Friday, April 30, 2010

If you are an IVF specialist, why are you talking to us about adoption , doctor ?


When I see new patients, even though I am an IVF specialist ( and the vast majority of my patients come to me for IVF treatment), I always explain to them that IVF is not their only choice; and that they have multiple options available in order to build their family. These include: childfree living and adoption.

Many patients get quite upset when I talk about adoption. They feel that the very fact I am discussing adoption means that I think they will not be able to have their own baby with medical treatment. They feel that this means I have a "loser mentality"; am not confident about our IVF success rates; and am very pessimistic !

Actually, none of this is true ! I am very optimistic, but I am also non-judgmental. I provide a very neutral list, which is not ranked or ordered in terms of preference - it's just a vanilla list. The only reason I talk about childfree living and adoption first is because these are non-medical options - and infertility is not just a medical problem !

I feel all these options are equally good - and each patient needs to decide what is right for themselves. These are not decisions which I can make for them, just because I am an IVF specialist !

One patient's mother argued - Why bring up adoption at all ? We already know it's a choice - and if we wanted to consider this, then we would not have come to you at all in the first place !

I needed to explain to her that when I counsel patients, I need to be as objective as possible - I cannot censor information, or assume that they know everything about And sometimes patients need permission from their IVF doctor to stop medical treatment and explore alternative options - and my patients need to know that they should feel comfortable talking to me about all their options - and that I will be happy to support them, not matter what they decide !

I feel all infertile patients need to keep an open mind, and be willing to explore all possibilities, even though some of them may seem repugnant initially. And if some infertile patients are not willing to discuss adoption with their IVF doctor, maybe I am not the right doctor for them !
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Thursday, April 29, 2010

Why I prefer website referrals


The source of patient referrals for most doctors has been other doctors. This is often a very cozy system, especially amongst doctors who practise in a hospital setting, who will often refer patients to one another.

For us , however, our major source of patient referrals is other patients - and our website ! I prefer this , for many reasons !

Firstly, I do not need to give any kickback or commission to the referring doctor. I am answerable only to my patients, which means I can focus on doing what is in the patient's best interests.

Also, website referrals automatically select for the type of patient we prefer treating - intelligent, curious, well-informed and well-read patients , who take an active interest in their treatment and want to be treated as intelligent partners. These internet positive patients are aware, do their own homework and do not blindly follow a doctor's orders. Not only is it much more fun to treat such patients, it's also a lot easier, because they have realistic expectations from the treatment and are appreciative of the hard work we put in to help them to have a baby ! Even better, because they are inquisitive , they often teach me a lot , based on their own research and experience - I can have intelligent conversations with them, which keeps me on my toes ! I feel it's important that the doctor-patient chemistry be right, and this kind of patient meshes very well with our philosophy of patient empowerment.


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Wednesday, April 28, 2010

What should a patient do when doctors disagree ?

A hysterosalpingogram. Note the catheter enter...Image via Wikipedia

I saw a patient who wanted a third opinion. She was completely confused. As part of her infertility workup, she had had a HSG ( hysterosalpingogram) done. The X-ray showed that her uterine cavity was normal; the dye filled the fallopian tubes , but the spill into the abdominal cavity was loculated.

When she saw her doctor with the report, he told her that this suggested that there were adhesions around the tubes, and she needed an operative laparoscopy to treat this. Another doctor, to whom she had gone for a second opinion advised her against the laparoscopy. He felt that since the tubes were open, her best option would be to do an IUI, to improves the chances of the eggs and sperm meeting. This patient then sought a third opinion, which is why she came to me !

The first thing I did was to ignore the earlier opinions, and asked to see a copy of the original HSG X-ray films, so I could make up my own mind . Unfortunately, there was only one film, and this was of poor quality . The radiologist had done a sub-optimal study, because he had not taken any delayed films ( perhaps to save some money ?), as a result of which it was hard to draw a firm conclusion based on the HSG films. This meant were now back to square one.

The choices were; repeat the HSG; do a laparoscopy; or assume the tubes were fine and proceed with treatment. Each has advantages and disadvantages, and patients need to think their way carefully through their choices, so they can make the right decision. Unfortunately, most patients are not used to making choices regarding their medical treatment. Even worse, most doctors are not comfortable offering these choices to their patients. "The doctor knows best" is the model most patients ( and doctors) are happy to adopt - which means that often the wrong decision is made ( and usually for the wrong reasons).

We could repeat the HSG in a better clinic and make sure that it was done under fluoroscopic guidance and that delayed films were taken. While this option would give a much better X-ray image of the tubes, she was understandably reluctant to repeat the HSG. This is quite a painful procedure - and few women have the courage to do it again !

Laparoscopy is a surgical procedure, which means it costs more; however, the quality of the documentation is much better, because the surgeon can take videos of the pelvic anatomy. However, it cannot provide information on tubal function - which is really the only thing the patient wants to know - are my tubes working properly or not ?

Doing a laparoscopy was an option - but this is an expensive surgical procedure - and while it provides useful diagnostic information, it often does not change treatment options , which is why we are very reluctant to perform this in our clinic. What's the point of doing a test if it does not impact treatment alternatives ?

So what are patients supposed to do when their doctors disagree ? Some of them get very angry and upset when doctors do not see eye to eye ! I actually feel it's good for patients when doctors disagree. Each doctor will present his point of view and justify why this is better than the alternative proposed by the other doctor . The patient gets to see the pros and cons of both options, so she can make a better-informed decision !
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My doctor does not tell me anything !

A statue of Asclepius. The Glypotek, Copenhagen.Image via Wikipedia

This is one of the commonest complaints patients have about their IVF treatment

Failing an IVF cycle is heartbreaking - but what make a bad situation much worse is the lack of transparency during and after the IVF treatment.

Many IVF doctors refuse to share even basic details of the medical treatment with their patients.
They do not bother to formulate a treatment plan or provide details of how the cycle is progressing. Patients do not even know simple information, such as how many follicles are growing; how many egg were collected; or how many cells their embryos have !

Patients who ask questions are usually fobbed off by saying - " Everything is fine, don't worry"; or " The doctor will talk to you and explain your results" - but the doctor is never available ! A lot of the treatment seems to be done on an "ad hoc" basis, with the decisions being made by junior doctors, since the senior doctor is often inaccessible

To add insult to injury, if the IVF cycle fails, the poor patient is treated as a pariah ! Rather than providing patients with emotional support and a shoulder to cry on, many clinics will refuse to give these patients an appointment, to help explain to them what went wrong and what can be done to fix the problem

Patients feel abandoned - and find it very hard to even get a get a simple treatment summary from the clinic !

Part of the fault is the doctor's - but I think there's little point in blaming doctors or complaining about them ! Good doctors will always behave well - and bad doctors will never improve ! I feel patients need to take the initiative and take a proactive approach. Before you sign up for the treatment cycle ( and most patients seem to feel that they do get royal treatment until they make their payments !) make sure your questions will be answered .

