Wednesday, July 23, 2014

Patient Compliments and Complaints for Malpani Clinic

Why IVF patients are treated as guinea pigs


I am very critical about the overtesting which is so rampant in IVF today. This leads to overtreatment , and ends up wasting a lot of time and money , because no one really knows how clinically useful a lot of these test results are. Just because tests make logical sense on paper doesn't mean that this logic always translates into clinical benefits.

The sad fact is that real life can be quite messy , and what sounds very sensible in theory often does not work out well in practice .

I recently saw a patient who had failed multiple ICSI cycles. His doctor had told him that this was because of his high sperm DNA fragmentation, and that we would need to use donor sperm.

I have a very low opinion of these sperm DNA fragmentation tests . They are of very limited utility , and have not been validated in clinic practice, because of the huge problem with false positives they suffer from.

He challenged me. Doctor, if you are so skeptical about these latest and newest cutting-edge tests, then how will medicine possibly advance ? Don’t we need to run tests to find the “root cause” of the problem ? Don’t we need to know the answer to the question – Why did the cycle fail, so we can improve our chances with the next attempt ?

I have nothing against new tests. Our IVF clinic is state of the art and we offer all the latest technology, including blastocyst transfer, vitrification, laser hatching,  and PGD using CGH. However, we don’t offer tests simply because of their novelty value ! I'm not a Luddite and I'm not old-fashioned . My point is that while some of these tests may be extremely useful in a research setting , they cannot be blindly applied in a clinical setting . Just because a test works in a mouse lab doesn’t mean it will work in real life for human patients . We cannot afford to get carried away by marketing pressures and technological jargon.

We need to understand the limitations of these tests before incorporating them into clinical practice . A lot of pressure to overtest comes from the marketing departments of the companies who invent and discover these tests. Also, some of the itch to order tests comes from doctors themselves . Doctors will often indulge in a game of one upmanship ! They all want to be one better than someone else , and one way of doing this is by ordering the latest or the newest test .

This way the doctor. can position himself as being state-of-the-art , because he's better informed than the other “old fogeys” whom the patient saw earlier , and who did not have the sense to order the test. This goes to “ prove “ that he's much smarter and has much more expertise than the rest of them , because he read about this test in the latest issue of a medical journal; or saw a presentation at the recent global medical IVF conference.

Patients need to be extremely wary about this kind of cowboy approach if they do not want to be treated as unwilling guinea pigs. Sadly, many patients pressurize doctors to order some of these new-fangled tests, because they have read about them on a website or a bulletin board. New is not always better , and it requires a mature and experienced specialist to say - No further testing is needed ! It’s very profitable for the doctor to order these tests, but good doctors know that if the test has not been proven to improve IVF clinic outcomes, then they should desist from ordering them.

We take pride in the fact that we refuse to treat our patients as  guinea pigs !

Tuesday, July 22, 2014

To be or not to be ( pregnant !)


Why some doctors are scared of Information Therapy


I recently had an interesting conversation with a senior doctor who was quite skeptical about the
value of empowering patients with information. He felt this was a fad, and would just create
more problems. He believed medicine was a complex subject – after all, it takes years of full-time training to become a surgeon, so how can one expect patients to understand the nuances of their medical problems in a few minutes? Isn’t it far better for them to trust their doctor, who is the true
expert, and who can help them heal quickly?

The doctor was very critical of patients who came with pages and pages of Internet printouts about
their medical illnesses. He felt they were often very confused and ended wasting a lot of their own time and his by wanting to discuss options and alternatives that did not make any sense. He also felt
that second-guessing just caused patients to doubt their doctor, and this loss of faith and trust would end up harming patients and doctors as well.

In general, he was quite dismissive about “well-informed patients” who felt they had become “half-doctors” by reading and researching their medical problem online. He believed a little knowledge can be dangerous, and patients who think they know a lot about their disease often created more problems than they solved by challenging their doctor’s decisions.

