Tuesday, December 31, 2013

A super duper IVF success story !


You hear IVF success stories every now and again but I'm sure ours will be a super duper one!!!

We, Susan and Sunil Silva got married 11 years ago, we didn't have (any biological) kids because  my husband had undergone a vasectomy in his previous marriage, after fathering 2 boys. The elder one is with his ex while the younger one chose to be with us- apple of my eye, my son!  About 7 years ago we started thinking about having one more child and and decided to give it a try undergoing an ivf! I started reading and searching for good clinics in the internet and always Dr Malpani's clinic came first in the list and I literally developed a virtual faith/trust to that clinic. Moreover the advice/second opinion which I got from Dr Malpani boosted my confidence and I was damn certain I want to go to Malpani's for my ivf. Unfortunately my husband was dead against about the idea of going to Mumbai for an ivf when there are n number of ivf clinics in Chennai itself! So we tried ivf in a clinic here in Chennai where which not only wasn't successful but also the whole episode highly unprofessional. There was absolutely no transparency as far as the treatment was concerned and we just left the idea of trying another cycle for a while then.

Then two years ago we decided to try another cycle (better late than never!) and this time my husband let me decide on the clinic (I made his life miserable enough for for 2 years for not listening to me, so much so that he would've taken me to moon if that's where I wanted to go for my ivf! ;)!!!

There was no doubt in my mind where I wanted to go! I landed in Mumbai in June 2012, the first meeting up with Dr Malpani itself made me think extremely positive about the whole exercise. I got conceived in the first chance itself with TWINS!!! I gave birth to my baby boys Jordan and Aidan in Feb 2013!!! Yippee!!!

The story doesn't end over here! My brother was diagnosed with obstructive azoospermia about 4 years ago and was left with no choice but ivf in order to have a child of his own! Both my sister in law and my brother tried an ivf cycle in kerala (against my advice on Malpani clinic) 3 years ago which was again a failure.. So vague that clinic was, they haven't even got a treatment copy from there!

Seeing me pregnant with twins, they too wanted to try their next cycle in Malpani's. They both started their treatment in June 2013, exactly a year after my visit!

And my sister in law is now six months pregnant with TWINS!!!!!  Yippee Yay Yay!!!! (Moral of the story is take me my advice seriously! :D)

I'm extremely happy with the experience I had in this clinic! I was very clear I would repeat the cycle if necessary in the same place with the same doctors! Both doctor Aniruddha and Anjali Malpani are highly professional, do understand the sentiments of each of their clients and are very supportive through the treatment emotionally as well! The staff here is very warm and friendly and are an excellent team! Thank you all from the bottom of my heart for what I've got because of you'll! Big hugs...

Susan Silva.


susan@silva.in


Monday, December 30, 2013

What questions should an IVF patient learn to ask ?


The most important skill IVF patients need to learn is that of asking the right questions. Infertile couples have lots of questions – especially when they have failed an IVF cycle, and they rightfully expect their doctors to provide them with answers. While it is true that the quality of the doctor’s answers depend upon him ( his personality  and whether or not he encourages patients to ask questions; how well-informed he is; and whether he can speak clearly without using jargon), they also depend upon the quality of the patient's questions !

Good -quality questions get good-quality answers. Many patients just pull out a generic list of questions and this can be quite irritating even for a well-meaning doctor, who has a limited amount of time to spend with each patient . He may try to go through the list patiently, but many will get visibly upset. Now this does not mean that he is trying to hide information – it just means that he is disappointed that the patient has not bothered to take the time and trouble to answer these simple questions for themselves by doing a basic internet search.

When this happens, patients start complaining that doctors refuse to answer their simple basic questions. While it is the doctor’s responsibility to educate the patient, it is equally true that it is the patient’s responsibility to educate themselves and not expect the doctor to spoon-feed them. Doctors are teachers, but good doctors do expect their patients to behave as good students and do their homework before coming for the consultation !

The good news is that there's more than enough information available online – and that most general questions can easily be answered without involving the doctor. The questions which are specific to your particular circumstances are best answered by your doctor – and these are the ones you should reserve for him. The more you know about your problem, the better the quality of your question ! The squeaky wheel gets the grease and doctors respect patients who ask good questions.

Bad questions are those which are general – and which you can find answers to for yourself by doing a google search. So what are good questions ? Not only should they preferably be tailored and specific to your circumstances, they should also be crafted in such a way that the doctor has to provide answers which are actionable, and which help you make better decisions !

Let’s look at an example. The first question patients with a low sperm count often ask is – Why is my sperm count so low ? This is a logical query – and the patient hopes that once we know what the problem is, we’ll be able to fix it ! After all, doesn’t diagnosis always come before treatment ? While it’s true that this is an important question, in real life the answer is not very useful for most patients. A far better question than Why ? should be What ? Thus, a better question should be – Now that I know I have a low sperm count, what should I do in order to get my wife pregnant ? This question is much more likely to produce concrete solutions which can lead to your desired goal – that of having a
 baby !

I believe answering the question why a man has a low sperm count is best answered in a research lab setting, rather than in a clinic. Te danger with this question is that the doctor then ends up ordering a battery of tests, in order to satisfy the patient . Not only do these end up wasting time and money, they are usually pointless, because they do not influence the treatment options the doctor can offer. Even worse , they distract from the primary goal – that of helping the couple to have a baby ! Instead of looking for problems, patients need to learn to ask questions which will help them to find
solutions !

At Malpani Infertility Clinic, we encourage our patients to ask questions   - and we teach them how to ask good question.

Not sure what questions to ask your IVF doctor ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Sunday, December 29, 2013

Why do IVF patients put up with so much rubbish ?


It always amazes me how badly some doctors treat their patients . What I find even more surprising is why patients put up with this kind of bad behavior from their doctors. IVF is an expensive treatment and patients are paying a lot of money in order to ensure that they get good quality medical care . The least they can expect is respectful treatment from their doctor. However, patients are often treated like cattle. They are made to wait for hours on end in order to get their lab results; get a scan done; or to see their doctor. I feel this is completely unacceptable .

There are some doctors who will pile up a huge number of patients every month, and do 50 IVF cycles in a period of 3 days. They take pride in these numbers , and proudly boast about how many IVF cycles they do every year. They treat patients as being widgets on an assembly line and think of themselves as running an efficient baby making factory !

Thus, these doctors will typically do embryo transfers for 5 patients in 10 minutes. They put all their patients in a single room , where they lie down with their legs up in the air , with lots of other women in exactly the same situation . There is absolutely no privacy – and a complete loss of dignity .The doctor then goes from patient to patient, depositing the embryos, one by one.  Husbands are not allowed – and God help the patient if the embryologist hands the wrong embryos to the doctor ! This is a set up for a disaster waiting to happen.

