Saturday, November 18, 2017

Egg freezing - how old is too old ? The limits of IVF technology


While the Times of India article about a celebrity carrying a twin pregnancy after egg freezing will help increase awareness about the option of social egg freezing as a method for preserving fertility in older women, I am very concerned about the misleading message this is going to  send to most  women!
They are going to start believing that IVF specialists are magicians  who can get anyone pregnant - and that a woman's biological age does not affect her fertility. Women will delude themselves that they can happily postpone having a baby for as long as they like , but this is false ! There is a price you pay when you try to have your cake and eat it as well, and the bitter truth is going to create a lot of unhappiness when they find out the truth.  When have a biological clock, and while egg freezing is a sensible option for women in their 30s, to try to offer it to women in their 40s is foolhardy.
This particular story itself is a little hard to swallow. The success rate of freezing eggs at the age of 41 is exceptionally low  - and then to get pregnant with twins with these frozen eggs requires one to suspend their credulity. Human reproduction is not efficient, and there is a lot of wastage and attrition even during IVF. Yes, we can make a 40 year old grow follicles, but many of these will not contain eggs; many of these eggs will not fertilise; and very few will form good quality blastocysts which are worth transferring.
Yes, we can get older women pregnant easily, but they have to be willing to use donor eggs , and this is not an easy decision. Of course, clever older women who use donor eggs to get pregnant can now claim that they got pregnant with their own eggs which they had frozen when they were younger - and no one's going to challenge them !
The facts are that the ovarian reserve for a woman drops off dramatically after the age of 38, and the pregnancy rate with IVF even with fresh eggs after the age of 40 is less than 5% per cycle. The live birth rate is even lower, because embryos from older eggs  have a much higher rate of  genetic anomalies !
The right age to freeze eggs is less than 35, because it gives women a good chance  of having a baby. Most IVF clinics will agree that doing this after the age of 40 is futile.
On second thoughts, maybe I shouldn't complain about this misleading article , because all IVF clinics will now get lots more  referrals from older women who want us to freeze their eggs, but giving patients false hope is hardly the right way to practise medicine !

Wednesday, November 15, 2017

Please don't do a laparoscopy !

Many doctors routinely do a laparoscopy and hysteroscopy for all infertile women.

They justify this by saying it's a simple diagnostic procedure, which will allow them to confirm that there is no anatomical problem.

They also say it's "minor surgery", which just involves a "small cut" and a few hours stay in a hospital.

What they don't tell the patient that there's absolutely no need to do a laparoscopy at all ! Let's not forget that the safest surgery is the one you don't need to do !

The truth is that laparoscopy does not provide us with any useful information which we cannot obtain with simpler non-invasive tests, such as a HSG and a vaginal ultrasound scan. Even more importantly, it really does not change the treatment options for the infertile couple.

The biggest danger is that it can actually reduce your fertility. Once the doctor puts a telescope inside your belly, he often gets "itchy fingers", and will do a procedure which is not called for at all !

If you doctor tells you to get a laparoscopy, just say No !

Wednesday, November 08, 2017

IVF failure - what next ?

After an IVF cycle fails, the first question patients ask is - What do we do differently the next time ?

The answer to this question depends upon analysing the failed cycle systematically. After all, in order to move forwards, we first need to look backwards, so we can plan the next IVF cycle more intelligently.

This is why it's so important that you insist that your doctor give you photos of your embryos and your medical records at the time of the transfer ! This information is worth its weight in gold 

Monday, November 06, 2017

How to judge the quality of your IVF doctor at the time of your first consultation

Most patients naively assume that all IVF doctors are equally good, but this is completely false.

There is a world of a difference between a good doctor and a bad doctor, and this affects your chances of getting pregnant enormously !

Please don't get misled by advertisements - you need to do your own research to make a well-informed decision.

The good news is that it's easy to assess the quality of an IVF doctor the first time you meet him, provided you have done your homework properly.

Is the doctor well-organised ? systematic ? Does he have a well-defined process ? Is he happy to answer your questions ? Does he spend time talking to you, or are you forced to deal with assistants ?

Selecting the right IVF doctor is a critically important decision, so please listen to your gut when making this choice !

What are my chances of getting pregnant with IVF ?


This is one of the commonest questions patients ask, but it's actually not a very helpful question for many reasons.

1. While clinics can share their success rate. remember that this percentage figure applies to a group of patients they have treated in the past, and this is not something you really care about. What you really want to know is what your chances of getting pregnant are  - and it's impossible for anyone to predict this for an individual patient !

2. For an individual patient, the percentage figure is meaningless, because the outcome for you is binary  - you either get a baby or you don't, which means the final answer is either 100% or 0 % !

3. For many Indian clinics, the figures they quote are not reliable, so take these with a large pinch of salt !

In any case, a far better way to think about this is in terms of delta , or difference.

The key question should be - How much will doing IVF improve your chances of having a baby, as compared to doing nothing ? Thus, if you have blocked tubes, you know that your chances of having a baby without IVF are zero, and you may decide anything is better than zero ! However, this is a very personal decision, and you need to make this for yourself, so you have peace of mind you did your best, and have no regrets later on.

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, November 04, 2017

Has your IVF cycle failed ?

Instead of allowing your doctor to subject you to a battery of useless tests which will just send you off on  wild goose chase, first make sure you review your medical records, and photos of your embryos.

This is invaluable information, which will guide you what to do next !

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 !




Friday, November 03, 2017

Should I use donor eggs to have a baby ?

