Saturday, October 07, 2017

Why IVF patients need to be optimistic !


Most IVF patients are extremely optimistic that their IVF cycle is going to work for them. If every patient didn't think in their heart of hearts that the cycle was going to be successful, no one would ever have the courage to start one. After all, a failed cycle causes a lot of heartache and heartburn . Patients are putting a lot on the line when doing IVF - not just in terms of money, but also in the form of hope, time and energy .
 
 They know that a lot rides on the outcome of the cycle , and because IVF gives them the best chance of having a baby , they're gather up all their courage and start off on a cycle. Of course, they're also very worried that the cycle may fail, and the ones who are realistic and well-read and have done their homework understand that the odds are stacked against them. After all, human reproduction is not efficient, and embryo implantation is a biological process which no doctor in the world can control. 
 
Even after knowing that the chances of failure are more than the chances of success in a single cycle, the fact that they're still able to go ahead does mean that they need to be highly optimistic. And even if this optimism may seem to be irrational, it's often the only thing which allows them to start a cycle. 
 
IVF is not an easy ride , and tests the emotional resilience and maturity of a patient. Lots of them are never be able to start another cycle when the first cycle fails because they had so much hope invested in the first one. That's why it's important to find the right degree of balance between optimism and realism when starting the treatment.  Patients need to be prepared that it can take 3-4 cycles to have a baby, and these patients will have the courage to bounce back and give it another shot even if their cycle fails.
 
I agree this is not easy, and every patient needs to find what works best for them. Yes,  it's important to hope for the best, but it's equally important to prepare for the worst , so you don't go to pieces in case the cycle fails.  This is why it's important to step back and take a long-term perspective . Even though an individual cycle may fail, we still have the ability to learn a lot from that failed cycle, and can use this information to improve your odds of success for the next cycle. 
 
It's important to think of IVF as a process which may take three or four cycles before it gives you the deeply-loved baby you want , rather than think of it as a single shot affair. Of course, in a perfect world , every IVF cycle would work, but then patients wouldn't need any counseling at all ! IVF technology has not brought us to that point as yet, so you need to be able to shield yourself from the possibility of heartbreak.

Unnecessary testicular surgery for the infertile man


A common fashion these days in some IVF clinics is to do TESE-ICSI for men with severe oligoasthenospermia ( low sperm count).

This is justified by saying that these men with " abnormal sperm"  have  high sperm DNA fragmentation, and this will result in poor fertilisation and poor quality embryos.

The solution they propose is extracting sperm directly from the testes, by doing a TESE, the theory presumably being that testicular sperm will not have as much DNA fragmentation because they are "fresh".
Of course, it also goes without saying that doing an additional procedure allows the IVF clinic to charge more !

This is complete rubbish, and TESE should only be done for men with azoospermia ( zero sperm count).

If there are sperm in the semen, then these should be used for doing ICSI - there is no need to use testicular sperm at all

Please don't let the doctor assault your testes for no rhyme or reason !

IVF scams never seem to end !


I am always impressed by how creative IVF clinics are - at cheating their patients !

The latest scam is " Biologically Active Peptide Concentrate or BAPC , to improve a thin uterine lining ! This is completely untested and unproven, but is being "sold" to patients as the latest and most advanced treatment !

It's scary how easy it is to take advantage of a gullible infertile patient's emotional vulnerability. All you need to do is to coin a clever new acronym, and start selling your product ! Pay the doctor a hefty kickback, and he'll be happy to "treat" his patients using your clever new innovation - even if it's no better than sterile water!

What can patients do to protect themselves ?

Tuesday, October 03, 2017

Why an IVF doctor is an active angel investor


I am a full time practising IVF specialist, which is why people sometimes wonder why I am investing in startups so actively. Why do I want to wear a new hat at this stage of my life ?

There are many reasons why I am very glad I have gone down this path.

I believe you remain young as long as you keep on learning new stuff, and while I know a lot about IVF, there's lots of stuff I don't know about many other fields. I am curious and I like learning more, and a great way of learning is by investing in start-ups . These founders are domain experts, who have the courage to have a contrarian point of view. They  think they can do a better job than the existing incumbents, which is why they're willing to challenge them. This requires a lot of conviction, and I learn a lot about the domains I invest in, thanks to them.  This makes life much more interesting , because practically everything I read is grist to my mill, and can be of use to one of my founders.  I need to be interested in what is happening in many domains, rather than be myopic and think only about what I need to do for my IVF patients.

