Saturday, May 14, 2016

What I wish I had known before starting my IVF treatment


Everybody says the same old cliché that the IVF journey is like taking a ride on a roller coaster - but no one really tells you that it's like riding one wearing blind folds! That pretty much sums up this experience to me. Despite all my extensive research, and all the non-asked-for-free-advise and warnings from well meaning but stressful friends and relatives - you can never be fully prepared enough until you take a dive into the actual IVF experience.

Having said that - what I would have loved to hear (and prepare myself for) before I had started IVF is that no two journeys are ever the same - so for god’s sake please don't stress yourself with other people's agonizing stories (both personal accounts and on-line blogs) of how physically and emotionally painful it is and how many cycles you might have to do.

To address the first point, (and I should start with the admission that I have a very low threshold for physical pain and especially the variety that comes attached to a needle,) I was pleasantly surprised to find the whole needle pricking business to be relatively innocuous - say out of a scale of 0-10, (0 being no pain and 10 being unbearable pain) I found it to be around 2 in the non-painful needles and 4 in the more painful type jabs, which is not bad compared to what I had built up in my head from others feedback. My trick to getting through the more painful ones was counting how long each injection was, and I found that they hardly lasted more than 4 seconds max. Regarding the surgeries, I had anticipated that they would be painful to me - but I opted to be put under anesthesia for the egg pick up procedure (which was optional) and again anesthesia for the embryo transfer (which was mandatory) -  and to my surprise I had no pain during the procedures (obviously) as well as the post surgery period. (This in fact made me more worried as I expected at least a little bit of pain as a normal person!) Another aspect that made IVF relatively pain free for me was that I did not have to take progesterone injections, thanks to the advances in medical science, and instead had to insert progesterone capsules which is akin to wearing a tampon.

Another piece of advice I would have welcomed prior to starting IVF is that it helps a lot to start the process with being able to accept the highs and lows at every step of the journey (going with the whole roller coaster analogy) and how at one moment things are looking bright but as you move forward there is also a downer you have to deal with. I found this to be a cyclical process from the start, where one moment my egg count was looking too low, then after changing my injections to another type, the egg count went higher, but then not high enough, to finding out I had enough embryos to go ahead with the process, then not having enough to freeze, but having two good quality embryos to implant in me. It can be nerve wracking to expect too much and get too pulled down by each turn in this road. The pace of IVF can also though you off as treatment can take such a rapid course in the first half prior of treatment and later decrescendos to a snail’s pace in the dreaded two week wait.


Connected to this last point of accepting the highs and lows of IVF, another piece of advice is that beyond a point, you just have to take a leap of faith and put trust in the process and the doctors (assuming you have done enough research into the doctor you ultimately choose.) I don t mean this to say that you should not use your head and ask all the necessary questions in the world - by all means it is important to get all your queries and doubts and confusions answered. (I know for a fact I hounded my doctors with my 15 point questions on a regular basis!) However, I found it is extremely helpful to mentally and emotionally take one step and day at a time, feel good that you have gotten so far, and then think about what you have to do immediately after, instead of worrying about what if this happens or that happens or if things go wrong down the line. I recall worrying about how I had a low AMH level and how I would probably have to do at least three cycles from what friends had told me, but to my joy I have conceived in my first attempt! Even now at times I worry that this might happen and that might happen, but then I try to remember that whatever worries I hold in me is something that gets stored in my body and affects the conceiving and pregnancy process, and then I allow myself give into to the moment and relax...

My last recommendation is to be kind to yourself - it's so easy to fret about you should have done and could have done and should do but I found all my body needed to do was relax, so take this as an opportunity to pamper yourself, especially during the two week wait where it's easy to let your imagination get carried away with itself. Therefore, having small little things to look forward to is a helpful way to get your mind occupied and off wondering what will happen this cycle.

For all of you who are beginning this life -changing voyage, perhaps as nervous and excited as I was, I wish you all the best and sincerely hope you have as much a positive experience as I have had!