He also highlighted the fact that doctors, not used to having patients disagree with them, can often end up getting upset and angry with “well-informed” patients, which makes doctor-patient relationships confrontational rather than cooperative.

While everything he pointed out was true, this doesn’t mean there is anything wrong with the idea of information therapy. Like anything else, information can either be used properly or misused and abused.

The key is that the information we provide needs to be reliable, updated, evidence-based and tailored to each patient’s needs. If every doctor prescribed information rather than forcing patients to
seek it out for themselves, this would create a win-win situation. The patient would trust this information since it was coming from his doctor and would not have to waste his time wading through pages of potential misinformation. The doctor would also be more confident that the patient was well informed and had realistic expectations of his medical treatment.

WHAT IS INFORMATION THERAPY ?

Information therapy can be defined as the prescription of the right information to the right person at the right time to help them make better health decisions.

The ‘right’ information is accurate because it is evidence-based, approved by experts, up to date, easy to read and understand, available in many different formats (including local languages and audiovisual formats) and referenced.

The ‘right’ person means this information needs to be delivered directly to the patient (and their
caregivers). This information is best dispensed to a patient by his or her own doctor – the person they trust the most when it comes to their health.

The ‘right’ time means the information should be provided when the patient needs it – that is, in time
to help them make the best possible medical decisions.

So, what is the ‘right’ information, and who decides what is right?

ON THE RIGHT PATH

There are several ways of delivering this powerful tool – it can be clinician prescribed, system-prescribed, or consumer-prescribed. At present, most patients get information through their own research, often online where plenty of unreliable and misleading information exists.
Unfortunately, patients are often not knowledgeable enough to conduct searches that yield valuable results. In an ideal world, all relevant information would be routinely handed over to patients by doctors.

It’s a fact that hospitals and medical centres that systematically implement information-therapy
applications will be in a better position to gain market share, profitability and prestige over those
that don’t. It actually makes good business sense in a world where healthcare is rapidly evolving
around the world. We now have empowered consumers (who demand time, information, control, and service), a new focus on quality (which promotes safer medical care and a move towards
pay for performance), and a new way of validating what does and does not work in medicine (the science of evidence-based medicine).

Thanks to the Internet, we are also equipped with the technology needed to reach out to consumers
– it connects anyone, anywhere, any time to quality information.

These drivers create a compelling case for information therapy, which revolves around an expanded patient role. As healthcare evolves, the following should occur:
• Every clinic visit, medical test and surgery is preceded or followed by information-therapy prescriptions.
• Information prescriptions sent between in-person visits will extend the continuity of care.
• Patients will play an active role in shaping how they want information to be delivered to them.

Information therapy is a very cost-effective solution that allows a doctor to put each patient at the heart of the care he or she provides. As the renowned poet and writer Kahlil Gibran once said, ‘Progress lies not in enhancing what is, but in advancing toward what will be’.

In the delivery of excellent patient care, you and every one of the doctors in your practice should be prescribing information to each and every patient.


BACK TO BASICS

It’s important to remember here that the word doctor is derived from the Latin word docere, which means to teach or instruct. When doctors don’t do so, we are abdicating our responsibility and forsaking our patients, who feel lost and are then forced to fend for themselves.

The solution is simple – doctors need to guide their patients, and prescribing information therapy is a simple way of doing so. This must be curated, reliable information that both doctors and patients trust, thus ensuring they are on the same page and are active partners in a healing relationship.


This article first appeared in the Autumn issue of the Private Practice Magazine, which is published in Australia.


Monday, July 21, 2014

The difference between follicles and ovarian cysts

  Cyst ? Or follicle ?

