . However, we are not in the business of trying to compete with other clinics for offering the lowest fees. We are proud to compete as regards our quality of care and pregnancy rates. If we need to continue to provide a service which put patients first , we will not compromise on our quality of care by reducing fees , just in order to compete with other clinics. However, we do provide discounts and subsidized treatments to financially deserving patients.

Lots of clinics ( especially the ones which run national chains ) charge less than what we do. They try to compete on price, so that they can attract more patients . Sadly, the price the patient pays in order to save some money is that they often end up reducing their chances of getting pregnant significantly .
Many of these clinics will take short cuts and not follow basic IVF protocols such as documenting photographs of the embryos and providing these routinely and proactively to their patients . In fact, some of these clinics charge the patient a hefty premium for using an embryoscope, by claiming that this increases pregnancy rates. However, in reality they don’t do so ( the point of an embryoscope is that it generates photos of the embryos as these are dividing in the incubator) , and the poor patient is none the wiser, because of the lack of transparency. 

If you’d rather be treated in an assembly line clinic which has lots of doctors in white coats milling around, then Malpani Clinic is not the right place for you. On the other hand, if you’d rather be treated hands on by an IVF expert with years of experience, then we are a great choice.

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