It's quite easy to judge how open the clinic is and what their philosophy is towards providing details by talking to the nurses; and to other patients ! Doing this will often provide you with much more insight into the doctor's attitude towards patients than anything else will. If the staff is rude , there's a high chance the doctor will be curt too, because staff members will often model their behaviour on what they see the doctor doing !


Also, talking to other patients can be helpful. If they are well-informed and are aware of their treatment details, this suggests the doctor has an open sharing and caring philosophy !
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Tuesday, April 27, 2010

But I am not a doctor, doctor !

I often ask my patients to interpret their own medical test reports. Some of them look at me as if I was crazy ! " You are the doctor, not me ! I am not a doctor - why are you asking me ? "
And I am sure some of them must be worrying that the fact I am asking them means I must be so clueless that I cannot interpret the results without their help !

I explain to them that I am not trying to make them a doctor - I am just trying to help them take an intelligent interest in their treatment. They need to make sense of their options, so they can select the one which is best for them. The good news is that many patients use the internet to do this on their own - and I try to facilitate this process.

If patients can make sense of their own problems, we can figure out solutions together - and it's my job as a doctor to help them to do so. I maybe the infertility expert - but they are the ones who are the real experts on their own lives .

This approach is useful for me too. Sometimes, as a doctor, I tend to acquire a a medicalised perspective on life , and take for granted the fact that patients understand the medical terms we use. Sadly, they often don't, but are too intimidated to ask questions or seek clarification. This ignorance can lead to unrealistic expectations - and a lot of heartburn and grief later on.

Asking them to interpret their own reports helps me to to see the world through their eyes; and also empowers them , because they know they need to do their homework before meeting me !

When patients ask me - How do I make sense of this ? , I remind them not to underestimate their intelligence. None of this is rocket science - and I am always their to help them understand the reports. Unfortunately, many doctors try to " complexify " infertility treatment. By using medical jargon, they try to put patients in their place, so that patients know who is the "expert". This is not a helpful approach, and we do out best to simplify and demystify treatment options for our patients. If, as Albert Einstein said : "It should be possible to explain the laws of physics to a barmaid", I am sure we can explain IVF treatment to our patients !

A good patient does her best to understand what is happening to her - and a good doctor will do his best to help you understand !

Monday, April 26, 2010

Follicles are not eggs

Ovarian follicleImage via Wikipedia

I just finished a consultation with a young woman who had a very low AMH level. I explained to her that this meant she had poor ovarian reserve, and might need to consider using donor eggs.

She was understandably very upset. " How can that be true, doctor ?" she demanded. " My gynecologist has done 4 IUI cycles for me and I had at least two 20 mm follicles in each cycle which would rupture on Day 14. She told me I was young and had good eggs, so how can you now say my egg quality is poor? "

Women know that their chances of getting pregnant depend upon the quantity and quality of their eggs - what is known as their ovarian reserve. They know that if they have regular cycles, this usually means that they are ovulating; and that egg quality declines with age. This is why most young women with ovulatory cycles usually assume that their egg quality must be good. This is a reasonable assumption, and one which most gynecologists also share.

However, it's hard to measure the quality of eggs. Eggs are microscopic structures, which can be evaluated only by doing an IVF treatment cycle, when the embryologist actually gets to see them under his microscope. Follicles, on the other hand, are just black bubbles on the screen which we can track on serial ultrasound scans. Since most follicles contain eggs, traditionally we have measured egg quality indirectly, by using ultrasound scans for follicular monitoring. If the follicles grow well and they rupture, the logical conclusion is that the quality of the eggs within the follicles must be good.

Unfortunately, this is not always true. The follicle is just a black bubble on the ultrasound screen; and some follicles may be empty; while others may contain poor quality eggs. And just because you ovulate every month does not mean that your egg quality is good enough to make a baby !

What about testing the estradiol levels ? This again has the same limitation. The estradiol is not produced by the egg, but by the granulosa cells which line the ovarian follicle. Thus , even if the estradiol levels are good, the egg quality may still be poor. FSH levels used to be the gold standard for assessing egg quality, but this is not very reliable either, for exactly the same reason. Thus, while most women with high FSH levels have poor eggs ( both the quantity and quality are likely to be impaired), many women will also have poor quality eggs, inspite of the fact that their FSH is normal, because the FSH is only an indirect marker of egg quality.

The most reliable test for egg quality is the new blood test which checks AMH levels. This is not foolproof either, but it does provide much more accurate information about ovarian reserve than the older tests. If you are infertile, please ask your doctor to get your AMH level tested - or get this done yourself. This will give you a much better idea of your ovarian function !



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Sunday, April 25, 2010

Why did my IVF cycle fail ?


This is one of the hardest questions IVF doctors need to answer - and many do a bad job of dealing with patients when their IVF cycle fails .

When the IVF cycle fails , patients are understandably upset ! All their time and money has gone down the drain and they are now back to square one ! What went wrong ? Was the medical treatment of high quality ? Or did the doctor goof up ?

Doctors are often on the defensive when the IVF cycle fails. This is because many of them overpromise success in order to attract patients. They provide false hopes to lure patients into doing IVF. When the cycle fails, they often refuse to talk to their patients, partly because they feel ashamed that they have not been able to help them achieve their goal.

This attitude ends up creating even more resentment ! Patients feel abandoned . They perceive that IVF doctors are just out to make money - and that while they talk very sweetly before the treatment, once the cycle fails they refuse to even have the courtesy to provide a followup appointment or answer some basic questions ! What's even worse is that some doctors flatly refuse to give patients a copy of their medical records or even a basic medical treatment summary . Because they want to hold on to their patient, they hold on to all the medical records well - and this often smacks of a shady cover-up job. This is illegal as well - patients have a legal right to their medical records, and no doctor can refuse to give you a copy !

This is sad, because good IVF doctors do not have anything to hide. The honest truth is that there are no often no clear answers as to why an IVF cycle fails, because our technology is not good enough to figure out why embryos do not implant .

A good doctor understands the importance of sitting down with the patient and analysing the failed IVF cycle. At the end of each failed cycle, I explain

* what went right ;
* what went wrong;
* what we still cannot understand; and
* what we can do differently the next time to maximise the chances of success.


Most importantly, good IVF doctors need to prepare patients for possible failure even before the treatment cycle starts ! Patients are intelligent and need to taught to have realistic expectations before they start their treatment.

So if the cycle fails, does that mean we are really back to square one ? Not really ! We learn lots of useful stuff from each failed cycle.

Did the follicles grow well ? What was the egg quality ? Was the fertilisation rate good ?
Did the endometrium grow well ? ?
Was the transfer easy ?

Often the next cycle has a higher success rate, because we can customise and modify the treatment plan, based on what we have learned from the patient's response in the first cycle.

So if your cycle fails, try to get as much information from this failure ( and getting a medical treatment summary including photos of your embryos is critically important !) ; give yourself time to grieve ; and then move on !

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Saturday, April 24, 2010

Secondary Infertility - Trapped between Fertile and Infertile Worlds !

Irregular cycles - PCOD or poor ovarian reserve ?