I believe in the T-shaped model of leading life, which means you acquire a lot of expertise and depth in one particular niche, and then apply it to other fields. Angel investing allows me to do this. If you want to be a good angel , you need to be a well read philosopher ! Because I invest across many different domains, I need to keep up to date on what's happening in all of them, so I can have intelligent discussions with entrepreneurs. This is why investing is the last liberal art !

Neither of my daughters  is a doctor, and  while one is doing her MBA at Stanford, the other is working in a clean-tech startup in San Francisco after completing her Masters in Environmental Management in Yale. I need to be able to understand what they are doing, and I don't want to lose their respect just because I cannot decipher cash flow statements. Angel investing allows me to keep up with them !

One problem with being a doctor is that you tend to hang out only with other doctors, and as doctors get older, they get a skeptical and cynical. They are always complaining about how people don't respect doctors anymore; and how patients are always on the internet,  trying to second guess their doctors. They keep on reminiscing about the good old days, but these aren't going to come back, so there's no point in wallowing in nostalgia ! The problem with hanging out with pessimists is that you become pessimistic yourself, and start thinking that the world is going to the dogs.

It's much more interesting to think about the future, and what we can do to make it better. Entrepreneurs have to be optimistic , because they're willing to invest time and energy on tackling complex challenges. My hope is that their optimism will rub off on to me as well !

Life has been kind, and because I have been lucky to have a friend like Rakesh Jhunjhunwalla ( India's Warren Buffett), I have more than enough money to be contented and happy.  Making more money is not going to change me or my lifestyle, so I would rather invest in startups, even though they are a riskier asset class. My investment in them has the potential to create much more good, especially because I have a soft corner for social impact investing. If I can help the next generation of entrepreneurs to make the world a better place by funding them, this is the best use I can find for my money ! This is why I find angel investing  very rewarding, and look forward to being an active angel investor in the future as well.

My next post will be on why being an IVF specialist helps me to become a better angel investor ! Stay tuned...




Monday, October 02, 2017

The poor infertile man


Male infertility is common, and is usually responsible for about 40% of all infertile cases. The commonest reason is the low sperm count, also known as oligospermia.

What breaks my heart is the poor quality of treatment which these men get. Typically, they go to a gynecologist who has no clue about how to deal with men , because all they do is deal with women. However, when confronted with something they don't understand, like most doctors, they mindlessly tick off lots of boxes on a laboratory order form, to "investigate" so they can make a "diagnosis". They usually order a panel of tests , including hormone levels ( such as FSH, LH, prolactin, tesosterone); karyotype                   ( chromosome test ) ;  and a doppler ultrasound ( to check for a varicocele). However, none of which these are any use whatsoever in a man with a low sperm count ! The very fact that the man has some sperm in his semen means all his tests are going to be normal ! Most minor abnormalities are of no clinical importance.
Even worse, these results don't provide any actionable information , because there's nothing we can do to increase the sperm count ! However, doctors are never happy just prescribing tests - they love to " treat" as well ! They advise a lot of lifestyle modification measures, such as eating a healthier diet; doing more exercise; taking cold water showers; wearing boxer shorts; reducing stress levels; taking holidays; as well all kinds of empirical therapy , such as antioxidants . All this expensive rubbish doesn't help with improving the man's fertility at all, but just ends up making him feel persecuted. Yes, a man's sperm count will occasionally increase , but this hardly helps - fluctuations in the sperm count are very common, even without treatment.
However, all this therapeutic meddling makes the poor man's life hell. As it is, he feels inferior and inadequate, because he can't get his wife pregnant - something which any normal man should be able to do with ease ! His low self-esteem just gets worse, and he blames himself for being the cause of his wife having to suffer taunts from the rest of the world.

Even after complying with all the onerous restrictions placed on him ( no social drinks, and not even an occasional smoke), most of the time there is no improvement in the sperm count at all. This is when he loses confidence completely in all doctors.

The man with a low sperm count should just accept the fact that there are lots of things doctors don't understand. One of these is why men have a low sperm count, which is why we can't do much to increase it.
If you are one of those unfortunate men who does happen to have a low sperm count, please stop beating up on yourself. Make sure you repeat the test again, preferably from another more reliable lab , to confirm the diagnosis. However, if the results  remain persistently poor, then your options are limited.

Some gynecologists and IVF centers will refer you to an andrologist , who's supposed to be a specialist in treating male infertility. However , the reality is there's very little this specialist can do for you.  Good andrologists will be honest and tell their patients, "Look, there's no point in wasting your money taking all the empirical therapy we're going to give you. It's far better to just go on and do ICSI".

