Monday, January 31, 2011
This is why we are seeing a huge number of " part time IVF doctors" in India. They spend most of their time seeing OB patients and gynec patients - but rather than refer their infertile patients to IVF specialists, they hold on to them and promise to do IVF for them. They will either take the patient to an IVF clinic and do the procedure there ( because they do not have the equipment or the expertise to do the IVF themselves); or they will invite a "travelling" IVF specialist to come to their clinic to do IVF on their patients, which they batch once a month.
This means that you are being treated by a doctor who is a jack of all trades and master of none. These doctors simply do not give their IVF patients the time and energy they need. Infertile couples are treated along with other OB patients and there is no acknowledgment of the fact that their needs are special . It can be very hard for an infertile woman to sit in a clinic full of pregnant women !
Since many of these doctors are gynecologists, they do not have the technical expertise or experience to provide IVF services. They have to depend upon imported IVF specialists who come from other cities. This means the care becomes fragmented, resulting in reduced success rates.
The sad truth is that beggars can't be choosers - and this is a useful service for infertile couples who do not want to ( or cannot afford to ) travel - after all, some service is better than no service at all ! However, if you want the best possible treatment, it's best to go to a full time IVF clinic. While this may initally appear to be more expensive, it may actually be far more cost effective because full-time dedicated IVF clinics have a higher success rates ! They are busier; more experienced; and have more expertise !
Saturday, January 29, 2011
Friday, January 28, 2011
I am always amazed by how smart my patients are ! It's fun learning from them and they keep me on my toes. Here's a first person guest post from one of my patients ( who is a PhD and knows more about fertility than most gynecologists do !).
She has done all her learning "on the job" - and this is an excellent example of what a highly motivated intelligent patient can do to help herself, when she sets her mind to it.
She has carried out a clinic trial on herself and done an extremely good job of it as well. In fact, based on her experience, I am now going to start studying the effect of Vit D3 supplementation on women with low AMH levels. If Vit D helps to improve their low AMH levels ( and thus their ovarian reserve ) this will be a big step forward in the treatment of these women !) It's true that one swallow does not make a summer but it's careful observation and experimentation which allows medical science to advance. The big difference here is that the experimentation was done by the patient herself - something which was par for the course about 3 centuries ago, when all scientists ( they used to be called natural philosophers in those days) experimented on themselves.
2 weeks post D&C bloodwork (fasting)
Low- very weird especially since FSH has been consistent normal (around 6.5, with E2 22-33) and my antral follicle count was 34 in an ultrasound done 4 months ago.
(ordered on a hunch)
Disregarding the lab’s ranges, anything below 10 is considered severely deficient while anything below 20 is considered deficient.
Optimal values are above 40 ng/ml
Lots of references linking this one to fertility issues…I’ve been putting the literature together, could send it to you if you are interested.
Fasting blood sugar was normal
Despite lab’s reference range, this value is in PCOS range for androgens. ( I think over 60 is considered in PCOS range)
I’ve had considerable variation with testosterone tests. …I’ve had 2 other tests done in the evening and there my values were low.
Interestingly, found out that testosterone levels have significant diurnal variation and are highest in the morning….repeating the test in the States, this time, fasting.
Over 200 is in PCOS range
I was the most concerned about low AMH levels. It seemed completely illogical given all my markers for ovarian reserve. On a hunch, I looked in the literature to see if there was any link between Vitamin D3 and AMH.
I found one study conducted by a group at Stanford University
This group has found that in certain organs of the body, vitamin D3 binds the AMH gene and turns on its expression. I asked the group if they had done any studies looking at AMH levels in vitamin D3 deficient woman and they said that though they were interested, it had never been explored.
Either way, I wanted to recheck my AMH after trying to increase my vitamin D3 levels. I took 60000 IU weekly for 2 weeks.
I rechecked antral follicle Count, AMH, vitamin D3, FSH and LH on the same day.
Optimal fertility according to the lab, or PCOS range according to this website
A 4 fold increase in 2 weeks, which I found just remarkable!
These tests were not done on a true ‘day 3’ it was just early in my cycle though.
Does not look like a PCOS ratio……?!?!?!
Her level of sophistication is commendable , and I just wish all doctors would engage their patients as clinical research assistants - all of us would benefit from this approach !
Thursday, January 27, 2011
After some difficult years including infertility treatments, despair and discouragement by infertility doctors (!), my husband and I decided we should take a sabbatical and rest for a while from all the disappointments of the past. We decided to travel to Asia and visit some wonderful countries.
After a few months however, my child wish was very strong again and we decided we should try one more time an IVF treatment.
The question was where? we had all these possibilities in all of these countries.
I decided to do a little research and I wrote to a dozen clinics in Thailand, Singapore, Malaysia and India.
Some clinics did not respond at all (!) other were very short in their information. This was not the case with the clinic of Dr. Malpani, as a well-informed patient I could see the difference very clear with the other clinics. The whole protocol was send to me within a day, including the names of medications, the dosage, the procedures etc.
Among all this clinics the response of Dr.Malpani was the most elaborate and professional.
So we decided to go ahead with the treatment in India.
Once settled in, the treatment began. I never met a doctor that was more helpful then doctor Malpani, providing me with lots of information when asked, even including some scientific articles.