I just saw a young woman who was sobbing as if her heart would break. She had had irregular cycles for many years, and I had just informed her that the reason for her irregular cycles was the fact that her egg quality was very poor, and that the only way she could have a baby was by using donor eggs.

She was very upset - and was actually quite angry with me ! She had been going to a gynecologist for the last 3 years in order to try to have a baby. He had diagnosed her as having PCOD ( polycystic ovarian disease) and had told her that this was the reason for her irregular cycles. She was given Duphaston every month to induce a cycle - and had even had 2 IUI cycles done.

On reviewing her records, I pointed out to her that her FSH level on more than 2 occasions had been very high - and this confirmed the diagnosis of ovarian failure.

Now she was angry with her gynecologist ! Why hadn't he made the right diagnosis ?
How could he miss the significance of the high FSH level ?

It was not until she came to me for a second opinion did she realise that her high FSH meant she had entered the oopause. She was very bitter, because she had always been very worried about her irregular cycles. However, her gynec had always reassured her, saying - " Don't worry - you are young ! Your eggs are fine !"

It's important to differentiate between calendar age and ovarian age - and not all young women will have young ovaries ! Unfortunately, for many of these women, the diagnosis is not made in time. The eye only sees what the mind knows, and many gynecs do not even consider the possibility of premature ovarian failure when treating young women, because the majority of their patients are fertile !

It's even worse when they are misdiagnosed as having PCOD. The reason her periods were irregular is because she did not ovulate. This is called anovulation. Now while it is true that the commonest cause for anovulation is PCOD, the other common diagnosis which needs to be ruled out is premature ovarian failure. The high FSH level should have allowed the gynec to make the right diagnosis !

When patients have irregular periods, we advise them to do the following tests.

1. Blood tests for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of the cycle, ( to check the quality of their eggs).

Patients with PCOD have high AMH levels; high LH levels; and a normal FSH levels. Patients with ovarian failure, on the other hand, have high FSH levels and low AMH levels.

This diagnosis can be confirmed by doing a vaginal ultrasound scan which checks for ovarian volume and antral follicle count. Patients with PCOD have large ovaries, with an increased antral follicle count. Patients in the oopause have small ovaries and a reduced antral follicle count.

The worst tragedy occurs when a patient with anovulation because of poor ovarian reserve is misdiagnosed as having PCOD. Some doctors will do an ovarian drilling for these patients - and this destruction of their normal ovarian tissue will cause them to have iatrogenic ( produced by a physician) premature ovarian failure !

Conversely, we also to see patients with PCOD who have done IVF and have been told by their doctors that they have poor ovarian reserve, because the doctor did not do a good job superovulating them ! It's a pleasure to treat these patients, because with the right superovulation, they have very high pregnancy rates !

If you are unsure of your diagnosis, the single most important test you can do is to check your AMH level. This is a reliable test - and makes it very easy to differentiate between PCOD and oopause !


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Friday, April 23, 2010

Donor eggs and donor embryos - how much should you know about the donors - and why ?


We have a very active donor egg and donor embryo IVF program. Many couples want to know more information about our donors - their physical traits; educational background; special interests; religion , and so on.

This is perfectly understandable - after all, this is an anonymous and confidential donation, and it's quite natural to be curious and learn as much as possible about the person who is making such an important contribution to your future family !

Also, I think patients' expectations have been set by US clinics and donor agencies, which provide extensive and detailed online catalogs and lists of donors. However, I sometimes wonder what the value of all this is. In my opinion, these resemble a shopping list too much for my liking ( but given the consumer culture in the USA, where everything is market-driven, this is to be expected ). The US attitude seems to be the more you know the better for you, but this is not true, because it turns prospective parents into shoppers and donor gametes into a commodity. The downside is that parents who are shopping for the "perfect donor" maybe disappointed if their child does not turn out to be perfect !

What is our approach ? We ask patients why they want to know any of this information and whether it will have any impact on their decision making process. If the answer to your question will not influence your actions, then why ask the question in the first place ? I am reminded of the famous anecdote, in which the celebrated dancer Isadora Duncan wrote to George Bernard Shaw declaring that, given the principles of eugenics, they should have a child together.

"Think of it!" she enthused. "With my body and your brains, what a wonder it would be."

"Yes," Shaw replied. "But what if it had my body and your brains?"


I agree using gametes from an anonymous donor in such a personal and private part of your life is a major leap of faith , but if you are not comfortable making it, maybe you should explore other alternatives !

We do screen our donors for their health and for infectious diseases and will match physical traits. I feel the focus should be on making sure the gametes and embryos come from healthy parents , and this is what we ensure. I feel the rest of the information is irrelevant. When you go to a blood bank, do you ask any of these questions ? How are they relevant to donor eggs and donor sperms ( which are also body fluids, after all !)

While the Nature versus Nurture argument will never be resolved, I firmly believe that your child is what you choose to make him/her ! The only important ingredient is love , and this should not depend upon the physical traits of the donor. Be grateful that someone is generous enough to be willing to make this donation - and then do your best to bring up your child as best you can !


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Wednesday, April 21, 2010

Unable-to-conceive-Here-s-help- Hindustan Times

Unable-to-conceive-Here's-help- Hindustan Times It’s a strange feeling. You meet someone who’s just starting to come to life as a four-cell embryo in a petri dish, and years later, when that someone’s grown into a bouncing five-year-old boy, you’re invited by his parents to be his godfather…

That’s why Dr Aniruddha Malpani, MD, who runs the Malpani Infertility Clinic in Mumbai with his wife, Anjali, loves what he does. Fertility specialists treat people who are unable to reproduce (men might have low sperm counts and other complications, women might have uterine problems, etc). “Being an in vitro fertilisation (IVF) specialist is one of the most rewarding careers possible, because you are changing the life of a family by helping them give birth to a deeply cherished child,” says Dr Malpani.

Poor ovarian reserve as a cause of "unexplained infertility"


One of the most frustrating diagnosis for infertile couples is that of unexplained infertility. In once sense, this is a " non-diagnosis" - it's a confession of our ignorance, and means that we do not know why the couple is not getting pregnant.

Infertile patients find it very hard to understand why doctors cannot pinpoint the problem. Their major fear is that if the doctor cannot even find the problem, how will he be able to solve
it ? Even worse, every menstrual cycle is a mixture of hope and dread. Every missed period may represent a pregnancy - finally ! And every time the period starts, the hopes are dashed and the waiting begins all over again !

The good news is that as our technology improves, and we learn more about about reproductive biology, we have developed better tools to diagnose problems which remained undiagnosed in the past.

A very good example of this is the blood test for checking AMH levels.

Women with regular cycles usually assumed that they had good quality eggs. Most gynecologists did so as well, because we really had no good technique for assessing egg quality. Eggs are microscopic, so it's hard to track these ! Doctors would have to depend on indirect tests to check egg quality, such as measuring the follicles in the ovary ( antral follicle count); or testing the FSH level.