However , this is not something which most patients want to hear, and they often pressurize the doctor into writing medicines for them. When the doctor can see the patient twist his arm for a prescription, he is happy to write this, so he can move on to the next patient , rather than wasting his time on these hopeless cases , for which he knows he really can't do anything. However, this means that another three months of the poor patient's life is wasted, and his poor wife keeps on getting older !

Sadly, the torture doesn't stop even after starting the right treatment, which is IVF/ICSI . If the embryo is of poor quality and the IVF/ICSI  cycle fails, many doctors blame the failure on the poor quality of the sperm, and suggest to the man that they use donor sperm the next time ! This is plainly ridiculous, since the only reason for doing the ICSI in the first place was the poor sperm . When doing ICSI, we need only 1 sperm to fertilise 1 egg , and it doesn't matter how poor quality the semen sample is at all !

The reason for poor quality fragmented embryos is much more likely to be a poor quality lab, but the doctor blames the man for this, and does even more pointless tests, such as sperm DNA fragmentation, to prove to him that the "fault" is his, and that it his poor sperm which are responsible for the IVF failure !

Saturday, September 30, 2017

Empirical therapy in IVF - good , bad and ugly


Doctors are very fond of prescribing treatments, and a lot of these are empirical - based on their personal clinical experience. This is especially true in IVF , because there's so much we don't understand about reproductive medicine. Thus, when we say someone has failed an IVF cycle because of " failed implantation" , this is just a label to disguise our ignorance , because we cannot study embryo implantation in utero.

The truth is that we have no idea why the embryo failed to implant, but patients don't want to hear the truth. This is why doctors don't want to admit that we are clueless ! The patient is very anxious, and if you acknowledge you are not sure , the patient will go hunting for a second opinion, because they want a doctor who can inspire confidence !

This is why empirical therapy has become so prevalent.  Empirical therapy simply means therapy based on experience. Its efficacy hasn't been verified by controlled clinical trials , because these are quite expensive .
Empirical therapy is of two type - good and bad.  Good empirical therapies are usually cheap, inexpensive, short-term and have no side effects. Thus, prescribing a 15-day course of antibiotics for a patient whom you suspect has endometritis is unlikely to do much harm.  Yes, it may not help, and that's something the patient needs to be aware of.

The big problem is that there a lot of very expensive empirical therapy as well, some of which can be harmful. Thus, many IVF specialists put all their patients on 9 months of anti-TB treatment based on unreliable TB PCR tests . Patients are subjected to expensive, time consuming treatment which can have a lot of toxicity - and this also harms the community by causing the spread of drug-resistant TB. You can read more about this at http://blog.drmalpani.com/2015/03/laboratory-tb-versus-genital-tb.html

Lots of other "treatments" are very expensive , and have many side effects . These include stuff like intravenous immunoglobulins ( IVIg); paternal lymphocyte immune therapy for treating " high levels of NK cells" ; intralipid infusions; and  PGS. It's a long list and that's why it's very important to explain to patients before starting  that this is therapy which has not been proven. The doctor needs to be honest and say, given the fact that we have limited options, we'd like to try this on you . However, we need to get informed consent from patients that this is treatment which has not been established as being scientifically sound because we don't have enough data, but if you want to try it, we're happy to go ahead and do this for you.

Sadly, most doctors don't do this, which is why IVF patients end up wasting so much money on wasteful and useless tests and treatments.

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 !





TB PCR testing is a waste of time and money, and causes harm

A patient just sent me this email

Sir I have 5 year baby girl...I have started treatment for conceive second baby before 4 year. ...but unfortunately I m not getting result... doctor give mi advice for doing laparoscopy because of both tubes are blocked.i have done laproscopy in april. after laproscopy I have try natural conceive for but result was not getting gud....I forgot to take report of tbpcr ...I was called the report in august.and unfortunately my tbpcr is come positive.and I was take AKT4 near about 15 days.but this medicine not suit to me.i stop medicine...and same month I conceive baby....I confused .....what I can do...baby pregnancy continue or abort.plz  give mi advice.thanku 
This poor patient never had genital TB, and was mis-diagnosed as having TB because of the TB PCR test result, which is extremely unreliable, because it is riddled with false positives .
Read more about this at http://blog.drmalpani.com/2015/03/laboratory-tb-versus-genital-tb.html

She fortunately decided to stop the medicines on her own, and then promptly got pregnant - without any medical "help".

However, she is now worried that her "TB" will harm the baby, and is thinking about terminating a completely healthy pregnancy.

Gynecologists should be ashamed of the harm they are causing to their patients by this kind of irrational prescribing !

