IVF/ICSI Success story for a man with globozoospermia

As a referral IVF clinic , we treat many patients who have failed IVF and ICSI cycles in other clinics. Here's a success story from such a couple.

Globozoospermia is a very rare condition , and most IVF clinics in the world will not be able to even properly diagnose this condition, leave alone manage such complex cases. While I am very proud of the fact that we helped our patient to achieve a pregnancy, I am even more proud of the fact that he has become an expert patient, who is very well-informed about his problem ! He now knows more about globozoospermia than most IVF specialists !


Here's his first person account.

We got married in August 2009, and  after marriage we were very happy and enjoying our new phase of life. After one year we thought of next stage of life - parenthood , which is very precious in every couple’s life. But our planning didn’t work. Then we approached the doctor. At that time we were in Kuwait we went to a famous clinic of Kuwait. The doctor suggested for complete diagnosis. The diagnosis resulted in identifying the reason for infertility is due to quality of sperm .However doctor said we can go for IUI treatment , and because of our lack of knowledge about infertility treatment , we underwent 2 cycles of IUI treatment in first half of 2011 with no success.

In June 2011, we shifted to UAE and the first thing we hunted for was the best infertility clinic in UAE .We took all our earlier reports and explained everything about our problem and the treatments that we had undergone previously. Then doctor suggested for a repeat of semen test and the results shocked me . All my previous reports showed semen counts of 30 million and suddenly semen results showed  just 3 million with less than 5% motility with 98% abnormal morphology. He suggested us to go for an ICSI cycle. We went for our first cycle of ICSI in UAE in November 2011. 2 eggs were fertilized .However the doctor mentioned the quality of embryos  was not good and the growth was very slow , possibly because of slow sperms. We waited for 14 days and did the HCG test , but the result was negative. Then we were frustrated and we decided to take a break . I decided to try to improve quality of sperm and went through a nine months  course of homeopathic treatment.

After ten months of treatment we went for a sperm analysis at SRL diagnostics Dubai. The lab analysis showed an improvement in sperm count and motility but reported a new term - 80% Globozoospermia (which means the acrosome or cap on the head of my sperm was missing).

Then one day I searched for the best clinic in India who can give us new hope. We found out about Dr Malpani. We mailed him all the details and the treatments that we have undergone in the last two years. He responded almost immediately to my mail, and I was very happy. Then in my next mail I asked him for an appointment.

We planned for our first cycle of ICSI @ Malpani clinic in October 2012. In our first meeting with Doctor , he asked us what our Plan B was ( if treatment is not successful ).We were surprised and bit confused but later understood the importance of having plan B when he explained this to us. He educated us about our problem. Our ICSI cycle was not successful and none of the eggs got fertilized. Dr called us to the clinic and embryologist showed us the eggs and the video of complete process of ICSI. I was told this is not normal and that globozoospermia was a very rare diagnosis. It was suggested I repeat the semen test with special stains for checking the presence of acrosomes on the sperm @ Dr.Avinash Phalkde, SRL Diagnostics , Shivaji Park. 

I was diagnosed with 98% Globozoospermia. Dr said  I was the first patient he had come across with this diagnosis. He emailed me a few research articles on Globozoospermia and the articles mentioned that lack of acrosome can cause complete fertilization failure after ICSI . There were very few success stories in the world for treatment of globozoospermia. Then we decided to go for plan B (donor sperm) and met Dr in Feb 2013. At this time, Dr explained the option of doing ICSI with about Assisted Oocyte activation using a calcium ionophore . He told us that they would be doing it for the first time in their clinic . We took few days time to make up our mind and then decided to go with the treatment.

We had our 2nd ICSI cycle @ Malpani clinic in March 2013 but this time with AOA with Calcium Ionophore. This time 2 of 8 eggs got fertilized and the quality of embryos was very good. And after 14 days of waiting time it was a great feeling, because  the pregnancy test was positive. We had our first scan  after 7 weeks of pregnancy and we have a bonus because  it is a twin Pregnancy.

All kudos and all credits to Dr Malpani for suggesting AOA with Calcium Ionophore. We thank Dr Malpani from the bottom of our heart.
             

Internet reviews about doctors: threat or opportunity?

This is an article which I wrote for the Indian Journal of Medical Ethics. This was a comment on the paper, Daniel Strech. Ethical principles for physician rating sites. J Med Internet Res. 2011;13(4):e113). doi:10.2196/jmir.1899

For most doctors (though perhaps not for the readers of this journal), the field of medical ethics remains an abstract subject which is of interest only to academics. However, ethics is applied to the resolution of conflicts in real life. This interesting paper uses the timeless principles of medical ethics to help to resolve a very modern conflict: how can we make sure that physician rating sites serve a useful purpose without causing harm?