Other doctors do multiple consultations at one time . There are 3 patients crowding around the doctor’s desk, clamoring for his attention , while there are 4 more waiting for their turn. Imaging trying to discuss sexual problems in this kind of setting ! Not only is there no privacy, the patient is never not sure whether the doctor remembers their name – or is mixing up their prescriptions with someone else’s. Just because a doctor is busy does not mean that they have the right to ill-treat their patients !

Many clinics treat their patients like widgets. They are asked to do their scans in one location ; the blood tests in a second ; and meet the doctor in a third. Egg collections are done in a completely different facility – and embryo transfers may be done somewhere else ! Patients are herded together in groups – and most do not have clue what is happening to them because they have not been told what to expect. This kind of treatment makes my blood boil. It’s very hard to provide good care if resources are stretched and the doctor has a long line of patients to process. He is likely to be rushed and make mistakes. Even worse, this attitude infects the other staff members as well, who start becoming uncaring as well.

I can understand why doctors do this . It makes a lot of sense for them to batch their patients and treat them together in groups . They can be much more efficient, and this kind of processing helps them to maximize their profits. What I cannot understand is why patients put up with this kind of behavior . After all, these are educated, affluential patients – not the illiterate poor , who don’t dare ask questions in a government hospital setting which provides them with free care.

So why do patients tolerate this kind of behavior. Many patients are completely dependent on the doctor. They are very reluctant to complain or speak up, because they are worried that if the doctor is upset with them, he will not look after them well. This is especially true in small towns, where there is only one doctor, which is why he can get away with bullying his patients, Secondly , some patients feel that their doctor is the only act in town. Since he is the “best”, they treat the doctor as God. They are scared to question him or get a second opinion , because of the amount of time and energy this will consume.

Thirdly, often patients don't know any better , because all the doctors they have seen have treated them in exactly the same shabby fashion . They expect that this is the standard of behavior .

The final issue is the problem of herd mentality . Patients feel that if 50 other patients are willing to put up with this kind of behavior, then this must be par for the course, so they dare not complain ! In fact, they perversely come to the conclusion that the very fact that the clinic is so crowded and that there are so many patients clamoring for the doctor’s attention is a signal that this doctor must be the best. After all, putting up with rudeness and bad behaviour can be a small price to pay if this maximize your chances of having  a baby. They are willing to accept an uncaring attitude , as long as the technical quality of care is good !

This is flawed thinking . There is no shortage of good doctors in India. Patients should demand respectful treatment from their doctors . If they refuse to put up with bad behavior from their
doctors , doctors would automatically be forced to improve ! It’s only because patients put up with this kind of rubbish that doctors continue to get away with it. Patients need to learn to vote with their feet.

At Malpani Infertility Clinic , we pride ourselves on providing respectful attention to all our patients. We are very hands-on and focussed ; and since we are a boutique clinic, we are good at pampering our patients !

Do you feel your IVF doctor does not treat you with respect ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Saturday, December 28, 2013

Why IVF patients feel they have lost control


IVF patients have lots of worries and concerns – and quite rightly so , because they don't know what the outcome of the IVF cycle is going to be . They obsess about lots of things and their mind plays all kinds of games with them ! Will I grow enough eggs ? Will my uterus reject the embryo ? Will my doctor be kind ? What if my embryos are not of good quality ? They also often have many regrets . I wish I had done IVF 5 years earlier, when I was younger ! I wish I had found this doctor earlier ! I wish I had insisted on getting photos of my embryos ! I wish my husband had a better sperm count !

A lot of these worries and concerns are misplaced , because there’s very little which a patient can do about these. These are “sunk costs” – and worrying about them cannot change anything, because they are outside the patient’s control. There’s little point in fretting about things you cannot fix – this really does not help anyone at all.  It’s far better to focus your energies on the things you can change !

The good news is that there is lots of stuff which you can do to improve your chances of getting
pregnant ! The key is what I called information therapy and it is important that you become a well-informed patient , so that you understand exactly what is happening to you . This way you have realistic expectations of the treatments – and even of the cycle fails , you have enough emotional resilience to be able to bounce back.

From a practical point of view, you will acquire the ability to judge how good your doctors are  - and whether they are providing you with good quality care . This is one of the most important variables which you can control –  selecting the best doctor is the one action item you can take which can maximize your chances of success !

IVF patients often feel they have lost control over their bodies because they cannot even make a baby on their own - something which millions of other women can do with such ease ! This is why they may feel inadequate , incompetent, and incomplete. At Malpani Infertility Clinic,   we allow them to regain control , by respecting their personal preferences and desires when we craft an individualised IVF  treatment plan for them.

Do you feel your IVF clinic treats you as a widget ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm , so that I can guide you better !


Friday, December 27, 2013

Why should I question my IVF doctor ?


I had an interesting consultation with an infertile couple yesterday. They had done an IVF cycle elsewhere and I was asking them some basic questions about their treatment (such as how many eggs were retrieved and the quality of the embryos). They seemed pretty clueless and when I told them I was upset with them because they were so poorly informed about their medical treatment details, they took offense.  “ Why are you asking us these questions ? You use your PC daily. Do you know how much RAM it has ?  We went to a good doctor and trusted him, so we know he did a good job and we didn’t dig for more details. After all, why should we ? Just like we trust you, we trusted him and don’t see any need to do a postmortem !  There’s no point in cluttering our brain with these technical minutiae – we’d rather let the doctor do his job and not interfere or ask question !”

I was a little taken aback about how proud they were about how little they knew about their treatment. I believe that patients need to become experts on their treatment . The more they know about what is happening to them, the better for them, and the better for their doctor, because they can then behave as well-informed partners and this will help them get the best medical care.

Asking question does not mean meddling with the doctor’s treatment or rejecting his advise. Neither is it a sign of distrust – it’s just what every patient needs to do, to make sure they are in control of their life. After all, IVF treatment does not have a 100% guaranteed success rate – and being well-informed helps patients to cope better with the IVF emotional roller coaster ride.

The couple did not agree with me. They felt that it was not their job to “monitor” or second-guess their doctor. They felt that trust in the doctor was an integral part of a healthy doctor-patient relationship – and that cross-questioning the doctor would harm this. It’s true that many doctors don’t like patients who ask questions - and some will actually get irritated and upset when the patient wants his doubts clarified.

I agreed that I was not the right doctor for them; and this was the first time in the entire consultation when they whole-heartedly agreed with me ! I guess the moral of the story is simple - Doctors get the patients they deserve – and patients get the doctors they like !

Looking for a better IVF doctor ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !





Thursday, December 26, 2013

I Will Teach You to be Healthy !

