Monday, February 28, 2011
I am the classic case of a woman who postponed starting a family to focus on her career while never believing that one day she would be facing infertility issues. I even believed that I could choose the month I wanted to get pregnant! I was almost 34 years old by the time my husband and I were out of school and settled enough in our jobs to start our family. I guess that is not really so old if there are no fertility issues, but if there are then time is definitely not on your side. By the time I turned 35 years old, we were living in Europe and began seeing a infertility specialist. In the middle of all the standard infertility tests, I managed to fall pregnant naturally. Our joy did not last long because at 8 weeks pregnant all that could be seen on the ultrasound were two empty gestational sacs. Nonetheless, the doctors felt that I had a good chance of getting pregnant naturally. I even had a laparoscopy done which showed that nothing was wrong. The doctors believed we had a good shot at IUI so we did 3 unsuccessful cycles before moving onto IVF.
I was 36.5 years old (tick tick tick) by the time we did our first IVF cycle. I always responded well to the medicines so we were confident that IVF would work for us. Our first cycle failed and our second cycle resulted in a chemical pregnancy. Frustrated after our third unsuccessful cycle, we changed clinics and found a doctor that would take a more aggressive approach. After two failed cycles, we changed clinics once again. The next cycle at the new clinic ended like all the others. in which I had 3 decent looking embryos transferred on day 3 but none of them implanted. The obvious conclusion was that there was a problem with my eggs. At this point, after 6 failed fresh cycles, I felt I had enough and could not endure another cycle. Above all, I did not think I could get pregnant with my own eggs. One of the worst things about infertility is that it slowly damages your self-esteem. No matter how much you know in your head that it is not your fault, you can not help but feeling like a failure. And as if that isn't bad enough, I would like myself even less because of all the feelings of anger and jealousy I had. But above all, I could not imagine living the rest of my life without children.
We searched the internet for egg donor options. In most European countries, it is illegal to pay egg donors so there are very few and the wait list is quite long. In the U.S., egg donors cost a fortune. We came across Dr Malpani's website. I was impressed by how much information was on the website, but most of all I was impressed with how well the emotional aspects of infertility were addressed. I began emailing Dr Malpani and he was always quick and thorough in answering all my questions. In fact, he was so quick in replying to my emails that I thought there must be something wrong! At one of the clinics we had been treated at we could not even talk directly with our doctor without making an appointment a few weeks to months in advance. After answering many of my emails, we felt that this was the right choice for us, but even so I was still a little unsure about going to a clinic in India and never having been there before or met Dr Malpani in person.
Dr Malpani found us an egg donor and 2 months later we were in Mumbai. I was still unsure about what to expect, but all my fears were laid to rest when we went to the clinic and were waiting with many other couples from around the world. Then after meeting Dr. Malpani and Dr Anjali Malpani I knew we made the right decision. We spent about a week and a half in Mumbai which was like a holiday for us. Everything was very smooth and easy.
After I got back, Dr Malpani continued to answer all my emails and ease my mind whenever I started to obsess negatively until I took my pregnancy test and got a positive result! We were so excited but still cautious until finally we saw and heard a beautiful little heartbeat at 6 weeks. Now I am experiencing all the joys of being pregnant, including the dreaded nausea!
Many gynecologists advise ovulation tracking as the first line of "treatment" for infertile couples.
This seems to be sensible advise. You just have to go for vaginal ultrasound scans which help you time precisely when you ovulate. You have sex at this time, and since eggs plus sperm = baby, you get pregnant in the first cycle itself ! How can this fail - especially if you are young and all your test results are normal ?
Actually, the tragedy is that patients have very unrealistic expectations from follicle tracking ! The success rate , even in a perfect cycle , is only about 10 % ! Remember that human reproduction is not very efficient, and just timing sex does not help ( unless you've never had sex at the right time earlier !)
Doctors often forget the downside of ordering follicular studies. It can be very stressful because you need to take time out of your office work duties to get ultrasound scans done . Even worse, it can play havoc with your sexual life. We all know that Men are from Mars and Women are from Venus - and this difference gets hugely exaggreated when you are battling with infertility, because you and your partner seem to be on completely different planets as regards having a baby . Most men would rather let nature take its own course - and having sex frequently in order to have a baby sounds like fun ! They just cannot understand why baby lust seems to have taken over their wife's life - and why you are obsessed with stuff like eggs and ovulation and fertile times !
Doctors can be very casual about advising scans and they underestimate the additional stress this puts on the marriage ! Husbands hate having to have sex on demand - they feel they have become reduced to becoming sperm donors who have to perform when ordered to do so. This takes all the fun out of sex, and adds to the marital disharmony when the wife refuses to have sex on any day other than the day of ovulation because she wants her husband to "store up" the good sperm ! This can often be the last straw which breaks the camel's back , because infertility already stresses the couple. Also, having to lie with your legs up in the air for the scans can be quite embarrassing and humiliating - and having a doctor insert an ultrasound probe into your vagina on a daily basis can be a major turnoff !
My advise is that one cycle of ovulation tracking is enough. This can be useful because it teaches you to correlate the scan findings with your body's signals , such as your cervical mucus and ovulation pain . Scanning also allows you to make better use of OPKs and the free online fertility calculator in future cycles, because you understand what's happening to your body, so you do not have to medicalise baby making sex in future cycles and track ovulation discreetly at home !
However, if your doctor advises repeated follicular studies, please get a second opinion ! Otherwise you ( and your husband) are likely to get fed up and frustrated before getting pregnant !
Saturday, February 26, 2011
Every once in a while I meet someone who restores my faith in humanity !
I took Mr and Mrs Rao to HELP today. They lost their young son, Satyajit ( Jeet) , who was in the prime of his life, to a fulminant T-cell lymphoma in USA in 1996. The untimely sudden loss of a grown up son can be the worst tragedy which could befall any parents. However, rather than wallowing in grief or cursing God, they set up JASCAP in 1996, in memory of their son, to help cancer patients with Information Therapy.