The follicle stimulation went well, the pick-up went well, and then of course the embryo transfer, for us a real all or nothing moment.
2 weeks later, on April the 12th I had my very first positive pregnancy test ever!!!! Nothing could surpass that moment until December the 19th when our baby-girl was born!!
As every birth is a miracle, I strongly believe my pregnancy is a perfect example of an incredible cooperation and understanding between a doctor an his patient.
Dr. Malpani has a very humane approach to his patients, providing them with all the information they ask for, listening very carefully and trying to meet their wishes as much as possible. Last but no least and he is funny too! :)
Professionalism and a very human approach, together with a lovely staff made this experience unforgettable.
For all the couples that have been struggling for years, please don't give up! It took us years to conceive, some dark days and months, but finally all of it was worthwhile as soon as you can hold your baby in your arms!
To Dr. Malpani and his lovely wife, please keep up the good work. Nothing is more important then to make a difference is someone's life.
God bless you.
A couple from the Netherlands
Wednesday, January 26, 2011
I am an IVF specialist, and know lots about IVF. I read all the medical journals and keep myself updated, so I can provide high quality medical care to my patients - after all, my professional knowledgebase is my major asset and I spend a lot of time on polishing my skills and keeping current with recent advances. Since IVF is such a specialised field, it's much easier for me to do so, as compared to a general physician, for example, who has a much broader area to cover.
However, no matter how good my intentions, the fact still remains that there will be areas in IVF in which I have blind spots. The good news is that my patients are getting smarter and are happy to help me fill in these blind spots. I have always respected my patients and I learn a lot from them all the time.
Medicine is a rapidly advancing field and doctors need to learn all the time. Our best source of information and knowledge is our patients - and rather than getting angry and upset when patients bring huge sheaves of internet printouts, we need to treat our patients are intelligent expert research assistants, who can help up to provide them with the best possible medical care by helping to keep us on our toes ! These expert patients can act as our eyes and ears - and explore areas we may not be aware of.
Not all these expeditions will be worthwhile or productive - but you never know what the next expert patient can help you to unearth !
Tuesday, January 25, 2011
You should be at the clinic that pays attention to every detail: it means they are more likely to be paying attention to the other important details too, like when to modify your protocol, or what is happening in the lab, or what the latest research says."
Makes a lot of sense to me ! It's practically impossible for patients to judge the technical proficiency of an IVF clinic - they all seem to be the same, and most doctors are very sweet at your first consultation ! However, if the clinic is disorganised and chaotic; and they make you wait for ever and ever; and do not respect your time or your privacy, these are good reasons for find another doctor ! Doctors who respect you as a person will take the time and trouble to optimise your medical treatment, and this will give you the best shot at getting pregnant !
I was flummoxed ! After all, isn't listening to a patient a part of the doctor's job description ? Why was he thanking me for doing something which is so routine and mundane ?
When I asked my next patient why I was being thanked, he said - That's because you are so different from most other doctors, doc ! Most doctors just rush like automatons through a long line of patients. It's like they are just processing an assembly line of people - and they have 7 minutes in which to listen to you . They are always rushed and harassed - and it's very hard to have a decent convesration with them. Most of them are focused on the medical issue at hand - while some only speak medicalese, so it's hard to make sense of what they are saying. It's a pleasure to meet a doctor who can have an intelligent conversation and is interested in me as a person.
I love talking to my patients ! They come from all over the world and have interesting stories to share ! I am naturally curious and love learning new stuff. Doctors tend to get very inbred and talking shop to other doctors can get very boring and monotonous. Listening to patients talk about their professions helps me to get a better understanding of what's happening in the rest of the world and broadens my horizons. Patients are smart and intelligent and are happy to talk to their doctors . They are a great source of intelligence - and I am not just talking about hot stock tips here ! They teach me about what's happening in the online world and help me to keep my website ( and my wits) sharp and clear !
Patients have a lot to teach doctors - I just wished doctors opened their hearts and minds and took the time to listen and learn ! Doctors need to be reminded that they are uniquely privileged in being given a ringside view to a person's innermost desires and struggles when their patients are battling with some of the life's most difficult moments. A smart doctor can learn a lot from his patients - both how to live and how to die when the time comes - he just needs to be willing to do so !
Sunday, January 23, 2011
Sometimes masterly inactivity is the best medical course of action ! However, it usually requires a senior doctor ( who has a lot of maturity , self-esteem and confidence) to be able to provide this advise to patients. Many doctors prescribe medicines ( even when they know that these do not work and are not required) because they feel that their patients expect a prescription ! Since when are professionals expected to pander to a client's whims ? A good doctor will prescribe Reassurance and Information Therapy far more frequently than he will prescribe drugs !
The reality is completely different ! It's not that our judges are corrupt - it's just that the system is so inefficient, that no Indian citizen really trusts the judiciary to dispense justice.
In fact, most good lawyers tell their clients that it's better to settle outside the court rather than to fight ! The only ones who seem to benefit from the interminable delays are the lawyers - and the guilty parties, who know they can get away with impunity for whatever they do, because the judiciary will take for ever and ever to bring them to book !