While ovarian age usually does correlate well with calendar age, this can sometimes be misleading . Some young women are infertile because they have poor quality eggs . After all, being young does not protect you from having poor quality eggs ! However, they were lulled by their regular cycle into a false sense of security regarding their egg quality , as were their doctors. Most would tell young women who were trying to get pregnant - " Just relax and continue trying - it's the stress ( such a hurtful word !) which is preventing you from having a baby naturally. "

The diagnosis of poor quality eggs in these young women with regular cycles was often missed with great regularity because doctors did not test for this possibility. These women had reached the oopause - but many gynecologists were not even aware of this condition !

The good news is that we now have a simple blood test to check for ovarian reserve. This is a blood test to check for AMH levels. This test is :

  • easy to perform
  • easy to interpret
  • reliable
  • does not vary from cycle to cycle
  • can be done on any day of the cycle
Just because you are young does not mean you cannot have have poor quality eggs - fertility problems can occur at any age. Telling a young woman that her egg quality is poor is difficult for a doctor, but it's better to know the truth, even if it is bitter ! I believe that no patient should be diagnosed as having unexplained infertility without getting an AMH level done to assess her ovarian reserve. Not having the right diagnosis made in a timely fashion can cause a lot of heartburn and needless distress later on !

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Tuesday, April 20, 2010

Healthy book sale at HELP - all books are 50% off !




HELP - Health Education Library for People
Excelsior Business Center,
National Insurance Building,
Ground Floor, Near Excelsior Cinema,
206, Dr.D.N Road, Mumbai 400001
Tel. No.:65952393/65952394

Do you need a hysteroscopy before doing IVF ?


In order for an IVF treatment cycle to succeed, the embryos need a healthy uterus in which they can implant. There are many tests to evaluate the uterine cavity and the endometrial lining. These include noninvasive tests such as ultrasound scans ( including 3-d vaginal ultrasound scans) and a HSG ( hysterosalpingogram); and invasive tests such as hysteroscopy. The most accurate method for evaluating the uterine cavity is a hysteroscopy, because it allows the doctor to actually look inside the uterus . However, because it involves a surgical procedure, it is expensive; and while this is a reason why many doctors what to do this, many patients are not keen on getting it done !

It's quite interesting to analyse the attitude of IVF clinics towards hysteroscopy. Some doctors will routinely perform a hysteroscopy for every patient prior to doing an IVF cycle. They consider this to be a part of their basic pre-IVF evaluation, along with the semen analysis and the testing for ovarian function.

Others will perform a hysteroscopy only selectively. Both these options have pros and cons, so let's look at these.

Doctors who routinely perform a hysteroscopy justify this by saying that it allows them to pick up ( and correct) problems which would otherwise be missed by other techniques such as ultrasound scanning , because these noninvasive tests are not as reliable or sensitive as a hysteroscopy. They remember all the patients in whom they identified a small polyp or adhesion prior to doing the IVF - a finding which was missed on the HSG or the ultrasound scan. They feel that if patients are going to spend so much money on an IVF, it makes sense to make them spend a little bit more, if this will improve their chances of having a baby. They feel a hysteroscopy is a simple , office-based procedure which can be done very easily; and that even if it is normal, it can still be justified, because it can provide additional reassurance to the patient that her uterus is normal. The big ( often unstated) benefit for doctors is that it is a great additional source of revenue.

So why don't all IVF doctors do hysteroscopy routinely prior to doing IVF ? Many doctors are quite conservative and feel that it is not justified to make the patient spend money on invasive procedures - especially if this information can be obtained less expensively and easily by non-invasive tests. It is possible that the hysteroscopy can pick up abnormalities which are missed by the ultrasound, but is it justified to subject hundreds of patients to a procedure in order to pick up a problem in only a few of them ? And is identifying these minor abnormalities of any clinical use ? Does correcting them actually improve IVF pregnancy rates ?

This is a vexed issue; and there is still no consensus on what the right approach is.

In fact, IVF doctors often find themselves in a bind. If you make patients do lots of tests, then patients feel that you are greedy and are making them waste their time and money on medical testing . On the other hand, if you do not do the test, then patients feel you are sloppy and your workup is incomplete and shoddy !

We try to take a balanced approach in our clinic. For the three critically important tests prior to IVF - semen analysis; blood tests for ovarian function ( FSH,LH,PRL,TSH,AMH); and the ultrasound scan, we will insist that patients do these from labs we can trust, as our entire treatment depends upon these results. These tests are easy to perform and inexpensive.

However, for expensive and invasive tests, we will take conservative attitude ; and do these ( or repeat them) only if our simple screening tests suggest there is a problem.

I have learned that there is no "one size fits all" solution. We try to tailor our approach to each patient and try to factor in the patient's preference when making these decisions. Thus, for patients who are fed up of tests, we will try to minimise these. However, for patients who have failed multiple IVF cycles or who demand a "complete checkup ", we will be more liberal with ordering tests. We do not have a rigid policy and try to involve the patient in these important decisions, so the patient is well-informed about the pros and cons of both approaches !
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Monday, April 19, 2010

IMSI versus ICSI


Doctors love coining new terms , and this seems to be especially true for IVF specialists. Infertile couples have to learn a whole alphabetic potpourri of medical terms - ranging from IVF to GIFT to ICSI to ZIFT. It's easy to get lost and confused; and most patients can't seem to make sense of any of these !

To add insult to injury, many IVF doctors claim to use "the new and latest" technique to improve pregnancy rates. Obviously, every "new" technique needs a new name - so the confusion gets compounded. It's a competitive business, and IVF doctors always try to keep one step ahead of other doctors ! While this is good because it allows patients access to the newest technology, the downside is that many doctors will then promote a particular technique – not because it is better, but simply because it is new !

It’s easy to get a lot of press coverage for a lot of these “new” advances, because reporters are often not medically sophisticated, and most are quite happy to oblige their doctor friends. Poor patients get even more confused – and will often flock to the doctor featured in the latest article, in the hope that this new technique will give them a baby ! This then sets up a vicious cycle, where doctors compete with each other, in order to be featured in the press. It often becomes a game of one-upmanship, where the doctor with the best PR firm wins !

The newest kid on the block is a term called IMSI ! This stands for Intracytoplasmic Morphology Selected sperm Injection – quite a mouthful ! This is simply a modification of the standard ICSI technique, in which the sperm are magnified even further. The rationale is very logically appealing – let’s use higher powered magnification, so we can select the “best “ sperm for ICSI ! One would therefore expect that this technique would result in higher pregnancy rates after ICSI.

Unfortunately, this is not true in real life. Not only does IMSI not improve pregnancy rates as compared to ICSI, it can actually decrease them. The reason is simple - IMSI takes longer to perform than ICSI because it's much harder to identify sperm when using such high magnification. At such a high power, the field of view is obviously very limited, which means that the embryologist has to scan for much longer to pick up the selected sperm. This means that the embryologist has to keep the fragile eggs ( into which the sperm have to be injected ) on the micromanipulator for longer while doing IMSI, and since eggs are very sensitive, and do not like being kept outside the incubator, this extra exposure can cause them to get damaged.