Thursday, September 28, 2017

The futile quest for certainty in IVF treatment.


Every couple who does IVF wants to get pregnant in the first cycle, and of course, every IVF doctor wants their patients to get pregnant in the first cycle as well ! It's very fulfilling to be able to add so much happiness to your patients' life by giving them a deeply loved baby, and if we had a 100% success rate, our life would be much easier !

Unfortunately, our IVF technology still has a long way to go .While we're good at doing certain things, there are lots of gaps in our knowledge . This is especially true after we've transferred an embryo back into the uterus. This is literally a black box , and we have no idea what's going to happen to the embryo in utero.

Implantation is a biological process which we cannot study in vivo . Since you're putting a live embryo back into the body , we have no non-invasive way of being able to monitor its progress or track its fate .

We need to be mature and accept the fact that our technology has limitations. We don't have answers for all our questions, , and we need to learn to live with this uncertainty .

However,  this is something which patients are unhappy about. They desperately want answers, and they will often ambush doctors into providing these answers. They will often unknowingly push their doctors into ordering lots of completely pointless and unnecessary tests. Doctors then add insult to injury, by offering " treatments " based on these " abnormal" test results.

It's easy to justify these tests saying, " These tests will give us more information," but the bitter reality is they don't provide any useful clinical information at all , whether it's PGS ( preimplantation genetic screening)  or ERA ( endometrial receptivity assays) .  While these maybe useful research tools, they  should be used only during clinical trials, and patients should not have to pay for the privilege of serving as guinea pigs !  Some Indian doctors are so creative that they offer tests which are available only in India ( such as PAMP testing) because these have never been validated anywhere else in the world !

While these tests may seem to make  a lot of scientific sense, sadly many of the equally logical treatments  touted widely in the past have failed to live up to their original hype - and this includes treatments such as paternal lymphocyte immune therapy;  or intravenous immunoglobulins ( IVIg);  or NK cell testing  -  it's a long list of useless tests and wasteful treatments.

This is why patients should be extremely careful before accepting the justifications which doctors trot out for justifying the use of these tests. The standard reply is - In my experience, it's helped other patients, so let's try it for you ! Any treatment can be justified by calling it empirical treatment - treatment based on experience, but not on evidence.

Fads and fashions come and go in medicine, and they change every few years, but the reality is that none of these treatments have been proven to be of any value at all. I think it's unfair that doctors use their patients as guinea pigs and try out  all these expensive and unproven experiments on them. Even worse, they charge their patients an arm and a leg for carrying out treatments which have not been  proven to be effective.

Yes, doctors would also love to attain certainty, and this is great if you're a researcher in a laboratory where you want to explore reproduction and embryo implantation in a mouse model - after all, that's the job of a researcher. We need to advance our understanding in the laboratory so we can apply this in the clinical setting.

However, clinicians should not be doing this kind of research outside of clinical trial, and it's completely unfair to patients who are being used as subjects of clinical trials.

Doctors add insult to injury by charging them for interventions which have not been proven to be effective in clinical practice, Not only do doctors need to shape up and improve by being more open and transparent with their patients, patients also need to start pushing back when doctors suggests these tests and treatments ! Please ask for medical journal articles from reputed medical journals, which prove that the .treatment being offered has been proven to work in a controlled clinical trial !

Want to make certain your doctor is giving you good advice ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !





Tuesday, September 26, 2017

The ovarian rejuvenation scam using PRP


I had this email conversation with a patient recently
Greetings. Writing to you from Mumbai. I am 40 years old with an extremely low AMH  and regular periods. Wanted to find out if you are doing ovarian rejuvenation using PRP ( platelet rich plasma) ? If yes, how do I go about getting in touch with your team ? I know doctors are doing it in Gujarat, Hyderabad and Chennai but not sure if anyone is doing this in Mumbai. Kindly revert at the earliest. 
I wrote back to her :
This is now the latest scam in IVF and reproductive medicine. Doctors offer to inject autologous "stem cells"  ( derived from the patient's own blood) into the ovary, with the promise that this will "rejuvenate" old ovaries and get them to start producing young eggs again.
Doctors are promising older women that they have now found the "elixir of life", and will be able to help them to have a baby, even though their ovaries are no longer producing any eggs.
The truth is that this just does not work, and these unscrupulous and unethical doctors are taking their patients for ride. They are using them as guinea pigs - and even worse, charging them for the privilege of serving as experimental subjects !
She replied :

Dear Dr Aniruddha,


Thank you so much for replying. My husband is also not a fan of this experimental treatment primarily happening in Greece, California, New York and a few places here and there. He doesn't believe in it. But Dr I am a part of a patient community and online forum, and lots of ladies who have  done PRP claim that their hormones have balanced out , and their AMH has also increased. Maybe it's a temporary increase , but I am really tempted to try it. I have even heard about PRP done in the endometrium, which helps strengthen the lining. My husband feels that this is just a fad and I should not go for it and stick to tried and tested fertility treatments but I am still confused with all this information coming by way. 