Over the last 15 years, on a shoe-string budget, they have published and distributed over 150000 copies of patient educational material on cancer in many Indian languages ! They started by selling books ( on a non-profit basis) from a briefcase outside a doctor's clinic in Tata Memorial Hospital . They now publish and distribute over 300 different publications about cancer in English and other Indian languages ( yes, English is an Indian language ! There are more Indians who speak English than there are Englishmen !)
Their mission has kept them young and full of energy. His favourite quote is - Find purpose and the means will follow ! I think Mr and Mrs Rao are great role models for patients and caregivers - they have transmuted their personal suffering , and evolved into citizens on a mission to help others.
This needs lots of guts and courage - but is the best memorial to their son, whose memory they have kept alive through their efforts !
HELP looks forward to working with JASCAP to promote patient education in India !
We see many patients who have failed multiple IVF treatment cycles in other clinics. Most of them are quite depressed and frustrated. They are not sure whether it's worth trying another IVF cycle with us, or whether they should explore alternative options .
The key question in their mind is - What can you do differently from the other IVF clinics ? What makes you better ?
I enjoy treating these patients . For one, they are a challenge, and if our treatment works where other clinics have failed, this is a feather in our cap ( doctors can be very competitive !)
Also, because they have done IVF earlier, they understand the basics of the treatment, so I can have an intelligent conversation with them and explain what we are going to differently. Because we are a full-service clinic, we can offer additional options which other clinics may not be able to.
These patients can be quite emotionally labile, but because we offer a lot of hand holding in our clinic, along with plenty of personalised support, we can help them to cope quite effectively.
Because we are very transparent in our approach and make it a point to educate patients and actively involve them in their treatment, most patients are appreciative of our approach because it's a refreshing contrast from what they have experienced in other clinics.
What has our experience with these patients been ?
While it's true that success rates do tend do drop in women who have had failed IVF cycles, this is not always true, and there are some refreshing exceptions !
Thus, many patients have taken treatment at sub-standard clinics. Their quality of care has been so poor, that for all practical purposes, all they have done is throw their money away. Doing an IVF cycle for them properly ( the way it should be done !) helps many of them to get
Similarly, some patients with PCOD have been very poorly managed in other clinics. Many doctors are so scared of OHSS, that they end up mistiming the HCG injection, as a result of which they get few eggs and poor quality embryos. We have extensive experience in doing IVF for PCOD patients, and our pregnancy rates are better than 45% per cycle for PCOD patients.
You can read more about this at www.drmalpani.com/pcod.htm !
Patients with male factor infertility are also often poorly managed in many IVF clinics. This is especially true for patients who need TESE and PESA. Because we do these procedures ourselves , we can use fresh sperm, giving us a much higher success rate ( unlike other clinics which have to depend upon an outside andrologist and therefore often have to use frozen testicular sperm which has a much lower success rate )
The other group of patients who are very fulfilling to treat are those with poor ovarian reserve. Because we are willing to use alternative medicine; supplements; and aggressive superovulation, we can often achieve a pregnancy in these patients ( whom other clinics shun because they are considered to be heartsink patients !)
Another interesting trend has been that most clinics in the West use gentle stimulation these days, because they want to transfer only a single embryo. While this works well for women with a good ovarian reserve, it's not the best approach for women with poor ovarian reserve. For these women, because we can superovulate more aggressively, we can often find the one good egg they have in their ovaries, and help this to become a baby !
Friday, February 25, 2011
She commented: 'There are a lot of myths around how people get pregnant. 'Women having fertility treatment who do not get pregnant early on often blame themselves for getting too stressed out and the longer they remain not pregnant the more stressed they get. This just reinforces the myth.'
However, she felt that it was important women did not ignore the stress that they were feeling: 'Fertility treatments are stressful in themselves. Women should not ignore feeling stressed - because apart from anything it could mean that they do not persist with treatment.'
Around one third of couples end assisted reproductive treatments early, because of the stress involved in undergoing treatment."
One of my patients recently asked me - Which protocol is better for IVF - the Letrozole Antagonist Protocol vs the Estrogen Priming Protocol ?
( In passing, I'd like to point out how impressive it is that patients are so well informed about medical minutiae ! Most gynecologists are quite unaware of all these finer details !)
Actually, the principles of any superovulation protocol for IVF are extremely simple. Superovulation forms the heart of modern IVF. We use medications to help you grow more eggs. Every month you start to grow about 30-40 follicles, but in a natural cycle, most of these undergo atresia (die), so that only one matures every month, in the normal course of events. With the help of medications, we are able to rescue follicles which would otherwise have died, so that we can help you to grow many mature eggs in one cycle.
Since follicles grow in response to the hormone FSH ( follicle stimulating hormone), this is the most important medication we use for IVF. This comes in many different forms . The traditional medicine has been urinary gonadotropin ( menotropin or human menopausal gonadotropin). Brand names include Menogon and Repronex ). This has been the work-horse of IVF for many years and is still the most cost effective medication available !
The gonadotropins now come in many new ( and much more expensive !) flavours, including the recombinant ( rec) gonadotropins, which are produced in vitro in a bioreactor. These are the rec-FSH and rec-LH preparations, and brand names include Gonal-F and Follistim. All these are very similar as far as their clinical activity goes , though the recombinant drugs are much more expensive ( and are therefore promoted much more actively, even though they are no better !)
We can also use tablets such as letrozole to help you grow more eggs. These act by boosting the prodction of your own gonadotropins, thus helping you to grow more eggs.These are much gentler and much less expensive , and are very useful for the minimal stimulation IVF programs.
So if all we need to make you produce more eggs is to superovulate you with medications, why is this such a big deal ?
Remember that we also also need to prevent the eggs from bursting on their own. We need to time egg collection in an IVF cycle very precisely. We want to collect mature eggs before the follicles rupture. We cannot afford to go in too early ( or we will get only immature eggs); and neither can we wait too late ( or the follicles will rupture and we will lose the eggs).