However, it's very easy to take patients for a ride, and many clinics are now pushing patients who have failed ICSI cycles in other clinics to do IMSI, claiming that the success rates are higher with IMSI.

Caveat emptor - let the patient beware ! More is not always better - and often established techniques are much better than newer ones !

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Making sense of your semen analysis report


The semen analysis report is the basic test of a man's fertility. However, this is a complex report and it can be hard to make sense of the numbers on this laboratory test.

Here's a free simple tool to help you make sense of what your sperm test numbers mean !

View a sample SEMEN ANALYSIS REPORT here !

Thursday, April 15, 2010

Embryo adoption versus surrogacy


We get lots of requests for surrogacy treatment . India is now acknowledged to be a global leader in IVF technology; and because surrogates are easily available and IVF treatment is much less expensive than in other parts of the world, many couples travel to India for surrogacy treatment.

While this is good news, because they can get cost effective treatment, the downside is that surrogacy gets very overused. Because it is very profitable, many doctors offer it to patients who do not need it - and even worse, those who will not benefit from it !

Typically, women who ask for surrogacy are older women, or women who have failed many IVF cycles. They are desperate and emotionally vulnerable and feel that the best solution to their problem of repeated failed embryo implantation is to use a surrogate. They have low self-esteem, and believe that fact that their embryos do not implant means that their uterus is defective. This is why they feel that using a surrogate is a logical answer which will help them to solve this problem ! They have very unrealistic expectations of surrogacy success rates - and a flawed understanding of reproductive biology

The commonest reason for failed embryo implantation is NOT a defective uterus, but rather genetically abnormal embryos. 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.

This is why if there is a problem with embryo implantation, changing the embryos is a better option than changing the uterus, which is why embryo adoption is often a much better option than surrogacy for these patients.

The reason is simple ! 9 times out of 10, the problem in patients with repeated failed IVF cycles is not with the uterus but with the eggs !

I think this fact needs to be emphasised. As women get older, they know their fertility declines. Most assume that this is because their reproductive system is aging - and for most women their reproductive system consists of their uterus. If menopause = no periods = nonfunctioning uterus, it is quite logical to conclude that increased age = reduce fertility = poorly functioning uterus. Seen from this perspective, changing the uterus to improve fertility by doing surrogacy treatment is very logical !

However, this logic is flawed. Hundreds of medical studies have proven that as a woman gets older and enters the menopause , even though her uterus stops functioning, this is only because of the absence of ovarian hormonal stimulation. If the uterus is exposed to estrogen and progesterone, it starts working one again - even if she is 72 years old !

I feel an effective solution to prevent the misuse of surrogacy is that this treatment option should be endorsed by two independent IVF specialists, before a patient is signed up for an IVF program. This should help to prevent the overuse and misuse of surrogacy treatment !

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Wednesday, April 14, 2010

Poor quality eggs - doctor or patient ?


I just received an email from a patient who wanted a second opinion. She was 25 years old and had just completed an IVF treatment cycle at another clinic. She had got only 3 eggs and 2 poor quality embryos; and her doctor had told her that her problem was "poor quality eggs" and that she needed donor eggs. She was very upset and frustrated, and wanted to know how we could help her.

Now while it is possible that young women can have poor quality eggs, this not common. Step number 1 was to review her IVF medical records, so I asked her to send these to me.

Unfortunately, she did not have any records at all ! " My doctor refuses to give these " was what she told me. This is extremely frustrating and makes my blood boil. I cannot understand why IVF clinics do not routinely provide patients with their medical records. This is their duty and why should doctors want to hide anything.

This meant that I had to try to reconstruct the cycle based on what she had been told. Unfortunately, her information was very sketchy and unreliable. She felt she did grow lots of follicles on ultrasound scanning; and that the doctor initially was happy with her ovarian response, but managed to collect only 3 eggs at egg retrieval.

I had to ask her to start from scratch and test her ovarian reserve, so I could find out whether the reason for the poor quality eggs was poor ovarian reserve; or poor medical care. Often doctors may not do a good job with superovulation, as a result of which even patients with good ovarian reserve end up growing few, poor quality eggs. Superovulation is a skill which takes time and experience to master.

This is especially true for patients with PCOD. Doctors are often so scared of OHSS, that they end up mistiming the HCG injection, as a result of which they get poor quality embryos ( even though they may collect lots of eggs). We use a special technique and have extensive experience in doing IVF for PCOD patients, which means our pregnancy rates are better than 45% per cycle for PCOD patients. You can read more about this at www.drmalpani.com/pcod.htm !

If you get poor quality eggs, remember that there are only 2 things you can change :
  • the doctor - find a new IVF clinic;
  • your eggs - use donor eggs.
While many doctors are quite happy to push you towards using donor eggs ( this has a high pregnancy rate and is much more profitable for the doctor), this should always be Plan B. It makes much more sense to change the doctor first !

So if your doctor says you have poor quality eggs, what should you do ?

Step number one is to ask for a copy of your IVF medical reports ( make this request in writing, so that it is honoured !)

Review your IVF chart, and look especially for the following details.

Number of follicles on ultrasound scanning
Number of eggs collected and their maturity
E2 ( estradiol) levels

If you have lots of follicles but not enough eggs , this suggests poor egg collection skills. This could be because of anatomic problems which make the egg collection technically difficult. An experienced and skilled doctor can usually do a much better job !

Did you have lots of eggs but not enough embryos ? This suggests the eggs were immature and that perhaps the HCG was not timed properly, which means egg collection was mis-timed. The other problem may be a lab problem. You will need to drill down deeper ! Was IVF done ? Was ICSI done ? How many eggs were mature ( metaphase II) ? What was the egg damage rate ?

The key step is to test your ovarian reserve. The best way of doing this is to check your AMH levels. This is a new test which many IVF clinics still do not offer, because they still use the old fashioned ( and unreliable) FSH level to check ovarian reserve. If your AMH level is normal, then suggests you have normal ovarian reserve, and you'd be better off finding a new doctor. This is especially true if the AMH is high, because this strongly suggests you have occult PCOD, a diagnosis your doctor has most probably overlooked.

If your AMH is low, then this does suggest you have poor ovarian reserve. In this case, your best option would be to change the superovulation protocol and use more aggressive superovulation. If your doctor insists on using the same old rigid protocol ( because their clinic policy does not allow them any flexibility), then it's a good idea to change your doctor. As Albert Einstein said, Insanity is doing the same thing over and over again and expecting different results !

Using donor eggs is an option, but this can often be very hard to come to terms with, which is why this should be Plan B !
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Monday, April 12, 2010

Why aren't abnormal sperm a cause of miscarriages ?

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

We know that the commonest reason for a miscarriage is a genetic abnormality in the embryo, and that 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.

We also know that abnormal embryos are the commonest reason for failed embryo implantation after IVF; and that this is the reason why IVF failure rates increase for older women.

Now, since the sperm provide 50% of the genes of the embryo, it is logical to assume that 50% of the time the reason for genetically abnormal embryos ( and thus failed IVF cycles and recurrent miscarriages) would be genetically abnormal sperm !

