Monday, March 31, 2014

Scaring IVF patients


We see lots of patients who have failed IVF treatment cycles in IVF clinics in smaller cities in India . This keeps us very busy, because these patients have learned the hard way that the technical competence, experience and expertise of the IVF doctor make a big difference in the outcome of their IVF treatment.

It breaks my heart when I see how poor the quality of medical care these smaller IVF clinics provide. Many of them have been set up as a response to the huge demand for IVF services in India today. Rather than refer infertile couples to the best IVF clinic, the senior gynecologists in these towns want to tap into this local captive patient population

This can be good for the patient when these clinics have a high success rate. They do not need to travel long distances to take treatment , which means it’s much easier for them to avail of IVF; and often the care is less expensive . However, all this applies only if the quality of care these clinics provide is as good as it would be in more established clinics . Sadly, this is often not true

Because these clinics often do not have the required infrastructure , expertise or experience , they are often tempted to take shortcuts . They will treat patients in batches, and will fly down IVF specialists from Mumbai , in order to fill in the gaps in their knowledge .

Sadly, most patients  are very poorly informed, and cannot differentiate between a good clinic and a bad clinic. This is especially true when they are doing their first IVF cycle , because most patients rarely do much homework until they have burnt their fingers. It’s easy to take uninformed patients for a ride , because they do not know any better.

Interestingly, while patients know that the care in Malpani Clinic is far better, the local doctors who run these IVF clinics so their best to scare patients from going to Mumbai , because they don't want to lose these patients do Mumbai clinics . After all, this would harm their profitability !

They scare the patient from going to Mumbai. They tell them lies that travelling back to their town after doing an embryo transfer in Mumbai will cause the embryos to “fall out”.  They fill their head with nonsense by saying that they need to take bed rest for 15 days after the transfer – and if they go to Mumbai, they will not be able to do so. They fill the patient's head with a lot of myths and misconceptions and cook up horror stories of patients who have developed complications after going to Mumbai. Patients are understandably worried about continuity of care, and do not want to antagonize their local doctor. After all, they have a personal relationship with the local doctor , who can easily persuade them into taking treatment locally.

Patients need to invest in Information Therapy in order to protect themselves . While the short term costs and inconvenience of travelling to Mumbai are a deterrent, often this is more cost effective , because the focus should be on maximizing the success rate in the first IVF cycle itself.

When there is so much at stake, they cannot afford to take a chance and do IVF at a second rate clinic, in order to save a few thousand rupees. This penny wise and pound foolish can come back to haunt them later, because if the first cycle in their local clinic fails , they may not be able to raise the funds to afford another cycle in a better clinic.

Interestingly, the cost difference between doing IVF treatment in Mumbai and in a small town is not much – and in fact, treatment at Malpani clinic is often much more cost -effective because of our high success rates.


Want to maximise your chances of IVF success ? 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, March 30, 2014

Facts about embryo transfer and embryo implantation


Even though Embryo transfer and Embryo implantation are entirely different, many IVF patients are often confused between the two.  Embryo transfer is a medical procedure wherein the embryo is transferred to your uterus using a plastic hollow tube called an embryo transfer catheter. By contrast,  embryo implantation is a biological process of the reproductive system. The two are different , but both are related because in a successful IVF cycle, the transferred embryos will implant and result in a pregnancy. During an IVF cycle, the doctor transfers the embryo into your uterus , where it then develops into a  blastocyst and then embeds itself into the uterus lining. This is embryo implantation. Embryo transfer is a mechanical procedure, and how well it is done does depend upon the skill and experience of the doctor. Implantation , on the other hand, is an in-utero biological process which in Nature's control - not the doctor's.

After the embryo transfer ( ET) starts the dreaded 2ww ( 2 week wait), where your mind plays all kinds of games with you, and you wonder what's happening to your precious embryos in your uterus ! Are they safe ? growing well ? being nourished properly ?