Thursday, May 12, 2016

Fuzzy thinking about pelvic tuberculosis



I just attended an infertility conference in Goa, and I am struck by how much fuzzy thinking and confusion there is about genital tuberculosis. I think this is one of the most over-diagnosed, mis-diagnosed, over-treated and mis-treated disease in infertile women in India today. There are some doctors who believe that every woman who is infertile has tuberculosis ! They label this as either hidden tuberculosis; latent tuberculosis; inactive tuberculosis; or dormant tuberculosis, terms which are badly defined. Most doctors then use these words to mean whatever they want it to be, which means when two doctors make a " diagnosis " of dormant tuberculosis , they're often talking about completely different things.

Not only are they confused themselves, they end up confusing patients and other doctors as well, because they are so confident and authoritative about what their viewpoint.

There are many reasons for this confusion and uncertainty, but the biggest issue seems to be prejudice. A lot of doctors practise medicine based on their personal clinical experience. They remember a particularly memorable  patient , and build up their entire picture about what genital tuberculosis is , and how it should be treated based on these individual cases. However, anecdotes mean very little , because it's so easy to fool yourself .

Unfortunately, there have been very few good studies about TB of the reproductive tract, and the confusion grows day by day. There are lots of questions which stump doctors in their daily practice. How does one make a diagnosis of dormant tuberculosis? And even if you do make the diagnosis, what does it really mean? What's the point of doing a TBPCR test? Is there any need to treat these patients? When you treat them with 9 months of toxic anti-tuberculosis drugs , what is the harm which you're causing them?

All these are difficult questions, and the biggest tragedy is that no medical college in India is willing to perform a clinic study to answer them definitively . It would actually be quite a simple study to do , where infertile patients are randomised and treated, but because no pharma company is going to sponsor such a study, the tragedy is that it will never be done .  This is why doctors continue sticking to their personal convictions.  One lazy knee-jerk reflex response - " TB is rampant in India, and because it's so hard to make the diagnosis, let's just treat every infertile woman with anti TB medicines.   Others will run an entire panel of tests to try to clinch the diagnosis, in order to confirm their " clinical " suspicion. Thus, if the TB DNA PCR of the endometrium is negative, then  let's do a TB RNA PCR. And if this is also negative then let's do a TB PAMP test. Some doctors will even go the extent of running all the tests at one time - and it's obvious that the more the tests you do , the better your chances of getting at least one  positive result.  Thus , if you do 5 tests and even 1 of them is positive , you go ahead and make the diagnosis of tuberculosis and treat the patient, even though this is highly likely to be a false positive.

Because so many of these tests do come back as positive, this is why a lot of doctors believe that genital tuberculosis is epidemic in India, and that if we " treat the TB ", the pregnancy rates will increase.

It's not that doctors have bad intentions - after all, we do want our patients to get better. However, we need to remember that we can harm our patients inadvertently as a result of this sloppy thinking. It's high time that we started doing good quality, randomized studies in order to be able to define what the right treatment plan is. There's been too much confusion about the entire field of tuberculosis, and this has been going on for years. The sad thing is that we seem to be making no progress towards achieving clarity.  This is why even those tests which  have been proven to be completely useless ( for example, the TB blood tests for  IgG, IgM ) and have been banned by the Government still continue to be ordered by gynecologists !

 The big problem with this diagnosis of latent tuberculosis is that every doctor can define it as he pleases.  This means that dormant tuberculosis can be anything you want it to be ! Thus, even if a patient has no symptoms and no signs , just because her test result is positive you can say, "Oh, she has dormant tuberculosis and she needs treatment because if I don't treat it , it will become active and will flare up , and this can cause her to miscarry, or will reduce her chances of IVF success."

How can one go about disproving this hypothesis? This is where the sloppiness comes in - because you have now created  a hypothesis which is not falsifiable. If you cannot prove that what you're saying is wrong ( disproving the null hypothesis) , then this is unscientific thinking, according to Karl Popper.