A patient just sent me this query

I am 29 and trying to conceive for past 4 years.I have irregular cycles. My doctor prescribed me Injection recagon 100units for 6 days from 12-May-2014. On 11th day of cycle during follicle study I got dominant follicles on both ovaries and doctor prescribed to take orgamed capsules for 14 days This month I didn’t get my periods and HPT is negative and even checked with doctor , it is negative again and she prescribed me regestrone tablets for 10 days I have a clarification . If I got dominant follicles on both ovaries, where the follicles would have gone? As per my assumption it should be either fertilized or I should have started periods . I'm so confused. Please guide me

It’s very common for infertile women to be confused about reproductive basics. They often do not understand the relationship between menstrual cycle and ovulation; or the difference between follicles and eggs; or how follicles are different from cysts.

We need to go back to basics, to make sure there is clarity going forward. Otherwise this poor patient will keep on going round and round in circles, cycle after cycle !

This was my answer.

The reason your periods are irregular is because you Do not ovulate. This is called anovulation. Read more at www.drmalpani.com/articles/anovulation.htm.

 This maybe because you have PCOD ( polycystic ovarian disease). You can read more about this at www.drmalpani.com/articles/pcod.htm.

 You need the following medical tests.
1.    Blood tests for you for the following reproductive hormones – FSH ( follicle-stimulating hormone),LH ( luteinizing hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone)
( to check the quality of your eggs). Do this from a reliable lab such as SRL ( www.srl.in);
2.     A vaginal ultrasound scan which should check for the following.
a.    Ovarian volume
b.    B. antral follicle count
c.    C. uterus morphology
d.    D. endometrial thickness and texture

Please send me the detailed test results and medical reports . You can scan them in as a single Word file and email them to me. Patients with PCOD will typically have a high AMH level; a high LH:FSH ratio; increased ovarian stroma; and many small cysts arranged around the periphery of the ovary.

 So what’s the difference between a follicle and cyst ?  A cyst is basically a follicle which does not contain an egg.  They both appear as hollow dark spherical objects in the ovary on ultrasound scans.  Since we cannot make out if the structure we see on scanning contains an egg, this creates a lot of confusion in the patient’s minds .

To make matters worse, doctors often loosely refer to the follicles seen on ultrasound scanning as eggs. In reality, eggs are microscopic, and can only be seen in the IVF lab when the follicular fluid is examined under the microscope by the embryologist. While there are many kinds of cysts, the commonest kind we see is called a functional cyst, which looks exactly like a follicle , except that it’s larger.

Thus, when a mature follicle ( which contains an egg) fails to rupture at the time of ovulation, it collects fluid and becomes larger. This is called LUF syndrome. Read more at http://www.drmalpani.com/articles/luteinized-unruptured-follicle-syndrome-LUF-infertility.htm

A functional cyst ( so called because it is functioning and produces hormones) will often result in the period being delayed, as a result of the hormones it produces. This is why it may cause the period to be delayed. It’s possible to make this diagnosis by doing an ultrasound scan. The period can be induced with medications . These cysts will usually resolve on their own.


Have a query you are scared to ask your doctor because he is too busy ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly!







Sunday, July 20, 2014

Great video on why human reproduction is so inefficient

Many infertile couples who do IVF are frustrated by the fact that the success rate is not 100%. After all, if the doctor is actually making embryos in the lab, then why shouldn't they get pregnant in the first cycle itself ? After all, isn't every embryo a potential baby ?

Sadly, human reproduction is not very efficient, and even fertile couples take time to make a baby. To see why, check out this brilliant BBC video , Inside the Human Body: Creation

Inside the Human Body: Creation [1/4] by silichip

Saturday, July 19, 2014

Hospitals can be dangerous to your health


Hospitals were originally designed to be places of sanctuary , where patients who are sick could be taken care off in a facility which was comprehensive because it brought lots of doctors and specialists and nurses and medical equipment together under one roof . It was much easier for the doctor. to provide care to ill patients in a hospital, as patients did not need to run around and all the medical facilities were available in one facility.

Both patients and their family members and doctors felt safe when the patient was admitted to hospital because they knew that the latest medical technology and medical expertise were available to take care of any complications.

Sadly , things have changed considerably . Hospitals used to be considered as the last resort , and if the problem could be managed at home , patients would prefer this option.