While I do not believe in conspiracy theories, keeping the judicial system so grossly inefficient seems to be a deliberate ploy by politicians and bureaucrats to ensure that citizens will come running to them for "alternate dispute resolution". This is why "fixers" still thrive in India - and while the judges do not actively encourage their growth, the fact that the judges continue to tolerate a system ( which they refuse to fix ) which is so inefficient and slow means they are willing to live within an unjust system of dispensing justice.
If you are not part of the solution, you are part of the problem ! There's no point in our judges being men of honour if they continue to be part of a system which can take upto 25 years to deliver a judgment. Justice delayed is justice denied - and the fact that Indians are so reluctant to go to court suggests that they do not feel they will get a fair deal within the present court system.
Part of the problem is the rigid pecking order and hierarchical seniority system in the judiciary. Even though young justices may be full of ideals, by the time they become senior enough to carry enough clout, they are likely to become jaded and cynical and are resigned to accepting the status quo as being the best we can do within the limitations of "our system". The judiciary needs to adopt creative destruction ( ala Schumpeter ) in order to evolve.
It's ridiculous that we still use a judicial system which was designed 200 years ago, in exactly the same fashion as when it was first designed. It's fine to take pride in our traditions - but not at the cost of being unjust to our citizens !
I'd like to propose a simple solution which will allow the judiciary to retain its strong points and fix its weaknesses !
The Chief Justice of each High Court ( and the Supreme Court) should appoint the youngest
judge as the Chief Iconoclast . His brief should be to innovate and use new technology to improve the productivity and efficiency of the court ! There are many possible solutions - and we can adapt and learn from other fields and other countries !
Allow online submission of briefs ? video conferencing ? set up more fast track courts ? insist on alternative dispute resolution for some matters ? The young judges could be appointed as champions of each of these disruptive innovations, and encouraged to experiment with them, till they come up with a better solution.
These judges should be encouraged and charged to " think out of the box"; take risks ; and accept challenges. These are the judges who have the most at stake , because they will be spending the rest of their life in the Court.Why not let them can make a meaningful contribution when they are in the prime of their professional career ? This approach will give them a chance to shine when they are at their professional peak. They are young and are comfortable with using the new technology. Also, they do not carry much emotional baggage ( as compared to some senior judges who accumulate a lifetime's worth of archaic ideas and practises) and are likely to be open minded and nimble in their approach.
Friday, January 21, 2011
For the report, Thomson Reuters and practice management company HCPlexus surveyed 2,958 physicians of various specialties on their views on health care reform, including health IT initiatives.
When asked about the impact of using electronic health records:
* 39% of respondents said EHRs would help patients;
* 37% said the effect would be neutral; and
* 24% said EHRs would negatively affect care (Fox, Reuters, 1/19).
This is hardly surprising ! A good EMR ( which is designed for doctors and by doctors) will actually help to enhance the doctor's workflow and improve patient care. A badly designed EMR can create a real mess !
If every doctor had their own website, then patients would find it very easy to find information on their doctor. Publishing this online would ensure that doctors would be transparent, honest and open !
SAIPRASAD GUNDETI, SENIOR EMBRYOLOGIST, MALPANI INFERTILITY CLINIC PVT. LTD.
Vitrification involves freezing the embryo about 600 times faster than ever before. This ultrarapid process is so fast that it literally allows no time for intracellular ice to form. As a result, vitrification avoids trauma to the embryo.
In conventional (slow) freezing, 20-30% of embryos do not survive the freeze-thaw, and those that do survive have less than half the likelihood of generating a pregnancy as do fresh embryos. In contrast, vitrified embryos have a better than 95% freeze-thaw survival rate, and a pregnancy generating potential that is comparable to fresh embryos.
Vitrification is now regarded as potential alternative to conventional (slow)freezing.
Major advantages of Vitrifiction over Slow freezing are :
- Its prevents ice crystal formation within the cells, which can damage the embryo.
- It eliminates use of expensive freezing unit(required for slow freezing).
- High survival rate post thaw.
- High pregnancy rate following transfer of thawed vitrified embryos.
At Malpani infertility clinic, we have been using vitrification for a number of years to cryopreserve both embryos and eggs. When it comes to embryo cryopreservation, we freeze all stages of embryos i.e. Day 1, Day 2, Day 3, Day 5 and Day 6.
Steep Learning Curve :
To avoid embryo exposure to high concentrations of toxic cryoprotectants for extended periods, vitrification protocols generally require that embryos remain in the vitrification solution for a fixed time. This can be difficult, especially since vitrification technique have an extensive learning curve before the technique is mastered. Even with practice, one may not be able to quickly pick up embryos and vitrify within the time required.
Therefore it's critical that we determine the length of time the embryos can safely reside in vitrification solution, so that we don't overexpose embryos to toxic cryoprotectants, which can kill them or lead to very poor post thaw survival.
How difficult is it to master the technique?
Vitrification technique is a difficult art to master:
- Due to high concentrations of cryoprotectants, vitrification medium is very viscous. High viscocity makes it very difficult to handle embryos, while they are in the medium. Needs lot of practice in order to get efficient.
- One needs to be quick while handling embryos in vitrification medium, as long exposure of embryos to cryoprotectants can kill embryos or lead to poor survival rate post thaw.
- Loading embryos onto cryolock is the most difficult part. It requires lot of practice. Improper loading can also affect the survival rate.