However, what is logical is not always true ! In reality, studies have shown that there is no correlation between abnormal sperm and failed IVF or miscarriages.

Let's look at a very common reason for infertility. This is the problem of abnormal sperm morphology, known medically as teratozoospermia. These are men who have a very large proportion of abnormally shaped sperm - more than 95% abnormal forms. The standard treatment for these men is ICSI, in which a single sperm is injected into an egg to fertilise it.

Now one would logically expect that the fertilisation rate in these men would be very low; or that many of these embryos would be abnormal, as a result of which they would not implant. Surprisingly, this is not true - and the fertilisation and pregnancy rate in these men is exactly the same as it is in men with normal sperm. This means that abnormal sperm do not create abnormal babies ! This is one of the reasons why all the new sperm tests which check for sperm DNA integrity are of such little clinical value.

This is very counter-intuitive, but this is the truth. What are the possible explanations ? Why do men play such a seemingly unimportant role in human reproductive wastage ?

One hypothesis is that it is possible that the egg can correct for the sperm’s problems. After all, the egg is much larger than the sperm; and the cytoplasmic machinery and energy which drives cell division after fertilization comes only from the egg. The other possibility is that the defects caused by abnormal sperm are lethal and incompatible with embryo development beyond a particular point.

In the mouse lab, it would be interesting to deliberately inject chromosomally abnormal sperm into eggs, and then to follow their fate, to try to figure out a possible explanation !

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The one question my patients hate me for asking

One question I always ask my patients before they start an IVF treatment cycle is - What is Plan B ? What will you do if the cycle fails ?

Many patients get upset when I ask them this question. They feel I am being very negative and that this means I think that their chances of getting pregnant are poor.

Actually, I am an eternal optimist; and because we have high success rates, many of our patients do get pregnant when they do IVF with us.

However, there's no need to prepare for success. It's far more important that they prepare for failure, as the outcome of any IVF cycle is always unknown. I need to be sure that they have realistic expectations from our treatment , so that they can cope with the ups and downs of an IVF cycle.

If they do not do this then IVF can become a very bumpy an emotional roller coaster ride !

Adoption versus embryo adoption

A picture of a young childImage via Wikipedia

Many infertile couples are happy to explore the option of adoption in order to build their family when IVF treatment fails.

They naively believe that after going through the ordeal of many failed IVF cycles, adopting a baby will be a piece of cake. However, many find to their dismay that there just aren't that many babies available for adoption anymore !

In one sense, this is hardly surprising ! With improving levels of education and the empowerment of women, unmarried girls use contraception and terminate unwanted pregnancies. Very few women will now carry an unwanted pregnancy all the way to term.

However, while the number of abandoned babies is gradually shrinking, the number of infertile couples is progressively rising. There are now long waiting lists - and many adoption agencies just do not have any babies available for adoption ! The ones they do have are often much older; or have a disability, which means many infertile couples are not happy about adoption them, because most would prefer a healthy newborn.

The good news is that there is now a newer option available, to help many couples satisfy their desire for a baby, if they are willing to consider adoption. This is the option of embryo adoption. Unfortunately, this is a choice which not many infertile couples are aware of. Sadly, even social workers in adoption agencies and gynecologists are not familiar with this new advance.

What does embryo adoption involve ? Rather than adopt a baby, couples adopt embryos ! The option has many advantages.

  • There are no waiting lists
  • The success rates are high
  • Couples get to experience pregnancy and birth
  • There is no social stigma, since the name on the baby's birth certificate is the infertile couple's
  • There is no need for the couple to get permission for this decision from family members

Where do these embryos come from ?

These are supernumerary embryos which young infertile couples going through IVF freeze and store for themselves. If they get pregnant in their fresh IVF cycle, many are happy to donate their embryos to other infertile couples, to help them build their family. Embryo adoption is usually anonymous and confidential.

You can read more about our embryo adoption program here.


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Saturday, April 10, 2010

The one number all women who are planning a baby need to know !


Many women these days are postponing having a baby in order to pursue a career. The good news is that while usually fertility does not decline too much until the age of 32, for some women the decision to postpone childbearing can prove to be one they bitterly regret later on. Fertility does decline as a woman grows older, and the problem is that it is not possible to predict the rate of decline for an individual woman. Most women are lulled into a false sense of security if they have regular period, because they assume that if their periods are regular, this automatically means that their egg quality if enough for them to make babies !

Unfortunately, this is not always true - and for some women, while their egg quality is enough for them to produce enough hormones to get regular periods, it may not be enough to make a baby ! Also, many women have very unrealistic expectations of IVF technology, thanks to all the stories of the over-40 celebs who have babies all the time ( often by using donor eggs, a fact which is very jealously guarded secret) !

How is an individual woman going to find out which category she falls into ?

Suppose you are 32 and want to postpone childbearing for another year because you have a very good chance of getting a promotion ? Is it safe to do so ? Or will this be something you will kick yourself for later on when your IVF doctor says - I wish you had come to me earlier ?

The bad news was that until now, there really was no very good test to check ovarian reserve. This often meant that most women had to just leave things upto destiny, which can be notoriously fickle.

The good news is that there is now a very good test to check your ovarian reserve !

The bad news is that most women are unaware of this test !

The good news is that this is a very simple blood test, which most labs now offer !

The bad news is that most family physicians and gynecologists are still unaware of this test and what it means !

So what's this test ?

This is a blood test for checking your AMH ( anti Mullerian hormone) levels. It can be done on any day of your cycle. The level correlates well with your ovarian reserve - the quantity and quality of eggs you have in your ovaries. Women with normal levels have good ovarian reserve; while those with low levels have poor ovarian reserve.

If you are more than 32 and want to postpone childbearing, I'd suggest you get this test done. If it's low, you might want to re-think your priorities. If it's normal, then it's fine to postpone childbearing, but do get the test repeated every year. If it starts dropping, this is a sign you might want to pay attention to your biological clock before it is too late !
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The 10 Laws of Medicine


  • First Law: The art of medicine consists of amusing the patient while nature takes its course.
  • Second Law: It is impossible to make an asymptomatic patient feel better.
  • Third Law: The urgency of the test is inversely proportional to the IQ of the insurance company preauthorization clerk.
  • Fourth Law: There is no cure for stupid.
  • Fifth Law: Bad things really do happen to good people.
  • Sixth Law: The better the surgeon, the more reluctant s/he is to operate.
  • Seventh Law:
    Part A: It has to be fun.
    Part B: If it isn't fun, see Part A.
  • Eighth Law: Half of what is taught in medical school is wrong, but no one knows which half.
  • Ninth Law: Poor planning on your part does not constitute an emergency on my part.
  • Tenth Law: A bad idea held by many people for a long time is still a bad idea.

Endometriosis and infertility - surgery or IVF ?

endometriotic lesions in the Douglas pouch and...Image via Wikipedia

Endometriosis is one of the commoner problem infertility specialists see. It is common in young women, so this is hardly surprising - but what is amazing is the amount of confusion and controversy it causes amongst infertility specialists.