Since we know that spontaneous follicular rupture is triggered off by an endogenous LH surge which is initiated by the pituitary gland, the drugs we traditionally use to prevent this spontaneous follicular rupture are the GnRH agonists. Brand names include Lupron and Buserelin ; and these switch off your pituitary gland, preventing it from producing any LH. However, they take a long time to act and need to be given for at least 10 days in order to be effective. These were administered as either a long protocol ( from Day 21 of the earlier cycle; or a short protocol ( starting from Day 1 of the cycle).
The newer generation of drugs which allow us to equally effectively prevent the spontaneous LH surge are GnRH antagonists, such as Ovurelix and Cetrotide. These act much more quickly, which means they can be started from Day 7 onwards, which means you need to take fewer shots ! However, these are much more expensive , as compared to the GnRH agonists, and are no better than them as regards their clinical efficacy.
In reality, pretty much any protocol works well for patients with good ovarian reserve, so there's not much to pick and choose between them, and most clinics get good results with whichever protocol they are comfortable with.
However, some patients can be quite tricky. These include patients with PCOD, who have a high risk of getting OHSS. They need much gentler superovulation, and closer monitoring.
The really difficult patients are the ones with poor ovarian reserve. They have fewer eggs left in their ovaries, which means they respond poorly to the standard superovulation protocols.
It is for these patients that doctors have developed newer protocols, in the hope that we will be able to coax these ovaries to produce more eggs !
A lot of the emphasis is on precycle preparation. The hypothesis is that if we treat patients prior to starting their IVF cycle with estrogens ( the estrogen priming protocol) or androgens ( such as DHEA) , they will produce more eggs because more follicles will be recruited when we start the superovulation . Many doctors will also use supplements like wheatgerm , Vit D3 and CoQ 10; as well as alternative medicine ( yoga and acupuncture) to boost ovarian response.
So much for the basics . However, I find many IVF doctors seem to deliberately complicate matters . They love coining fancy new names for their "new" protocols ( which are actually very similar to each other in reality !)
Why do they do this ? I think there are 2 reasons. If you use long complex technical names, this helps to put patients in their place . If you make it complex, patients don't ask too many questions because they are out of their depth, and they respect you even more because you are the expert who has mastered all these esoteric medical details !
Doctors also have a fascination for anything which is new . Doctors like to innovate - and it's fun to design and do something new !
Finally, it's a clever marketing ploy, because it helps to attract patients who have failed IVF cycles elsewhere. Patients who have failed IVF are desperate to do something different ( and preferably something new !)
Just remember that new is not always better - and please try to understand the principles behind the treatment, so you do not get taken for a ride !
Thursday, February 24, 2011
Remember that the testes are sperm production factories which produce billions of sperm daily. The efficiency of this factory is affected by many variables, many of which we still cannot identify ! Even in a normal healthy fertile man, sperm counts fluctuate all the time - and can vary all the way from 10 million per ml to 80 million per ml !
What makes a bad situation worse is the fact that many medical laboratories are not very good at testing the sperm. A semen analysis is a high-complexity test, but because it costs very little, many laboratories do it very casually, and provide erroneous results, which just cannot be trusted !
The problem of varying sperm counts is exacerbated in infertile men ! While the truth is that we do not know what causes the sperm count to drop ( or to rise for that matter), when the count drops, men often tend to blame themselves. Wives will often add to their guilt by blaming the drop on the usual culprits : a poor diet; unhealthy lifestyle; late nights; stress; or on smoking or drinking.
Many wives will nag their husbands to completely stop smoking, drinking or partying. It's very unlikely that social drinking or an occasional smoke affects the sperm counts and all these prohibitions just create unhappiness and bickering. Some men will deliberately throw away all their bad semen analysis results and just show the good results to their wife and the doctor
( and some continue to refuse to believe that a macho man like them can have poor quality sperm !)
We need to understand that we really know very little about sperm production - and there's very little the poor man can do to improve his sperm count ! In all honesty, there's very little the poor doctor can do either ! All we can provide are the standard platitudes - Eat a well-balanced nutritious healthy diet ; exercise regularly ; avoid stress; stop smoking; stop drinking; take vitamins; take supplements ; take these medicines ; and so on, but all these measures have very little effect on the infertile man's low sperm count !
Wednesday, February 23, 2011
That's why I tell my patients to email me rather than phone me. It disciplines me into providing thoughtful careful answers - and also makes them do their homework, so they can ask intelligent questions !
The standard solution to the chronic shortage of doctors has always been the standard knee-jerk response - train more doctors ! This solution comes in many different flavours - open more colleges; or create a new cadre of barefoot village doctors. However, these are just short-term fixes - and the problem recurs every few years, because doctors create a demand for their own services. This means that churning out more doctors will never help - it will just exacerbate the problem !
The solution is surprisingly simple - empower patients to take better care of their own health !
How can patients figure out when they need to go to the doctor ( and when they can take care of themselves as home ? ) How do they determine which problems they can solve for themselves and which should make them seek medical attention ? Is this headache a migraine ? or a brain tumour ? Is the fever because of a viral URTI ? or is it TB ? How is the poor patient going to figure this out ? Isn’t that what you need a doctor for ?
Right now the standard response for all patient queries is - Ask your doctor ! ( Isn't it ridiculous that most books and websites on fitness and exercise have this disclaimer - Please check with your doctor before starting an exercise program ! ) All we end up doing is making patients more dependent on the doctor and unnecessarily increasing the doctor's workload ! What we need to do is make patients more independent, so they can fend for themselves !
The trick to making patients do all the work is to develop clever tools which will help the patient to make sense of what is happening to them so they can communicate clearly with their doctor. The vast majority of health problems are self-limited and just need reassurance. They can easily be managed by a phone call or an email.