The implantation process involves three steps namely apposition, adhesion and invasion. All these steps are based on various hormonal and molecular signals in the uterus. This biological process cannot be controlled externally – and is not impacted by physical activity or diet or stress levels.  We give you given hormonal therapy to prepare the uterine lining for implantation, but it not possible to control the process or guarantee implantation. We still cannot control or pinpoint the complex mechanisms involved in this process.All we can do is hope and pray. It's only  after the 2 week wait, when you get your HCG results, will you know if your embryos have implanted or not !

In many cases it so happens that the embryo fails to implant – after all, the human reproductive system is not perfectly optimized. Though the reason for a failed implantation in IVF cannot be deduced every time, most of the times the reason is a genetic abnormality in the embryo. Often, these are subtle defects , which cannot be diagnosed even after using sophisticated modern genetic technology such as CCS ( comprehensive chromosomal screening). However, we do know that the eggs of older women are at higher risk of having genetic defects due to the aging process.

When the embryos fail to implant after the transfer, this does not mean that the IVF lab was bad or that your uterus is “rejecting” the embryo. It just means that implantation is not a sure shot process, and it’s important that patients understand this, so that they have realistic expectations of IVF success.

Want to learn more ?
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, March 29, 2014

How can infertile patients ask the right questions?


One of the commonest friction points between patients and doctors is the quality of information exchange and medical knowledge transfer during a consultation. Patients feel that doctors don’t spend enough time answering their doubts, while doctors believe that patients waste too much time asking them pointless and irrelevant questions.

When patients approach a doctor for infertility treatment , their mind is filled with queries about the treatment and their condition. They want their doctor to address each question and explain every aspect. This is not possible for an overloaded doctor. The doctor usually does not have the time or the energy to reply to every question of  every patient. Patients may feel dissatisfied and may conclude that the doctor is unable to solve their problem. The easiest solution to this problem is for patients to learn to ask the right questions to get the best answers from the doctor.

Patients may have a long list of queries, but many of these questions can be easily answered by doing a quick internet research. The best way to approach this problem is for the patient to make a list of their questions and then start looking for answers. While google searches are helpful, because there’s so much unreliable and untrustworthy information available online, that you are much better off finding the answers at reliable sites such as www.drmalpani.com !

Good-quality questions are those which relate to your specific problem ; and which require the doctor to tailor the information specifically to your condition . This approach will create a win-win
situation , where patients get satisfactory answers to all their questions ; and doctors are happy because they've been asked intelligent questions , and their time has not been wasted on generic stuff.

Not happy with your doctor's answers ? Want more information on IVF ? 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, March 28, 2014

IVF horror stories



We treat patients who've taken IVF  treatment in many other IVF clinics from all parts of the world. While some of them  have received excellent clinical care, some of them have some horror stories to share.

There are leading IVF doctors who extort money from the patient by demanding a huge amount of payment in cash just before the egg collection. Patients are vulnerable and scared that the doctor will not do the treatment properly if they refuse to pay, which is why they are forced to cough up.  This collection of money under the table from the patient is a cash transaction , which is not documented or authorized. Now the patient is too scared to challenge this at the time of the treatment, but it always amazes me why they do not complain more vocally about this kind of malpractise after the treatment cycle.

How can you expect a doctor who takes money under the table to be ethically upright or honest. If he is willing to cheat the Government, why will he not be willing to cheat you as well ?

In order to maximize his income, he may do all kinds of dodgy stuff, such as “donating” your eggs to another infertile couples – or using donor sperm for you , without informing you, in order to maximize  his success rates and their profits. How can you trust someone who does illegal transactions ?

While it’s sad that even leading IVF specialists , who are extremely well-off , indulge in these malpractises, what amazes me even more is that patients are willing to comply with these unethical and illegal requests !

In this day and age, when it’s so easy for  articulate patients to complain about unethical doctors , why are they willing to be accomplices in these shady transactions ? Doesn’t this mean that it’s the patients themselves who are contributing to the problem ? It’s easy to justify this by saying that patients are helpless and don’t really have a choice , but this is simply not true – especially in an area like IVF , where there are so many choices available to the patient .

If the patient is willing to go to a doctor who asks for money under the table , and then not complain about this , then I don't think the patient should complain when they get poor quality care .