The introduction of the Internet has already changed the way most of us find information, make phone calls overseas, keep up with the news, stay in contact with our friends, book airline tickets, etc. It has already had a major impact on the doctor-patient relationship in the United States, and it is just a matter of time before it  plays an equally important role in the lives of Indian doctors and patients. While the technology has many benefits, it creates conflicts as well, because it gives patients a much bigger say in their own medical care – a concept most doctors feel threatened by, because it is so unfamiliar and new. One of the controversial areas is the sprouting of physician rating sites, which allow patients to rate, comment on, and discuss doctors' performance online, visible to everyone. This can be a mixed blessing, especially when patients are not happy with their doctors and use these rating sites as a platform to vent their frustrations.

This is a timely paper, because there are now many physician rating sites. Some have been created by private agencies, while others have the blessings of government organisations and health insurance companies. Although these have attracted a lot of attention from patients as well as the popular press, there has been very little discussion about these sites in medical journals, even though they are likely to have a significant impact on the way we practise medicine. While government and health insurance company representatives are vocal in their support for these sites because they believe they encourage transparency, many physician representatives argue against them because they are worried that they could compromise physicians.
This paper purports to have two aims. First, it offers a structural framework which can be used to debate the ethical principles behind these sites, thus providing a useful starting point for further decision-making and discussion: what should physicians and policy decision-makers take into account when discussing the sites and their impact on the doctor-patient relationship?

Because there is very little direct evidence of the harms and benefits of these sites, this paper also discusses how evidence from the related area of public reporting of physician performance can help to guide research in this new field.

The paper uses the three basic ethical principles of patient (and physician) welfare, patient autonomy and social justice.

In theory, the availability of information about the quality and competence of physicians (as assessed subjectively by their patients) can help patients stay away from bad doctors, thus helping them to get better medical care and enhancing patient welfare. The provision of online doctors' report cards encourages transparency of medical performance, and this could also result in greater public trust in the healthcare system.

While discussing the principle of welfare, the authors remind us that we also need to consider the impact of these sites on physicians' well-being. While the majority of reviews of these sites appear to be positive, negative reviews can cause both psychological and financial harm to the doctors concerned.
Physician rating sites also encourage patient autonomy, because they empower patients with information. The authors look at this benefit through the interesting prism of improving the patient's health literacy at three different levels: functional, interactive and critical.

As regards the third principle of social justice, the fact that these sites are online means that only patients with access to the Internet can use these services. This means they can actually worsen the digital divide between the haves and have-nots.

The most interesting question these sites raise is: do they provide reliable and useful information? Or is it possible to game these sites, as a result of which the ratings can no longer be trusted? Can doctors manipulate them by requesting their happy patients to provide positive reviews? Or can disgruntled patients ruin a doctor's online digital reputation by posting negative, biased and dishonest reviews about him/her on multiple sites? How can patients trust the information that these rating sites provide? And what can doctors do when they encounter negative ratings which they feel are unfair and biased?

The most useful nugget of information I found in this paper is tucked away in a table, which describes the five basic conditions which need to be met in order for a physician rating site to be useful. These include: transparency, justification, participation, minimum conflicts of interest, and openness to revision. Most sites have not been able to meet these conditions. Indeed, there is a lot of scope for improvement in how these sites are created and maintained, and paying attention to these basic principles will help to ensure that the next generation of physician rating sites provides value for all stakeholders in the healthcare ecosystem.
I enjoyed reading this paper because it discusses an issue which is very close to my heart. However, I feel the author has done his readers a disservice by unnecessarily complicating the issue. He has used a rather formal, heavy style so that making sense of the article is an uphill task. Just because this article is written for an academic journal does not mean it should be hard to understand. Perhaps the fact that the author is from a non-English speaking country may explain why the language is not lucid.

After reading this article I encourage physician readers to google their own names to see what their patients are saying about them. It is going to be increasingly important for doctors to manage their online digital reputation, because whether we like it or not, our patients are going to talk about us. We must learn what our patients feel about us. Ignorance is not bliss; in fact it can actually be harmful.

Patients have always had opinions about their doctors; after all, this is how a doctor's reputation develops. Traditionally, this was by word of mouth, a slow process, and it could take a doctor a lifetime to build a reputation. Physician rating sites have accelerated this process dramatically.  However, while many patients will swear by their doctor, there will be others who will swear at them.