Doctors can learn a lot from retailers. In the past, customers went to the shop and the shopkeeper would have to physically carry the selected objects and then pack them and bill for them. The shopkeeper was the major bottleneck - and had to do all the grunt work. The new supermarkets make the customer do all the work, thus allowing them to service a much larger number of customers - for much less ! It's true that the retailing ecosystem had to change to allow this evolution to occur ( better packaging; better shelf displays; better branding; and more customer education), but this has now become the standard - and the retail industry is doing very well for itself, thank you !
Here's a simple example . A lot of the doctor's time is spent on taking a medical history. Many busy doctors do not have the time to do this themselves, which is why they get an assistant ( who may not be very competent !) to do it for them. We make our patients do this themselves by making them fill a very detailed and complex form ( see a copy at www.drmalpani.com/malpaniform.htm)
This has many advantages. It saves me time. It ensures the history is complete and that I have not overlooked any important information. Even more important, it helps to educate my patients ( because they need to do their homework to be able to fill in the form intelligently !). It also ensures they are better organised, because they need to collate all their medical test results and summarise their history !
Please note that I do not expect patients to make their own diagnosis ! However, patients are the experts on their problem, and helping them to help the doctor will help everyone !
Tuesday, February 22, 2011
The vast majority of patients are usually completely satisfied with their medical care and are grateful to their doctor. However, in some cases, problems can occur, and you need to know what steps you can take if you are unhappy or dissatisfied with the outcome of your treatment.
In the first instance, you should try to resolve the problem as quickly as possible. Talk to the doctor or the hospital administration to try and settle matters at the earliest, especially with regard to minor complaints ( such as rude staff, telephone calls not being returned or unpalatable hospital food). Most complaints originate due to seemingly trivial problems.
If however, if you have a serious complaint about your medical care, and if you are convinced that your doctor has been negligent, you can take appropriate action. However, do remember that just because the outcome has not been satisfactory ( for example, a patient dies during surgery) , it does not necessarily mean that the doctor has been negligent or irresponsible! There are many reasons why patients do not do as well as expected; after all, medicine is an inexact science which deals with many biological variables that are beyond anyone's control. Consequently, in spite of the best care, a patient may die or his condition may become worse.
There are many avenues open to you to get redressal, and you may choose any or all of them. For instance, you can make a complaint to the local professional medical body, usually the state medical council. The appropriate medical council can punish the doctor: for example, by removing his name from the medical register, if he has been found guilty of serious professional misconduct, either permanently, or for a specified period, so that he can no longer practice medicine.
Before taking legal action, you should carefully consider all the implications and repercussions. The process can be a very long and expensive one. You must also ascertain precisely what you want to achieve by initiating litigation. Do you merely want an apology from the doctor? Are you angry with the doctor because you feel he was careless and you want to seek revenge? Do you want to expose the doctor's incompetence to the public to protect other patients? Do you want monetary compensation? While all or any of these objectives may provide sufficient reason to go to court, do remember that medical malpractice lawsuits are powerful double-edged weapons which should be used only as a last resort. Not only can such lawsuits damage a good doctor's reputation, they can also create a lot of tension between patients and doctors in general. Let me point out, in this context, that unnecessary and excessive medical litigation has led to the regrettable situation in which American medicine finds itself today, in which both doctors and patients have become losers.
Monday, February 21, 2011
Everyone loves advising infertile couples ! ( After all, if they've had a baby in their bedroom and proven their fertility , this makes them fertility experts, right ? )
The commonest advise is - Just relax ! Do not stress - do not take any tension ! This advise is even more pronounced during an IVF treatment cycle. If you want your IVF to succeed and the embryos to stick, you've got to "go with the flow" and not stress out. If you get too stressed out, your uterus will reject the embryos and they will not implant !
This is very unhelpful advise ! Of course there's a lot of stress in an IVF cycle - after all, no one wants to come to Dr Malpani to have a baby ! All my IVF patients are stressed out - and even the hyper ones do get pregnant ! It's true that patients need to learn constructive ways of dealing with this stress but to pretend that there's no tension involved is just being unrealistic.
The worry is that this kind of advise leads to blaming the victim. " You did not get pregnant because you were too stressed out ! Your IVF cycle failed ( what a cruel word) because you did do not relax enough !" This is hogwash. Don't forget that even a woman who gets raped ( whose stress levels must be through the roof) can get pregnant !
IVF patients understand the importance of optimism. However, many of them are very scared of getting their hopes up . They have been let down too many times in the past so far; and they are worried that if they become too optimistic, the crash down to reality will be much more painful if the cycle fails. This is why many patients keep their expectations low - so that they are better able to cope with failure .
Personally, I find a balanced approach the best option.
I request my patients to remember the Serenity Prayer -
God grant me the serenity to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.
Having a Plan B ready even before starting the IVF cycle can help you better cope with the IVF emotional roller coaster ride !
Sunday, February 20, 2011
I see patients who have done IVF cycles in other clinics all the time. How they responded in the earlier IVF treatment cycle provides me with valuable information, based on which I can tailor a better treatment protocol for them.
One of the basic questions I ask them is - Please tell me more details about your earlier IVF cycles . What were the meds which were used for superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? How many embryos were transferred ? What was the embryo quality ? DO YOU HAVE PHOTOS OF YOUR EMBRYOS ? What was the endometrial thickness ?
Can you please show me the printed treatment summary from your IVF clinic ?
Many of them look at me blankly. ( I am sure some of them wonder why I expect them to know all this - after all, they are just patients, and not doctors ! )
Others get defensive and say -
" The doctor did not tell us anything. "
" The clinic does not provide medical records. "
" They keep a copy of the medical treatment and do not give the patient anything at all."
Now I think that any clinic which does not routinely give the patient a treatment summary of their IVF cycle at the end of the treatment is a bad clinic . However, while the absence of the medical treatment summary reflects badly on the doctor who provided the treatment, it is also a reflection of the fact that the patient has been a bad patient as well !
" The doctor did not give me a copy of the records " is not a good answer. Getting a copy of your medical treatment details is not only your right, it's your responsibility as well ! And if you do not assert your responsibility, then you are as much to blame as the doctor is !