There are many treatment options, but for treating endo in an infertile woman, doctors have to choose between endoscopic surgery; or IVF.

Most gynecologists like operating. They feel that it's obvious that the mechanism by which endo causes infertility is anatomical; and that surgically removing the lesions and the adhesions should fix the problem and restore fertility. Surgery is often less expensive than IVF - and if normal function is in fact restored after surgery, than you can make a baby in your own bedroom ! This is a common approach but is flawed because it is not an accurate representation of reality. After all, surgical correction can restore anatomy , but not function !

IVF specialists see many patients with endo who have had repeated surgeries, but have never been able to get pregnant. Because an operative laparoscopy is "minimally invasive" surgery and so easy to repeat, many surgeons just keep on doing it again and again ! Patients will often move from surgeon to surgeon, each of whom will promise to " fix the problem " by using the latest gizmo or toy they have just purchased , whether this is a laser , a bipolar cautery or a harmonic scalpel. Surgeons are nortoriously macho, and often believe they can do a much better job than the earlier surgeon ! The poor patient is subjected to surgery after surgery, until her belly resembles a battle field - but with nary a single positive HCG in sight !

So does that mean all patients with endo should be referred to IVF specialists for IVF treatment ? Of course not ! This would be overkill , as many patients with minimal endo can be treated with simpler treatment options.

If you go to a gynecologist or endoscopic surgeon, the odds are he will advise surgery. And if you go to an IVF specialist, he will advise IVF ! After all, if you have a hammer in your hand, all you see are nails !

So how is the patient to decide which is the best option for her ? Some will take an opinion from multiple doctors - and end up getting thoroughly confused, upset and frustrated !

The trick to finding out what your best plan of action is actually quite surprising - you need know what your ovarian reserve is ! Unfortunately, this is something very few patients know about - and very few doctors bother to check !

Your ovarian reserve is a marker of your fertility and gives us an indication of how many eggs you have left. It declines with age; is negatively impacted by endometrisis; as well as the surgery which is done to treat the endometriosis ! Unnecessary surgery reduces your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your impaired ovarian reserve even further .

The best test for your ovarian reserve is a blood test to check your AMH levels.

If you are older and/or have low AMH levels, then it's far better to not waste time with surgery, and move on to IVF directly . This is also true if your husband has a low sperm count.

However, if you are young and have normal AMH levels, it is quite reasonable to attempt reconstructive surgery to treat the endometriosis before considering IVF, which is usually much more expensive than surgery ! If you do choose to have surgery, make sure your doctor checks your AMH levels before and after the surgery ! Many doctors do not bother to do this - and this can reduce your chances of having a baby !

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Friday, April 09, 2010

Confused about progesterone ?

Lots of infertile women are confused about what progesterone does. They know that progesterone is a key reproductive hormone; that it is present in birth control pills; and that it is used to induce a period when this is overdue.

Therefore, when their doctor prescribes the same progesterone when they are pregnant, explaining that it is being used to support the pregnancy, they are very confused. How could a hormone which is being used to bring on a period possibly also be used for supporting a pregnancy ? It just does not make any sense.

Actually, it does ! Progesterone is the hormone which the corpus luteum in the ovary produces to help during the implantation of the embryo . It creates secretory changes in the uterus lining, so that it is ready to receive the embryo. This is why it's role in supporting the pregnancy is quite straightforward. Even the name, pro ( = for, towards, helping) -gest ( = pregnancy) -erone ( = steroid hormone) suggests this role - it supports the pregnancy !

So how is this used to induce a period ? Remember that it's not the progesterone per se which induces the period. In fact, if you take progesterone for long periods of time in high enough doses, the period will get indefinitely postponed. When your doctor induces a period for you with progesterone, he gives it only for a short amount of time - for about 3-5 days . The period starts 3-8 days after you stop the last tablet of progesterone , because the uterine lining has lost the support the progesterone was providing. This is why this progesterone induced bleeding is called a " withdrawal bleed" - it's the withdrawal of the progesterone which causes the onset of the period ( just like it does in a normal menstrual cycle , when the corpus luteum dies and stops producing progeserone because there is no embryo to produce HCG to rescue it !)

Thursday, April 08, 2010

A Bombay doctor visits Ahmedabad - an eye opener !


I was recently invited to give a talk to the Ahmedabad medical association on How to be a Successful Doctor. After my talk, I went to visit 2 private hospitals, to see how doctors in Ahmedabad delivered medical care.

This visit was quite an eye-opener. Bombay is widely accepted as the Medical Center of India - and Bombay doctors treat patients from all over the country, including lots of patients from Ahmedabad !

I saw two hospitals. One was an IVF center; and the other was a Urology clinic. Each of these was a stand-alone 4-floor purpose-built building , covering about 20000 square feet. In comparison, in Bombay, where real estate is about 10 times as expensive, the typical private nursing home or hospital is about one tenth the size !

Because there is no shortage of space in Ahmedabad, doctors can build large hospitals for themselves - something which is impossible in Bombay ! These doctors are hard working specialists in private practise. They have a very entrepreneurial bent of mind, since they run their own hospital . While it's true that their patients are not very well off, and do not pay too much ( which means they charge a fraction of what Bombay doctors do ), these doctors have a huge patient workload and a lot of clinical expertise .

The doctors I visited have invested lot of money in buying top quality high end medical equipment , imported from all over the world. They do not skimp on buying medical equipment when they feel this is cost effective and helps them to perform better. This is why they provide high quality care- at a fraction of the cost which doctors in Bombay do !

Travelling to Ahmedabad is easy and the infrastructure is improving dramatically. Accommodation for patients and their family members is cheap; and these doctors have developed lots of clever indigenous innovations to keep costs down ! These have been clinically proven to work well in practise , allowing them to offer low cost high quality care !

I feel doctors from Bombay - and in fact doctors from all over the world - can learn a lot from doctors practising in Tier 2 and 3 Indian cities such as Ahmedabad.

If this is true, then why don't they attract more patients ? And why did I have to make a trip Ahmedabad to learn about the work these doctors are doing ? Why don't patients know about them ? And why don't other doctors learn from them ?

I think the answer is simple and is two-fold. The first problem is a limited vision. While there are some notable exceptions, most of these doctors are quite contented taking care of local patients. The other major problem is poor marketing. They do have websites, but these are poorly maintained and are rarely updated. Because of limited English language skills, the websites are full of grammatical errors and typos - all of which create a poor impression.

Why don't they do a better job ? This is honestly a million-dollar question I cannot answer ! These are easy problems to fix ! They can easily start websites, and especially if they do these in local Indian languages, they will have practically no competition ! While the internet may be global, it's great for attracting local patients ! I think doctors still underestimate the power of the internet and do not realise how many patients use this these days to find the best medical care for themselves.

Some doctors are intimidated by the technological complexity which they think is involved in running a website; while others do not bother , because none of the other doctors in the town have one either. Others have tried, but were very disappointed with the results, because they had very unrealistic expectations. Digital marketing is inexpensive - but requires a lot of patience ! These doctors can easily use video to reach low literacy patients - and this will become increasingly important as internet penetration in India improves; and every one carries a smart phone.