While it is all very well to take the moral high ground when talking about the right of patients to freely express their opinion about a doctor, I can vouch from personal experience for the fact that negative reviews can raise one's hackles quickly. While some such reviews may be well-deserved, others are unfair because they have obviously been penned by disgruntled patients, venting their bile. Others may even be planted by the competition.

Can we censor these sites? Let us not fool ourselves; the horse has left the stable. It is a fact that we will need to learn to live with patient complaints – including the ones posted online on doctor rating sites, for all to see.

The good news is that these doctor rating sites can actually help doctors to become more patient-centric. Hopefully, we will start treating our patients better, because we know they can harm our reputation by going online and posting negative reviews. Doctors should read the patient feedback stories at doctor rating sites to educate themselves as to what patients want from their doctors. The good news is that what patients want from their physicians is not all that different from what good physicians want to offer their patients. Patients are generally not unreasonable, high-maintenance consumers; they simply want doctors who care, listen, and know what they are doing. By reading the positive ratings, doctors will have role models of good physicians to emulate, and by reading the negative ratings, they will learn what to avoid. Smart people learn from the mistakes of others, and we can learn a lot about what a medical encounter feels like from the patient's perspective by browsing through these websites. They will help us become more empathetic doctors if we are mature enough not to take the negative ratings too personally.

In the big picture, these rating sites are a great opportunity for the medical profession to be open and transparent with patients. Medical associations should set up doctor rating sites to ensure that the basic information which patients need about a doctor (clinic location, credentials, professional qualifications and so on) is available. Also, these sites will be comprehensive because they will provide information on all doctors. If these are seen to be fair and frank, patients will be happy to refer to them as an authoritative source of information on doctors, rather than waste hours scouring dozens of unreliable and incomplete sites. It is also a good way of identifying the bad eggs in our profession, those who end up giving all of us a bad name. Even though we know who these are, we often prefer to participate in a conspiracy of silence and to turn a blind eye to their antics. Rating systems will allow the truth to come out in the open more quickly, helping with self-regulation of the profession.  The Medical Council could take cognisance of repeated complaints about a doctor, and take action to prevent problems from flaring up.

Infertility and Mother's Day

This is a guest post from our expert patient, Manju.

Many infertile women who are struggling to become mothers view Mother’s Day as a curse, because it cruelly reminds them of their inability to become a mother. While the rest of the world celebrates motherhood, they suffer from Mother's day blues.

Just stop and think about this picture - did the lady ever carry a baby in her womb ? No – but even though she never gave birth, she will always be fondly remembered as Mother Teresa. When we think of Mother Teresa, we remember :

her caring ways;
the selfless service she rendered to the poor and needy;
the love and compassion she showered on suffering souls;
the dedication she showed in the work she did;
and
the sacrifices she made did to make this world a better place.

It’s these qualities which prompted people to call her "MOTHER" affectionately , and not the fact that she had undergone the biological process of giving birth !

Mother's day is a celebration of all the sterling qualities that exist in a human being - LOVE, AFFECTION, DEDICATION, SACRIFICE, COMPASSION, and EMPATHY.

Being infertile actually brings out these latent qualities which lie within all us. Can you show me an infertile women who doesn't love children ? Being infertile teaches you empathy – and all of us learn a lot from adversity.

Infertile women are usually much more caring – and can reach out to a fellow soul in pain because they are suffering themselves.  The truth is that carrying a baby for 9 months doesn't make anyone a mother - caring does !

Is there anyone else who knows how precious motherhood is than we do :)

So, my dear friends, have a very Happy Mother's Day ! Every one of us deserves as many Mother's day wishes as any other women !



You can email Manju at manjupadmasekar@yahoo.com

Her blog is at www.myselfishgenes.blogspot.com

Video Guide to PCOS ( Polycystic Ovarian Syndrome)

Reaching out to patients directly

Hospital CEOs are smart and understand that in order to fill their beds and to maximize their revenue, they need to reach out to patients directly. This is after all what marketing, advertising and branding is all about . However, these are expensive propositions – and though these traditional methods have been used for many years , they don't work well for multiple reasons. This is why lots of hospitals incentivize doctors to refer patients to them. This can be in the a form of kickbacks , cuts, “referral fees”, “assistant charges” “ medical consultant fees” or commissions . This works initially,  but is a broken model for multiple reasons .

For one thing the hospital is effectively signing away 10 percent of their profit to the doctor . Even worse, he's not likely to be loyal at all , because if another competing hospital offers 15 percent, the doctor will then start sending his patients to the other hospital !

