Sunday, February 28, 2010

Misusing technology in an IVF clinic - high tech mumbo jumbo and hocus pocus


My blood often boils when I see how technology is misused in many leading IVF clinics. It's a long list - and the variety is mind-boggling !

Reproductive Immunology tests include tests for NK cells and other complex and expensive tests, which are difficult to standardise and impossible to interpret - but very profitable to order ! Many doctors will send the samples to labs in the US, to ensure the results are "reliable" ! This just adds to the cost - and the mystique !

PCR tests for TB. Going by the large number of positive PCR tests for endometrial TB ( ordered by gynecologists) I see daily, there must be a virtual epidemic of genital TB in India ! These tests are all rubbish - but continue to be ordered . A positive result often means the patient has to endure 9 months of toxic antiTB chemotherapy for no rhyme a reason. Often this is such a traumatic experience, that most patients just decide never to have a baby at all !

Sperm DNA fragmentation tests. This is one of those tests which no one can make sense of. They are fun to order and expensive to perform - but give little useful information for the individual patient. Many fertile men also have high abnormal sperm DNA fragmentation levels !

Using FISH to check the sperm DNA . This is a test of no clinical utility - but will be used to convince patients that their sperm are "genetically abnormal" !

Karyotype for chromosomal studies. Minor anatomic variants ( such as an elongated arm on a chromosome) are often "blamed" for reproductive losses and IVF failures and patients are pushed to using donor eggs or doing PGD based on these "abnormalities" !

PGD is used to test embryos which have arrested in the IVF lab. We already know that even normal fertile women will have many genetically abnormal eggs which create genetically abnormal embryos. These are common and are often because of random genetic segregation . By doing the PGD,the doctor can charge a bomb for the test - and then explain to the patient that the reason they are not getting pregnant is because their embryos are genetically abnormal !

Based on the " abnormal results" of all these genetic tests, the doctor can than show the patient that the reason for the IVF failure is a genetic problem in the patient - and that they need donor egg treatment - which becomes even more expensive ( and much more profitable for the doctor !)

While some of these tests are fine as research tools , it's not acceptable to use these for clinical practise. Then why do some doctors use them routinely ?

Doctors often do this to generate revenue - the more the tests they order, the more they earn ! However, there are other reasons as well !

Infertility specialists are often highly competitive- and some of them play games to score points over the "competition" ! Often these tests are used to impress clueless patients as to how thorough and complete their clinic's evaluation is - and how much smarter and better equipped they are than the earlier IVF clinic the patient went
to , which did not bother to order these tests . Most patients are awed by medical technology which they do not understand, and many feel that more tests = more care = better care. In reality, more tests = more expense = more confusion !

Also, doing these esoteric ( and very expensive !) tests helps to put patients in their place . Instead of being honest with the patient and telling them that we often do not know precisely why they are infertile or why their IVF cycles fail, these tests allow the doctor to put on an aura of omniscience, and by using medical jargon and scientific mumbo-jumbo, re-emphasise the fact that the IVF doctor is the real expert and the patient needs to just leave everything in his expert hands !



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Saturday, February 27, 2010

I am sorry - your HCG level is negative


These are the words every IVF doctor dreads having to tell their patient - and which every patient fears having to hear. There is so much hope, energy,time and money invested in an IVF cycle that when it fails, patients go to pieces. No matter how well you may have prepared yourself intellectually for the fact that not every IVF cycle succeeds, the news that this one has failed is still a major emotional blow, and it takes time to recover. The failure is often taken as a personal failure - and often reinforces the feelings of low self-esteem and inferiority which many infertile women suffer from.

" I cannot get pregnant in my bedroom - and couldn't even get pregnant after IVF. My body is flawed and useless. I let everyone down - my husband, my doctor and my family. I am a failure. I'll never ever become a mother ! What did I do wrong ? "

The first question often is - Is the test result reliable ? Maybe the lab goofed and mixed up my sample ? Coming to terms with the reality of failure is very difficult ! However heart wrenching this maybe, it's best to accept the truth, so you can deal with is. After all, every problem has a solution.

For many patients, the biggest problem is - How do I break the news to my partner ? This can be very difficult and it's very painful to watch your loved one break down. It's hard to provide a shoulder to cry on when you are breaking on the inside as well !

Some common questions are:

What happened to my embryos ?

When the embryo fails to implant, the cells in the embryo die because they no longer get any nourishment. These dead cells are then reabsorbed in the body. This is a silent process, with no symptoms or signs. We cannot determine why the embryos did not implant as we do not have the tools to monitor this intricate and complex biological process.

But I still haven't got my periods ? Doesn't this mean I am pregnant ?

The reason the period is often delayed is because of the luteal phse support provided by the estrogens and progesterone the doctor prescribes. The period will start once the meds are stopped.

Did I do something wrong which cause my IVF cycle to fail ?

No. This is a biological process which we cannot monitor or control

Did the doctor do something wrong ?

No. Most IVF cycles fail, and this is the sad reality we need to deal with today. The technology is not perfect.

Will I need a D&C ?

No, a failed IVF cycle is not a miscarriage. The embryos are microscopic and the utrine lining will shed on its own once the luteal phase support is stopped.

There's always a lot of recrimination and soul-searching , but most of this is misplaced. Most IVF cycles fail not because of anything you did or did not do, but because human reproduction has always been inefficient right since it first evolved.

You need to let yourself grieve - but you also need to learn to look forward ! What did we learn from this cycle ? What went right ? What went wrong ? Do we need to do anything differently the next time ? The failure of one IVF cycle is not the end of the world - and you need to bounce back and move on to Plan B !

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Friday, February 26, 2010

Myths and misconceptions about infertility - clearing the air

Congrats ! Your beta HCG is positive !


These are the words every patient wants to hear after the 2 week wait - the magic words which make the stress and the suspense of the IVF cycle all worthwhile. These are the words every doctor would like to tell every patient after each IVF cycle , so they can share the long-awaited joy with their patients !

A positive HCG is great news - and a major landmark in the IVF cycle - but while it marks the end of one journey, it also signals the start of a new one. Remember, a positive HCG just means that the embryo has implanted - and you want a baby - something which is still 36 weeks away.

There are still many hurdles to be crossed and most of these are problems which crop up in the first 4 weeks. Is the pregnancy healthy ? Is it in the uterus or the tubes ? How many are there ? Many questions - most of which can only be answered as time goes by. Most IVF pregnancies are closely monitored with HCG levels done every 3 days; and ultrasound scanning from 6 weeks onwards - not because an IVF pregnancy is at high risk for a problem, but because these are precious pregnancies, and patients need a lot of hand-holding and reassurance.

What can I eat ? Can I go to work ? Can I have sex ? Should I curtail my activities ? Every minor spotting or blood stained discharge results in panic - and distress calls to the doctor. Am I miscarrying ? Did I do something wrong ? Is everything going to be OK ?

We know that of all pregnancies - whether these are IVF or natural conceptions, 10% are destined to end in a miscarriage. Human reproduction is an inefficient enterprise, and IVF does not change this sobering fact. Of course, when a problem occurs in an IVF pregnancy, patients often blame the IVF treatment - and even the doctor, but this is unfair.

If you have a positive HCG result, pat yourself on your back ( and your doctor too !) and enjoy the fact that you are pregnant. You now have to start the process of preparing yourself for a baby !

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Thursday, February 25, 2010

Does stress affect the outcome of an IVF cycle ?


When an IVF cycle fails, often the patient's world falls apart. Everyone does a post-mortem including the couple, the doctor and the rest of the world ! Why did it fail ? Why did the uterus reject the embryo ? Did we do anything wrong to cause the embryo to fall out ? What can we do differently the next time ? Are we destined to fail every time ?

In the desperate search for answers, many doctors will play the game of blaming the victim. Rather than be honest and tell the patient the plain truth that we really have no way of determining why an IVF cycle fails, they will tell the patient that the cycle failed because she did not rest enough, or because she was too stressed out !

This is very unfair - and blatantly false ! Stress has very little to do with the outcome of an IVF cycle. Implantation is a biological process which is not influenced by the state of mind . After all, even rape victims do get pregnant !

I agree that it's best for IVF patients to have a positive approach. It's much better for the doctor, for example , because I'd much rather treat patients who are smiling ! However, by telling the patient to "relax" or "not take stress", I think we sometimes do them a disservice. If the message is that a positive attitude increases IVF success rates, the hidden sub-text is - the IVF cycle failed because you were too negative or too stressed out ! This is adding insult to injury !

Programs like the Mind-Body program and books like The Secret are useful - but only upto a limit. We all need a more balanced approach. Many smart patients prefer being pessimistic and keeping their expectations low, because they find it easier to handle failure using this tactic. If we blame their failure on their " negative " state of mind, they just end up feeling even worse and thinking of themselves as losers.