It takes two to tango - and while you cannot change someone esle's behaviour, you can change your own ! Start off from the first visit by observing what happens in the clinic. Does the doctor give you a copy of your consultation sheet ? your lab tests ? Do other patients have their records with them ? Ask at the first visit itself what the clinic policy is about medical documentation.
If your doctor refuses to give you your records after your treatment is over ( because he does not want you to go to another doctor), then you need to become assertive ! Ask for a copy of your medical records - and make this request in writing, with a copy to the Administrator of the Hospital. If you do not get a reply, then ask your lawyer to write the letter for you - I can guarantee this will produce results !
Saturday, February 19, 2011
This is a guest post by Saiprasad Gundeti, Senior Embryologist, Malpani Infertility Clinic.
As an embryologist, I help in making the dreams of infertile couples come true ! Most couples do not know what happens in an IVF lab, so I am happy to describe a day in my life !
This is the daily routine we follow at our centre :
First thing in the morning –
Cleanliness is a very important factor in IVF Lab. We need to make sure everything is sterile ! Because I work alone in our lab, it's much easier for me to ensure that everything is clean !
- Hood and bench work surfaces (including microscope working areas, heat baths, petridish warmer) are cleaned and wiped down with 6% Hydrogen Peroxide.
- Once a week centrifuge rotors and carriers as well as outside area of the centrifuge are cleaned and disinfected using 6 % Hydrogen peroxide
- Floor is nicely cleaned with 6 % Hydrogen Peroxide.
Monitoring and Maintenance of All Equipments
Your embryos can be quite demanding, and we need to keep them happy in the IVF lab ! We do this by ensuring that the conditions in the lab are just right for your embryos !
- The Incubator CO2 % is confirmed with the help of CO2 analyzer. Calibrated if any anomaly seen in the readings. Temperature is measured with the help of digital thermometer. Calibration is done in case of any temperature variation seen.
- Temperature is measured for all heating baths, heating plates of all microscopes and petridish warmer.
- Gas cylinders connected to CO2 incubators are checked. Cylinders are changed if they are found half empty.
Monitoring of embryo development
- Fertilization assessment of each patients eggs on which ICSI was performed a day before.
- Stripping (denudation) of eggs on which IVF was preferred.
- Transferring fertilized eggs to new dishes (prepared, labeled with patients name and incubated a day before)
- Assessment of embryo development grading of day2, day3, day4, day 5, day 6 embryos.
- Documentation in IVF file as hard copy and IVYSITE ( our electronic medical record) as soft copy.
- We routinely give all our patients photos of their embryos. We take pride on our work, and good quality embryos are a testimony to the fact that we are providing a high quality service to our patients !
Preparation for the Cases
- Preparation for ICSI procedure -
- Preparation of ICSI dishes
- Preparation of Hylase dishes (for stripping eggs before ICSI procedure)
EMBRYO TRANSFER PROCEDURE
This procedure involves the transfer / placement of day-2 or day-3 embryos to the patient's uterus. It is performed transcervically with or without anesthesia.
Showing embryos to the patient
We at our centre show every patient their embryos before transferring them to their uterus.
- The nurse in charge brings the patient couple to the lab and introduces them to me.
- I walk them through their cycle, giving them details about –
- Number of eggs retrieved
- Procedure done (IVF/ICSI)
- Number of mature eggs
- Details about husband's sperms (fresh/frozen/epidydimal/testicular)
- Number of eggs fertilized
- Quality of embryos
- Number of top quality embryos
- Number of embryos that will be transferred
- Number of embryos that will be cryopreserved
- I show them the embryos and grade them in front of the patient couple. Many women get quite emotional on seeing their embryos !
- Guide them to the operation theatre.
- I select the best embryos and transfer them to "Embryo transfer" dish.
- When the OT is ready, I confirm with the doctor, as to which catheter to be used.
- I load the embryos into the catheter. A nurse stands as a witness while loading.
- I hand over the catheter to the doctor, by verbally confirming the name of the patient.
- The doctor gently guides the catheter through the cervix and gently pushes the embryos into the uterus.
EMBRYO CRYOPRESERVATION PROCEDURE
This procedure involves freezing of supernumerary embryos after transferring the best embryos.
The procedure is done only after taking patient couple's consent.
- This procedure is done at room temperature. So temperature of microscope stage is brought down to room temperature.
- Vitrification (freezing) medium is taken out. Freezing dish is prepared by placing droplets on the dish.
- Cryolocks are labeled with patients name, date of freezing, number of embryos per cryolock.
- After the embryos are frozen, the cryolocks are stored in cryocanisters.
- Details are documented in the register.
COLLECTION OF SEMEN SAMPLE FOR HUSBAND OF PATIENT UNDERGOING OVUM PICK UP PROCEDURE
- The patient is given a pot labeled with his name to collect semen sample.
- Once the sample is collected, it is brought to lab along with the file.
- Sample is processed for the procedure (IVF/ICSI)
PREPARATION FOR OVUM PICK UP ( OPU) PROCEDURE
- Temperature of instruments are checked.
- Patient's ID is checked with doctor/ nurse in charge.
- Petri dishes are arranged on a petridish warmer
- Remind clinician to collect clean follicular fluid (~3-4 ml). I Pour this in warm petri dish.
- subsequent follicular fluid is poured into a fresh warm petridish.
- As soon as egg (Oocyte Cumulus Complex) is located I take clean follicular fluid in to Pasteur pipette and pour 2-3 drops over OCC and then take OCC into the Pasteur pipette and deliver in the dish at 12 O'clock position.
- Inform the clinician by loudly saying "EGG" when the egg is identified.
- I inform Dr. Anjali about presence of egg in the tube by loudly saying "EGG".
- If there is no egg in the tube I inform by loudly saying "NOTHING" and I do inform about the presence of Granulosa cells in the fluid.
- Similarly I identify and collect all the eggs at 12 O' clock position in 60mm petridish.