- Thawing procedure (called Vitrification Warming) is as important as the Freezing. Improper thawing may lead to poor survival. So one needs to thaw embryos carefully in order to ensure good survival of embryos.
How do I vitrify your embryos and eggs?
We use Quinn's Vitrification Medium at our centre for freezing Embryos and Eggs.
Quinn's Vitrification Medium contains 2 media, "Equilibration Medium" and "Vitrification Medium"
Equilibration Medium contains Base Medium(Hepes buffered Medium) + 7.5 % ethylene glycol + 7.5 % DMSO (Dymethyle sulfoxide) + 20 % Protein supplement
Vitrification Medium contains Base Medium(Hepes buffered Medium) + 7.5 % ethylene glycol + 7.5 % DMSO (Dymethyle sulfoxide) + 0.5 M Sucrose + 20 % Protein supplement
Preparation of Vitrification Dish :
Place 1 drop of 0.1 ml of "Equilibration Medium" and 4 drops each of 0.05 ml of "Vitrification Medium" as shown in the figure.
The entire Freezing procedure is performed at room temperature.
We need to leave the Petri dish in the workstation for 15 min, for the medium to recover to room temperature.
- Place embryos or eggs to vitrify in equilibration medium. (This will be number of embryos or eggs that will be placed on 1 cryolock). We don't put more than 3 embryos or eggs on 1 cryolock.
- Once embryos or eggs are placed in Equilibration Medium, they spontaneously begin to shrink . This is when the intracellular water comes out.
Picture of shrunken embryo, after placing it in the equilibration drop.
- The shrunken embryo or egg will gradually recover back to its original size. This takes approximately 7 to 8 minutes. This may be less or more than 7 to 8 minutes in some embryos and eggs.
- Once the embryo or Egg recovers back to its original Size, its ready to be vitrified. I generally vitrify the embryo or egg once it recovers to about 80% of its original size.
- Pick up the embryo or eggs from equilibration drop with a flexipet and place them in the 1st drop of vitrification medium.
- Once the embryo or egg is placed in the vitrification drop, it again starts shrinking. Keep the embryo or egg in the 1st vitrification drop for 10 sec. This is basically to get rid of Equilibration medium, which is carried along with the flexipet while transferring them from equilibration medium.
- While the embryo/egg is in the first drop of vitrification medium for 10 sec, rinse the flexipet by pipetting the vitrificaition medium to get rid of equilibration medium.
- After 10 sec, pick up the embryos/eggs from the 1st vitrification drop and transfer them to series of 3 drops of vitrification medium one after other.
- Quickly load the embryos onto cryolock with very little medium. Make sure to gently remove excess medium in case a bigger drop is made on the cryolock.
- immediately plunge the cryolock in Liquid Nitrogen. Now the embryos are vitrified.
- Slowly put the cap to the cryolock, while it is immersed in the liquid nitrogen.
- Put all the cryolocks in one visitube.
- Put the visitube into canister.
Vitrification Warming (thawing)
Quinn's vitrification warming medium contains 3 media, "Thawing Solution", "Dilution Solution" and "Washing Solution"
Thawing Solution (TS) contains Base media (Hepes buffered medium) + 1M Sucrose + 20% protein supplement.
Dilution Solution (DS) contains Base media (Hepes buffered medium) + 0.5M Sucrose + 20% protein supplement.
Dilution Solution (DS) contains Base media (Hepes buffered medium) + 20% protein supplement.
Preparation of dishes :
- Place a drop of 0.2 ml of Thawing solution (TS) in one dish as shown in the figure.
- Keep the dish for warming at 37 deg. C on a warming plate for about 15 min.
- Place 1 drop of 0.1 ml of Dilution Solution (DS) and 2 drops each of 0.2 ml of Washing solution in another dish as shown in the figure.
- Keep the dish at room temperature.
0.2 ml of Thawing Solution at 37 deg. C.
- Identify the cryolock (embryos we want to thaw) and put in the box containing Liquid Nitrogen.
- Remove the cap of cryolock, while it is immersed in Liquid nitrogen.
- Quickly submerge the cryolock tip into thawing solution under stereomicroscope view.
- The embryo will automatically dispel.
- Leave the dish at 37 deg. C for 1 minute.
- After 1 min, carefully collect the embryos from the thawing solution to Dilution Solution at room temperature making sure carrying forward minimal amount of thawing solution along with the embryos.
- After 3 min. pick up the embryos and transfer them to 1st washing solution. The embryos will recover back to its original size approx after 2 min.
- After 3 min. transfer the embryos to second washing solution.
- after 3 min transfer the embryos to culture dish.
- Incubate the embryos for 2 hours before transferring them to patient's uterus.
What mistakes can a beginner do while vitrifying, that can lead to a poor survival rate?
Preparation of vitrification dish
Placing only 1 drop of vitrification medium, trying to cut down on the amount of medium consumed.
- Using only 1 drop of Vitrification medium doesn't allow us to get rid of Equilibration medium before actually vitrifying the embryo/egg.
- The Equilibration Medium is not very effective when it comes to cryoprotecting , as compared to Vitrification Medium.
- Use 4 drops of vitrification medium.
- Serially transfer embryos/eggs through the series of these 4 drops of vitrification medium. This allows us to get rid of the equilibration medium effectively.
- This will definitely ensure better survival rate.