One of the biggest problems in medicine today is managing patients with chronic illnesses such as diabetes, asthma, arthritis, hypertension and obesity . These are primarily lifestyle diseases , and while doctors can prescribe medicines to treat some of the consequences of these diseases, the most effective long term solution involves improving the patient’s lifestyle by changing his behavior. The problem is that changing behavior is extremely hard to do , as we all know from personal experience
( keep a track of how quickly you will end up breaking your 2014 New Year’s Resolution to eat healthily and to exercise daily ! )

So why do people ( most of whom are rational and intelligent and understand the importance of stopping smoking or losing weight ) find it so hard to actually do this in real life ? It’s obviously not that they don't understand why they need to do this – or even how to do it. There’s plenty of information available on these topics and the doctor can easily tell them what they need to so !

The reason why very few people can actually implement this well-meaning advise in real life is because most of this information is just theoretical advice . It’s a long list of what they are not allowed to do – and no adult likes being lectured to !

Also, patients carry a lot of emotional baggage . They remember the last time they tried to stop smoking and failed miserably. They start doubting their “will-power” and start thinking of themselves as being failures.

There is no magic key by which we can get people to improve their behavior. However, one of the most effective way of doing this is by getting them to interact with other people who've been successful in overcoming the same hurdle – someone just like them, who has “been there , done
that “.

These experts serve as role models of success  and are far more inspiring for patients , because their advise is much more believable and actionable. When patients see that someone who was in exactly the same situation they are in was able to master their problem and succeed in fixing it, then they have renewed hope that they do so this as well.

Equally importantly , this person talks exactly the same language as the patient , so that it’s easier for the patient to identify with him. Also, the advise is likely to be more trusted, because patients understand that the expert patient has no axe to grind and is doing it because he wants to help.  Patients need this kind of support and motivation , because they know their mentor will be rooting for them and cheering them on.

Expert patients are likely to be happy to help, if we provide them with a platform which they can use; and pay them for their services. Most will be very pleased about the fact that they can help someone else to learn from their expertise and advice . While doctors, nurses and health professionals will always be in short supply, there will never be a shortage of expert patients who are happy to help others ! Expert patients will need to teach patients  how to change, and the trick is to get them to focus on their strengths. We all have areas  of life in which we have succeeded – we just need to learn to apply these success skill sets to our healthy behavior, in order change the undesirable behavior .



( The title of this post has been borrowed from Ramit Sethi's bestseller, I Will Teach You to be Rich )

Wednesday, December 25, 2013

Our IVF success story - a test of determination, love and professional support

It was the 3rd year of our marriage -2011. We lost our first baby girl at full term due to meconium aspiration. Just 2 days before this fatal day I had lost my mother to another doctors’ negligence. As a precaution, I had insisted our ob-gynaecologist on the next day of my moms’ death to perform C-section on my wife and then I could also break the news to my wife. She ignored my request despite my in-laws visiting her on the same day with my request to her clinic. All along she kept telling us that it was a precious pregnancy , a successful IUI outcome after diagnosis of mild endometriosis. A well planned c-section was indeed, as the medics would say, a part of “Protocol” having also done prophylactic os-tightening ( cervical stitch) on the same lines. To me, I had definitely read a single para on a webpage dedicated to meconium aspiration as the last hurdle to successfully complete a precious pregnancy like ours. I even had pinned it in my mind. But my mom’s illness and treatment seemed to divert my focus while my wife was at her parents place for last 2 months. Plus the doctor kept telling us all is well. Thus the tragedy happened.

But the actual credit for the success of that IUI was more to Dr.Malpani’s free second opinion service than our existing gynaecologist who had prescribed us Anti-TB treatment for 3 months after carrying out diagnostic laparoscopy simply because she got a borderline positive (false positive) result.

Dr. Malpani advised us through email after going through our electronic data to ignore the anti-TB treatment as there was no credible basis indicating the need.
We took his advice and had insisted our gynaec perform the IUI. That was successful in first attempt. That’s when our faith in Dr. Malpani took roots.

Back to story, my dear wife was uninformed by in-laws about the death of my mother as per my directions , and was therefore unaware of our shocking loss and was dreaming of our precious baby to arrive. I did visit her once and cracked a few jokes, choking the tears in my eyes and gulping the lump in my throat.

Anyways we headed down the hospital after 2 days of my request being turned down due to labor pains. It was a Monday morning. Everyone in hospital were getting warmed up to their weekly routine at our cost. And what they kept telling us was a normal delivery by the end of the day, became an emergency C-section in just under 2 hours of our admission. We lost 2 important persons of our lives in 4 days.

The test actually begins here. You see I have a father who suffered a stroke because of the 2 shocks and a sister who was once again preggers for 6 months who had also lost a baby at exactly 6 months just a year back before then. There is no way we could afford another loss.

We broke the news of the 2 losses, back to back, to my wife as soon as she regained complete consciousness in the hospital to avoid post-partum psychosis. That was the next day after the C-section. Hoping that 2 negatives would effect something positive. Yep, instead of suing the negligent gynaec I thought it prudent to protect my wife from mental shock. We succeeded as will be seen later. And I am sure the gynaec will never sleep peacefully without this incident haunting her.

We collected ourselves and devoted each second to look after my pregnant sister. My wife did each and every chore for my sister who obviously was in no state of enjoying her pregnancy but awaited re-birth of our mom in the form of her baby as told by me.

Imagine the predicament of my wife who attended my sister within 2 weeks of the loss as we try to appear normal with baby inside the tummy of my sister!

We dedicated our next 3 months to my sister’s care and she delivered a healthy boy by the end of 2011. Of course, I had no option but to lie that my moms’ last words were she would return as my sisters’ baby to ensure my sister did not lose her baby due to excessive grieving.

My wife insisted on going for IVF but I kept resisting the idea, as IVF to me, was the last resort. At the age of 32 yrs, I thought that was a little to early a call. Plus, I wanted my wife to be subjected to as few fertility drugs as possible. After all, I wouldn’t want to lose my soul mate to ovarian or any other type of cancer because of frequent usage of these fertility drugs.

So now we started TTC again and mis-carried 3 times (2 out of 3 were natural cycles). Of course we had changed to another gynaecologist. But they all start their script from scratch.

We then approached Dr.Malpani in early 2012 and looking at our file he simply said that he guarantees that we will have a baby. But he cannot do IVF for each and every patient who comes to him and we should do IUI at least twice before we see him again.

All that he said made sense to me. Yes, you bet one can say he is a very sensible doctor in the world. But not to my wife. She was growing desperate despite me calming her every now and then.

Finally after 2 more D & Cs we decided we had battled enough and that time had come to see Dr. Malpani. After all we had lost time (almost a year), money and overexposed ourselves to fertility medicines. All medicines do have some side effects no matter what the doctors say!

So we visited Dr. Malpani in mid 2013. In hard economic time, we had barely managed his professional fees for the ICSI procedure.

After following his protocol we extracted 22 eggs of which 8 were of grade A and frozen at day 3. Dr. Anjali Malpani wonderfully explained to us (me and my in-laws) about the procedure and precautions to prevent OHSS later on.