- I Take out OPU dish labeled with ( Patient Name) and ( Egg Wash)-prepared one day earlier.
- I Rinse all the OCC's in the outer well containing Flushing medium and transfer them in to the centre well of the same dish containing Fertilisation medium
- Following OPU, OCC's are cultured in fertilisation medium in CO2 incubator till IVF or ICSI being done on them.
Continuing medical education
IVF is a field in which technological advances occur very rapidly. I read the journals, Human Reproduction and Fertility Sterility, to ensure that I am uptodate !
Preparation for the Next Day
- I go through the files of all patients that are scheduled for next day.
- Preparation depends on what procedure patient is undergoing.
- Fertilisation check dishes:
dishes for each patient
- Dishes / medium for OVUM PICK UP :
- Dishes for IVF (No. of Dishes dependent on no. of follicles):
- Dishes for ICSI (3 Dishes for each patient):
1 tube with Oil (6ml)
1 tube with Flushing medium (6ml)
- Dishes for Frozen Thaw (2 Dishes for each patient) :
- Medium for Embryo Transfer :
Friday, February 18, 2011
I want all my IVF patients to become an expert on IVF , which is why we spend a lot of time and energy in educating them; and in creating unique online educational tools to help them to learn more about IVF.
Now, I am not trying to teach my patients how to do IVF in their bedroom ! The reason we want them to know as much about their treatment as possible is because this is the best way of explaining to them why we are so good at what we do - and what makes us better than other IVF clinics . The outcome of any IVF treatment is always uncertain, and no matter how good I am , there is no certainty that the IVF cycle will be successful. Also, it's a very competitive field, and there are over 40 IVF clinics in Bombay itself ! Sadly, most patients are quite clueless, and do not have the ability to differentiate between a good IVF clinic and a bad IVF clinic.
If we actively involve patients in their IVF treatment, they are better able to understand what makes us one of the best IVF clinics in India. When they understand the science behind IVF, they appreciate all the time and effort we take in monitoring them and in personalising their treatment . We work hard in order to help our patients to have a baby, but only well-informed patients can truly appreciate all the effort which goes on behind the scenes !
Also, well-informed patients have realistic expectations from the IVF treatment . They understand that human reproduction is not an efficient enterprise and do not go to pieces when the IVF cycle fails.
Most IVF clinics are extremely stingy about providing patients with information about their medical treatment. They seem to take the approach that patients are stupid and will not be able to understand anything about their IVF treatment because it's very complex ! Some don't even bother to provide a treatment summary - while very few provide photographic documentation of the embryos.
We routinely provide our patients with photos of their embryos . Making embryos is the heart of what an IVF clinic does and we take pride in our work ! This is a tangible end point I can deliver and seeing high quality embryos reassures the patient that they have received high quality medical care - and this helps to build patient loyalty. Many will frame these photos and use them to start their baby's album !
Educating our patients is an investment in helping them to achieve peace of mind that they have received high quality medical care, so that no matter what the final outcome, they know that they have had their best possible chance at having a baby by taking treatment in our clinic !
Thursday, February 17, 2011
It takes a lot of courage to place your life in a doctor's hands ! How can you be sure your doctor is any good ? Or that he will take good care of you when you have a problem ? It's hard to judge a doctor's competence and doctor shopping takes a lot of time and energy. It's also not very smart to go purely by a friend's recommendation !
Here's an easy test. Ask the doctor a question about your problem ( preferably an easy question which you already know the answer to !) and see how he responds.
Does he get irritated ? Does he brush off your query ? Does he answer brusquely ? Does he use medical jargon ? Does he send you to his assistant for answers ?
Does he take the time to explain in simple terms ? Does he bother to check that you have understood his answer ? Does he offer to give you educational materials to clarify your doubts ?
As a patient, you are likely to have lots of questions and how your doctor handles your questions is an excellent way of judging how good your doctor is ! The best time to find out is as the first consultation, rather than regret your choice at leisure later !
Wednesday, February 16, 2011
Our experience began in summer 2010, and we decided to begin the pre-treatment that Dr. Malpani suggested us by e-mail while we were in Spain before treatment in Mumbai. He explained to me everything that had to do: medicine, testing, planning, guidance and even where to stay in Mumbai. The day that we arrived at the clinic we were surprised by the number of couples who were there, and by their different nationalities.
That day, Dr. Aniruddha Malpani welcomed us into his office and he discussed our case with the evidence and history that we send, and he explained us the steps of treatment and medicines that provided us for the following days. Our stay in Mumbai was not easy, because it is a chaotic and noisy city that never sleeps, but our goal and dream of having a child gave us the strength to withstand all.
Dr. Anjali Malpani, is the wife of Dr. Aniruddha Malpani, she is the one responsible for making the scans, egg collection and check the status of the uterus. She is a woman of easy-going and very understanding. The day of the transfer and before transferring the embryos, she informed me that we could to go to the lab to see it. Saiprasad Gundeti is the biologist and laboratory technician responsible for the selection of embryos, which showed us the embryos which were transferred me.
The day of transfer I went to the clinic and I was there waiting for my turn, I was taken to the operating theater where two nurses were cleaning and talking to me, the truth is that Indian people is very kind people in general. Dr. Aniruddha Malpani came to the operating theater and never stopped talking to me during the transfer process that was a few time, at the end, he literally asked, "How do you feel?" I replied, "Happy" but he said: “not happy, you must to feel pregnant.”
After embryo transfer, Dr. Aniruddha Malpani recommended I rest for 2 days, and then we went to say goodbye to them all, included clinic nurses and staff. At the end, we were in Mumbai about 24 days and we returned to our home to our normal life. Them they spent 14 days, I went to make hormone beta HCG analysis and the result was positive, I'm pregnant!!! I made 3 blood tests to see increased levels of the hormone beta HCG and they informed me that is a multiple pregnancy. I sent results to Dr. Aniruddha Malpani for his information and assessment. After doing some vaginal sonography, my gynecologist confirmed me that I have triplets. Today I am 21 weeks pregnant and I feel great. What concerns us now
is to be born healthy. Our experience was successful with Dr. Malpani.