This was my reply :

Don't trust everything you read on online bulletin boards ! Many of these so-called patients are actually agents of the IVF clinic , who are paid to post positive reviews for them. The reviews are false and designed to deliberately mislead.
Please use your common sense ! If this really worked, then wouldn't all IVF clinics offer the treatment to their patients ?

The problem is that it's easy to take emotionally vulnerable , desperate patients for a ride - after all, hope lives eternal in the human breast !

Patients will continue getting cheated by crooked doctors out to make a quick buck at their expense, because good doctors don't speak up against these unethical and unproven practices ,and allow their patients to be duped !

Monday, September 25, 2017

Why are we seeing an epidemic of new IVF clinics in India?


There seems to be a new IVF clinic starting in practically every nook and corner in every town in India. Why this sudden spurt of IVF clinics coming up all over the place? Is it that the number of infertile couples has increased so dramatically that the requirement for IVF has gone up so sharply?

The reason is actually far more crass and commercial. Senior obstetricians and gynecologists who are tired of delivering babies and hysterectomies want to do something new and different and cutting-edge. Many think IVF is a very lucrative field, and rather than referring their patients to an IVF specialist and  losing all that potential income, they feel, "Why don't I just start an IVF clinic myself? After all, how difficult could it be? I've been a gynecologist for so many years, and with my expertise and experience, I am sure I could IVF equally well ! "

Because so many gynecologists want to get on the IVF band wagon, lots of companies have sprung up which are happy to help gynecologists to set up their own IVF clinics. They do this on a turn-key basis, and their charges vary from Rs 10 lakhs to Rs 1 crores, depending on the pay capacity of the gynecologist. This means that you make your payment, and you have an IVF  laboratory set-up for you in a few weeks !  You then just have to attend a workshop, or two, get trained in doing IVF in a few days, and you can call yourself a gynecologist and IVF specialist ! No one can stop you from doing this in this great country of ours, because no one really checks to see whether you have the adequate training ; skills ; experience ; expertise; manpower; or equipment to actually do the IVF for your patients. Once you are ready to go, since you are a practising gynecologist, you already have a captive patient population, and can start doing IVF on them .  In India, it's perfectly acceptable to use your patients as guinea pigs - they are trusting and naive, and don't know any better. And if you want, you can always hire a traveling embryologist and a visiting IVF specialist to come and do the IVF procedures for you, if you don't want to do them yourself !

As long as you're making money, everything's hunky dory , because no one really cares about your success rates - and no one is going to check them ! The tragedy is that this has been going on now for many years now, and the pace has been accelerating over the last four or five years. Sadly, medical colleges don't provide IVF treatment to their patients, which means most MD gynecologists don't have any practical exposure to doing IVF, or even seeing IVF patients.

Finally, it's the poor patients who end up being been taken for a ride . They don't understand any better, and they assume that any doctor who calls himself an IVF specialist must be a good doctor, especially when they're so senior and have been practising a gynecologists for so many years. Sadly, the government of India has turned a blind eye to this exploitation of infertile couples, so that even though the Indian Council of Medical Research is supposed to regulate IVF clinics and make sure that they have the equipment and expertise which is required, they do this purely on paper only.

Most IVF clinics in India do not have the infrastructure or manpower needed to do IVF, and the majority have not even bothered to register with the ICMR, and yet they continue functioning merrily. The Law which was supposed to regulate IVF in this country in order to protect infertile patients is still on the back-burner, and no one knows when it's ever going to be passed. As a result of this, infertile patients continue being taken for a ride, and this is tragic , because doctors who should be speaking up are all keeping quiet, because we don't want to speak any ill of our colleagues.

Indian patients cannot rely on either the government  to protect them; or on doctors to regulate themselves. They need to learn to ask their doctors pointed questions about the IVF treatment they offer , otherwise they will continue being exploited.

The good news is that you need to ask only one question to find out if your IVF doctor is any good. The simple question you need to ask is - Do you give photos of embryos before transferring them ? If the doctor says no, this is a red flag , and means this particular laboratory is not well equipped. If you don't want to get cheated, you need to find someone else !

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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