This is just the tip of the iceberg . These clinics force their patients to buy their medicines from a particular shop  - or do all their tests from some private laboratory ( which provides kickbacks to the referring doctor).

Most IVF patients are very resigned to waiting for hours to see the doctor; or have accepted the fact that the “brand name” doctor ( for whom they go to the clinic) is never available – and that their care is provided only by nurses and assistants.

They routinely have to wait in line , along with lots of other patients, in a partially undressed state , for their ultrasound scans . There is no privacy, and there are lots of patients who are waiting, and the doctor and his assistants will openly discuss personal and private medical details about other
patients , in front of them . This is not my idea of good medical care , but this happens routinely in many high profile IVF clinics  !

I guess it’s because these clinics are run by doctors who are very famous , that they can get away with this kind of behavior.  Patients fall into line, because they believe that if this is the way all other patients are being treated, then this is an accepted part of the system , and they have to go along with this.

Why aren’t patients willing to be more articulate and to complain ? If they do not speak up, these practices will continue to spread – and this will harm other patients as well. By emailing mute, patients are serving as partners in crime, and doing a major disservice to the entire community.  It is this deafening silence which contributes to the sad state of medical practice in India today. The only reason doctors can get away with this kind of atrocious behaviour is because their patients put up with it !


Thursday, March 27, 2014

Why doctors are reluctant to acknowledge errors



When doctors make a mistake , they find it very hard to acknowledge the error. There are many reasons for this.

Doctors do their best to not to make mistakes , and therefore , just like all of us , when we do make a mistake , the first response is to always try to justify or explain it away by blaming someone else . Common justifications are – It wasn't my fault that a mistake was made – it was made by my nurse or my assistant ! We all need to live with our self-esteems intact , and doctors have egos which need protection, which is why it's hard for them to acknowledge that they are human and can err.

Doctors think of themselves as being in a helping profession and want their patients to get better. When they realize ( often to their horror) that they have committed a mistake which has ended up harming their patient, it becomes hard for them to live with this bitter truth. In order to prevent cognitive dissonance , it’s perfectly natural for them to refuse to accept the truth – and even hide the fact from themselves.

Doctors will often try to cover up errors because they are scared that if they acknowledge that they have goofed, their colleagues will think poorly of them – and their juniors and staff members will no longer respect them.  They are also understandably worried that that if their patients find out that an error was made, they will want to punish them , by taking legal action against them in a court of law .

Also, doctors have been brainwashed by their professional liability insurance companies , hospital management professionals,  risk management companies and lawyers to never confess to having made an error. They are told to clam up and shut up, rather than say sorry or apologise to the patient. This is because lawyers are worried that if doctors are truthful and acknowledge that they have made a mistake, this will be used against them in a court .

Doctors are also scared that  if they tell the patient they made a mistake , the patient will no longer trust them , and this will damage the doctor-patient relationship . This is why the reflex action for most doctors is to cover up mistakes, much like a child does, rather than face up to them , like a mature adult should.

The first response is often one of denial - to hide the mistake , not just from the patient or from the rest of the medical team , but even from themselves . It is hard for all of us to acknowledge the fact that we have made an error - not just for doctors!

All doctors will agree that mistakes are made commonly in medical practice – but all of them will also claim in  the same breath that they have not made any.  This is why you start to wonder – who makes all these mistakes ?

Doctors need to learn to be honest and open - not just with patients , but with themselves also , so that even if a mistake occurs , they can do something constructive about it . Not only will this minimize the harm caused by the error, they can also take action to prevent this mistake from happening again . This is extremely important , not just for the patient and the healthcare system in general , but for the doctor. himself . Trying to cover up mistakes ends up in creating a major burden of guilt and shame , which can get progressively worse as time goes by .

Doctors need to remember that patients can be quite forgiving , and many will accept the fact that honest errors were made . They can forgive their doctor for these – but they will never forgive a doctor for trying to cover these up by lying to them.