I know this is a chicken and egg problem. Optimistic patients who success will broadcast their success to the entire world - and many will attribute their success to their positive attitude. They will then advise other patients to adopt the same attitude as well, if they want to succeed ! However, the truth is that pessimistic and negative patients have successful IVF cycles too - they just don't talk about them as much !

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The elephant in the room for infertile couples

Clinic Painter (eponymous vase)Image via Wikipedia

When infertile couples come to me for treatment, I usually tell them they have 3 options:
to live childfree;
to adopt a baby; or
to pursue medical treatment.

Actually, there is one more option, which most doctors will not discuss, but which most infertile couples think of - often unconsciously. This is the option of getting married again or finding another partner - a real-life option which some people will pursue, but few will discuss, which makes it the elephant in the room for many couples.

Having a baby has been extremely important through the ages and before the advent of effective medical treatment, societies would resort to alternative non-medical options in order to keep the family unit intact.

Even today, many Indian villagers will resort to these alternative options, especially in extended traditional families which frown on taking medical treatment for infertility, which is often seen to be a punishment from God. This is also an acceptable option amongst Muslims, who are legally allowed to have more than one wife.

Many wives are scared that their spouse will remarry if they cannot get pregnant - and this is a very common worry in Africa as well. However, most couples are reluctant to discuss this openly, which means the fear remains suppressed.


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Wednesday, February 24, 2010

Why is my husband refusing to get his semen tested ?


A common problem many women face is that while they are willing to go to the doctor to get her testing done, her husband often refuses to get his semen tested. In most cultures, having a baby is the "woman's job" which is why women take the initiative when they are having difficulty falling pregnant. Biologically as well, while women can hear their biological clock ticking away, most men are blissfully unaware of this fact. They are quite happy to let Nature take its own course and are reluctant to meddle or interfere. It's much more fun to make a baby in the bedroom, so why do we need a doctor's help ? And sometimes the fact that they may need medical assistance is a threat to their ego. Since all their friends have managed to get their wife pregnant without any outside assistance, they feel it is demeaning to ask for help in this department. Isn't sex a simple biological function they perform so well on their own ? Since their sexual performance leaves nothing to be desired, doesn't this automatically mean that their sperm must be excellent too ? Why do they need a stupid lab test to prove this fact when they are so obviously virile ?

The truth is that while most men enjoy playing with technology, the one kind of technology they are uncomfortable with is reproductive technology because they understand so little about the woman's body. They are scared of hormones and shots - and are worried about the effect these will have on their wife. ( All men dread the PMS, and since they know that PMS is caused by female hormones, this means that hormones are bad for their personal well-being, and are best avoided as far as possible !) Also, some do not want to put their wife through the pain and discomfort of an IVF cycle just to have a baby, because this is not something which is high on their priority list.

Finally, a major reason why many men do not get their sperm tested is the fact that they are afraid. Suppose there is a problem with my sperm ? Suppose my sperm count is zero ? Suppose I am shooting blanks ? Then what ? Most men have a very fragile ego and they do not want to risk harming this !

Wives need to learn to be empathetic. Please understand that when your husband refuses to get his semen tested, it is not because he is being difficult or ornery. He may be just plain scared and maybe he is too afraid to admit his fear to you ! Reassure him that you love him for more than his sperm - and that together, will be able to find a solution to the problem , even if it does need some medical intervention !


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Sunday, February 21, 2010

The sperm or the egg ?

Oogamy in animals: small, motile sperm on the ...Image via Wikipedia

One of the biggest problems in an IVF clinic is the patient with poor quality embryos. The question we then need to answer is - are the poor quality embryos because of a sperm problem ? or an egg problem ?

In a mouse lab , it would be very easy to answer whether the problem is with the egg or the sperm scientifically ! We would do crossover testing, using donor egg plus husband's sperm versus donor sperm plus wife's eggs in the same incubator. This would allow us to pinpoint what the problem is easily. Unfortunately, it's not practical to do this in a human IVF clinic !

Step number one should be to rule out a lab problem first ! Are the other patients' embryos of good quality ? Or are everyone's embryos fragmenting ? This suggests a lab problem - for example, because of a bad batch of IVF culture medium. While this phenomenon has been well documented, it is very hard for patients to get accurate information about this because labs are very unlikely to accept the fact that they have had a global problem. Unfortunately, this is often something which is still covered up.

If a lab problem has been ironed out, then we need to drill a little deeper. If IVF has been done, and the problem is total failure of fertilisation, then this usually means this is because of a sperm problem - the sperm are functionally incompetent and are not capable of fertilising the eggs. Sadly, it is often not possible to identify this problem prior to treatment and the only reliable ( and admittedly very expensive !) way to make the diagnosis of sperm dysfunction is by doing an IVF treatment cycle. The good news is that it can be corrected by doing ICSI in the next treatment cycle.

What happens if there is a low fertilisation rate after ICSI ? We need to analyse the problem closely. Have a lot of the eggs been damaged or killed ? If so, then this suggests a technical problem, either because of embryologist inexpertise or micromanipulator technical malfunction. However , if the embryologist is an expert, and the eggs have not been damaged because of technical issues, then poor fertilisation after ICSI usually suggests an egg problem. This is because once the sperm have been delivered into the egg with ICSI, their job is mostly done. It is the egg which is then responsible for the rest of the dramatic events which unfold. This is because it is the egg cytoplasm which contains the mitochondria , the energy powerhouse of the cell, which are responsible for powering the process of fertilisation.

What about problems on Day 2 ? Embryo problems at this stage could present in one of two ways.
1. Poor quality ( low grade) embryos , with lots of fragmentation
2. Embryos which have arrested ( failed to develop beyond a particular stage).
Often both these problems will go hand in hand.

In these cases as well , the problem is usually an egg problem because it is the mitochondria which provide the energy needed for cleavage. Unfortunately, there is no test available for this; and this could happen in young patients , with normal ovarian reserve and normal FSH, AMH levels and normal antral follicle counts. This is because the clinical tests for ovarian reserve only estimate egg quality and quantity and cannot allow us to assess mitochondrial function in the eggs.

This means that if we start with good looking eggs and end up with poor quality embryos, the problem is either in the lab; or with the eggs. Often the diagnosis is one of exclusion. Does the problem recur in another cycle ? Does the problem recur in another lab ? If so, then we can confidently say we are dealing with an egg problem - though we can never prove this.

What is a practical plan of action for these heart-sink patients ? The next step is to repeat the IVF cycle with a more aggressive superovulation protocol. If the problem persists, then it's a good idea to try another IVF lab. If the problem recurs, then the best option is to consider using donor eggs.

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Saturday, February 20, 2010

How can I reduce my FSH levels ?

Human oocyte with surrounding granulosa cells,...Image via Wikipedia

One of the key factors which influences the outcome of an IVF cycle is the number of eggs the wife grows. This depends upon her ovarian reserve and this is a key metric which IVF doctors need to track.

We can measure the ovarian reserve using three tools:
• the antral follicle count;
• the AMH level ; and
• the FSH level.

Of these, the FSH level has been the blood test which has been around for the longest and is the one most infertile women are familiar with. It often becomes a number which many women start obsessing over, just like infertile men obsess over their sperm counts. This is especially true for older women, who know that the success of their IVF cycle is often dependent upon this.

It’s important to remember that the FSH level is just a marker for ovarian reserve. This means that the high FSH level is not the problem – it simply signals the fact that you have poor ovarian reserve. In fact, it’s very easy to reduce the FSH level – just take estrogen medications , and it will go down to normal in one week. This because estrogens suppress the high FSH level ( in a mechanism called negative feedback), and bring it back to the normal range. However, using estrogens to bring the high FSH level to the normal range obviously does not improve the ovarian reserve. We know that women are born with a certain number of eggs , and this ovarian reserve gets depleted as time passes, until it reaches zero, at the menopause.

So what can you do to reduce your high FSH level ? Women are often confused because they often get conflicting information from IVF specialists. Most will say that a high FSH is not treatable and will recommend the use of donor eggs straight away. Others will recommend alternative medicines such as acupuncture and DHEA to try to improve the ovarian reserve. To add to the confusion, there are lots of anecdotal success stories and first person accounts on bulletin boards all over the internet of women who have brought down their high FSH levels using diet and detoxification . A good website which compiles a lot of this information is highfshinfo.com. Unfortunately, one swallow does not make a summer – and lots of time there’s precious little we can do to affect ovarian reserve.

The major danger is the large number of websites which sell herbal medications and magic potions which claim to reduce the FSH level. Examples include Fertility Blend. They make a lot of unsubstantiated tall claims, but because they are very cleverly marketed, they find it easy to dupe thousands of desperate women who are very unhappy with their doctors who cannot help them.

It is true that FSH levels do vary from cycle to cycle, and this makes it even harder for women, because they simply cannot make sense of what causes it go down in one month and then increase in another.

So how can you make sense of your FSH levels ?

Firstly, understand that this is just one imperfect marker of ovarian reserve – and that doctors do not treat numbers, but patients.