Unfortunately my wife’s’ endometrial lining was irregular and thin so we could not transfer the embryos in that cycle. This could have been due to numerous D&C’s and/ or side effect of Clomiphene Citrate during earlier IUIs,

So the transfer was postponed to next cycle. To me this was a blessing in disguise as I was worried about OHSS affecting my wife if transfer was done in the same cycle.

But when the clinic informed me that there would be additional costs for the postponed transfer it is needless to say that it came as a shock. It did not make any business sense to me, I being a businessman. I had already paid for the entire IVF cycle including the transfer. And when the transfer was postponed due to non-favourable lining I had also paid the fees for freezing the embryos.

Well, being an honest and straightforward person I spoke to Dr.Malpani about my discomfort with this fee policy and requested him to consider a discount - after all , I did not want anything for free. I understood the value of his time as well as his overheads that would be at our service during the next transfer.

I still remember his exact words. He said you don’t get anything until you ask for it. So I asked for a discount. He asked me how much. I said whatever he could afford. I don’t know if that was smart or stupid, still. He said that I actually deserved none , to which I protested and requested for a 50% discount.

He graciously accepted it adding that he is well off anyways. Our eyes lit up like small happy children.

But our next challenge was growing a good endometrial lining. And though we both were anxious, we did have faith in Dr. Malpani. It is such situations that we need to be calm, patient (though medically, we have been patients long enough) and keep faith in self and the doctor.

So in the next cycle we started a drug protocol to improve the lining. Unfortunately it did not look good as we were passing the transfer point. And Dr.Malpani dropped another bomb of suspicion of uterine adhesions and a possible hysteroscopy for adhesion removal. This meant more waiting time and more financial problem. We did an ultrasound immediately and found it to be negative thus relieving us.

Imagine the roller coaster my wife is riding mentally. I can only hold the roller coaster with firm mind and prevent it from taking off from standstill. I just can’t allow it to run.

Dr.Malpani then increased the dosages to see an appreciable increase in thickness of endometrial lining , though it was not still exactly tri-lamilar. We even took supplements like Vitamin E and L Arginine since Dr.Malpani had no opinion on these supplements , negatively or otherwise.

Finally a call was made to transfer 3 grade A embryos and these were transferred by Dr.Malpani in my presence. We right away started feeling pregnant as soon as he put the embryos in the uterus . Yeah, that’s what he had asked us. And that’s what I had answered at that point.

After the anxious wait of the + UPT, we found out that we were carrying twins making us very happy as well as more anxious. Intermittent spotting due to sub-chorionic hematoma kept us worried but Dr.Malpani calmed us down by telling us not to worry and that it will resolve. My wife was off her toes for 12 weeks though not strictly bed rest but under house arrest nevertheless. This meant I had to cook, do the dishes and deal with her food aversions.

At 12 weeks past 3DT, the hematoma was gone and our twins were jumping to the radiologists prodding.

We are now off the hormonal support as per Dr.Malpani’s advice (hesitantly though, due to online stories). It is more than a week now and we are doing fine eagerly awaiting the arrival of our twins.

Hope our story becomes a support and inspiration to souls married to each other for life to welcome another beautiful soul whom they can call their own with Dr.Malpani’s support.

And I wish Dr.Anirudha and Dr.Anjali Malpani all the very best in their endeavour to help couples like us to find a happy solution.

Disclaimer: I am writing this true story of mine not for Dr.Malpani but for couples like me; remember, Dr.Malpani is  well off!

Prasad Girap

pgirap@gmail.com

Tuesday, December 24, 2013

Investing at the NASSCOM shark tank event


I was invited to be an investor at the NASSCOM Shark Tank event held recently in Mumbai. I feel the older generation has a responsibility to encourage youngsters and I am happy to put my money where my mouth is. I enjoyed myself thoroughly - interacting with young clever people who are passionate about what they do
( which is true of most entrepreneurs) can be a lot of fun ! The entrepreneurial ecosystem in India is gradually evolving and there's lots of scope for both entrepreneurs and investors to participate.

So why is it called a Shark Tank ? Is it because investors are thought of as being hungry sharks, who prey on entrepreneurs ?  Or that investors go into a feeding frenzy when they come across a clever startup which they think will make them rich ? While this maybe the first thought which comes to mind, I am much more kindly disposed towards sharks, thanks to the comic strip, Sherman's Lagoon !  I feel sharks are misunderstood and don't deserve the bad press they get. They are actually great role models for ambitious humans, and I feel a kinder explanation would be that entrepreneurs need to behave like sharks - they need to keep on moving and hunting for opportunities, otherwise they will die. Also, let's not forget that sharks are survivors - and entrepreneurs need to be hungry and thick-skinned !

The master of ceremonies , Mukund Mohan, of Microsoft Ventures, did a great job with engaging with the audience; and there were some great presentations by Rahul Sood ( Microsoft Ventures, USA ); Ashish Hemrajani (Founder-CEO, Book My Show), and Anupam Mittal (Founder-CEO, People Group), who described their entrepreneurial journey. RehanYar Khan (Investor, Orius Ventures) and Ravi Gururaj (Chair, NASSCOM Product Council) emphasised the differences between the Indian scenario and what's happening in other parts of the world.

I learned a lot at the event - from the entrepreneurs; from the other investors; and from the audience. There was a lot of positive energy in the room and this can be contagious ! Congrats to NASSCOM for doing such a good job. I did invest in 4 startups -I look forward to learning from them.

However, I was disappointed that there wasn't a single woman in any of the presenting teams. What's wrong with the young women in India ? This is a growing country and there are going to be millions of opportunities to exploit. Why aren't women coming forward to take advantage of these ?

Also, there wasn't a single healthcare startup in the event.  The Indian healthcare system is sick, and we need clever young doctors to come up with disruptive innovations to fix the rot ! I found the absence of doctors disheartening. Aren't doctors supposed to be smart and driven ? Healthcare is a huge opportunity in India today - and doctors are healthcare experts , because they have to deal with the challenges of treating patients on a daily basis. Could it be that the grind of the Indian medical educational system saps them of all creativity and drive ?

How to Choose an IVF Specialist Best Suited for Your Needs?

An IVF patient often has a hard time when she has to select an IVF doctor. There are so many choices , which is why there are millions of doubts that run across her mind while trying to select the best specialist. The success of the IVF treatment is highly dependent on the right patient-doctor chemistry. Once the patient is completely satisfied with her doctor, she can be comfortable during the procedure. Since IVF is a complex and intricate and demanding treatment, it is important that the patient be able to trust her doctor completely.

There are many methods patients adopt when hunting for the right IVF specialist. The most common among them is asking their relatives, friends and neighbors. She trusts them, which is why a doctor recommended by them will often be her first choice. A family doctor’s recommendation is also influential, but may not always be reliable in this day and age of kickbacks and referral fees. More savvy patients will do a Google search , but this can also be misleading because the sites are often so similar. 