However today it seems that any time a person falls ill, no matter how trivial, the knee jerk response of the doctor is to advise hospitalization. Hospitals are a great place for doctors to be, because they spend most of their time here. It’s much more convenient for them to see lots of patients at one time during their hospital rounds, rather than make home visits. It’s also logistically easier for them to do all the tests and get the second opinions they need.

However, hospitals are not good places for patients to be in ! In fact, they can actually be dangerous,  because of problems such as hospital acquired infections . Patients need to be aware of the fact that even if the doctor. advises hospitalization , this may not always be in their best interests .

While hospitalization makes sense for an emergency situation or for someone who's acutely ill, for most
cases , there are usually much simpler ( and much less expensive ) alternatives . Sadly, health insurers also contribute to the problem of unnecessary hospitalization, by refusing to reimburse for ambulatory medical care.

Once you get admitted in a hospital and put on a hospital gown which leaves you half-naked and vulnerable, you to lose a lot of your autonomy . Things can easily spin out of control. Your doctor is never available, and the standard answer for most questions is – This is “ standard hospital policy , and this is the way we do things here. Often one thing leads to another , and patients often fall prey to the domino effect. Thus, even if you are admitted for abdominal pain, if  a “ routine “ chest x-ray shows a suspicious shadow , your doctor will ask for a specialist opinion; and will then order additional tests such as a CT or MRI . This means the focus of attention is no longer on the original problem for  which the patient got admitted . Incidental findings which are commonly picked up during routine tests ( especially for older people) often have no clinical importance , but once the patient is in a hospital , the doctor. cannot afford to ignore these findings.

Doctors operate under certain compulsions , and are so worried about being sued these days, that they will do extensive tests to chase up red herrings. Ironically, the problem is exacerbated for very rich patients, for whom finances are not a limiting factor, and who get overtested and overtreated.

Hospitalization can be extremely disruptive , and it's important to discuss and explore what alternative options you have with your doctor.  A good doctor will try to keep you out of hospital as far as possible !



Friday, July 18, 2014

Low cost IVF treatment in developing countries

" The unmet need in developing countries is higher still. That is partly because people have less money, but also because infertility is more common. Genital mutilation, unsafe abortion and poorly attended births cause infections that leave women with blocked Fallopian tubes, making normal conception impossible. Sexually transmitted diseases scar both men’s and women’s reproductive systems. The World Health Organisation estimates that around 50m couples worldwide have been trying to conceive for at least five years without success. Almost none of those in developing countries can hope to get treatment.

The grief of infertility is sharper in poor countries, too. In Africa and much of Asia it carries a stigma, nearly all borne by women. Male-factor infertility is rarely acknowledged except when a man has failed to father children with several women. A “barren” wife is often ostracised, beaten or abandoned, or infected with HIV/AIDS as a result of her husband straying in the hope of a child. She is at higher risk of being murdered or committing suicide."

http://www.economist.com/news/international/21607881-vitro-fertilisation-once-seen-miraculous-now-mainstream-rich-countries-soon

India has a great opportunity to become a market leader in the low cost IVF  field. Unfortunately, IVF is still not provided in teaching hospitals and medical colleges ( who can afford to provide it at a fraction of the cost which private IVF clinics charge).  Not only is this unfair on poor patients, it's also means that the new generation of gynecologists has no hands-on experience in providing IVF treatment. This means that when they start practise, if they want to start doing IVF ( as so many want to these days), they are forced to attend a 7-day workshop. While this gives them a "certificate", it also means that their skills in doing IVF leave a lot to be desired, as a result of which patients suffer needlessly.

Expert advise about IVF from an expert patient

This was a question a reader posed to Manju, our expert patient.