Also, understand the inverse relationship between estradiol levels and FSH levels. It’s a good idea to check both at the same time, whenever you test your FSH level

Finally, remember that there are now better tests for checking ovarian reserve, such as AMH ( antiMullerian hormone) levels, which can be used to confirm a diagnosis of poor ovarian reserve.






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Friday, February 19, 2010

Website for Doctors is finally live and kicking


Website for Doctors is finally live and kicking. We have setup websites for ten doctors within the first month of going live, which means the idea behind the venture is a solid one. Doctors have a business to run and need to provide high quality information to their patients to give high quality service. A website is a great medium to communicate with patients – and has now become a key tool for every doctor in private practice.

Why does Website for Doctors appeal to the doctors who are signing up? Because we are a specialized service, like a highly specialized clinic, serving only doctors. Since we focus on dealing only with doctors, we understand their needs and wants , so we can deliver what is best for them.

Every website we have done has gone live online within 48 hours of the doctor providing us with the required information. What’s more important is that after the doctor takes the first step of choosing a template and sending us his basic data, we can send him his personalized dummy site by the next day. Seeing it live and understanding that his clinic is now live on the web enthuses doctors to ask for more ! Seeing is believing !

What allows us to bond with doctors and give them the solutions which they need ?

- our specialization based galleries;
- our dedicated team ; and
- our medical domain expertise, because of the knowledge we have acquired as a result of developing our EMR products .

The websites we create can be tweaked and the content modified to give the doctor’s patients exactly what they need from the doctor's website. A superspecialist consultant can get exposure to international patients; while a small city specialist can get publicity and provide directions to his clinic.

There is still long way to go in actually making Websites for Doctors from a doctor’s “want” to a “need”, but the process has begun ! Apart from the basic features of a website, there are some simple tools which can go a long way to improve your website experience for your patients. Our aim at Website For Doctors is to recommend these tools , such as health calculators, video galleries, online patient history forms ; customized ask the doctor queries; and google maps which provide directions to the clinic.

You can check out some of our work at www.websitefordoctors.in. Some of our client sites include: www.ashutoshchaudhari.com, www.swatiallahbadia.com, www.charakchildcare.com .

All these websites were ready in double quick time and to the satisfaction of these doctors. Even today we provide suggestions and accept them to tweak them to make them better. As Mercedes says “the road to perfection has no finish line” but it definitely gives us , and the doctors who have decided to take this journey along with us , a goal for the future!

Aditya Patkar, Marketing Director, Plus91




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Thursday, February 18, 2010

What precautions do I need to take after an embryo transfer ?

8 cell stage, prior to morula formationImage via Wikipedia

Most patients are very excited when they reach the stage of embryo transfer. This is a major milestone in their IVF treatment, and the fact that they have made embryos provides them with a lot of hope that their chances of having a baby are high. After all, this proves that their sperm and eggs work properly and that the doctor is doing a good job ! Now all the embryo has to do is to stick - and shouldn't that be automatic ? After all, it is a natural process which happens all the time !

Unfortunately, the sad truth is that not every embryo become a baby. Human reproduction is not an efficient enterprise - whether it is in vivo or in vitro !

Many patients are petrified that they will do something wrong which will cause their embryo to "fall out " ! They worry about what precautions they need to take - and even if they don't, lots of their friend, relatives and well-wishers will have lots of well-meaning ( but completely wrong !) advise about what they need to do !

What can I eat , doctor ? Are any foods too hot ? or cold ? Can I have a hot water bath ? a shower ? a swim ? sex ? Will the embryo fall out if I go through a pot hole ? Can I take a pain killer if I have a headache ? Can I dye my hair ?

Remember that the embryo transfer procedure is a short 30 second procedure in which the doctor mechanically pushes the embryos into the uterus with the help of a fine plastic catheter. However , implantation is a biological process which we cannot control. Just because we have transferred the embryo artificially into the uterus does not influence implantation – this is a natural process which occurs as it normally would !

After all, what special care do women take after having sex in their bedroom ? The embryo does not care whether it reached the uterus after normal sex - or after spending 3 days in the IVF lab incubator ! There's no need to change your normal lifestyle just because you've had an embryo transfer !


Unfortunately, when the embryos do not implant, patients blame themselves unnecessarily for this failure. And there are lots of nosey-parkers who will claim that the cycle failed because the patient did not take "strict bed rest" after the transfer !

The fact is that no special precautions are needed after the embryo transfer - the human body has been designed with enough sense that the embryos are safe and secure in the uterus. All you need to do is to use your common sense - and not do anything which you will regret later on !

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Wednesday, February 17, 2010

Free Cartoon for infertile couples - What to expect when you aren't quite expecting



You can download this free at http://drop.io/infertilitycartoon !

What patients dislike about IVF doctors

One of the commonest complaints patients have about their IVF treatment is how secretive most IVF clinics are about the treatment. Many doctors deliberately obfuscate and do not provide any clarity regarding the plan of action. Everything seems to be done on an ad-hoc day to day basis, so the patient is often completely clueless about what is going to happen next.

It's often hard to talk to the doctor ( who is very busy) , which means most decisions seem to be taken either by the nurses or the assistants. Even basic information ( how many follicles are growing on the ultrasound scan ? how many eggs were retrieved during the egg collection ?) is not provided - and the commonest answer the sonographer or assistant provides is - the doctor will explain to you ( but the doctor is never available ! )

Even after the treatment is over, patients are not given a printed treatment summary. No photos of embryos are provided, which means most patients are completely in the dark about the fate of their eggs and embryos - and what went right and what went wrong.

It's high time IVF patients started insisting on clear documentation ! It's best to do this before the cycle starts ( before you part with your money !)

Why embryo adoption is more useful than surrogacy

There is still a lot of confusion amongst patients about the difference between embryo adoption and surrogacy.

Surrogacy gets a lot more media coverage, but in reality, it is applicable for a much smaller group of patients . This is because surrogacy is best reserved for women with no uterus ; or those with an irreparably damaged uterus. Unfortunately, it is often misused and overused for patients with : multiple failed IVF cycles; recurrent miscarriages; older women. Actually, none of these patients need surrogacy at all.

Let me explain.

The commonest reason for IVF failure is failed embryo implantation. This means most women who fail an IVF cycle will produce beautiful embryos, but these will not implant, even though the embryos are good quality ; the uterine lining is thick and trilaminar; and the embryo transfer was easy.

Why healthy good looking embryos do not implant is still one of those things we do not control
However, we do know that the vast majority of the time this is because of an intrinsic genetic defect in the embryos which we cannot detect because our technology is not yet good enough. Similarly, the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for.

However, when an infertile woman fails an IVF cycle or has a miscarriage, she usually "blames" her uterus . Infertile women have low self-esteem - and when the cycle fails, they feel it is their body which is flawed and defective. This is why they believe that using a healthy woman's uterus will help them to have a baby. However, this is flawed reasoning. If your uterus is healthy, then using a surrogate's uterus will not help at all ! Not only is doing surrogacy illogical, it's also much more expensive and complex because of the numerous ethical and legal challenges surrogacy creates. Unfortunately, few doctors bother to explain these facts, simply because surrogacy is so much more profitable for them to offer , as compared to enbryo adoption !

From a medical point of view, embryo adoption is a much better solution for most of these patients which a much higher success rate. After all, if the problem is with the embryo ( even though we cannot detect it), then it makes much more sense to replace the embryo , rather than the uterus.

Of course, just because solution is logical does not mean it is easy to accept. Most people are very strongly attached to their genes, and want to be able to hand these over to their offspring ! This is the major problem with embryo adoption for many couples - it is difficult for them to accept that their child will not have their genes. This comes down to the Nature versus Nurture argument - and what is more important in being a parent - biology or love ? Embryo adoption is not the right solution for everyone, but it's a very good option for couples who are comfortable with the idea of adopting a child they can bring up as their own.

Monday, February 15, 2010

Problem of Recurrent miscarriage - a couple from Bangalore / USA

My wife had 4 recurrent miscarriages with ultrasound scanning showing a fetal pole & no heart beat. We met Dr. Malpani on May 3rd 2008 personally in his clinic after contacting him through emails. Dr. Malpani diagnosed it as an occult PCOD and suggested the following empirical treatment for 4-5 months and recommended we try naturally , since there was no issue with conceiving.

Please take the following.
Tab ASA-50mg 1 tablet daily
Tab Folvite (5mg) 1 tablet daily
Tab Glyciphage (500 mg) 3 tab daily


In fact, Dr.Malpani suggested the same treatment in his email also (free second opinion service) and he re-iterated the same while we met him in person. We just followed above empirical treatment and got the success through natural intercourse. Dr. Malpani has been so kind to guide us through emails giving reassurance after conceiving naturally asking my wife to continue the above empirical treatment along with 600 mg vaginal progesterone suppositories daily till 20 weeks.