At the time of the first consultation, the patient is unsure whether or not she can trust the doctor. She needs to know that the doctor will be available to hold her hand during her IVF journey; and whether he will be able to provide her support before, during and after the procedure. Some of these patients have experienced bad doctor relationships when they have failed IVF cycles in the past. They need to be reassured of the effectiveness of the treatment and the competence of the doctor. At Malpani Clinic, we make sure every patient receives personal attention and we do our best to address all her concerns . This ensures that the patient is happy with us – and this helps to keep us happy as well ! .

The doctor should take efforts to reduce a patient’s nervousness by being accessible and friendly . This is something I do personally – a consultation is too important to leave up to an inexperience  junior or an assistant. It is much easier to establish a rapport when patients come for a consultation. I can give them enough time so we can get to know each other well.  What about follow on questions ? Most patients want to phone the doctor to get their doubts clarified, but this is not a very efficient way of solving problems. The best way to communicate with your doctor is by using email. I prefer this as emails are written , which the patient can access whenever she wants. I can also address every concern in detail.

Finding the right doctor is a challenging task, but doctors like Dr. Malpani are taking efforts to make this easier for the patient.



Looking for the best IVF specialist ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !





Monday, December 23, 2013

Expert patients as health coaches for population health management


20% of patients consume about 80% of healthcare resources . These are typically patients with chronic illnesses,  such as diabetes , asthma or heart disease . Since patient behavior plays a large role in the successful management of these illnesses , lots of companies have tried different methods in order to motivate and incentivize these patients so that they can take better care of themselves.

Most population health management tools today use a combination of technology and nurses ( or physician extenders ) as health coaches, in order to teach patients with chronic illness what they need to do to manage their disease . Typically, they use data analytics to identify patients who are at high risk for complication and poor outcomes ( for example, those whose blood sugar levels are out of control; or those who fail to keep their medical appointments ).  The nurses then reach out to these patients, and use behavioural modification techniques, so that they regain control of their illness. However, nurses are an expensive resource, because they are in short supply.

I think a far cleverer way of doing this would be to use expert patients as health coaches. For example, for diabetes, an expert patient would be one who has managed his diabetes well for the last 3 years. He would be trained; and would then serve as a health coach on the population health management system, which would serve as a platform where he could connect with patients who needed help with managing their diabetes. He would then be able to guide and help patients who are having difficulty with their disease, as to what they can do to help themselves .

The platform could be created as a marketplace, where expert patients could offer to sell their services as health  coaches. Patients could then search for a coach who matches them closely ( for example, with regards to age and location). Interested patients could then select the coach they feel who would best meet their needs . Over time, the coaches would be ranked, so that the best coaches could become more visible ( much like fiverr.com does).

Not only is this going to be a far less expensive method as compared to using healthcare professionals, it’s also likely to be far more effective . Patients are likely to be more effective as health coaches once they’ve been trained, because they’ve “been there and done that”. They know first-hand what it's like to live with a chronic illness , which means they are going to be far more empathetic . They are also more like to provide “real-world advise” which patients can put to immediate practical use. Patients are much more likely to bond and respond to someone who understands their problems and provides them with actionable solutions . Peer to peer counseling can have a long lasting impact, because the advise is likely to be unbiased and impartial.

What about quality control ? Calls can be recorded and transcribed, so there is documentation of what is being said. This can help to weed out ineffective health coaches. Also, patients are smart enough to understand that what another patient suggests is not medical advise, so they will use their own common sense and filter this advise.

We can thus use the collective wisdom of patients to help other patients to get better !

Saturday, December 21, 2013

Why changing physician behavior to fix the healthcare system is not likely to work


The healthcare system is broken . This is as true in India as it is in the US . While the healthcare ecosystem is complex, there are two key targets whom  we can work on – doctors and patients . In order to fix the problem , we need to change their behavior . It’s much easier to work on trying to change the behavior of the physician , because there are much fewer physicians as compared to doctors; and they are all trained professionals, who are more likely to listen to reason.

This is why physicians are often the primary targets when we try to reform healthcare. Because they are gatekeepers for medical care , we believe that they are the ones who hold the key to success, because they are extremely influential. They control what tests are ordered ; what treatment is advised; and most patients will pretty much do whatever their doctor tells them to.

If doctors learn to diagnose correctly and prescribe sensibly, a lot of money can be saved . Today, we are seeing an epidemic of overdiagnosis and overtreatment, as a result of which healthcare costs are going through the roof.  If we can improve physician behaviour, we will be able to achieve the goals of improving patient satisfaction ; increasing quality of care ; and reducing medical costs . This is why so much money is being spent on trying to incentivize doctors to do what is right for patients; and pay for performance is the fashionable mantra today.

While it’s true that it’s easier to target physician behavior, it’s also equally true that doctors are independent professionals who don’t like being told what to do. They are quite intelligent and find it quite easy to game the system . Every doctor feels they are competent and they don’t like being monitored and controlled. They have high self-esteem and each doctor believes he is doing the best he can for his patients. They do not think they are not likely to benefit from someone else’s advise – especially when the source is a meddlesome government bureaucracy; or a highhanded health insurance company who wants to call the shots just because they are footing the bill.

The problem is that good physicians are ethical professionals who don’t need monitoring – and that bad ones will never improve, no matter what anyone tells them. It’s very hard to change physician behavior, especially when they have invested 10 years of the prime of their life in being professionalized and indoctrinated.  While well-meaning bureaucrats will continue fiddling with incentives and penalties to try to get doctors to play nice, I feel that on a long-term basis , the only durable way of fixing the problem is by helping patients change their behavior !

Friday, December 20, 2013

The cost of not doing IVF


Everyone know that IVF is an expensive treatment , and this is one of the reasons they are so unwilling to do it. The fear is that if I spend that much money, and then don’t get pregnant, all my money will have gone down the drain ! While it is true that IVF is costly , one of the things you need to factor in is the cost of not doing IVF !

You pay a price for every decision you make in life , and not all these costs are financial. When you choose to do IVF, it’s fairly straightforward to figure out what the cost is going to be . These are primarily the medical expenses of the treatment, along with the possible emotional cost if the cycle fails . However, if you do have the option to do IVF, and then refuse to do it, the cost you pay will be the opportunity cost – the regret , when you are older and are looking back at your life, that you didn't give yourself the best possible shot at getting pregnant . By failing to do IVF , you deprive yourself of the opportunity of making use of the most advanced medical treatment option, which offers the highest chances of success.

While there are many poor couples who just can’t afford to even think of doing a single IVF cycle, there are many who don’t do IVF , not because of the financial hurdle, but because of all the horror stories they have heard about the treatment ( for example, myths that the hormonal injections make you fat; or that the risk of ovarian cancer increases because of the superovulation).