- Keeping the embryos in Equilibration medium for a short period of period before transferring them to Vitrificaition medium.
- This happens when we rely on fixed time period for each medium.
- Once the embryo/egg is placed in Equilibration medium, it will shrink spontaneously and slowly recover back to its original size. The recovery period varies for different embryos.
- When we rely on fixed time period for e.g. 5 min in Equilibration medium, it may not be enough for the embryo/egg to recover to its original size.
- If we transfer the embryo/egg to vitrification medium before it recovers back to its original size, it doesn't vitrify properly, which leads to extremely poor survival rate post thaw.
- Rather than relying on a fixed time, it's best to individualise the time, based on the shrinkage and recovery of each individual embryo/egg , to ensure better vitrification.
- The embryo/egg can take approximately 7 to 8 min. to recover back to its original size.
- In some embryos it can be less or more than 7 to 8 min.
- Making a large drop of vitrification medium along with embryo/egg while loading it on cryolock.
- A large volume of vitrification medium on cryolock will not allow proper vitrification of the embryo/egg.
- If the embryo is not vitrified properly, it leads to poor survival.
- Make a flat small droplet of vitrification medium.
- Even if the drop is large, get rid of the excess medium by aspirating it gently.
- An embryo placed in a minimal amount of vitrification medium on cryolock vitrifies perfectly.
Tuesday, January 18, 2011
From the first meeting, Dr. Malpani's optimism and the lack of judgmental attitude in his clinic put me at ease. I am not going to lie, physically IVF is very tough on a woman's body, even when you use donor eggs. The drug protocol is harsh, and the side effects can be very discouraging. I persisted through 2 cycles, one done with fresh specimens, the second with frozen embryos. Neither was successful and because each involved so much juggling of our work and personal schedules, not to mention the fact that I had moved from one city to another and taken a more senior and stressful position for work, I began to despair that we would ever succeed. Through it all, Dr. Malpani never expressed doubt, and merely advised me to take a break after the 2 back-to-back cycles. Then I started to have irregular cycles and thought this would be another strike against me. However, I took a break and approached the 3rd cycle almost with an attitude of "it's probably not going to work, but what the heck." I was consequently very relaxed throughout the cycle and my husband and I had a very short belated honeymoon in Goa before going to Dr. Malpani's clinic for the third, all fresh, cycle. After some discussion, Dr. Malpani transferred 4 embryos, 2 Grade A, 2 Grade B, and I flew back to the US 2and a half days later and returned to work almost immediately. After 7 days, I was dismayed to find some staining and though I could not possibly be pregnant. On day 16, I went to my ob/gyn for the HCG blood test. A day later, I was advised that the test result was POSITIVE. Because I could not wait until the end of the day to tell him the fantastic news, I called my husband with the test results and he thought I was joking!!! In the meantime, between days 7 and 16, poor Dr. Malpani was living through the tortuous wait with us. At one point he suggested we not wait for the HCG test but take a home pregnancy test on day 14 (in the US, day 14 fell on a Saturday when all medical facilities are closed for the weekend). I was so convinced that I was not pregnant that I did not take the home test.
So now, I am getting into my second trimester. Two ultrasounds have revealed a healthy baby and God willing, everything will continue to progress well. I am due in July 2011, and am feeling great. To all of you out there, I know God will work a miracle as he did for us. And without Dr. Malpani, Dr. Anjali and their caring staff, the miracle might never have happened. My husband and I wish you all the best of luck and a healthy and baby-filled 2011.
It's success stories like this which make being an IVF specialist so meaningful - the fact that we change people's lives for the better ! And the fact that we get so many blessings daily every time our patients see their children is an added bonus :)
Monday, January 17, 2011
Friday, January 14, 2011
Many IVF doctors in India travel extensively. They have many clinics all over the city ( and in some cases, all over the country). Naive patients get impressed by such doctors - wow - he is so busy and so much in demand that he needs to travel all over the place. In fact, some doctors even go to Dubai and Africa ! While this seems very impressive, in reality this means that the quality of care they provide to their patients leaves a lot to be desired. Let me explain.
The personal goal for these doctors seems to be to maximise the number of patients they treat, so they can maximise their throughput and their revenue. While it's very good for an IVF clinic to be busy, it's also important that the quality of care provided to their patients not be compromised in the quest for quantity !
How do these doctors manage to do IVF in so many locations ? They usually do so by batching groups of patients together, so they treat lots of patients within 1-2 days. After they finish one batch of patients at one site , they then move on to the next site ! While it's medically quite feasible to program IVF cycles, the truth is that ensuring that all patients grow eggs at exactly the same time so that they will all mature on the same day for egg retrieval is simply not possible. The doctor is forced to cut corners for some patients because he's trying to force a square peg into a round hole - and this is especially harmful for older patients ( with poor ovarian reserve); challenging patients ( who have failed many IVF cycles in the past) ; or patients with PCOD ( who may end up hyperstimulating), because it's not possible to individualise their superovulation protocol. Such a rigid travel schedule means the doctor cannot afford to be flexible or cater properly to the "outliers".