The above success story really shows the expertise and kind hearted nature in this commercial world of a doctor who gave suggestions through emails. I would like to recommend Dr.Malpani for any of your obstacles in having a baby. Both these doctors are GOD sent and excellent, there is no match for the kind of quality service that they provide.

Murthy

Sunday, February 14, 2010

Egg banking - Hindustan Times article

Personal Medicine International - Discover a better solution

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Recent studies have confirmed what you already know – that due to declining reimbursements and rising malpractice premiums, incomes have fallen over the past decade. As a result, most primary care practitioners feel they have no choice but to cut appointment times and increase the volume of patients – sometimes up to as many as 40 per day.

“The great danger is that you stop caring. The goal of each day and each night is simply to move everyone through, to clear the decks, rather than to deliberately and expertly care for those who need it and reassure those who do not.” – Victoria Rogers McEvoy, MD, from How Doctors Think


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The Personal Medicine Team is co-founded by Pediatrician Natalie Hodge, MD, a mother of 3 who spent a decade running on the treadmill of a high-volume pediatric practice.

Extensive research led Dr. Hodge to a clear conviction: That combining the traditional benefits of house call medicine with the advantages of state-of-the-art technology in a direct medical practice model would result in a dramatic improvement in healthcare – and in the professional satisfaction of primary care physicians.

Today, Personal Medicine is proud to provide an innovative platform that makes house call-based medicine an excellent supplement or alternative to your office-based practice. Whether you are contemplating implementing concierge practice or researching your practice alternatives, the Personal Medicine solution will help you transition away from your dependency on third party payors and take control of your life!"

Saturday, February 13, 2010

Common mistakes IVF doctors make

I often see patients who have done IVF treatment at other clinics and sometimes I cringe when I see how poor the quality of the care provided was.

Here's a list of the common mistakes IVF doctors make.

1. Inadequate counselling. This is a very common problem. Because doctors seem to be so anxious to "grab" the patient and start an IVF treatment cycle ( before she runs off to some other clinic), many will advise a series of tests and commence treatment straight away. Most IVF clinics take pride in how many IVF treatment cycles they perform - irrespective of whether the couple needs it or not - and they want to maximise this number to maximise their income. This seems to give them bragging rights - see how many cycles I do and how much money I earn ! From a patient's point of view as well , the busier the clinic , the better it must be ! ( Actually, this is not true. There is an optimal number for every clinic, which is a function of how many doctors and embryologists they have on staff). Each patient is a potential source of income - and even if an alternative treatment might be a better option, they rarely bother to discuss these. Also, there is often no plan of action , and treatment is provided on an ad hoc basis, which means patients often don't know what to expect - and what to do if the cycle fails !

2. Overpromising. This is very common. Even brand new clinics which have never been able to achieve a single IVF pregnancy will claim success rates of 40% per cycle. They can get away with these tall claims, because there's no way of being able to verify them - or disproving them !

3. Being unavailable. Some doctors are so busy ( doing a humongous number of IVF cycles or running around from clinic to clinic or even town to town, to maximise their income), that they are just not available to answer the patient's questions. In fact, many couples complain that the only time they saw "their doctor" was at the time of the consultation. After this, everything is done by assistants , nurses or technicians - the doctor is "too busy" to be able to see you, sorry !

4. No customisation of the treatment plan. Many doctors blindly use a "one size fits all" treatment protocol. They make no attempt to tailor this to the individual patient's clinical needs - which means many cycles are cancelled either because of the risk of hyperstimulation ( too much stimulation) ; or because of a poor ovarian response ( too little stimulation) . These clinics use a standard cookbook approach which works well for about 80% of patients - but is of little use to the challenging or difficult patient ( older patients; patients with poor ovarian reserve;PCOD patients; and those who have failed IVF cycles earlier).

5. No documentation. This is a huge problem. No effort is made to document either the treatment given, or the patient's response. There are no ultrasound scans of follicles grown; or photos of the embryos in the lab. While this maybe because of outdated technology in some clinics, in many it's simply that the clinic refuses to provide this documentation to the patient. Many clinics keep all the records themselves - and refuse to even provide copies to the poor patient , who is left completely in the dark !

6. Not enough expertise in treating the infertile man. This is a very common failing in many IVF clinics. Since most IVF clinics are run by gynecologists, many do not do a good job of treating male infertility. They often refer the man to a urologist, which means that the right hand often has no clue what the left hand is doing. To make matters worse, they are often not set up to provide surgical retrieval of fresh testicular or epididymal sperm - causing a dramatic drop in pregnancy rates.

7. Many IVF clinics are not full service. For example, many do not have either the technology or the expertise to be able to freeze and store supernumerary embryos. While they may claim to do so, many still have terrible survival rates after thawing the frozen embryos - information they often hide from the patient.

8. Using outdated technology. Many IVF clinics do not bother to upgrade their equipment or their skills, which means they are not able to offer the newest advances, such as vitrification for egg freezing; or blastocyst transfer. If a pointed question is asked, they claim to offer these - even when they are not able to do so , simply because they know they can get away with lying !

9. Depending upon an "outside" expert to do the IVF. Many IVF clinics depend upon the expertise of a traveling IVF specialist or a visiting IVF embryologist. This means that the treatment is provided only in batches - and if you have the temerity to grow eggs too slowly or too quickly, your treatment will suffer, because the egg pickup has to be timed for a single day only !

If you feel your doctor is making any of these errors, you should look for a second opinion ! Don't take chances with your treatment - why should you suffer because of your doctor's mistakes ?

Free websites for Indian doctors

The first website sponsored by HELP for an Indian doctor is now live ! Check this out at
www.drvijaykulkarni.com !

There are now millions of Indian patients online, looking for medical information . Unfortunately, most of what they find comes from places like mayoclinic.com . We need Indian doctors to establish their own web presence, so that information about Indian healthcare services is easy to find.

We hope these grants will help Indian doctors to showcase their talent, and help grow their practice ethically. This will help patients as well , who will become aware of what medical facilities are available in India. The transparency which the web imposes will help to improve the doctor-patient relationship, by allowing much more open communication between doctor and patient, and cutting out the middleman. Interacting with patients online will help doctors to become more patient-centric and empathetic.

Information Therapy - the right information at the right time for the right person - can be powerful medicine ! Ideally, every doctor and clinic should have an online patient education resource center, where people can find information on their health problem . This will create a positive virtuous cycle.

We feel we can leverage Indian IT skills and Indian medical expertise. This combination can allow India to become a global medical powerhouse and promote medical tourism.

Plus91 , a healthcare technology company at www.plus91.in, normally charges Rs 5995 for a professional website. HELP will offer this website free for the first hundred doctors who apply.

Please email me at malpani@vsnl.com and explain why you feel you should be awarded this free website. Include your resume; what your present online activities are; details of your publications; how you expect to grow your website. I will shortlist 100 doctors and Plus91 will get in touch with you so they can publish your website. Doctors who are specialists; have an academic interest; and practice in cities will be given first preference.

Plus91 will provide all the technological support needed, including:

• Registering the unique personalized domain name you choose . For example, if you are a pediatrician, this could be www.mumbaipediatrician.in or www.childdoc.in. You can check out what your website will look at by going to www.websitefordoctors.in !
• Hosting your website
• Uploading the initial content, so your website is live in 2 days
• You will also be able to publish your own content , using the easy OneClick WebPublish Content Management System, which allows you to become your own webmaster
You can publish as many pages as you like – there is no page limit !
• You will also get your own personalized email

Friday, February 12, 2010

Why Proxeed is not useful in treating a low sperm count

The man with a low sperm count presents a very frustrating problem for doctors. Not only is he frustrated that he is " shooting blanks " and cannot get his wife pregnant , he also expects the doctor to provide a quick solution to his problem. Most men ( and their wives) naively think that the doctor will be able prescribe a medicine which will help him to increase his sperm count. After all,isn't a low sperm count a very common problem ? And hasn't medical technology advanced so much that we can treat cancers and heart disease ? So shouldn't treating a low sperm count be child's play ?

It is true that conventional treatment of male infertility in the past used a wide array of medicines to try to improve a low sperm count in the infertile man. These included : HMG and HCG injections; clomid; and testosterone. Unfortunately, none of these work ! Sperm counts tend to vary widely on their own ( even when no treatment is being given); and many of these medicines would actually cause the count to drop rather than to improve, just adding to the patient's frustration !

The newest medicine on the block is Proxeed - and many websites and advertisements claim that Proxeed helps to treat male infertility.However, while Proxeed may increase sperm counts in selected men ( and reduce them in others) , it hasn't been proven to be effective in increasing pregnancy rates.

But what about all the websites which extol the virtue of Proxeed ? Actually, if you drill a bit deeper, you will find that this is all just very clever marketing. For example, look at the page which talks about how great Proxeed is at http://www.malereproduction.com/04_proxeed.html . Here you have a respected doctor endorsing Proxeed - so it must be good, right ? However, if you scroll down, you will find the website is promoted by IHR.com - and if you go to the order page for Proxeed, you will find that Sigma-Tau HealthScience , the manufacturer of Proxeed is an IHR.com sponsor ! This is slick and sneaky marketing at its best !