When they finally do their homework and realize that IVF is a safe and effective treatment ( for example, when one of their friends has an IVF baby), they are the couples who pay the steepest
price , because they realize ( too late !) that they chose not to do IVF for all the wrong reasons. Living with this regret can be very hard !

Not sure if IVF is the right option for you ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Thursday, December 19, 2013

Small is beautiful when selecting an IVF clinic


For infertile couples, the most important criterion when selecting an IVF clinic should be its success rate – how competent is the doctor at making babies ? However, suppose you have a choice between 2 clinics with a similar success rate – one is a large IVF clinic located in a hospital, while the other is a boutique standalone clinic, then which one should you choose ? Now I am admittedly biased, but here’s why I feel that IVF is best done in smaller clinics.

IVF is different from most medical treatments. Infertile couples are not patients – they simply have a medical problem , and they need medical assistance in order to have a baby . Because most doctors are employed by and work in hospitals, this means that it’s much more convenient for them to provide medical care in a hospital setting. However, just because it’s easier for the doctor does not mean that medical care delivered in a hospital is always best for the patient !

However, most patients still associate medical care with hospitals , which is why many of them will go to hospital-based IVF clinics, even though the quality of care they are likely to get in a stand-alone IVF clinic is likely to be much better.  They feel hospitals are safer – and that in case there is a complication, the hospital will be able to manage this better. However, because hospitals are really not geared towards providing care for infertile couples ( after all, they are designed primarily to deal with ill patients) , there are lots of problems and disadvantages of going to a hospitals for IVF treatment.

A big issue is that of red-tape.  Infertile couples find that they have to wait in long lines, along with other patients – and hospital bureaucracy ( for billing and admission and discharge) can be very painful. Also, because the chances of complications with IVF treatment in a good clinic are so low, the ability to take care of complications is only a theoretical benefit. 

Small clinics are focused on taking care of infertile couples, because they only provide IVF treatment, and do nothing else . This is why they have honed their skills to perfection . Not only are they very good at providing medical care , they also have systems in place to offer handholding and the emotional support which infertile couples need. These clinics are smaller and warmer, as contrasted to hospitals which care be big, cold , sterile and uncaring. This is why it’s much easier for couples to establish a personal equation and rapport with the staff members here . Also, it's far easier for them to get their problems resolved , because they don't have to go through layers of hospital bureaucracy .

Stand alone IVF clinics are also much more responsive to infertile couple’s needs , because their very survival depends on delighting their patients ( unlike hospitals, who have many other departments, such as cardiac surgery or joint replacement, which are more glamorous and profitable) . This is why these IVF clinics are much more cost-effective and efficient as well, as compared to clinics which are embedded with the hospital system, because they do not have to deal with the huge unnecessary costs of administrative overheads.

Not happy with the attention you are getting from your IVF clinic ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Wednesday, December 18, 2013

Implantation Failure in IVF - Is the Uterus or the Embryo?

Using a systematic protocol will help in determining the cause of repeated failed implantation during In vitro fertilization treatment.

In vitro fertilization does not have a 100% success rate. Good IVF doctors educate patients about the chances of failure before they go in for IVF. When the IVF cycle fails, patients who have not been properly counseled may lose trust in the doctor’s abilities , if they are not well- informed.

Disheartened patients then consult another doctor in a desperate attempt to conceive. In order to prove that he is better than the old doctor, the new IVF specialist may then order a battery of expensive tests, to try to “pinpoint” what the reason for the failure is. Often this is a game of “medical one-upmanship” because most tests rarely provide any useful information.

If the next cycle also fails, patients lose faith in IVF doctors and will often choose to abandon in vitro fertilization as a treatment option . Others will doggedly continue their search for the right doctor. The trauma of repeated failures , combined with the lack of a clear explanation about the cause of the failures leads to continued stress in patients. Repeated switching of doctors adds to the stress !

The fundamental reason behind switching doctors is to find a doctor who can guarantee them success with the In Vitro Fertilization procedure. Unfortunately, there are few guarantees in life . The mindless repetition of identical treatment protocols without doing a thorough analysis becomes taxing for the patient – both emotionally , as well as financially. To add insult to injury, many doctors end up blaming the patient for the IVF failure , by stating that it is because they are too stressed that their uterus is rejecting their embryos ! The poor emotionally vulnerable patient gets even more depressed on hearing this.

If embryos fail to implant after transfer, the problem could lie either with the uterus or with the embryo ( assuming the embryo transfer procedure goes smoothly ). If the embryos are of poor quality, then the likelihood is very high that it is the embryos which are responsible for the failure. The commonest reason for poor quality embryos is poor quality eggs . Other reasons include a bad IVF laboratory ; and a sub-optimal superovulation IVF protocol.

Sometimes, the problem is with the uterine lining, and this can be diagnosed during the ultrasound scans, which show that the endometrium remains thin and does not become trilaminar. This damage maybe because of an earlier D& C, which has created adhesions; or uterine infections , such as TB.

If the patient’s embryos develop into Grade A blastocysts in the lab; and she fails to conceive after the transfer of 6 Grade A blastocysts over 3 cycles, then it is reasonable to consider alternative options such as surrogacy .

Not sure why your IVF cycles are failing ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

The Ideal IVF Patient !

The attitude of the patient plays an important role in successful IVF treatment.

One of the little known secrets of IVF treatment is how much a patient can contribute to their IVF success ! When an infertile couple is advised to have IVF, they move heaven and earth to get treatment from the best possible IVF clinic. Sadly, very little time and effort is spent on thinking about what they can do to maximize their chances of IVF success. A well informed patient can be a boon for the IVF doctor !

A highly qualified competent doctor with an able team is crucial to the success of IVF. The patient can contribute to this success by doing her homework. Doctors respect patients who take the effort to ensure they have glitch-free IVF treatment. At Malpani Clinic, we provide Information Therapy, so our patients can become partners in their IVF cycle. There are some basic expectations that any IVF doctor has from a patient and it is the patient’s responsibility is to try and fulfill these to the best of their ability.

Adequate and reliable information about IVF treatment can go a long way in allaying your worries and doubts. The internet can be a useful source of information, if used wisely. Please take the time and trouble to understand as much as you possibly can about IVF, before you go in for the treatment. This will protect you from fly by night, poorly equipped IVF doctors, and provide a powerful shield against overtesting , medical fraud and unnecessary investigations. A knowledgeable IVF patient commands respect from the doctor.

Please ask any queries that come to your mind , both before and during the procedure. You will be able to go through the IVF treatment cycle in peace, once you receive satisfactory answers to all your questions , because you are confident that your doctor is well-informed and well-equipped. If you choose not to voice your concerns and bottle up your doubts, this will add to the stress of your IVF treatment and reduce your chances of success.