It's hard to have to accept that you may need to use donor eggs in order to have a baby - after all, we all want to pass on our genes to our children !

You might find this classic poem by Kahlil Gibran useful in guiding your decision !



On Children
 Kahlil Gibran
Your children are not your children.
They are the sons and daughters of Life's longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them,
but seek not to make them like you.
For life goes not backward nor tarries with yesterday.
You are the bows from which your children
as living arrows are sent forth.
The archer sees the mark upon the path of the infinite,
and He bends you with His might
that His arrows may go swift and far.
Let your bending in the archer's hand be for gladness;
For even as He loves the arrow that flies,
so He loves also the bow that is stable.

Sunday, October 29, 2017

Why is it so hard to interpret a semen analysis test?


The sperm test is the simplest and commonest test done for evaluating an infertile couple. It allows us to evaluate a man's fertility, and because it's cheap, it's the one which is done first.

However, its apparent simplicity conceals how complex interpreting this test really is !

Because it's a routine test, one of the biggest problem is that lots of laboratories do it , and most of them have no idea how to do the test properly ! The technician does not have enough experience, and will often not have the right equipment ( such as a phase contrast microscope; or calibrate sperm counting chambers) .
This is why a lot of men end up with very unreliable reports, which their doctor cannot interpret intelligently, because they can't be trusted. This creates a lot of confusion ! This is why we see many men whose sperm counts fluctuate all the way from 5 million per ml to 60 million  per ml, depending on which particular laboratory they do the test from ! The irony is that all the reports are most probably wrong.  To add insult to injury , doctors will start "treatment" based on these reports - and it will be impossible to assess whether the treatment is helping - or harming !

Thus, it's very common to find round cells in the semen and these are usually sperm precursors, which are quite normal. However, these are often mis-reported as " pus cells ", and the poor man is treated for months on end with antibiotics to treat the " infection " !

Similarly, most labs are just not capable of staining the sperm to check their morphology - the proportion of normally shaped sperm in the sample, and these numbers are just cooked up by the technician.

The problem is not just poor quality labs however. Often men don't do the test properly because they have not been given the right instructions. There needs to be at least a 3-day abstinence period ;  the man needs to make sure that he collects the entire ejaculate in a clean container ; and the sample should be delivered to the lab within an hour or so . Unfortunately, lots of men don't follow these instructions , and sometimes they are too embarrassed to tell the lab that they have spilled the sample !

Another  huge problem is that gynecologists don't have the expertise to interpret the semen analysis report properly . Gynecologists are specialists in taking care of the health of women, and never see a man in their professional practice. Yes, they can figure out if the report is normal or not, but unfortunately they're not good at being able to understand the nuances of an abnormal sperm test report. This is why they often end up confusing the patient , and send him for all kinds of "advanced" sperm function tests ( which are promoted by the sperm testing laboratories  because they generate extra revenue for them!)  These tests serve absolutely no purpose at all, and make a bad situation even worse, because they don't provide any useful clinical information at all.

Often gynecologists will refer men with an abnormal report to a urologist or an andrologist, and this just compounds the problem,  because the left hand has no idea what the right hand is doing, and the treatment of the infertile couple gets fragmented and uncoordinated !

The truth is that there is very little effective treatment a male infertility specialist can offer, but because he needs to demonstrate his expertise, he will ask for a whole new batter of additional tests ! These include all kind of pointless , expensive and embarrassing tests, such as a colour Doppler to check for varicoceles ; and transrectal scans to check for ejaculatory duct obstruction. As part of the panel of tests which are ordered to be "thorough" with the evaluation, many doctors now also order hormonal blood tests ( FSH, LH, prolactin, testosterone); as well as chromosomes studies - all of which are a complete waste of time and money. The poor patient ends up going from one doctor to another , and since no one has a clue what is happening, he loses confidence in all the doctors.
It's not just a limitations with doctors - the truth is that medical science still doesn't know what a normal sperm test report is ! Many decades ago, a normal sperm count used to be considered to be 60 million per ml.  A few years ago, it was 20 million per ml. Currently, the "new normal" is 15 million per ml. It's hardly surprising that infertile men are going to say, "Hey, if science doesn't even know what a normal sperm count for a fertile man is, then how can they help me to interpret my particular report?"

The dirty little secret is we can't. We can tell a man with a zero sperm count that he can't father a pregnancy in the bedroom, but we can't really tell a man who has sperm in his semen whether he can get his wife pregnant or not !

This might seem surprising ! After all , isn't that the purpose of a semen analysis ? Yes, that's what an ideal sperm test would do, but a semen analysis is an extremely crude test , and doesn't provide us with that information. Yes, it does tell us what the sperm count is, and whether the sperms are moving or not, but that's not the question which the man is asking ! He wants to know, "Can I get my wife pregnant or not?" This is a completely different question , and because it's much more complex , it's not possible for us to answer this as yet.

After all, the fertility of a couple doesn't just depend on the man's sperm count or motility - it also depends on his wife's fertility ! This means that it's possible that if he had married a younger, more fertile woman, then he would have been able to get her pregnancy even with a very low sperm count !

This is why infertile men often end up getting such a raw deal - and this is why it's best for them to go to an infertility specialist , who deals with the infertile couple as a unit - and not just either a gynecologist ( who has no idea how to deal with infertile men) or an andrologist ( who has no idea how to treat infertile women!

You can see what a sperm test report should look like at
http://www.drmalpani.com/knowledge-center/resources/book/chapter4b

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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