But if it's sold in the US as a drug, then it must be FDA approved - and doesn't the US FDA insist on clinical evidence before allowing the sale of Proxeed ? Doesn't the FDA have to verify all the claims the manufacturer makes ? Again, the answer is No ! Proxeed is sold as a dietary supplement - and if you read the fine print at the bottom of the Proxeed manufacturer's website, it clearly says - *These statements have not been evaluated by the U.S. Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease and is not designed to improve sperm quality that is already optimal.

Please note that even the manufacturer does not claim that Proxeed treats the disease of low sperm count ( oligospermia) ! All they say it does is that it improves "sperm health". This is a very clever term which they have coined - and not one you will find in any medical textbook at all, because we really cannot test the health of the sperm. All we can do is test for sperm dysfunction at present ! This means they can make this claim - and get away with it, because there's no way of challenging it !

What about the 2004 study which showed an increase in pregnancy rates ? One swallow does not make a summer - and it's quite remarkable that on one seems to have been able to duplicate these results in the last 5 years !

What about the fact that it is an antioxidant and reduces "reactive oxygen species" ? So what ? The bottom line is simple - does it improve pregnancy rates ? The sad truth is that there is no evidence that it works. However, since it's just a simple tablet, and in any case it " does no harm", many doctors will prescribe it - and many patients will take them.

Many men will observe that their sperm count increases after taking Proxeed and they get very excited when this happens. However, do remember that sperm counts fluctuate all the time - and often the increase is inspite of the medicines, not because of it . In any case, a sperm count is not like a bank account that you should get excited when it increases ! The end-point is not an increase in the sperm count or motility - it's a baby ! While Proxeed may improve sperm counts in some men on some occasions, double blind clinical trials have shown they do not help to improve pregnancy rates. This criticism is also true for the currently fashionable Proxeed, which is being marketed very aggressively and cleverly in the USA.

The problem with the medical treatment of a low sperm count is that for most people it simply doesn't work. After all, if the reason for a low sperm count is a microdeletion on the Y-chromosome, then how can medication help ? The very fact that there are so many ways of "treating" a low sperm count itself suggests that there is no effective method available. This is the sad state of affairs today and much needs to be learnt about the causes of poor production of sperm before we can find effective methods of treating it.

However, patients want treatment, so there is pressure on the doctor to prescribe, even if he knows the therapy may not be helpful . When most patients go to a doctor, they expect that the doctor will prescribe a medicine and treat their problem. Since most people still believe there is a "pill for every ill", they expect that the doctor will give them a medicine ( or an injection) which will increase their sperm count. No patient ever wants to hear the truth that there is really no effective treatment available today for increasing the sperm count.

Since most doctors know this, they are pressurised into prescribing Proxeed for these patients, because they do not want the patient to be unhappy with them. They are worried that if they do not fulfill the patient’s expectation of a prescription, the patient will desert them, and go elsewhere, which is why they often do not tell the patient the complete truth. The doctor also remembers the occasional anecdotal successes (who come back for followup , while the others desert the doctor and are lost to followup) is why patients with low sperm counts are put on every treatment imaginable - with little rational basis - Vitamin E, Vitamin C, high-protein diets, hoemeopathic pills and ayurvedic churans. However, the very fact that there are hundreds of medicines itself proves that there is no medicine which works !

Many doctors justify their prescriptions by saying - " Anyway it can't hurt - and in any case, what else can we do? " However, this attitude can be positively harmful. It wastes time, during which the wife gets older, and her fertility potential decreases. Patients are unhappy when there is no improvement in the sperm count and lose confidence in doctors. It also stops the patient from exploring effective modes of alternative therapy - such as In Vitro Fertilization and ICSI Today empiric therapy should be criticised unless it is used as a short term therapeutic trial with a defined end-point.

A word of warning. Medical treatment for male infertility does not have a high success rate and has unpleasant side effects, so don't take it unless your doctor explains his rationale. The treatment is best considered "experimental" and can be tried as a therapeutic trial. Make sure, however, that semen is examined for improvement after three months and then decide whether you want to press on regardless.

It is worth emphasising how small the list for male infertility treatment is - especially as compared to female treatment. This simply reflects our ignorance about male infertility - we know very little about what causes it, and our knowledge about how to treat it is even more pitiable !

Times of India article on Embryo adoption



Embryo adoption is latest trend - Times of India

Here is an article from the Times of India which appeared on 12 Feb 2010.

When Patricia Bohanon, an American teacher, flies home to Colorado on Sunday, she will carry a precious made-in-India baggage: an embryo.

This embryo, which was born in a petri-dish out of anonymous contributions from an Indian sperm donor and an egg donor, was transferred to Bohanon, who will deliver the Indian baby as her own in the first week of December.

Welcome to an assisted reproduction technique that is fast gaining popularity in a world where fewer children are available for donation, and adoption norms are getting more stringent. Not surprisingly, this method is called embryo adoption or embryo donation, depending on which side one looks at it from.

Dr Anjali Malpani, an infertility specialist who treated Bohanon, now performs about three to four embryo adoptions a month as opposed to the random annual procedure, which was the case until a few years back. Says Dr Malpani, "With availability of better infertility treatment techniques, embryo adoption/donation is becoming popular of late across the world." In the US alone, where embryo adoption is about a decade old, over 1,000 babies have been born using this method.

"Adopting an embryo allows a woman, who is infertile, to experience motherhood, complete with labour pains, as against rearing an adopted child," says another infertility expert Dr Indira Hinduja.

Bohanon, a 51-year-old single mother of two 30-plus women, had literally yearned for a houseful of children. "But being a single mother without a fancy income, it was impossible to adopt." The English teacher enrolled as a foster-mother, but couldn't find a young child she could adopt. When her work took her to Vietnam and China, she explored adoption norms in those countries as well. "Vietnam closed adoption for foreigners except those who are based there for a long period. China doesn't allow single mothers to adopt. Cambodia closed adoption after corruption charges were levelled," says Bohanon.

But the charges were high—an embryo alone would work out to over $10,000 (Rs 4.64 lakh) with a similar amount for running Infertility treatment cycles. "I went online and came across the Malpani Infertility Clinic," says Bohanon, who landed in Colaba on January 26 for the e-adoption costing less than Rs 1.25 lakh all inclusive.

Ever since the birth of the first test-tube in England 32 years ago, embryos have been grown in petri-dish. As technology improved, more and more eggs were harvested from infertile women and more embryos grown per couple. It is this glut of sorts of embryos that has, in a way, resulted in the popularity of embryo donation.

Says Dr Malpani, "We are living in a world driven by technology. On the one hand, technology has given us contraception, that has meant fewer babies in general and fewer still for adoption. On the other hand, technology in infertility treatment has allowed us to freeze embryos." In other words, embryos can be adopted years after they were made.

There also are better techniques available to allow women, even those who have undergone menopause, to carry a child. "Within two weeks, we can ensure — with tablets and a single - injection every day — that the woman's endometrium, the inner lining of the uterus, is thick enough to sustain a pregnancy," says Dr Malpani, who feels embryo adoption is best option for elderly women.

Apart from technology, Dr Indira Hinduja, who is credited with India's first test-tube baby born in KEM Hospital 20 years ago, cites an emotional reason contributing to this newfound popularity of embryo donation. "If you adopt an embryo, the whole world sees you pregnant. You don't have to publicise that it was someone's egg and sperm. The law says that you are the biological mother as you have delivered the child. Moreover, you get to feel the baby kick, you go through labour as well as breast-feeding." Women, she adds, thus get to go through a complete motherhood experience.

Whenever a couple comes up for infertility treatment, doctors treat her medically to harvest the maximum number of eggs. Says infertility specialist Dr Hrishikesh Pai, "We create many embryos per couple on the presumption that a couple may need to undergo many cycles to get pregnant. But many couples get pregnant in the first attempt and that too with twins. Instead of throwing their other embryos, they allow us to donate them to other childless couples."

Dr Pai, who is the vice-president of the Indian Society for Assisted Reproduction, feels it is this glut of embryos in infertility clinics that is adding to the popularity of embryo-donation. His clinic in Lilavati Hospital, Bandra, alone has nine cans of embryos store in liquid nitrogen.

But patients like Bohanan are not complaining — even though she realises an Indian baby will be difficult to pass off as her own. "I may let the child know as soon as possible that it was adopted—albeit in a different manner."
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Banking on healthy eggs- Hindustan Times

Banking on healthy eggs- Hindustan Times: " Reva Kamte is 34, single and leads a rather hectic life managing her cloth business in south Mumbai. A recent casual remark by her gynaecologist that the quality of the ova or the eggs produced by a woman’s ovaries starts declining after the age of 35, began niggling her.