An active engaged IVF patient who is willing to take interest in every aspect of the treatment is better than a passive one. If you show an interest in the procedure , the doctor is more likely to go the extra mile for you. A passive patient often burdens the doctor , who then has to take the responsibility of making every single decision.

The ideal IVF patient has realistic expectations about the IVF process and outcome. She knows how the treatment works , and what her chances of success are. This saves a lot of heartburn in case the cycle fails, and ensures that she can bounce back to normal much more quickly !

Want to become an ideal IVF patient ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Amenorrhea and infertility

Summary: The commonest cause of amenorrhea is anovulation and Malpani Clinic can help you in making the right diagnosis , so you can get the correct treatment.

Amenorrhea is the absence of periods. It is a symptom which is a result of some underlying disorder of the reproductive system. It may or may not be accompanied by other symptoms like headache, excess facial hair, and abdominal pain depending upon the cause. At Malpani Infertility Clinic, we diagnose the cause of your amenorrhea by taking a careful history and doing a thorough workup. A detailed record of your menstrual periods and any associated symptoms will help us in making the right diagnosis.

Amenorrhea can be either physiological or pathological. Physiological Amenorrhea is the absence of periods before puberty, during pregnancy and after menopause ; while pathological Amenorrhea is a result of some disease. Another way of differentiation is primary and secondary Amenorrhea. When a girl does not get her periods by the age of 16, she is diagnosed as having of primary Amenorrhea. The absence of periods for over 3 months in a woman with a history of having menstrual periods in the past is referred to as secondary Amenorrhea.

Secondary Amenorrhea can be caused by various reasons. The extended list of probable causes includes: polycystic ovarian disorder, drugs, stress, malnutrition, excessive exercise; and chronic illness. Normal menses occur when the uterine lining is shed cyclically under the influence of the reproductive hormones produced by the ovaries – estrogen and progesterone . In simple terms, smenorrhea occurs either due to a disorder affecting the uterus or the reproductive hormones.

Amenorrhea and infertility

The commonest cause of secondary amenorrheaiIn infertile women is anovulation. Anovulation is the failure of ovaries to either produce or release eggs. This is usually easy to treat, if diagnosed properly.

The commonly prescribed tests are : blood tests to check for prolactin; TSH; FSH;LH and AMH; and a vaginal ultrasound scan. The commonest reason for anovulation is usually PCOD (Poly cystic ovarian disorder) . However , it is important to rule out other causes, such as multicystic ovaries ; premature ovarian failure; or a functional ovarian cyst.

Many infertile women naively believe that if the doctor can regularize their period, they will get pregnant. However, do remember that it is the underlying cause of the irregular periods which needs to be treated if you want to have a baby. Thus, if the reason for anovulation is PCOD, you need treatment to induce ovulation in order to get pregnant. Just inducing a period with progesterone hormonal therapy will not help you to achieve a pregnancy.

Not sure your doctor is treating your amenorrhea properly ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Please freeze your embryos


IVF treatment is very effective today and a good IVF clinic will be able to create many embryos for most young patients , because of our ability to superovulate them . In a good lab, most of these embryos are of high quality , and since we don't want to transfer too many embryos at one time, because this increases the risk of a high order multiple pregnancy, the question is -  what do we do with the supernumerary ( spare) high quality embryos ?

We strongly encourage all patients to freeze all their spare good quality embryos, but inspite of this advise, many patients decide to discard their embryos , because freezing embryos costs them extra money. Since this is often a decision they regret later on, let’s look at why they make this choice.

Many patients feel that since the embryos which the doctor is transferring are of such high quality , my chances of getting pregnant are excellent in this cycle itself, so why should I waste money freezing the spare embryos ? The truth is that no matter how  perfect your embryos look, the success rate in an IVF cycle is never 100%; and most embryos do not implant and fail to become babies, no matter how perfect they look, for reasons we still do not clearly understand.  In case the fresh cycle fails, having frozen embryos as a back up plan gives you an excellent chance of conceiving, at a fraction of the cost of a new fresh cycle . Because the new technology for freezing uses vitrification, the survival rates of frozen embryos after thawing is nearly 100% in our clinic !

Some patients believe that freezing embryos will damage them; and that the “ice-babies” which are born from these frozen embryos are likely to be abnormal. This is faulty reasoning. Thousands of babies have been born after embryo freezing, and this has been proven to be a very safe procedure.

Another ( often unvoiced) concern is that if the best quality embryos from this batch ( which the doctor will transfer in the fresh cycle ) do not implant, then doesn’t this mean that  the chances of the other frozen embryos from the same batch implanting are going to be even lower ?

This sounds logical, but the truth is that  the chance of a good quality embryo implanting is independent of the fate of the other embryos from the same batch. Even if you don’t get pregnant in the fresh transfer, the chances of getting pregnant with the frozen embryos remains extremely high . In fact, there are some IVF clinics which do not transfer any embryos at all in the fresh cycle, because they believe that the superovulation distorts the hormonal milieu and reduces endometrial receptivity. The routinely freeze all the embryos; and transfer them only after thawing in a natural cycle, and can boast of a very high pregnancy rate.

What if you do get pregnant in the fresh cycle ? Then won’t you have wasted your precious money on freezing your embryos ? No ! The fact remains that frozen embryos do not have a shelf life; and you can then use these same frozen embryos to have Baby N 2 after a few years, when you want to complete your family. The pregnancy rate with these embryos is likely to be very good – and they have a much better chance of achieving a pregnancy than a fresh cycle ( because your eggs will have aged, but your frozen embryos  will remain young forever, until you thaw them ) Freezing suspends all metabolic activity, so the embryos are frozen in time  ( much like Sleeping Beauty) !

Sadly, a lot of IVF doctors fool their patients by telling them that freezing embryos is of no use. This is because they don't have the facility or expertise for freezing embryos. This is why they then “donate” your spare embryos to other patients, without getting informed consent, either from you or from them. This is tragic , and this is why you need to be sure that your IVF clinic has a robust freezing program which uses vitrification technology.

Tuesday, December 17, 2013

IVF is the ultimate diagnostic test for unexplained infertility


IVF was first developed as a treatment  option for women with blocked tubes. Today, it is often the therapeutic procedure of choice for many infertile couples , because is maximize their chances of having a baby. However, a little known secret is that IVF is the best diagnostic test for couples with unexplained infertility. You can read more about this at  http://www.drmalpani.com/unexplained_infertility.htm

Unexplained infertility can often be a  very frustrating diagnosis , for both patients and doctors. In one sense, it’s actually a non-diagnosis. We are effectively telling patients we don’t have a clue why they are not getting pregnant – and this can be very upsetting. Patients start believing that if we cannot even find out what their problem is, then how will we able to solve it ?

