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 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 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.

Monday, August 25, 2014

What are my chances of getting pregnant ?

This is the commonest question the IVF specialist is asked – especially by someone who has failed an IVF cycle.

In one sense, it’s an easy question to answer. IVF clinics keep statistical records of the pregnancy rates we achieve in the women we treat, which means we can quote success rates in various groups of women ( for example, women under 35;  women over 40; and so on.)

The trouble is that these figures apply to groups of women . How can we intelligently extrapolate these to the individual patient sitting in front of you and asking the question?

Thus, not all 40-year olds are the same. Some have good ovarian reserve and produce excellent quality embryos; while others make embryos which are fragmented and which arrest in the lab. It’s not fair to lump apples and oranges together  when providing an answer, because it’s likely to be inaccurate and unreliable.

The truthful answer is more nuanced. It is – It depends upon how many good quality embryos you make – which in turn depends upon the egg quality.

Now while we do try to judge a patient’s ovarian reserve by checking her antral follicle count and measuring her AMH levels, these are fairly crude tests, with limited predictive ability. The final proof of the pudding is in the eating – and  its’ only when we actually superovulate her during an IVF cycle will be know how good her ovarian response is.

While the pre-IVF tests will give us some idea, these tests have limitations, and it’s impossible to predict how a biological system will behave.

The final proof of the pudding is in the eating – and finally it’s the number of good-quality embryos we are able to make which determine the chances of IVF success.

However, patients are not happy with this answer, even though it is accurate. They want a specific number, and would prefer a doctor who tells them - Based on my extensive experience , your chances of getting pregnant in my clinic are better than 56% ! This is a load of rubbish, but patients love this kind of pseudo-accuracy .

These doctors are very good at massaging figures , that selectively present the success rate in patients who have the best prognosis. Because patients are not sophisticated enough to read between the lines, they are suitably impressed and are happy to sign up.

Patients need to learn to ask better questions. Rather than push doctors to provide a figure ( which is often fabricated), the question they need to answer for themselves is – what is the magic number at which I will decide not to go ahead with the IVF cycle. Let me explain.

Suppose the doctor says your chances are 30% or 40%, if the patient has decided she will go ahead with the treatment if the success rate is better than 20% per cycle, then  the actual number the doctor quotes is unimportant, because it will not affect her decision. Of course, she may want to select a clinic which has a higher success rate overall , and these figures ( which are statistical averages for all the patients the clinic treats, and do not apply to individuals) are available online.

On the other hand, if she feels that if her chances of success are less than 10%, then she would rather not go ahead with the treatment cycle, because the slim chances do not justify her spending so much time, money and energy, then this is the key number she should focus on.

This means that the patient should then decide what particular success rate will allow her to make a go/no go decision ; and then share this information with the doctor,. so that he can answer the question a little more intelligently and honestly.

Remember that it’s just a question of statistics - it's also question of the individual patient’s personal preferences.  This is where both the clinic's overall success and the patient's decision-making process overlap.

Thus , we will have some patients where even if their chances of success are less than 5%, they are happy to go ahead, because 5% is better than zero ! They want to give it their best shot, because they never want to regret afterwards that they didn’t try. However , this is the kind of soul-searching the patient needs to do , even before asking the doctor the question - What are my chances of getting pregnant ?

Need help in getting pregnant ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Saturday, August 23, 2014

Doctors get paid too little

The general perception in society seems to be that doctors charge too much . They are seen to be greedy; loaded with money ; drive around in a Mercedes ; and play golf on weekends. They are perceived as being crooked because they make a lot of money on the side by : cheating health insurers by padding hospital bills; taking kickbacks from pharmaceutical companies for prescribing their brands; and from diagnostic centers for referring patients for expensive scans and tests which are unnecessary .

Ironically, people don't mind splurging money on luxuries ( such as going to dinner at a 5-star hotel or going for a holiday abroad), because they value the experience this provides them. However, they grudge having to spend money on their medical care. They feel this is money which was wasted , because all the doctor does is get you back to normal – it doesn’t leave you any better off than you were ! This is why going to a doctor is seen as a wasteful expense, rather than as a positive investment in your health.

When you are ill, you are willing to pay the doctor whatever he wants. When you recover, then you grudge him his fees !

This reminds me of the joke of the businessman and the doctor.

When the wealthy businessman choked on a fish bone at a restaurant, he was fortunate that a doctor was seated at a nearby table.

Springing up, the doctor skillfully removed the bone and saved his life.

As soon as the fellow had calmed himself and could talk again, he thanked the surgeon enthusiastically and offered to pay him for his services.

"Just name the fee," he croaked gratefully.

"Okay," replied the doctor. "How about half of what you'd have offered when the bone was still stuck in your throat?"

Be that as it may, how much should a doctor charge ?

This is a difficult question to answer, so let’s look at what our wise judiciary has to say about how much a human life is worth.

If a doctor is negligent, and a patient dies as a result of this, the court is willing to award damages in crores of rupees. Using the same yardstick, then the doctor saves the patient’s life, then why shouldn’t he charge 0.1% of the value of the life saved ? I am sure most doctors would be very happy with this !

We need to be consistent, and it’s unfair to pay doctors so little when they do their job well; and to then punish them so severely when they don’t !  Pediatricians would easily become the richest specialists, because of the number of quality life-years they add to a child’s life.

Friday, August 22, 2014

IVF emergencies and complications

IVF treatment is usually fairly straightforward . Patients are usually young and healthy, and the treatment usually goes smoothly as planned. This is why most IVF cycles are uneventful without any problems at all . However, sometimes there can be emergencies which patients need to be aware of.

The commonest medical emergency is ovarian hyperstimulation syndrome or OHSS. This occurs when the patient grows too many follicles, and if the doctor doesn’t know how to manage this problem , patients can end up with severe hyperstimulation which can be life-threatening . The good news is that hyperstimulation is a preventable problem , and can also be treated effectively by a knowledgeable doctor. We have lots of tools and techniques to prevent the problem , and to ensure that it doesn't become severe.

The other medical emergency IVF clinics have to deal with is that of ectopic pregnancy . Even though we transfer the embryos into the uterus in an IVF cycle, sometimes the embryos move out of the uterus in a a retrograde fashion into the fallopian tube, resulting in an ectopic pregnancy . In a good clinic, hCG levels are actively monitored routinely in order to make sure that the pregnancy is in the right location , If an ectopic is diagnosed in a timely fashion , it's very easy to treat this medically by giving a methotrexate injection which can kill the ectopic pregnancy. However , if the diagnosis is delayed or missed, then an ectopic pregnancy can rupture and be life-threatening.

In the past, a high order multiple pregnancy was a common complication of IVF because doctors transferred too many embryos in order to inflate their success rates. However, by restricting the number of embryos we transfer, this can be prevented.

There can also be complications during the egg collection, such as vaginal bleeding or infection. However, in a good clinic, these are very rare.

One of the vexing emergencies is that of a difficult embryo transfer , where the doctor has technical difficulty in depositing the embryos through the cervix into the uterus. This may be because of cervical stenosis; or a sharply angulated cervical canal. This can be extremely distressing for both doctor and patient, because a difficult embryo transfer does reduce the success rates. This is why many clinics will routinely do a dummy embryo transfer to prevent this situation from arising.

Finally, the commonest emergencies are the emotional ones , where patients break down when they find their beta hCG is negative and the IVF cycle has failed. This is best managed by an empathetic doctor,. who can provide patients with a shoulder to cry on , and explain to them that it's more important that they focus on the long-term perspective , rather than get disheartened just because one cycle has failed.

Need to learn more about how to prevent complications in your IVF cycle ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

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