So what happens to these patients ? They fail to get pregnant - and unfortunately they are not sophisticated enough to realise that the failure is not because there is a problem with them, but rather because they are not good candidates for "programmed" IVF ! They need a more focussed clinic which can spend the time and energy needed to optimise their chances. However, doctors who are focussed on the bottom line are really not very interested in treating these challenging patients. They would rather treat lots of young patients and improve their turnover, rather than take pride in getting the difficult patients pregnant !
The other major problem with this kind of itinerant IVF is that it's not possible to develop a relationship with your IVF doctor. In fact, you may not even see the IVF specialist for more than a few minutes, because this "big-shot, big-name" doctor may just breeze in, do the embryo transfer, and then breeze out ! If you have questions, you will never know whom to get the answers from, because all the juniors are uncoordinated and cannot make decisions, because they do not have the expertise or the experience to do so !
Now there's nothing wrong with this McDonald approach - after all, it seems to work well for these doctors ! This is because in each batch, the young patients who are good ovarian responders , will get pregnant ( though the success rate will not be as high as it could be in a full-service IVF clinic). But this approach is obviously not right for all patients ! If you've failed an IVF cycle; or have poor ovarian reserve; or need TESE or have PCOD, then you should rather select a clinic which provides all its services all the time in one location !
This is why all the world's leading IVF clinic all operate from a single location. They understand that IVF is a very labour intensive process, which needs close monitoring and extensive tweaking to optimise outcomes for their patients. Good doctors would rather focus on each individual patient, and are confident that if they are good, patients will come to them, rather that their having to go to other cities to find more patients to treat !
If you need a second IVF cycle, and if your IVF doctor is not present in the clinic all the time, you should be very worried about the quality of the care you will get ! If you want to maximise your chances of getting pregnant, send me your medical details by filling in the free second opinion form at www.drmalpani.com/malpaniform.htm and I'll be happy to help !
Wednesday, January 12, 2011
Infertile patients expect that their doctors will provide them with treatment to improve their chances of having a baby. Tragically, some medical procedures can actually end up reducing your fertility !
Here's a list of the top ten procedures which can actually harm you, rather than help you ! If your doctor advises any of these, please get a second opinion before agreeing !
1. D&C ( dilatation and curettage) . This is a "minor" surgical procedure in which the doctor dilates the mouth of the uterus ( the cervix) and scrapes the uterine lining using a curette
( curettage). This endometrial tissue is then sent for pathological examination. In the past, when doctors had very little to offer to their patients, this used to be the mainstay of the treatment of an infertile couple. In fact, even today, some women will ask the doctor to do a D&C for them because their mother conceived after doing this procedure ! They feel that it helps to "clean the uterus", thus improving their fertility ! While it is true that some women will get pregnant after a D&C ( sometimes this is just a placebo effect; while sometimes the endometrial inflammation induced by the procedure can improve uterine blood flow and fertility), this is an obsolete procedure which should be used in this day and age only for confirming the diagnosis of endometrial tuberculosis.
2. Metroplasty. This has become quite a fashionable procedure in some parts of India, where the doctor "improves" the shape of the uterine cavity to improve fertility. It can actually create uterine scarring and induce fertility. It's only in India that doctors use this technique for "treating" infertility. In all other countries, it is reserved for correcting uterine anomalies or removing intrauterine adhesions.
3. Hydrotubation. This is a procedure in which the doctor flushed the uterus and the tubes with fluid ( which often contains a concoction of chemicals such as steroids and antibiotics) to treat infertility. While it can help some women with cornual blocks, for the vast majority this painful treatment ( which is often repeated many times in one month) is a waste of time and money.
4. Empiric treatment for abnormal sperm . This continues to remain a major time-waster for infertile couples. Tragically, most doctors are still unaware of the recently revised criteria of what a normal sperm count is - and will often reflexively treat men with what they think is an "abnormal sperm report". There are various levels of sophistication to this futile effort. To cloak this with an aura of scientific respectability, high tech labs will now test sperm for DNA fragmentation levels - and doctors are quite happy to "fix" the problems these tests will often pick up. What many patients do not realise that there is very little correlation between these test results and their fertility potential - and that even fertile men have high DNA fragmentation levels ( but are fortunately unaware of this, as they have enough sense not to get their sperm tested in a lab !)
5. Treatment for genital tuberculosis. We are now seeing an "epidemic" of uterine TB in India - especially in north India, where it appears that practically even woman who goes to a gynecologist has TB ! Doctor use dodgy tests called PCR to test the endometrium for the presence of DNA fragments which are supposed to be be specific markers for the tubercle bacilli - without even bothering to determine what the prevalence of this TB PCR positivity is in the fertile population ! Not only do these poor patients end up taking 6 months of toxic and expensive drugs; their husbands will often stop having sex with them ( because they are worried that they will transmit the TB to them); while others are scared that they will give the TB in their uterus to their baby !
6. Treatment for TORCH infections. Women who have been unfortunate enough to have a miscarriage will get routinely ( and mindlessly) tested for the presence of antibodies against the TORCH group of infections. If any of these tests is positive, the doctor then promptly treats this infection with antibiotics ( which are completely useless and uncalled for !). The truth is that pregnancy. You can read about this at www.drmalpani.com/torch.htm
7. IUI ( Intrauterine insemination ) for treating couples men with a low sperm count. Since everyone knows that " you need just one sperm to fertilise an egg", it seems to make a lot of sense to treat infertile couples who have a low sperm count with IUI . After all, IUI is a simple and inexpensive treatment, which every gynecologist can offer - and patients understand the logic as to why it should help. The truth is that the problem with men with low sperm counts is not just that their sperm count is low - its often that the sperm are functionally incompetent - and no amount of concentrating the good sperm or washing them is going to help !