The trouble is that doctors continue deluding themselves and believe they are offering their patients, the right treatment. They are blissfully unaware of how flawed their thinking is, and how much harm they are causing their patients. Practising doctors attend conferences in the hope that some expert will shed light on this contentious issue, but their confusion just gets worse , because you typically have to listen to 5 different experts saying 5 different things ! What's even worse is that infectious disease specialists , who are TB experts, have refused to put a brake on the overtreatment which gynecologists continue to indulge in.

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 !





Wednesday, May 11, 2016

Using virtual patients to improve medical education in India



One of the responsibilities of the Medical Council of India is to make sure that the medical education provided in medical colleges all across the country is of a sufficiently high standard, so that when medical students graduate, and go out in the community to practice as doctors , they provide safe and effective medical care to their patients.

This is a complicated task, and it's quite obvious that the Medical Council has not done a very good job so far.

The majority of colleges are private medical collages, which are run by politicians. These are designed to make a quick buck for their owners, rather than to create good doctors. They often don't have the necessary infrastructure - either in the form of beds, equipment, patients or staff. The system is riddled with corruption and this has been well documented. On the day of the MCI inspection, they will add medical teachers on their rolls; and pay people to come in and pretend to be dummy patients , in order to meet the criteria which the Medical Council of India lays down.

The point of certification is not to count how many beds the hospital attached to the medical college has; or how many books there are in its library; or how many medical professors they employ. All these are just surrogate markers for the quality of training they provide, but this is all the MCI can track and monitor. What we really need to do is to check the technical competence of the doctors they train. Is the medical knowledge base of their graduates sound enough so that he can practice competently as a doctor?

This is a challenge, especially when there are so many medical colleges, and so many specialties. The medical examinations which are designed to test the competence of the doctor are of poor quality.

All they do is test the ability of the doctor to regurgitate medical knowledge on many multiple choice questions. This is not a very good way of judging whether he's going to be competent once he starts actually seeing patients.

This is why the Medical Council of India should now move on and start using simulation technology which deploys virtual patients to test trainee doctors before they are allowed to graduate. Virtual Patients are interactive computer simulations of clinical scenarios and can be used to test the clinical decision making skills of residents , to see if they can be set loose in the real world. They are great testing tools, because they check whether the doctor can apply the knowledge he has acquired to the patients he will see in real life. You can check them out atwww.i-human.com and www.medsims.com.

A common medical exit graduating examination which utilises virtual patients will serve as a platform which can be used to test medical students across the country. The MCI will be able to track the performance of all the medical students of individual medical colleges, and red flag those whose students continue to perform miserably, so that they can be shut down before create too much harm by churning out too many incompetent doctors. It's also a much more transparent system , because it will no longer be possible for the medical college owners to bribe the MCI inspectors into giving them a passing grade. There will be much less corruption, because everyone will be held to the same standards. This way, we will no longer be measuring inputs, but will be able to focus on outputs - on the quality of the students who pass out through their gates.

The MCI will have access to dashboards to compare which colleges are doing well, and where the students are persistently failing. This will allow them to identify the positive deviants who are doing an outstanding job; and also help the laggards to correct their gaps and deficiencies.

This kind of platform is very easy to scale up. It's also easy to modify , so that the database can be updated to keep pace with the newest advances. Online testing technology has evolved a lot and we can learn from other examinations which are conducted online, such as the GMAT. It's high time that the Medical Council of India started using this new technology, in order to make sure that the doctors who graduate are of high quality.

Sunday, May 08, 2016

Did our IVF doctor cheat us ?


I just received this email from a patient.

Sir, we are feeling cheated.....my wife's tube was blocked....ivf centre said go for icsi.....my wife ovum pick up done and my semen collection done....then doctor said 4 embryo prepared but you have to do FET because of high injection dose given to wife.....we are called after 1.5 month for embryo transfer.....on transfer date doctor said only one good embryo prepared , you have to go for embryo donor....please advice us what should do...we are feeling cheated.....please help us... 