She wants to have children, but hasn’t found the “right man”.
So last December, Kamte decided to store her ova at an egg bank at the Malpani Infertility Clinic in Colaba.

Although still in an experimental stage, banking on their healthy eggs is now an option that women, who choose to delay motherhood, are exploring. It is the egg, which gets fertilised by a sperm to form a foetus. “Conceiving a baby becomes difficult with age. The egg quality after 35 declines drastically increasing the risk of the baby having physical or mental deformities,” said Dr Anirudh Malpani.

While infertility specialists have been using donor eggs for test tube babies for couples unable to conceive, banking on one’s own healthy eggs is a recent trend.

In January 2008, Lilavati Hospital in Bandra was the first to start such a bank. So far, ten women have deposited their eggs at the egg bank and the hospital claims to receive at least three enquiries every month. Across the city, some 60 women, in their early 30s have stored their eggs with various in-vitro fertility (IVF) centers. So far, none of the eggs stored in the banks have been fertilised to make a baby.

Recently, a popular model stored her eggs at Lilavati Hospital’s egg bank. “They want to keep their options open without compromising on their careers or the desired man,” said Dr Hrishikesh Pai, gynaecologist and in-vitro fertilisation specialist at Lilavati Hospital.

A study conducted by two prominent UK Universities, published in January in the Journal Public Library of Science One, has found that nearly 95 per cent of the women in the 30s have only an average of 12 per cent of their original egg reserves. It further diminishes to three per cent by the age of 40.

While most of the women opting for such banks are ambitious or single, it is also an option available to cancer patients whose ovaries are likely to get damaged when exposed to treatments such as chemotherapy and radiotherapy. Alpana, a 28-year-old cervical cancer patient from Andheri was asked to deposit her ova in an egg bank by her cancer specialist.

However, IVF expert Dr Gautam Allahbadia says these banks are just an option and will only pick up after the results will be out. The procedure is not only new but also expensive and tedious. Moreover, the success rate abroad, where the technique has been in use for several years, varies from 10 to 30 per cent."

Thursday, February 11, 2010

Why do patients put on weight after IVF ?

The biggest worry many patients have about doing IVF is that it will cause them to become fat. Lots of women who have done IVF will swear that IVF makes them put on weight - and isn't it well known that the hormonal shots needed for IVF treatment cause weight gain ?

This is a myth which I would like to dispel .

It is true that women will put on weight due to fluid retention during the superovulation phase of the IVF cycle. The high estrogen levels do cause fluid retention, but this is only temporary. Once the superovulation stops, the hormones get excreted promptly into the urine and do not have any long term effects . This means that most women will promptly lose the fluid they accumulated, and will go back to their normal body weight.

What about the ones who do gain weight ? The reason for this is simple, and has nothing to do with the IVF treatment ! In order to gain weight, caloric intake needs to be more than caloric expenditure. None of the IVF meds affect either caloric intake or expenditure , which means the equation remains undisturbed.

However , most patients will rest a lot more after their embryo transfer. This maybe because physical exertion causes discomfort ( superovulated ovaries can be large and bulky); while others will deliberately curtail physical activity because they are worried that their embryos may "fall out" of the uterus if they go jogging !

Some women will also eat more during their IVF cycle . IVF can cause tremendous mood swings and overeating is a very common response to dealing with stress. This is especially true if the beta HCG result is negative - food and chocolate can offer a lot of comfort at this time.

Both these factors - the reduction in physical activity and the increase in caloric intake will cause some women to put on weight after IVF. Most of them will blame the IVF hormones for this , but this is not true !

How ultrasound scans are used for treating infertile couples

Monday, February 08, 2010

Why infertile couples fight over sex

How email improves doctor-patient communication

Many doctors are worried that email will ruin doctor-patient communication, because they feel that face to face interaction is vital to preserving the doctor patient relationship.

Actually, for established patients, email is a far better way of communicating with the doctor, as compared to a phone call.

I find that patients are quite reluctant to phone a doctor with their "minor doubts" because they do not want to disturb the doctor. This means that a lot of worries remain unresolved. With email, on the other hand, they are much more willing to ask for clarifications, because email is much less intrusive, and they know I can answer at my convenience ! Email allows me to provide reassurance and comfort much more easily to my patients.

My replies can be thoughtful and reasoned - and because I am not rushed ( as I might be in the clinic when I have lots of patients waiting to be seen), it is actually easier for me to be more empathetic by email !
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Thursday, February 04, 2010

Does computer use in patient-physician encounters influence patient satisfaction? -- Lelievre and Schultz 56 (1): e6 -- Canadian Family Physician

Does computer use in patient-physician encounters influence patient satisfaction? -- Lelievre and Schultz 56 (1): e6 -- Canadian Family Physician: "It was hoped that the introduction of computers and electronic health records into medical practice would revolutionize medicine, improving quality of care and patient satisfaction. Electronic health records do bring with them many benefits, including easy access to legible notes, prescription-writing systems, drug interaction systems, and, in some cases, laboratory and imaging information. Other demonstrated benefits include greater adherence to preventive care guidelines and a decrease in the cost of care in the long-term. However, apart from the obstacle of the initial investment (it is estimated that it would cost a total of $18.7 billion to create an appropriate Canada-wide electronic health record system), physicians have numerous concerns regarding electronic health records. These include security, time-effectiveness, loss of eye contact, and negative effects on patient-physician relationships."

Many doctors ( esepcially the older generation who is not adept at using computers) will roll out many excuses as to why they don't need computers to practise good clinical medicine. In fact, some of them claim the computers will harm the doctor-patient relationship as the doctor will spend more time with the PC than with the patient. This study is very reassuring - and shows that patients actually prefer doctors to use an EMR. It gives patients confidence that the doctor is well organised; and that their medical records are well documented and safely stored !

Two suggestions I give young new doctors who are just starting practise are :
1. make sure they have a website; and
2. use an EMR.
This will be their USP and will help them to stand out from their seniors and the rest of the competition !

Knowing we practise good medicine: Implementing the electronic medical record in family practice -- Dawes and Chan 56 (1): 15 -- Canadian Family Physician

Knowing we practise good medicine: Implementing the electronic medical record in family practice -- Dawes and Chan 56 (1): 15 -- Canadian Family Physician: "We aim to be good physicians, providing safe and effective care to our patients. But is that really the case? Family physicians deliver care through the process of our practices and the method of our consultations. To understand what sort of doctors we are, we need to evaluate both aspects of care. Your initial response is probably scepticism or disbelief. You don’t have the time or the energy, and even if you did—so what?

We would be concerned if half our patients with hypertension had systolic blood pressures greater than 160 mm Hg; if our patients with suspected herpes zoster had no way of seeing us within 3 days; if we ordered a blood test, urine test, or x-ray scan at every consultation; if we didn’t listen to patients; or if we finished every consultation by pushing a prescription at the patient. We don’t believe these things occur, but how can we be certain? To make sure we provide good quality medical care, we need electronic records."

Top 50 Healthcare IT Blogs

Top 50 Healthcare IT Blogs: " So many great blogs about healthcare IT exist, but — unfortunately — many of them are not updated on a regular basis. This point is important for blogs that deal with an ever-changing field. This is one point we considered in the following list of top fifty healthcare IT blogs…the other points we considered were relevant information along with a good following and a well-written and easy-to-comprehend blog."

The Patient's Doctor is proud and pleased to be part of this august company !

Wednesday, February 03, 2010

A UK success story - from the heart !

Since both of us moved to UK after marriage, the settling down process took its toll and we initially felt that this stress was the main factor obstructing us in our progress towards having kids? Meanwhile, we resorted to medical aid in UK despite a lot of financial hardships. We had 2 IUI attempts and one abandoned IVF in UK with no success. The infusion of so many hormones and the stress of maintaining a job had its toll on me emotionally and my relation with my husband got affected-I had mood swings, bouts of depression etc. After another year, my husband started thinking of adoption. I was not averse to the idea myself. In fact, I wanted to have a baby of each race in my house; they all have their unique beauties. But my great faith in medicine was not ready to accept the fact that we can’t have our own kids when we both were medically fit. I knew that my biological clock was almost dying but why rob my husband of the joy? So I started scanning the internet and zeroed in to two Doctors in India.

I chose India because I am still an Indian at heart and there was definitely less Red Tape. Moreover, I knew that I would have to take an egg donor and the legal system in India allowed anonymity of the egg donor for life time unlike UK where the child has the right to know the donors at a later stage.

No doubt, we were initially very hesitant to get any treatment in India mainly because of lack of secrecy and a broad understanding on the advances of medicinal science from family. We were not confident about how good the Indian medical professionals may be though they have made quite a niche in UK and USA. As you know bad news travels faster and influences a person more. However, the doctors in UK informed me that there was nothing wrong with my reproductive system or with my husband’s and that it was a matter of time when God would bless us.