CEOs realize that they need to establish a direct one-on-one relationship with their patients, rather than go through a middleman. This is a challenge,  and he needs to know how to do this cost effectively. After all , his priorities are to provide high quality medical care , and he has a limited budget . He has to chose how much money to spend on marketing, branding and advertising – and which channels to use . There are multiple opportunities , but because one of them is right under his nose, he often fails to see this !

When a patient is admitted, the focus is on providing good medical care. Unfortunately very little attention is paid to the needs, wants and desires of the people accompanying the patient – the patient's friends, relatives and neighbors who come to visit the patient in hospital . All these visitors are potential future customers and clients , because they're all going to fall sick at some point ! If they have a good experience when they come to the hospital as visitors, this will create a positive experience, so that when they fall sick at some point in the future, they're much more likely to choose this hospital , rather than go somewhere else.

What can the CEO do to make sure that all the visitors have a wow experience , so that they are happy to talk about how great the hospital is ? If we assume that the technical care which is provided by the medical staff is good , then you only need to do so basic simple stuff so that visitors feel like valued guests, rather than as barely tolerated pests !

However, because hospital CEOs are so focused on things like maximizing bed occupancy , keeping their doctors happy, and buying new equipment , that they don’t spend enough time thinking about what they can do to provide a better experience to the visitors who come to his hospital !

Healthwise awards Dr Malpani the Patient Champion Medal

The most neglected person in the hospital

Hospitals are designed for doctors. They have been created so that the doctor can collect all his patients under one roof , and provide medical care to them in a setting which maximizes his productivity and efficiency. They provide the doctor with easy access to medical equipment, labs, technology, consultants , specialists, nurses and assistants. Unfortunately , hospitals are not very friendly places for patients , who will often feel lost and uncomfortable , because they are scary places ! The good news is that a lot of work is being done on improving the patient experience within the hospital. Studies prove that improving patient experiences is good, both for the patient and for the hospital and for the medical staff.

However, even more neglected than the poor patient is the hospital visitor. Most hospital will allow visitors only during specific visiting hours , at which time the hospital overflows because there are so many other visitors who are forced to come to visit the same time. Most visitors are treated as a necessary evil . There are lots of do's and don'ts as to what they are allowed to do and what they are not. They are usually treated as dirt by the staff, which is why most visitors are quite intimidated about going to the hospital.

Actually this is such a huge opportunity which hospital management is neglecting , by not focusing on the needs of the patient’s visitors ! Visitors need to be treated as a valued guest in a hospital setting , because all visitors are going to be potential patients at some point . Hospital visitors are very aware of their own mortality , and are much more likely to be receptive about their health and illness prevention . It always amazes me why hospital managements don't recognize this ; and why they don't spend a little bit of time , energy and effort in making visitors feel welcome. This is an extremely worthwhile investment,  because when these visitors fall ill (as all of us will some day ), they are likely to remember the hospital which treated them with respect and care , and are far more likely to select this hospital for their healthcare needs. Hospitals have a captive population of visitors, but instead of capitalizing on this , they often neglected and ignore – or even worse, ill treat them !. This is a huge opportunity which is waiting to be exploited - and the good news is it's very easy to engage this population. Thus , while they are waiting, they can be given educational materials to read; and patient education videos could provide information about the medical services the hospital provides. Smart hospitals could give all visitors a free health education DVD – or a book on how to take care of common medical problems. This is a great branding exercise – and is a very cost effective way of acquiring new patients for the future !

Can the level of HCG in blood tell me whether my pregnancy is a healthy one or not ?

Yes – but only to a certain extent.  The HCG ( human chorionic gonadotropin) hormone is a remarkable molecule which is very unusual because it is produced only by the cells that will become the placenta of the developing embryo (trophoblast cells). Once the embryo implants in the uterine lining, these cells start producing HCG . It takes a few days for the HCG hormone to build up in the body to a level, which is high enough for it be detected in the blood or urine of pregnant women. Normally, you do your first pregnancy test (HCG blood test) 14 days after embryo transfer.  At this point, if the embryo has implanted, you will also get a positive urine pregnancy test. The HCG hormone level in the blood doubles every 48-72 h. If the HCG level doubles well, this indicates that the cells of the embryo are dividing well , suggesting that the pregnancy is progressing normally and is healthy.  This is why monitoring the HCG blood levels during the first few weeks  helps to make sure that the pregnancy is advancing as expected. A drop in HCG level during this time is a sign that the pregnancy is not healthy.  Make sure that you measure your HCG level in the same lab each time to avoid discrepancy in the results.