Question:
Need your advice - IVF . I have been on menopur 75 iu and gonal f multi dose 450 iu from 3/7/14 to date taking 225/0 in the morning and at night. I am 42 years old. Yesterday my scan and blood test showed estrogen level of 69 with 4 follicles. I have one ovary and the size of the follicles are 7.6, 6.4, 6.1 and 6.0 the nurse said they are not growing fast enough and we should cancel on Saturday I.e tomorrow if the estrogen level does not increase and if the follicles don't grow.  I need your advice.. I decided to give it my all and continue to take the meds ...I am also taking royal jelly,  maca powder, flax seed in order to improve my levels by tomorrow.  Any other suggestion.  I want to have a baby. I hope you will reply before my visit tomorrow.  I am off from work,  I am unable to focus had to leave work as I was crying too much. I don't want to loose hope this is my only chance.

Answer:

I understand your pain. Please calm down ! Getting tensed and crying will not help a bit. I understand it hurts, but you have to have realistic expectations about your situation. You are 42 years old. You want a baby badly and decided to try IVF. When they stimulated your ovaries they found that your ovaries are not growing any follicles even after giving lots of gonal F ( this is the highest dose anyone would use ). Now you are heartbroken that your dream is slipping out of your hand and you are desperate to find out whether you can do something to grow your follicles, isolate few eggs, get some embryos so that you can become pregnant. Your wish is very much justified BUT your body is not cooperating. Your heart yearns for something but the reality is different. You adamantly hoped that everything will go on well but now it is not so. Why not accept the reality A ? Then the pain gets lesser and you can think clearly of your next move.

A woman's ovary runs out of eggs as they age and that is what has happened in your case.Since your ovaries are not growing follicles even after using maximum dosage of gonal F, it is clear that your ovaries have no more eggs in them. A, I am really sorry to say this - there is nothing you can do to grow the follicles or to coax your ovaries to produce eggs; the present scientific development is not intelligent enough to help your ovaries to produce eggs. Just because you can't produce eggs it doesn't mean you can't enjoy a pregnancy or have a baby. You just have to embrace other treatment options that are available. Using eggs of a young woman will give you a very good opportunity to conceive and enjoy a pregnancy. If you ask me whether you would be able to love a baby which doesn't carry your genes - yes you will  ! Actually our genes are not that important as we might think. Just close your eyes and imagine what will happen 100 years from now -  none of us will be alive, NONE. Is it then worth worrying about your genes ? :) Any baby you love will be yours. So please do not lose heart. Do not get afraid and upset tomorrow if the doctor says that your estrogen did not rise as it should. Ask him what else you can do to have a baby?

I am sure you will not like my answer but this is the bitter truth. I wish you lots of good luck in your endeavor! May all your wish come true!

Be strong and happy!

Reply:

I appreciate your reply. I will ask about donor eggs.  I am trying to stop crying but it's hard.

Reply:

Thank you for setting me straight.  I just left the doctors office... the result was that we cancelled.  But I came to my senses and accepted it all and decided to continue with donor egg. I guess even though I don't know you....your email helped me a lot. Thanks again!





Need IVF advise from an expert patient ?


 You can email Manju at manjupadmasekar@yahoo.com


Her blog is at www.myselfishgenes.blogspot.com

Wednesday, July 16, 2014

Infertile Patient query - IUI versus laparoscopy ?


Physicians perform laparoscopic stomach surger...

Hi, Dr Malpani.

I have been reading your blog and have found it to be very helpful. My husband and I have started infertility treatments and options. Briefly, this is what has happened: -We have been trying for a year naturally (both 29 years old) -Did blood work to check all hormonal levels and everything is normal -Husband did semen analysis and that is better than normal -PCT was done twice (wish I had known this is kind of outdated and most doctors don't do this but oh well, what is done is done!) and both showed that sperm were not swimming like they should at all -Doctor/OBGYN had recommended using mucinex but cervical mucus seemed "perfect" for each PCT