The two doctors chosen by me were Dr. N, and Dr. Aniruddha Malpani, Mumbai. I emailed both the doctors. I had to remind Dr. N to respond to my emails on a very bad mobile network whereas Dr. Malpani replied the very next day.

Dr. N simply said,’ Come over, we can do it.’ I was aghast; how is it possible without asking any preliminaries like my age, my physiological state, medical updates or reports etc. I had also put an enquiry on Dr. N’s website that was picked up by some agent of theirs in UK who dealt with European queries due to language problems. However, my sixth sense said, NO.’

I was very impressed by Dr. Malpani’s responsive behaviour and professional attitude. I sent him umpteen queries to which he responded with all patience. I even asked him point blank why he was more expensive than others and I liked his confidence when he replied that he knows that they are the best. We planned each and every thing in great detail as we had very limited time. Because of all this planning, I was able to traverse practically all the four corners of India with my other engagements within four weeks without affecting my treatment. This was possible because I was able to contact Dr. Malpani by email or by phone wherever, I was and also kept sending him my results whist on his monitoring schedule. And if he was busy, he ensured that he returned my call or responded by email. Hats off to technology and the professionals who know how to use it in the right way!

I arrived in Bombay in the last 10 days of my Great India tour and was joined by my husband. Dr. Malpani had everything under control-my tests were coming fine, the donor was ready and my husband was in time.

Finally, the eggs were retrieved. There were 12 eggs. Three fertilised healthy embryos were then transferred into my uterus . I felt great being part of such a marvel in medical science.
Dr. Aniruddha Malpani and his wife Dr.Anjali Malpani, the embryologist, Dr Sai and the whole team of nurses and receptionists were very supportive. While transferring the embryos, Dr. Malpani asked me,’ which god are you praying to?’ However, I was too elated to pray at a time when I knew that a miracle is being performed and at that time I was more aware of the messenger of God-Dr. Malpani, than God himself. I knew that we would succeed. On reflection, I realised that actually I do believe in God as a power but I have not been able to give any particular name or face to any of the gods. I believe in all religions and specifically in Humanity and the doctor was the epitome of that. I had a few hours rest at the clinic. That night I dreamt two embryos were floating down into my body and nestling comfortably in my womb. So much for wishful thinking! I told my husband the next day and he brushed my talk aside saying,’ Just leave it to God. At least we tried.’ May be he was too scared to even think positive after all that we had gone through all these years. We flew back to UK after 3 days of the transfer. But I must say that though we had been on holidays before this one was the most relaxed and enjoyable holiday I ever had in my whole life. No family/relative obligations, no dinners to attend to, and no work obligations. We would get up in the morning leisurely and then hit the few selected restaurants for lunch, watch movies in theatres or walk around Taj and then come home late after dinner like we used to do in our courtship days.

Back at home in UK, we had to wait 14 days before I could go for a HCG blood test to confirm my Million Pound lottery and that day fell on a weekend and the surgery was closed. So my husband bought a Pregnancy test and I tested with baited breath and saw the blue line appear like a boon. It was unbelievable. In my previous tests I had thought that this Blue line never ever shows but there it was right in front of my eyes!!!

Further blood tests followed and then an early ultrasound confirmed that I was carrying twins. I had few problems initially with bleeding and lots of weakness that was well looked after by doctors in UK. All is going on fine now. My twins have started kicking-one is a quite one with gentle kicks while the other seems a bit aggressive-good complementary personalities, it seems! I am just praying for all to go well am eagerly awaiting the arrival of new joys in the family.

My advice to all those couples who are planning to go through medical treatment is that it is no use wasting time and money in IUI, if you really want a child, one should go for IVF straightaway. And no doubt, I would highly recommend Dr. Malpani and his team in Mumbai, India.

Accelerating Innovation In Information And Communication Technology For Health -- Crean 29 (2): 278 -- Health Affairs

Accelerating Innovation In Information And Communication Technology For Health -- Crean 29 (2): 278 -- Health Affairs: "Around the world, inventors are creating novel information and communication technology applications and systems that can improve health for people in disparate settings. However, it is very difficult to find investment funding needed to create business models to expand and develop the prototype technologies. A comprehensive, long-term investment strategy for e-health and m-health is needed. The field of social entrepreneurship offers an integrated approach to develop needed investment models, so that innovations can reach more patients, more effectively. Specialized financing techniques and sustained support from investors can spur the expansion of mature technologies to larger markets, accelerating global health impacts."

I completely agree ! This is why I am an angel investor in startups such as Plus91 which will use IT cleverly to improve health care in India !

Cell-Phone Medicine Brings Care To Patients In Developing Nations -- Feder 29 (2): 259 -- Health Affairs

Cell-Phone Medicine Brings Care To Patients In Developing Nations -- Feder 29 (2): 259 -- Health Affairs: "At the Mexico City HIV clinic, Carlos has seen these mobile health tools transform HIV/AIDS care for himself as well as for new patients starting treatment. With VidaNET, he says, patients 'have more power' to drive their own care and convey their concerns to doctors. In fact, it’s not too much of an exaggeration to say that e-health could help to bring about a 'democratization' of illness in countries like Mexico—now that access to much of the world’s medical expertise is increasingly just a text message away."

We need lots more success stories like these ! The cost for innovation in places like India and Mexico is much less than in the US, and the impact of these innovations is far more because they can reach out to so many more people !

E-Health Technologies Show Promise In Developing Countries -- Blaya et al. 29 (2): 244 -- Health Affairs

E-Health Technologies Show Promise In Developing Countries -- Blaya et al. 29 (2): 244 -- Health Affairs: " Is there any evidence that e-health—using information technology to manage patient care—can have a positive impact in developing countries? Our systematic review of evaluations of e-health implementations in developing countries found that systems that improve communication between institutions, assist in ordering and managing medications, and help monitor and detect patients who might abandon care show promise. Evaluations of personal digital assistants and mobile devices convincingly demonstrate that such devices can be very effective in improving data collection time and quality. Donors and funders should require and sponsor outside evaluations to ensure that future e-health investments are well-targeted."

I believe that a lot of the e-health innovations will come from the developing world. Mobile penetration is very high here; and there just aren't enough doctors to go around, which means the demand and the need for clever e-health applications is far greater !

Tuesday, February 02, 2010

Surrogacy - making sure we do a good job !

There is no question that surrogacy remains one of the most complex issues society faces today. While it is an effective way of helping some infertile couples to have a baby, it raises a number of complex ethical and legal issues which we have still not been able to tackle effectively.

How do we ensure that infertile women who do not have a uterus can use surrogacy treatment to have a baby , since this is the only medical treatment option available to them ? How can we ensure that poor infertile women are not coerced or exploited into becoming host wombs ? How can we make sure doctors provide surrogacy treatment only to couples who actually need it ? How can we resolve the challenging issues of genetic parenthood and social responsibilities ? And how do we resolve the rights of the genetic mother versus the birth mother if there is a dispute ?

Some countries have taken the easy way out and just banned surrogacy outright. I think this is unfair. Why should a woman who does not have a uterus, and who can have her own baby with the help of surrogacy, be deprived of the chance to use this option ? In fact, I would go so far as to say that it is unethical to ban surrogacy, because this encroaches on an individual’s reproductive autonomy.
Let’s look at some of the simple situations first, before we move on to the more complex ones.

Most people would be quite comfortable with allowing a sister to be an altruistic surrogate for a woman who does not have a uterus, if she is comfortable doing so. This means that most people are not averse to the idea of surrogacy itself , if it’s done properly and helps infertile couples to have the children they desire. Similarly if a woman who already had kids agreed to be a surrogate for an infertile woman who could have carry her own babies, most people would not object.
The problems start cropping up when we talk about commercial surrogacy, because money is now changing hands. Once money enters a transaction, then things become much murkier. Why is this so ?

In reality, there’s nothing wrong in paying someone to being a surrogate . Just because someone agrees to become a surrogate for money does not make this unethical. As long as all parties involved understand what is involved and are happy to take part, this is fine. After all, it is a voluntary transaction between consenting adults, each of whom is choosing to participate.
So when so eyebrows start getting raised ? It’s when clinics start taking shortcuts and arranging surrogates purely for commercial considerations, without considering what’s in the infertile couples or the surrogate’s best interests. The tragedy is that this is going to become increasingly prevalent because of the ICMR guidelines, once these become law.

This is because the ICMR has put the burden of sourcing and counseling surrogate mothers onto commercial agencies. Unfortunately, while the ICMR Rules have strict guidelines as to what an IVF clinic needs in order to be recognized and registered, there are no guidelines for who can be a surrogate agency. This means all kinds of agents, middlemen and fixers are crawling out of the woods today , and approaching IVF clinics, offering to “find” surrogates for them, so that they can make a quick buck. Most doctors are too busy to care – and are quite happy to turn a blind eye, as long as they can continue treating their patients. They feel that looking after the surrogate is the agency’s job, and do not critically examine how the surrogates are counseled or looked after.