It breaks my heart when I receive emails like this.

This poor patient has been obviously taken for a ride. Sadly, he has no documentation, and has been kept completely in the dark by his doctor. Patients are not fools, and when doctors try to hide information from them, they are understandably angry and resentful.

Even worse, when some IVF doctors start cheating their patients like this, the reputation of all IVF doctors takes a beating. This is why IVF clinics in India have such a bad reputation today. All clinics get tarred by the same brush, when we refuse to police ourselves or make any effort to weed out the bad apples in the profession. Most doctors prefer to take a "see no evil, hear no evil and say no evil" approach, and will refuse to say anything critical about another doctor, because they don't want to rock the boat ( or perhaps because they stay in glass houses themselves ?)

The damage has already been done for this poor patient, but what can IVF patients do to protect themselves ?

The first step is that you need to understand that knowledge is power,  and you need to take an active interest in your treatment, by asking pointed questions before starting your IVF cycle.

The good news is that you need to ask only one simple question - Do you provide embryo photos routinely to all your patients ? If the IVF clinic does not do this, this is a red flag, and you should look for an alternative !

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 !




Thursday, May 05, 2016

How specialised fast track courts can speed up the Indian judicial system


The judicial system needs to start using technology more intelligently. There is a lot of data which is generated by the courts, and data analytics can be used intelligently in order to shed light on what the reason for the ever increasing back logs is.

What kind of cases are getting backlogged ? And why ? Is the interpretation of a section of a particular law a major bone of contention ? Where are the back logs the most ? In a particular district ? Or in of a particular court ? Where are the bottlenecks ? Which judges seem to be hopelessly slow ? And which ones are doing the best job at delivering judgments expeditiously ?

This is information which should be put in the public domain , and citizens and lawyers should be asked to contribute solutions as to how to deal with some of this backlog. We'd be able to identify whether some courts are more efficient than others, and then try to figure out why. I am sure this is stuff which the legal community knows informally, but it needs to be discussed more openly, if we want the judiciary to become more accountable. I agree it will create problems, because no one likes to be at the lower end of the spectrum, but this kind of sharing will help everyone , as the less efficient judges could learn from the more efficient ones.

Why do we pretend that all judges are equally good ? We all know that there are differences - and it's important that the not-so-good ones get to learn from the better ones. Perhaps the names could be hidden, so as not to embarrass the laggards , but if the information is openly shared, then people can apply their collective wisdom to think of clever solutions. This information already exists within the system - we just need the courage to share it openly.

We need to slice and dice this data and encourage people to ask intelligent questions so that we can come up with clever answers. Why is there so much variability between the judgments of certain judges ? Which judges get their decisions reversed all the time ? After all, if we want transparency in the medical profession, then why shouldn't we demand transparency in the judicial profession as well? We want doctors to report how many cases they do; how many of their patients survive; and how many of them die. Hospitals need to do this as well, if they want to be accredited and certified. Why shouldn't we demand this of our judges as well?

And the same rules should apply to lawyers as well. For example, their win-loss track record should be shared so that clients can make a better-informed decision as to which lawyer to select. How long do they take to get a decision ? How many times do they actually appear in court ? How many times do they depute a junior ? How many cases have they taken on ? Analysis of these records will allow clients to select the lawyer who is right for them; and for the judiciary to track which lawyers use delaying tactics to clog up the system; and which ones are efficient and effective. All this is the staple fare of judicial gossip, but why should this information remain secret, so that only a select few are privy to this ? Why shouldn't it be shared publicly ? This will incentivise lawyers to get their act together; and will also help clients to see which lawyers are overbooked and too busy to pay attention to their case, so that they don't waste money on them. This will help to improve the performance of the judicial system, when judges and lawyers know that the world is looking at how well they're doing in comparison with their peers.