However, do remember that because the HCG is produced by the trophoblastic cells of the embryo, just because the level is rising well does not always mean that the pregnancy is healthy. Thus, while a drop in HCG confirms the pregnancy is doomed, a rising HCG level provides limited information.
Also, once the HCG level crosses 1000 mIU/ml, a vaginal ultrasound scan provides much more useful information than just the HCG levels,  because it allows us to actually visualize the development of the growing embryo.

What is a chemical pregnancy ?

Sometimes, the joy of being pregnant can be very short lived. You might get a positive urine pregnancy test, or a positive blood pregnancy test, two weeks after (or even earlier !) your embryo transfer. But, to your agony, the subsequent pregnancy tests you take  might reveal a dropping HCG value ; or your urine pregnancy test may become negative. This is a very hard situation to face because you feel disheartened and cheated. Such a pregnancy, which dissolves quickly, is termed a chemical pregnancy. This means your embryo implanted in your uterine lining , but failed to develop further. This is quite common and occurs because the embryo is not competent enough to grow further. Please do not blame your life-style or other activities for this ! A chemical pregnancy cannot be prevented by any means what so ever - taking extra progesterone,  avoiding certain foods,  avoiding intercourse or taking strict bed rest cannot prevent a chemical pregnancy, so please do not beat up on yourself !



This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.


 You can email Manju at manjupadmasekar@yahoo.com


Her blog is at www.myselfishgenes.blogspot.com

The unhappy hospital CEO

Dr Desai is a bright young hospital CEO . After finishing his M.D. in internal medicine he completed his MBA and now runs a 100 bed multispecialty hospital. The hospital is doing well , but he is unhappy . He knows that his hospital has excellent equipment and that his doctors are very skilled and competent. However, he is concerned that his bed occupancy is still low. He wonders what he is doing wrong and why more patients don’t come to his hospital.

One major problem is the competition. Most patients prefer going to the big brand-name hospitals such as Apollo and Fortis, because they have much larger marketing budgets , and can spend much more on advertising and creating brand-name recognition. This is why it’s easier for them to attract patients – and there’s no way he can spend so much money on advertising !

What can he do to make sure that patients will come to his hospital, rather than go somewhere else ? He knows that even though his hospital is smaller, the quality of clinical care is actually much better , because it's much more like a focused factory . They only do certain procedures , but they do these extremely well , which means they can provide high quality services much more cost effectively than the larger hospitals.

Thus, his hospital does not offer expensive and esoteric treatment options such as transplantation. Now while transplantation programs attract a lot of headlines and seem to offer cutting-edge medicine , in reality they impact only a very small proportion of patients However , to run a transplant program requires a lot of infrastructure and expenditure , and because the large brand name hospitals are so focused on promoting these high profile specialty departments , they spend a disproportionate amount of money on these , as a result of which their other more basic departments ( such as general surgery and obstetrics ) will often get second-class treatment.

This means that these departments, which provide  the bulk of the common medical care which most patients require , end up being treated with much less loving care then the high-profile departments . Even worse, they often over-charge, because they need to subsidise the glamorous high-tech departments such as robotic surgery or transplantation surgery.

The CEOs’ problem is – how can I explain these facts to potential patients ? How do I show them that even though our hospital is not so large , we are much better at taking care if them because we don’t have all the fancy bells and whistles. This is quite a challenge , and something which he's been grappling with.

How can he reach out to patients directly ? The traditional route was to go through their family physician, who was often the point of first contact when patients fell ill. In the past, patients would trust their family doctor to guide them and select the right specialist and the best hospital or them. However, times have changed – and many patients don’t even have a family physician any more !

The answer is simple – go to where the patients are – and all patients are online now ! They are hungry for information and will spend lots of time in trying to understand their disease; research their treatment options; and get a second opinion. The good news is that if he focuses on addressing their needs, he can capture a large proportion of these affluential patients.

Dr Desai is confused. Our hospital already has a website , which means it’s easy for patients to find us. What else should we be doing ?

This is part of the problem. While it’s true that Dr Desai’s hospital does have a website, it gets very little traffic, because the website just talks about the hospital and the services it offers. It offers very little information on what the patient is interested in -  his symptoms; or his disease ! However ,writing high quality medical content specifically for patients can be a very difficult and time consuming to create.


The good news is that he can now instantly license over 30000 pages of reliable updated trustworthy patient education content from the world leader in patient education, Healthwise Knowledgebase !  After seeing the demo at www.healthlibrary.com/healthwise.php, Dr Desai is convinced that this is a very cost effective investment, which will help him:

Engage  with online patients
Encourage them to call his hospital as the provider of first choice
Build trust
Increase patient satisfaction
Build loyalty and stickiness