This is a shame, because it allows all surrogacy arrangements to be viewed with a jaundiced eye. Unethical surrogacy agencies will use pimps to hire prostitutes to become surrogates; while other swill confine 10 surrogates to live in a single room, away from their own children , for the duration of the pregnancy. Once these kind of unsavoury arrangements come to public notice, there will be a hue and cry – and the standard knee jerk reflex will be – Ban surrogacy !

What about the activists who claim that surrogacy allows people to treat babies as commodities; or that surrogacy is just a kind of prostitution, where the woman is selling a part of her body for financial gain. I feel this is an unfair criticism. Infertile couples resort to surrogacy to have a baby only after a lot of soul searching . It is never a “spur of the moment” thoughtless impulse decision – and the babies born as a result of surrogacy treatment are deeply loved and cherished. Is the surrogate “selling” her womb ? Again, I think this is unfair. Just because a woman is poor does not mean she is stupid – and as long as she understands what she is doing and does this of her own free will, she should be allowed to exercise her freedom to do so. This is far better than having a professor who lives in an ivory tower dictating what she is allowed to do – and what she is not, just because she is poor !

I agree that the present system leaves a lot to be desired. It is broken and it needs to be fixed urgently ! What’s wrong with it ? For one, it’s open to a lot of abuse and misuse. Let’s look at these one by one

1. Overtreatment. There’s no doubt that surrogacy is overused, misused and abused. Infertile couples are often fed up and frustrated – especially when they have failed multiple IVF cycle or suffered from many miscarriages. They are depressed and disheartened – and feel that surrogacy would be the perfect option for them. Little do they realize that surrogacy is an expensive and complex treatment option, which is best reserved for women without a uterus. Research shows that the reason for failed implantation is much more likely to
be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem; and that embryo adoption or egg donation would be a far better solution for them. However, they have low self-esteem are often not capable of thinking critically – and when a doctor offers to do surrogacy treatment for them, they feel this is the best solution for all their problems, as it bypasses all the hurdles mother nature has created for them. So why do doctors suggest surrogacy for them ? Unfortunately, the reason is purely commercial – for the sake of money. Doctors can charge much more for surrogacy treatment, as compared to the simpler options, so most of them are quite happy to do so, without discussing simpler ( and less expensive) options ( which may actually be better for the patient) with them.

2. Dishonesty. Because there is very little transparency in most of these surrogacy arrangement, many unscrupulous doctors take undue advantage of this by lying to their patients. There are doctors who tell the patient that the treatment worked and that their surrogate is pregnant after the embryo transfer ; collect the balance payment due – and then tell them that she unfortunately miscarried at 8 weeks of pregnancy ! It’s very easy to take these patients for a ride, because there is no documentation – and there is no way the patient can verify or dispute these claims. The poor patient is completely dependent on the doctor’s honesty and professionalism – and unfortunately, not all doctors are upright.

3. Secrecy. Because most clinics prefer being very secretive and hush-hush about surrogacy treatment ( and I always wonder why ? After all, what do they have to hide ?) it’s often the sad reality that the middleman siphons away most of the money, and the surrogate gets only a pittance. This is exploitation – and it must be prevented

4. Poor documentation. The surrogacy treatment paperwork today leaves a lot to be desired. Lots of doctors don’t even bother to do it – while others fudge it or do a bad job. This can create lots of potential problems – some of which have become headline grabbers already, as in the Baby Munjee case.

Surrogacy is a complex process , because it involves multiple players, each of whom may have different interests . It is this complexity which leads people to believe that it’s not possible to streamline this process. It’s stupid to take an ostrich in the sand attitude and pretend that the problem does not exist. It’s far better to address this proactively, so we can prevent problems from arising !
What we need to do is to look for solutions ! I’d like to propose a very simple cost effective solution which can be easily implemented , at no additional cost, and which will help to keep everyone happy.

The solution is this - only adoption agencies are authorised to provide surrogates. Adoption agencies have experience and expertise in family building – and in dealing with infertile couples; doctors; lawyers; and babies ! Also, it helps to reinforce the idea that surrogacy and adoption are complementary option, not competitive, because the adoption agency can offer them both options. Moreover, the money earned on the surrogacy treatments can be used to promote adoption as well. In this model, the doctors are only treatment specialists – as they should be !

How would this work out in real life ? The infertile couple who wanted surrogacy would approach an IVF specialist, who would evaluate their problem and decide if they needed surrogacy or not. If he thought they did, then he would contact the adoption agency and ask them to organize a surrogate mother for this couple. The couple would then go to the adoption agency with this referral note; and would put their name down on the surrogate wait list. The adoption agency would have an active surrogacy recruitment program, where they would screen and counsel prospective surrogate mothers, to decide if they were good candidates for this. The agency would then match up the couple with a surrogate; collect the fees which would be placed in an escrow account; and use their in-house lawyer to sign the surrogacy agreement contract. Armed with this, the infertile couple and surrogate would go back to the IVF clinic, where the doctor would perform the IVF treatment. Once the surrogate got pregnant, the doctor would then refer her back to the adoption agency. The agency would then ensure that she got excellent prenatal care from an independent obstetrician; and home visits to her house would ensure that she was taking good care of herself. After the baby was born, the agency would ensure that the intended parents’ name was placed on the baby’s birth certificate; and handover the baby to the infertile couple. This would ensure that most loopholes are plugged and that surrogacy treatment is performed properly.

The adoption agency thus plays a very important role in this process, and makes sure that the counseling, the legal paperwork and the payments are all performed properly ; that the surrogate is protected and looked after well ; and that after the baby is born, the right baby is handed over to the right infertile couple. This way, the doctor focuses on his core competence – doing the IVF – while the rest of the non-medical tasks are performed by the adoption agency. Infertile couples are much happier that the process is transparent and open; and society is reassured that surrogacy is performed ethically and correctly, and that exploitation and misuse is being prevented.

This way, the complex process of surrogacy is broken down into its individual pieces, each of which is performed by the organization which is best suited to doing so.

What role does the judiciary play in all this ? It is important to have regulations laid down, which will authorize only adoption agencies to provide surrogate mothers to IVF clinics. Also, since most surrogacy arrangements will sail through smoothly, no judicial intervention will be needed ordinarily, thus preventing an additional burden to our already overstrained courts. It’s only if and when disputes arise that we will need to take recourse to the courts.

Even more importantly, it’s a fact that the law has not been able to keep up with reproductive technology – and this will always be a problem with all laws and regulations . The involvement of social workers will ensure that advances, as and when they occur, will be utilised sensibly, keeping the best interests of everyone - the infertile couple; the surrogate and the baby in mind ! Allowing social workers to provide oversight is effective. They are trained professionals who will be motivated to perform efficiently.

With this system, transparency is encouraged, which will prevent exploitation. Good clinics will set the benchmark , and others will be forced to follow suit. Thus, if the clinic routinely shows photos of embryos to the patients, this will soon become the norm for all surrogacy clinics !

Equally importantly, this system protects everyone. Infertile couples are happy that their surrogate is being looked after well; surrogates are fairly compensated; and doctors can focus on improving their medical treatment and pregnancy rates, since the paperwork is taken care of by the adoption agency.


What do we do when things go wrong ? Yes, they will – but the reality is that things go wrong only when the surrogacy treatment is not done properly. The chances of problems arising when it’s done properly are low.

What’s the danger of leaving things as they are ? The biggest danger is that the present guidelines encourage the establishment of “for-profit” commercial surrogacy agencies. While some of these will be run by ethical professionals, the danger is that a few bad apples will take unsavoury shortcuts to make a quick buck – and the resultant bad press will end up harming everyone – good IVF clinics; and infertile patients who need surrogacy as well. All IVF doctors will be painted as villains, who are willing to go to extremes, just to make a quick buck.

Is this going to be a panacea for all problems ? Of course not ! I understand that adoption agencies can often be bureaucratic organizations which get bogged down in paperwork. And there will be some unethical and incompetent social workers as well ! It’s just that having adoption agencies actively involved in the process will help to prevent lots of problems. Problems primarily arise because of poor patient selection; inadequate counseling of surrogates; poor surrogate selection; lack of transparency; the presence of legal loopholes; and the involvement of “for-profit” unregulated middlemen who subvert the process and exploit patients and surrogates for money. Since adoption agencies are non-profit bodies, who employ social workers who are skilled in counseling and family building; and are used to dealing with lawyers and infertile couples, they offer a perfect solution to this problem. The beauty is that no additional organizations would need to be created to tackle this onerous problem – we would just have to make more efficient use of the existing organizations. Even better, the money which adoption agencies make from these surrogacy arrangements could be used by them to take better care of the abandoned children they put up for adoption; and to promote their adoption efforts as well !
The problems surrogacy presents are not unique to India – they are present all over the world ! It’s just that India today has a great opportunity to create a smoothly functioning system which can serve as a model for the rest of the world !
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