These small doctor-owned hospitals are often far better than corporate hospitals , because they provide personalised care, at a lower cost. However, unless these doctors learn to use the internet to market their services, they will continue losing their well-off patients to doctors from Bombay ! They need to think of the future or they will remain stuck in the past !


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Wednesday, April 07, 2010

Medical flying squad to protect doctors


Medical Flying squads were created in order to handle medical emergencies . They were first developed by obstetricians, and a team of medical personnel was rushed to help women with complicated labours and childbirths. They were very useful and were responsible for saving many lives .

While flying squads are no longer very common, the Ahmedabad Medical Association has created a new concept of medical flying squads to help doctors who are faced with unexpected complications or emergencies.

One of the nightmares for any doctor in practise is an intraoperative emergency or complication. Unfortunately, no matter how careful and competent the doctor, it is a sad fact of life that complications will occur. For example, a patient may have a cardiac arrest during a minor surgical procedure; or a patient may die because of uncontrolled bleeding during a caesarean section.

When this happens, angry relatives and friends ( often goaded by goons ) will take matters in their own hands. There are now many instances where doctors have been beaten up and hospitals have been damaged, when these kinds of incidents occur. Doctors feel vulnerable and defenceless - and this has led to a rift between doctors and patients. Doctors will often turn away emergency cases because they do not want to take a risk in case the patient does not do well.

Unfortunately, the police are of little help in such emergencies. They will often fail to turn up - or even when they do, they often refuse to intervene or protect the doctor.

Even more significant than the physical damage these incidents cause, it is the irreparable harm they do to the doctor's psyche and his reputation which are especially worrisome. The doctor's broken bones will heal - but a good reputation created over a lifetime of providing good medical care goes down the drain in a few minutes. The media is quite happy to add fuel to fire, by reporting on the " doctor's gross medical negligence", without ever bothering to find the facts.

These incidents have an impact on other doctors as well, who then develop an patient-unfriendly attitude. Rather than treat each patient encounter as an opportunity to serve and heal, each patient is seen to be a potential adversary !

On a recent visit to Ahmedabad, I was very impressed to learn about a very clever initiative which the Ahmedabad Medical Association, an organisation which is now over 108 years old, has developed. Rather than depend upon the police to help them in their time of need, doctors have banded together to help each other.

The Association is remarkable for the sense of unity and camaraderie which exists amongst its members ! Practically all doctors in Ahmedabad are members - both family physicians and specialists. They have set up a medical flying squad, which consists of a group of senior doctors, who will rush to the aid of any doctor, no matter what time it is, whenever they receive a distress call.

An intraoperative emergency or complication is every doctor's nightmare - especially when this occurs in a small private nursing home. With this kind of backup service available, doctors in private practise can rest assured that help is just a phone call away !

Not only does the squad provide valuable medical assistance and a useful second opinion in handling the emergency, they provide a cool head to assist the doctor, who is often scared witless when the patient has a complication. This group of doctors provides reassurance to the relatives, that their patient is getting the best possible medical care from the leading specialists. They help to maintain peace and order - and can also organise police support if needed, as they are respected citizens who are held in high regard.

I think this is a great service and this is a model all Medical Associations all over the country can learn from. Senior doctors - including those who have retired, can offer to serve on these Flying Squads. Not only will this help them to keep gainfully occupied, it will also help them to earn a lot of respect and goodwill. After all, if doctors do not help each other, then who will ?

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Tuesday, April 06, 2010

Unexplained infertility

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This is a great solution - and will encourage patients to maintain their own PHR !

Ectopic pregnancy - the time bomb in the tube

Saturday, April 03, 2010

How good is your IVF doctor ?

8 cell stage, prior to morula formationImage via Wikipedia

How can a patient judge how good ( or bad) an IVF clinic is ? Success rates are a useful marker, but they have their own limitations , because they apply to groups of patients, not to individuals ! Also, clever clinics can easily game the system to artificially inflate their success rates.

What do you do if your cycle fails ? Should you continue with the same doctor ? Or should you find another doctor ? The outcome of an IVF cycle is always uncertain, and just because the cycle fails does not mean the IVF doctor is incompetent ! It's often much easier to stick with the same clinic. Some of this is just inertia - after all, he "knows your case" and you now have a relationship with him, so why switch ? Also, finding another doctor is hard work , and is it worth taking all that effort to do so if your present doctor is good enough ?

The secret fear is that it's possible that the reason for the failure is the fact that the IVF clinic you have selected is not very good, and you'd actually be better off going to a new doctor ! How do you make this decision ?

In order to do so, let's look at the three tangible deliverables a good IVF clinic can provide.

1. Growing eggs
2. Making embryos
3. Transferring the embryos

1 . Growing eggs. This is called superovulation and is the basic clinical skill of the IVF specialist. The doctor needs to select and adjust the dose of HMG used for superovulation , and to monitor the cycle to ensure optimal growth of eggs. While it's easy to get most young patients to grow lots of eggs, this can be quite a challenge for older women ; and for those with poor ovarian reserve. While most clinics will use a rigid standard superovulation protocol, a good clinic will tailor this to the patient, depending upon her age; antral follicle count; ovarian reserve; and her response to superovulation in prior IVF cycles. A good clinic will show you your follicles during the ultrasound scanning, so you can understand what is happening !

Patients with PCOD are also quite taxing, because of the risk of developing OHSS. They need careful gentle superovulation, with close monitoring.

Egg retrieval is another important skill. While many IVF doctors take pride in being able to complete an egg collection in 5 minutes, this is not necessarily in the patient's best interests. This is especially true when there are only a few follicles. In these patients, the technical skill of the surgeon can make all the difference between retrieving 6 eggs or just 2 eggs. Careful, patient surgeons will spend time carefully flushing each follicle, to maximise the chances of collecting all the eggs you have !


2. Making embryos. This is the heart of IVF technology and this is what the embryologist does in the IVF lab. For many patients, this remains a "black hole" area , but it is the expertise of the IVF lab which marks the key difference between a mediocre clinic and a good clinic. Lab skills play a key role in the ability of the clinic to make a large number of good quality embryos. Not only does this maximise chances of success, it also allows the clinic to freeze spare embryos. Does the clinic offer blastocyst transfer ? freezing using vitrification ? How many incubators do they have ? These may be technical minutiae, but make a world of a difference in the final outcome ! A good clinic will document the quality of your embryos by providing you with photographs !

3. Embryo transfer. The final step in the process is that of embryo transfer. This is a blind process, which is deceptively easy to do, but needs to be performed with love, skill and care ! The endometrium should be optimally receptive; and there should be no bleeding or trauma during the procedure. If there is cervical stenosis, a good clinic should be able to offer the option of tubal transfer using the ZIFT technique.

If your clinic refuses to treat you like an intelligent adult and share information with you; if they refuse to provide you with a treatment summary; if they do not show you your follicles during ultrasound scanning; and if they do not give you photos of your embryos, you should beware ! These are all red flags, which suggest you might be better off finding a better clinic !







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