8. Diagnostic laparoscopy. Once upon a time, a laparoscopy was a major advance in evaluating the infertile woman, because it actually allowed the doctor to visualise the ovaries and fallopian tubes without having to cut open the patient ! Minimally invasive surgery was a major advance then , but now it's being overused. Many doctors still routinely perform a laparoscopy for all infertile women, which is completely unnecessary surgery, as is does not change the therapeutic options for these patients. The status of the fallopian tubes can as easily be checked with a simple HSG, which is much less expensive ! It's true that a laparoscopy allows the doctor to also "find" adhesions and endometriosis, but making the diagnosis of this ( or "treating" them ) does not really improve the patient's fertility at all !
9. Medications for treating endometriosis. Endometriosis is an enigmatic and frustrating disease; and mot doctors will still reflexively "treat " this with medications, such as GnRH analogs. While these medications are great at suppressing the endometriosis (and will provide dramatic pain relief), this suppression is only temporary - and does not improve the patient's fertility at all (since they also suppress ovulation at the same time !) Once the meds are stopped, the endo recurs ! Even worse, "treating" the endo with meds just wastes the patient's time - something which most infertile patients cannot really afford to fritter away !
10. Operative laparoscopy for myomectomy and cystectomy. One problem with today's high tech diagnostic tools ( such as vaginal ultrasound scans) is that it allows the doctor to "diagnose" small 1 cm size ovarian cysts and fibroids. Now while cysts and fibroids are very common in fertile women as well; and small cysts and fibroids do not affect fertility, once the sonographer has "reported" his "diagnosis", the patient often panics ! The doctor is happy to point out these abnormalities - and convinces the patients that it is these abnormalities which are the cause of her infertility - and that once these are "treated", she'll get a baby quickly ! What's worse is that it's easy to do the surgery with a laparoscopy ( which is just "minor surgery"), that patients are quite happy to sign on the dotted line without realising that these are incidental findings of no clinical importance; and that the surgery will not help them. What's worse, is that this unnecessary surgery can reduce your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.
I sometimes think we are seeing an epidemic of overtesting and overtreatment. Doctors seem to like doing tests - and patients like being tested ! Unfortunately, patients are still not sophisticated enough to differentiate between useful tests and useless tests - and the truth is that some tests can actually be harmful !
The hidden danger with a lot of these unnecessary testing is that patients get fed up; lose confidence in doctors; and refuse to pursue more effective treatment options, because they do not trust doctors any more !
The message is simple - if you have a medical problem, remember that Information Therapy is invaluable ! Please get a second opinion if you are unsure and confused. Send me your medical details by filling in the free second opinion form at www.drmalpani.com/malpaniform.htm and I'll be happy to help !
Tuesday, January 11, 2011
The decision in Re L attracted front page national headlines because it marks a significant watershed in the history of UK surrogacy law. For the first time the court has made clear that the child's welfare will trump public policy on payments.
This is why it's so important for infertile couples to find a reliable IVF clinic before entering into a surrogacy arrangement !
Monday, January 10, 2011
A chocolate cyst of the ovary ( also known as an endometrioma, endometrioid cyst, or endometrial cyst) is found in some infertile women who have endometriosis. In this disease, the inner lining of the uterus ( called the endometrium ) grows in various abnormal locations within the pelvis . One of the commonest sites this aberrant endometrial tissue can be found in is the ovary. With every menstrual period, this tissue grows, enlarges , bleeds, and sloughs off . Here it forms a cyst; and because the contents of this cyst are black, tarry and thick, they resemble dark chocolate , hence the name ! ( I feel that sometimes doctors can have a perverse sense of humor . For most women, the word chocolate produces happy feelings, because chocolates are a woman’s favourite treat. To label a disease condition after a dessert is something which only an unfeeling man would do ! )
How is the diagnosis made ? While an alert doctor will often suspect the diagnosis in infertile women with progressively painful periods, often women with chocolate cysts may have no symptoms at all. This means this diagnosis is made during a regular infertility workup ; or even during a routine pelvic examination. While some cysts are large enough to be felt on pelvic examination, many are small and cannot be detected on clinical examination.
Ultrasound scanning is an excellent way of diagnosing chocolate cysts and can pick up cysts which are very small. On scanning, chocolate cysts are complex masses ( which have both solid and cystic components); and are often tender. They have a typical ground glass appearance because they contain old blood. They can vary in size from a few mm to over 10 cm; and can be bilateral. However, it’s not possible to make a definitive diagnosis of endometriosis on ultrasound scanning, as many other conditions can also produce cysts in the ovary. The diagnosis can be confirmed either by aspirating the cyst under ultrasound guidance ( and finding the typical dark old blood which is diagnostic of endometriosis); or by doing a laparoscopy.
In the past, a laparoscopy was the gold standard for making the diagnosis of endometriosis, as this allowed the doctor to actually inspect the pelvic contents. However, because it involves surgery, many infertility specialists no longer do a laparoscopy for their patients.