Typically, these patients have had an extensive battery of tests done, all of which come back as normal. All we can tell them is that the fact that you are not getting pregnant means that either your sperm are not fertilizing your eggs in your fallopian tubes ; or your embryos are not implanting in your uterus, and sperm are not meeting in your fallopian tubes when you are trying naturally, even though there does not seem be any abnormality in your test results.

In one sense, this is a limitation of our testing technology . Thus, while our tests for semen analysis allow us to check the sperm count and motility; and more advanced tests of sperm function allow us to check some aspects of how well the sperm are working , none of these tests can answer the key question – are the sperm functionally capable of fertilizing the egg ?

IVF provides invaluable diagnostic information for these couples, because it allows us to answer this crucial question. Of course, it can be quite a rude blow to the man when he finds out that even though his sperm count and motility are fine, for all practical purposes he is still shooting blanks, because his sperm cannot fertilise his wife’s eggs !

IVF is also very helpful for checking egg quality. Many women naively believe that just because they are ovulating; or that because they are growing good follicles when ultrasound scans are done during their IUI treatment, this means that their eggs are fine. Doctors also contribute to this confusion, because they often use the terms eggs and follicles interchangeably. However, a follicle is just a black bubble which the doctor can track on ultrasound scans. Eggs, on the other hand, are microscopic, and can only be seen in the IVF lab after egg retrieval, under a stereozoom microscope. Not all follicles will contain eggs – and not all these eggs are of good quality.

IVF is the only method by which we can prove that the eggs are of good quality ; and that the sperm are able to fertilise them. The proof of the pudding is in the eating !This is why IVF provides invaluable diagnostic information, which we can use to plan the treatment protocol, thus maximizing the patient’s chances of success.

In any case, I always remind patients that their question should NOT be “Why am I not getting
pregnant ? “Rather, it should be – What can I do in order to get pregnant ?” After all, no one cares about problems – we only care about results – about having a baby . IVF allows us to bypass all the problems, and allows us to take a cost effective shortcut to their goal of getting pregnant !

Frustrated with your diagnosis of unexplained infertility and worried that your doctor cannot help ?
Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !










Monday, December 16, 2013

I am a big fat zero - the azoospermic man


I was doing the final consultation of the day . The couple who walked in were well-dressed and poised. The wife was a CA ; and her husband was an athletic six-footer , who worked as an equity analyst in a leading hedge fund . When I asked them - How can I help you ? “ , much to my surprise, he became extremely emotional.

" Doctor, I am a failure. My sperm count is zero and I cannot give my wife a baby ! Even though I have a great job , a big fat bank balance, and get to travel first class all over the world , my life has become meaningless because I am shooting blanks. I don’t even feel like having sex anymore, because it’s of no use – I know with a zero sperm count, I cannot get my wife pregnant.

I have stopped going out and have become a social recluse. I used to be a party animal, but the first question everyone asks my wife is – So when are you planning to have a baby ? And it hurts when I see her having to cover up for me. This is sore issue, and seeing her in pain makes me feel helpless and hopeless.  Her friends and classmates talk about their kids all the time  - and she doesn’t have a common topic of conversation. What’s worse, is that they pretend to feel sorry for her, and this false pity hurts even more !

This has started affecting my self-esteem and has started impacting all aspects of my life . Ours is a love marriage, and my wife is extremely kind and loving . She doesn't talk about this too much , because she knows the topic hurts me, and this is now the elephant in the room, which has created a huge barrier between us .

I know we can have a baby if we use donor sperm , but this is an idea I find very difficult to swallow . I don't think I'll be able to love a child born by donor sperm. I know she would be happy if I agreed to using donor sperm, and she believes that once the baby is born, I will overcome my doubts and hang-ups and love the baby. However, because she knows that I have issues , she's reluctant to broach the topic so we just ignore it . Most nights we just turn away and go to sleep , without talking about an issue which is playing havoc with our lives. This problem is driving me crazy and I really don't know what to do about it  !

I can’t discuss this with any of my friends and I can’t continue leading a life like this . It’s so unfair on my wife. I feel the best thing for me to do is to divorce my wife , so at least she can get married again , and find a fertile man . I'm just a big failure ! "

The diagnosis of azoospermia can have a corrosive effect on a man’s self-esteem . It’s very hard for them to express their feelings. They have been taught to bottle up their emotions since childhood, and this suppressed guilt can slowly poison their life.

The good news is that for lots of men with a zero sperm count, modern IVF technology can offer new treatment options, which can successfully allow these men to have a baby with his own sperm. Sadly, many infertility specialists, gynecologists , urologists and andrologists are not aware of these advances.

If your doctor has written you off as a hopeless case just because your sperm count is zero, please ask us for a free second opinion . The technology has improved dramatically , and there is lots we can do to help many azoospermic men today ! Thus, techniques such as TESE-ICSI ( testicular sperm extraction with ICSI) allow us help many men with a azoospermia.

Sunday, December 15, 2013

Unnecessary infertility tests - red flags that your doctor is wasting your money !


Many doctors routinely order a panel of tests for all the infertile patients they see. They do this mindlessly, as part of a "standard protocol", by simply ticking off a list of tests which the patient needs to do.

There are however, several tests that are not indicated and/or are not cost-effective if done routinely. 

1) Don’t perform routine diagnostic laparoscopy for the evaluation of unexplained infertility.
In patients undergoing evaluation for infertility, routine diagnostic laparoscopy should not be performed. In patients with a normal hysterosalpingogram or the presence of a unilaterally patent tube, diagnostic laparoscopy typically will not change the initial recommendation for treatment.
2) Don’t perform advanced sperm function testing, such as sperm penetration or hemizona assays, in the initial evaluation of the infertile couple.
Studies document that extreme variability exists among these tests, with very little correlation between results and outcomes.  They have also been shown not to be cost-effective and often lead to more expensive treatments.
3) Don’t perform a postcoital test (PCT) for the evaluation of infertility.
This is a test where the cervical mucus is examined around the time of ovulation for sperm about 8 hours after intercourse.  The PCT suffers from poor reproducibility and its predictive value for pregnancy is no better than chance.  Utilizing the PCT leads to more tests and treatments but yields no improvement in cumulative pregnancy rates.  I have not performed a postcoital test for mare than 25 years now!
4) Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation.
There is no indication to order these tests, and there is no benefit to be derived in obtaining them in someone that does not have a history of bleeding or abnormal clotting and in the absence of any family history.  This testing is not a part of the infertility workup.  Furthermore, the testing is costly, and there are risks associated with the proposed treatments, which would also not be indicated in this routine population.
5) Don’t perform immunological testing as part of the routine infertility evaluation.
Diagnostic testing of infertility requires evaluation of factors involving ovulation, fallopian tube patency and spermatogenesis based upon clinical history. Routine immunological testing of couples with infertility is expensive and does not predict pregnancy outcome.

So who created this list  ?

This is a definitive list, published by the American Society for Reproductive Medicine (ASRM), the leading organisation for infertility specialists in the USA !

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