After we Visited Infertility Clinic: -Vaginal Ultrasound completed: Showed that my uterus was slightly tilted; Right ovary looked great and easy to find; Left ovary difficult and painful to find -Completed HSG and one tube the "spill" was great, the other seemed tangled - due to scarring? endometriosis? something else? -Tried 1 unsuccessful IUI (follicles on the "open" tube seemed good, so IUI seemed like a good option) Now the doctor has two options, and after reading some of what you have written and what he has suggested it seems like Option 1 would be the best choice:

Option 1: Use drugs such as Clomid to increase egg development and use IUI as an intervention to see if that helps. Option 2: Laparoscopy My Dr. things it might be best to do Option 1 which is less invasive and easier. I guess I just worry, will my issues - whatever they may be - make it hard to get pregnant again later? Will they keep me from getting pregnant right now? I'd hate to do a bunch of IUIs and then find out surgery would have helped the whole thing. Three of my friends who have infertility issues all got laparoscopy, and two got pregnant after, one did not and did IVF. Both my husband and I are healthy - it's just such tough decisions. I think we will go with Option 1 but I would love to hear your opinion and other information you could give me that would help me to be better informed going through this difficult process.
Thanks, A

A is a well-informed patient – my model of an expert patient. She has done her homework, and is now on the horns of a dilemma.

 Her question is simple – Should I have a laparoscopy or not ?

This is a deceptively simple question, but there is no easy answer.
Actually, there is no one right answer, because both the answers are correct.
Each has pros and cons, and she needs to think through these rationally, to make the right decision.  However, it’s important she does not  use the experience of her friends  as a guide – every infertile woman, is different, and their case is not the same as hers

Many doctors will advise doing a laparoscopy routinely for all infertile women. They position it as being a simple diagnostic test, with the added advantage that the doctor can “fix” problems if there are any at the same time of the laparoscopy.  They tell the patient that a laparoscopy is the only way of making the diagnosis of subtle diseases such as peritubal adhesions and endometriosis, which is why it’s compulsory to perform this.

It’s fairly easy to convince patients, because the laparoscopy is described as being a “ minimally invasive” surgery . “ No cut or scar – just a bandaid”. It seems temptingly easy to do, and since patients are hungry to find out what the problem is,  many will sign up without even realizing that this is not always a good idea.

While laparoscopy may be “minor” surgery for the doctor , the truth is that for the patient, every surgery is  major ! Also, the focus should never be on finding problems – it should be on finding solutions. While it’s true the doctor may find a few minor lesions , this does not mean that these were the cause of the infertility; or that “treating” them will improve her chances of having a baby ! In fact, sometimes overenthusiastic laparoscopy can end up actually reducing the patient’s fertility. Thus, the doctor may find a small chocolate cyst which is of no clinical importance. However, now that the doctor has a laparoscope in his hand ( and can also charge more for doing an operative intervention, as compared to doing only a diagnostic procedure), he  goes ahead and removes the cyst. The patient  is  also very happy. She feels the doctor was smart, because he has diagnosed the problem, and treated it.

However, 6 months after the laparoscopy, when she fails to get pregnant , she realizes her hopes were misplaced and she is back to square one ! In fact, this surgery may end up reducing her fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing her ovarian reserve.
Most good doctors prefer being conservative. After all, the first rule of medicine is – “ Do No Harm”.  They prefer using non-invasive tests to make a diagnosis, rather than doing a laparoscopy.

The question should NOT be “Why am I not getting pregnant ? “
Rather, it should be – What can I do in order to get pregnant ?”
After all, no one cares about problems – we only care about results – about having a baby !

This is my advise.

The fact that you are not getting pregnant means that the eggs and sperm are not meeting in your fallopian tubes when you are trying naturally.
The next step would be IUI. We prefer HMG/IUI, as this has a higher pregnancy rate than clomid/IUI. If 3 cycles of IUI don’t work, then we suggest IVF.

This “stepped-care” treatment plan does not need a laparoscopy, as the laparoscopy does not affect the treatment options at all.

Finally, patients should remember that while the process is in their control, the outcome is not. The should follow their personal path of least regret, so they have peace of mind they did their best.


Need your query solved ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?






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