For example, this data could be used to set up fast-track courts to deal with specific problems. Many cases which clog the system are very similar - they are often disputes about the interpretation of a specific section in a particular law. It then happens that one judge gives a particular decision , and another judge gives a completely different decision, which can get very confusing. Of course, this is great for lawyers, because then they can cite case laws , and argue in front of the judge, who also love this kind of intellectual debate. However, it's not really helpful for the litigant. After all, you want a system which is open and transparent, so that litigants have a high chance of being able to predict what the outcome of their case will be , rather than be shocked and surprised at each turn.

Thus, we could set up fast-track courts , where you would have a specialist judge who would look at all the cases of a particular kind - for example, electrical disputes in the city of Mumbai. If these were all grouped together and brought under one roof, imagine the amount of efficiency you would be able to create . The judge would become a specialist very quickly in that particular field because he would know the law backwards and forwards, and no lawyer would be able to confuse him. He would be consistent, and would provide similar opinions in all the cases. This would allow for a lot more replicability and predictability in the system, so that litigants would know what to expect, as a result of which there would be much less reason for them to be dis-satisfied and go into appeal.

Citizens themselves would feel far happier, because they could see that justice was being meted out fairly, because similar decisions were being provided to all the litigants , based on the facts of the matter. This would be more fulfilling for the judges as well, because they would acquire a lot of expertise and depth in one particular field. We do this with the Income Tax Tribunal , where we have specialists in finance deal with contentious tax issues, and they have done a good job in this field. Why can't we apply this to other areas as well ?

Today, we have the technology to be able to determine what the key issue in any given case is, by using algorithms to parse the text in the petitions. These could be then assigned to a particular court, instead of the litigants to join the queue and wait for their turn to arrive - which can often take months. This will help to clear the backlog, and allow the judge to process cases much more efficiently, since most cases would have very similar issues. This kind of transparency and efficiency will help everyone to become happier.

Why not have specializations for judges? We already have this for lawyers , some of whom practice only in one particular field. Why can't we do this for judges as well? This will help the system to become far more efficient . Justice would become far more predictable, because litigants and lawyers would be able to study all the judgments which that particular special court has delivered in the past , and have a much better chance of predicting what their chances of winning are. They wouldn't have to depend upon legal gossip or lady luck, and wouldn't have to waste time searching the archives of hundreds of cases from all over the country , most of which will provide completely differing results and end up confusing them.

 Why do we expect judges to be masters of all the laws? This is not something which makes any sense to me. After all, just as doctors specialize, why can't judges ? You don't expect a neurologist to treat a patient with heart disease, do you ? In the past, we divided cases into civil and criminal cases. We now have the technology to become far more granular in our approach, and we should start doing this ! For example, all the cases which deal with a particular law should be addressed in a court which specialises in handling this. If we have specialists in medicine, why do we expect all judges to remain general family physicians ? There are judges who enjoy judging cases in a particular area , because they have a special interest in that field, so why not let them do more of what they are good at? I'm sure there are many areas which bore them, which they'd rather not be bothered with, so why force them to provide judgments in that field ? What's happened today is that most judges are forced to become a jack-of-all-trades , and master of none. This is really not fair either on them or on the litigants.

Wednesday, May 04, 2016

How the Medical Council of India can use technology to improve medical practice in India

The Medical Council of India has been empowered with an extremely important role - to make sure that medical practice is carried out ethically. Unfortunately, it doesn't have a track record of having done a very good job so far, for multiple reasons which I will not bother to spell out as they are now common knowledge.

However, rather than list all the problems which plague the MCI, let's focus on solutions. I believe that a lot of these can be solved if the Medical Council starts using technology more intelligently in order to do a better job.

Read more at http://health.economictimes.indiatimes.com/news/industry/the-mci-needs-to-use-technology-to-improve-medical-practise-in-india/52102294
 

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