There are 3 key factors which doctors need to evaluate when making a decision as to how to treat chocolate cysts in infertile women.
1. Whether the patient has any symptoms
2. The size of the cyst
3. The AMH level
Thus, when a small chocolate cyst is picked up when doing a routine vaginal ultrasound scan in a young asymptomatic infertile woman , the best course of action maybe masterly inactivity. This is because this is an incidental finding which is best documented and left alone. Remember that doctors do not treat ultrasound images - we treat patients ! Many fertile young women also have endometriotic cysts which they live with happily for all their lives ( and because they have enough sense not to go to a doctor, they often do not even know that they have a chocolate cyst !) Unfortunately, many doctors tend to be trigger-happy, and when they find a cyst on a pelvic ultrasound scan, they reflexly perform laparoscopic surgery – both to confirm the diagnosis; and to treat the cyst ! The danger is that this unnecessary surgery can actually reduce your fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.
Small cysts ( less than 3 cm in size) can be happily left alone . If they are larger, they can be monitored by serial scans, before making a decision as to what the definitive treatment should be.
As regards treatment choices, the options include medical therapy or surgery. Medical therapy consists of medicines such as danazol or GnRH analogs to suppress the endometriosis; and while this is very effective in providing temporary symptom relief , it is not very effective in treating the cyst, which tends to remain inspite of the treatment.
The definitive solution is surgical; and this usually consists of operative laparoscopy . Very few doctors will now do open surgery ( laparotomy) to treat a cyst, no matter how large it is.
There are many controversies regarding the optimal surgical management of chocolate cyst s in an infertile woman, which is why it is important that you go to an expert. In the past , doctors would try to excise ( completely remove) the entire cyst , to reduce the risk of its recurring . However, because this meant that they needed to also sacrifice normal ovarian tissue during this process, they often ended up pushing infertile patients from the frying pan into the fire by reducing their ovarian reserve and worsening their infertility ! This is why most doctors today prefer to be far more conservative in infertile women with chocolate cysts ; and will usually just create an opening in the cyst wall ( marsupialisation) to drain the contents. This often provides dramatic temporary relief. During the operative laparoscopy, the doctor also has an opportunity to remove the adhesions (scar tissue) and the other endometrial implants which are often found in women with chocolate cysts and treating these can also help to enhance their fertility for a few months. The chances of achieving a pregnancy are maximal within a few months after the surgery. However, if a patient has failed to conceive within one year of the surgery, then the chances of success with repeat surgery are quite poor; and it’s better to consider assisted reproduction.
The major bugbear with chocolate cysts is that they tend to recur. This is why doctors will often combine medical suppression with surgical treatment. However, all these are temporizing measures, which help to buy the patient time – we really do not have any way of curing this enigmatic disease !
If the chocolate cyst recurs, patients are understandably upset, and feel that the doctor was incompetent and did not do a good job with the surgery. This is not always true, because endometriosis can be quite an aggressive disease in some women, and can recur even if the surgeon was very skilled. It’s important to ask for DVD documentation of all surgical intervention, so that the video can be reviewed later on, if needed.
If the cyst recurs, patients will often go to another surgeon ( who they feel is more expert) to try to correct the problem. The pelvis in some of these patients starts resembling a battle field, because they often end up having many laparoscopies done by many different surgeons, each of whom claims to be the best ! The surgery can be extremely challenging in these patients . The scarring , adhesions and previous surgery tend to distort the anatomy and the pelvis sometimes is completely frozen. Operative complications in these cases ( for example, inadvertently opening the bladder or rectum) are not uncommon.
The AMH level is a very important factor which many doctors tend to overlook in treating infertile women with endometriosis. The major danger with endometriosis is that the chocolate cyst replaces normal ovarian tissue, as a result of which many of these patients have little normal ovarian tissue and poor ovarian reserve as a result of their disease. This is why it’s important to assess your ovarian reserve by checking your AMH level and your antral follicle count before doing anything further ! If your AMH level is low, then it’s best to avoid surgery and to move on to IVF to maximize your chances of having a baby quickly ( before the disease becomes worse and eats away more of your precious reserve).
For young women with normal ovarian reserve, open fallopian tubes ( as proven on HSG) and small chocolate cysts who have no symptoms, it’s worth trying IUI before doing anything more aggressive. However , if the patient is symptomatic and the endometriosis is causing pain, then this become a trickier issue ! You need to set your priorities – is pain control more important ? Or is having a baby more important ? This is often a difficult decision to make, but you need to decide. It’s best to make a list of all your options so you can think through these logically.
If having a baby is key, then it’s best to manage your pain symptomatically and concentrate your energies on getting pregnant quickly. IVF is very effective , as it maximizes your chances of getting pregnant quickly . The beauty with IVF is that it allows you to kill 2 birds with one stone – not only do you get your deeply desired baby, you also have dramatic pain relief for at least 1 year ( because your periods will stop during your pregnancy and your postpartum period ). As an added bonus, the endometriosis will also get better as a result of the pregnancy in some women ! This is why many doctors advise that the best treatment for a young woman with endometriosis is a pregnancy. Of course, this is easier said than done, because endometriosis does affect your fertility !
Do you have a chocolate cyst and are unsure what to do ? Send me your medical details by filling in the free second opinion form and I'll be happy to help !