Dr. Malpani and his wife showed great respect and proper treatment during our stay, although some days of consultation, the waits were long but no problem. They encouraged us and empathize with us. Communication with staff maybe could be most appropriate, because of language, but we asked many times to avoid doubt. They treated us well to know everything about treatment.
Our experience tells us that we must be relaxed, be positive and be communicative to get confidence and no doubts. You need to have patience with several unknown things and to trust in the possibilities. Note that there is no 100% chance and to have no despair.
Dr. Anjali Malpani and Dr Aniruddha Malpani have over 10 years experience in fertility and their nurses and staff also has much experience. We hope our experience will serve to encourage couples to clear up their doubts and encourage them to use this opportunity to be assisted, helped and loved by Dr. Malpani.
Tuesday, February 15, 2011
Monday, February 14, 2011
I was so tired & bored that I started channel-surfing and I stopped on this program called “70&Pregnant” on the Discovery/TLC Cable Channel. Boy! Did it wake me up? Mark & I have tried for years to get pregnant and we realized about 15 years ago that because of my premature ovarian failure, only a donor egg would work for us. So needless to say when I saw this program, I perked up immediately…. On this program, they featured an Indian doctor who helped a 70 year old Indian lady get pregnant and have child with a donor egg. The donor came from a nearby Indian village & the cost was cheap by U.S.A. Standards for IVF.
During the program, the doctor discussed the cost of IVF in Indian and immediately, since fertility treatments for me & Mark are too expensive, when I heard the cost of IVF in India, I jumped up & started researching Doctors in India right then and there. I could barely sleep that night.
When I woke up the next day, I went straight to the Indian Embassy here in D.C. – no appointment, no announcement, nothing…. and just talked to whomever I could about the country. The receptionist was the sweetest and kindest lady in the world. She told me so much about the country, the time differential, how to dial abroad, etc. Then finally I asked, hey do you have a science or medical representative here from India as a part of your staff? She said yes and she directed me to the Counselor of Science for the Embassy. He happened to be free, praise God, so he & I chatted for about 20 minutes. I was so excited about the cost of IVF in India that I didn’t even beat around the bush. I told him exactly what I wanted and he poured out all the information he could. He bent over backwards to help me.
He told me, if you are going to India and you don’t know of a Dr. I’d recommend Dr. A. Malpani. I keep hearing their names and I’ve read extensively on them & their practice. I’m told they are the best in Mumbai. You can’t go wrong with them. They have a lot of good write-ups and in my field, this it he name that comes up when referring to IVF in India. This was a name he had in his memory. He didn’t have to ask anyone or call anyone. This made me feel really good because how many people have an IVF specialist’s name at the tip of their tongue just waiting for someone to come in and ask for it? Then he introduced me to the media and newspaper staff, I had tea, then walked around and met other staff who gave me DVDs, Maps, CDs, Newspapers, Hotel contacts, etc. I was even put on the Embassy’s newsletter’s mailing list for events. The folks at the Embassy were the most pleasant people in the world to deal with. They took all my concerns about traveling abroad to a country where I didn’t speak the language away instantly. They also told me that they would help me an in any way they could in the future.
So I went home, armed with all this good literature, DVDs, CDs, etc. and started researching on the internet and made contact with Dr. Malpani. This was in June 2010. I’ve asked Dr. Malpani questions weekly if not 2 and 3 times a week since June 2010 about IVF, donors, his/her practice, policies, procedures, etc. I’ve inquired about things on the internet, things I’ve heard, etc. and within a 24 hour period including Saturdays, Sundays and all holidays, Dr. Malpani’s answered my questions. I’ve even asked Dr. Malpani about questions that if I knew a little more about the internet I could have found on their web site, but Dr. Malpani, pleasantly & patiently answered them for me anyway.
While over the last 8 months of speaking with Dr. Malpani I’ve come to trust and value the practice, there was only one issue that held Mark and I up from flying to India and seeking IVF treatment immediately. We needed to find a donor that we could see & visually approve of 1st hand before the IVF procedure. Most doctors in India do not allow the recipient to see photos of the donors prior to the IVF treatment. Dr. Malpani’s practice is to match a donor to you and choose the donor anonymously. This didn’t sit well with me & Mark because while having a healthy donor is primary to us, it’s also important to us to see from whom ½ our baby’s identity will come.
After we told Dr. Malpani this, the option of advertising for our own donor was suggested. So we set out to find a donor by advertising in the local papers and on the internet. Dr. Malpani warned us to be patient, that it could take some time. So we placed ads in newspapers in India. We’ve even gone to Donor and Surrogacy Agencies and it’s been a world-wind experience.
We’ve spent about $2,500-$3,000 U.S. dollars on several newspapers, internet services and donor agencies just advertising and viewing photos. While we aren’t happy about the cost, we are delighted that we’ve seen the photos and chosen to see our donor. It’s renewed our resolve to see our donor no matter the cost or length of time it takes to find just the right one.
In the meantime, let me tell you what we’ve experienced while searching…Oh MY GOODNESS! We’ve had men tell us they could provide us with eggs. We had to explain (via email) so many times that men aren’t born with eggs that we just decided to come up with a “cut & paste reply” to all those emails from men that answered “Female Egg Donors ONLY please Advertisements”. Then during our 2nd newspaper, we had men tell us you really need sperm & not eggs, let us supply them. We’ve had people email us nasty comments about what they think of science and what we are doing. Of course we deleted these and moved on as if they were never sent. We’ve had husbands respond to the ads & lie to us about their wives ages only to have the wives tell the truth later when we indicated that official birth certificates and Indian govt identification would need to be submitted to verify the accuracy of the age of the donor. We’ve had people treat us like an ATM because they knew we were calling from the USA and quote astronomical prices that multi-billionaires wouldn’t pay for golden eggs. We’ve had people tell us since we weren’t Catholic they couldn’t supply eggs after they answered the newspaper advertisements. We’ve had husband tell their wives no after their wives answered the advertisement. We’ve had people play really high priced negotiation games with us until we realized that they might not finally give up the eggs or would possibly hold them hostage if we dealt with them. We’ve had people call us back weeks later asking to donate for our original offer, after they realized we never called them back to offer a higher price. We’ve had people offer us eggs if we could guarantee them a job and flight over to the USA. You name it, we’ve had it. Most of it has been funny because we are committed to not get frustrated but I’d be lying if I said it wasn’t getting old at times.
All of this had us thinking once or twice…do we really want to try to find our own donor? Do we really know what we are doing? Then we’d go back and look at some of the photos and say, yes, let’s keep plugging along. Then when we finally were so tired and ready to give up & take an emotional break, the most stunningly beautiful donor replied to our advertisement. She was nice, well educated and seemed to be quite stable. Once we discussed the process, she said oh no. So here we were thinking we landed a donor, only to be stressed out with her back & forth fear of medication-taking, injection phobias and overall paranoia about egg retrieval. While we understood her lack of knowledge about what was required, we were drained emotionally by the process of trying to explain to her what was expected. We also found ourselves perplexed as to why she’d answer an advertisement when she should have expected that at least 1 needle was involved somewhere along the process.
Eventually we told her that this was more stressful than we could endure and we declined to continue further. She came back and said she was willing to think about it again once she had verified the process with Dr. Malpani. So she eventually spoke to Dr. Malpani and finally bowed out one last time. I must admit, I didn’t do a good job of telling her about the medications. I was too honest and this was best something left up to a Dr. to explain because just listing them out is scary to someone who’s not seeking a child and just wants to help, even if it is for monetary gain. I should have thought about that before I blurted out all the medications and injections. I now know it’s best left to a trained physician to tell patients about stuff like that.
So in the end, Mark & I knew it wasn’t meant to be so we didn’t get too upset by her resurfacing only to bow out one more time. We believe what’s meant for us is meant for us and will come our way without a bunch of coaxing and cajoling.
So we continued to plug on. Then Dr. Malpani suggested egg sharing. We were elated with the option but then we ran into a road block when the only person who has offered to share her eggs wasn’t of Indian descent. This mattered greatly to us because of my heritage so we again, prayed about it, declined that egg sharing opportunity and are now moving forward.
So, 8 months later we are still looking for an Indian egg donor. We’ve put our IVF plans on hold until we either find one through an agency willing to allow us to pay them a referral fee and use their donor or until we locate a donor whose photo we approve of. Most practices aren’t interested in sub’ing their donors out so this may result in us going back to the newspapers for more advertising.
Mark and I’ve talked about this until we are blue in the face. It’s most important for us to have a healthy child. But it’s secondly (not equally) but still important to us to have a child that looks like me as much as possible or like she/he could have been related to someone in my family, even with ½ of my husband’s DNA injected in the mix. Because we’ve located two women who fit this bill but who bowed out because of (a) fear of the procedure to extract the eggs and the 2nd because of a family and medical emergency, we’ve decided to press on because we now know that in a country of over 5 Billion and in a city like Mumbai of 22 Million, she’s out there. We just have to be patient and allow God to deliver her to us.
Traci & Mark.
Sunday, February 13, 2011
Dr. Houston is currently involved in several more studies that will examine the broader use of storytelling in patient care and delineate ways in which it can best be integrated. Nonetheless, he remains certain of one thing: Sharing narratives can be a powerful tool for doctors and patients.
“Storytelling is human,” Dr. Houston said. “We learn through stories, and we use them to make sense of our lives. It’s a natural extension to think that we could use stories to improve our health.”
The great thing about the web is it allows people to share stories so easily ! Online support groups, blogs, forums and bulletin boards make it much easier for patients to reach out and touch someone else's life !
We have lots of IVF success stories on our website and reading these helps patients to cope better with their IVF treatment. I'd also like to point out that while reading these stories is very useful for patients, writing their stories and helping others is also very helpful ! Sharing stories helps both the sharer and the sharee !
Friday, February 11, 2011
The problem is much worse for men who know that they have a low sperm count. They are secretly petrified that their sperm count may drop even further , which is why they are so reluctant to get their semen re-tested ! ( They also know that if their sperm count is low, their spouse will nag them incessantly to stop smoking and stop drinking - and is having a baby really worth giving up all the pleasures of life for ? )
This reluctance on the part of the man is not something many wives understand - " I am the one who has to go through all the painful tests and shots , so why is he making such a big deal about getting his semen tested ? " Ironically, the wife is being amazingly unempathetic in this case. While it's true that it's usually men who are clueless, any wife who does not understand the heartburn an infertile man goes through when his sperm count come back as below normal is being remarkably obtuse and clueless. The secret fear many men with a low count have is that the sperm may keep on dropping until it goes to zero - and then what ? Men are masters as denial - and since most of them hate going to a doctor for any medical problem, it's quite understandable that they are not happy about allowing their vulnerability to be exposed to the whole wide world ! And while producing a semen sample is not as painful as doing a HSG, being forced to produce semen on demand in a dark, smelly bathroom when there are five other men waiting in line can be very unpleasant ! Even worse , if the man fails to get an erection and produce a sample when asked to, this can often be the last nail in the coffin of his self-confidence. He'd rather go and shoot himself than put himself through the humiliating ordeal once again.
Sadly, many doctors do not realise the enormous stress some infertile men go through when producing a semen sample - and this just contributes to the difficulty. Since most nurses in an IVF clinic are female, it's very hard for a man to talk about his personal problem to anyone ( the doctor's never available in any case !) And if he fails once, this often becomes a self-fulfilling prophesy, setting up a negative vicious cycle which is very hard to crack. Seeing his wife angry and upset just adds to the man's woes - and he'd rather just forget about having a baby rather than subjecting himself to the stressful exercise all over again !