Wednesday, March 26, 2014

Malpani Clinic specialises in treating women with failed IVF cycles



Injecção do espermatozóide e retirada da micro...

After a failed IVF cycle it's often hard to bounce back. Even though your head understands that IVF doesn't have a 100% success rate, it's hard to deal with the failure. In their heart of hearts, every patient who starts an IVF cycle believes that this cycle is going to work ! ( If they didn't, it'd be very difficult to even start the cycle ). However , failed IVF cycles are a fact of life and over 50% of cycles will end up as failed IVF cycles, no matter how good the IVF clinic. The failure rate is much higher in poor quality clinics.

Many IVF doctors do not like treating these patients, because they believe they have reduced chances of success. They do not want to tackle such challenging IVF patients, because they may not have the required expertise. Other IVF clinics are worried that treating these patients may reduce their IVF success rate. This is why many IVF clinics will push these patients into doing donor egg IVF, rather than trying to help them achieve success.

At Malpani Infertility Clinic, we specialise in treating challenging and difficult patients. Because we have years of experience, and are very hands-on when doing IVF ( since we do not have any assistants), our success rates even in these difficult IVF patients is high !

After a failed IVF cycle, your hopes go crashing down, and it is difficult to pick up the pieces and carry on living. This is why it's important to give yourself some time and grieve , so that you can bounce back after a failed IVF cycle. Rather than get stuck with thinking about " if onlys " and "woulda, coulda, shoulda" and blaming yourself for the failure, you need to use an analytical framework, so you know what to do next.

Failed IVF cycles cause enormous heartache - for patients and for doctors. Most IVF doctors find it difficult to counsel patients when they have failed IVF cycles.  Many doctors start avoiding patients who have failed IVF cycles, so that these poor patients start feeling abandoned and believe they will never be able to have a baby. 

However, a failed cycle is not the end of the world. Often, it represents a new beginning. Experts like Dr Malpani can learn from the failed cycle, so we can improve your chances of success in the next cycle.

Most patients get stuck in the phase of asking questions to analyse the  failed cycle. Doctor, did I do something wrong ? Did the embryos fail to implant because I did not rest ?

IVF treatment can be stressful, but there's no need to add to the stress by blaming yourself for something which is not in your control.

An unexpressed concern is - Did the doctor do something wrong which resulted in a failed cycle? Patients are often desperate, and will spend hours scouring the internet, to try to find answers to their questions.

Actually, these are very unproductive questions. The quality of answers does depend upon the quality of questions; and after a failed cycle, rather than ask - What went wrong ? or Why did the embryos not implant ? a far more useful question would be - What can we learn from this failed IVF cycle ? And based on this additional hard-earned information, what can we do differently in the  next IVF treatment time to increase our chances of success ?

If it's been a perfect IVF treatment cycle ( transfer of Grade A top quality embryos; trilaminar endometrium of more than 8 mm; and an easy transfer), then often all one needs to do is to repeat the IVF treatment until it works. This requires a lot of patience and fortitude, but human reproduction is not an efficient enterprise, and you don't have a better alternative except to pray and try again.

Several factors may lead to in vitro fertilization (IVF) failure. However, many women who have had a failed cycle will have a subsequent successful cycle which results in a live birth. While not all issues related to IVF failure can be corrected, some issues can be addressed in an effort to reduce the likelihood of another failed cycle. It’s important to understand what factors are involved in each individual situation.

What are some of the things which you can change for the next IVF treatment cycle ?

For example, if your follicles did not grow properly ( your ovarian response was poor ) , you can tweak the superovulation protocol. At Malpani Infertility Clinic, with our years of experience, we are very good at doing this. We can help you grow more eggs, of better quality, based on studying your earlier response. Thus, if you are a poor ovarian responder, we can use the Letrozole Anatgon protocol for aggressive superovulation, so help you make the most of your eggs.

After a failed IVF cycle, remember that it is more useful to change your doctor rather than give up hope . If you have lost confidence in your doctor; or if you find that after the failed cycle, your doctor is not being open or transparent and is not providing satisfactory answers, it's always a good idea to get a second opinion, to confirm you are on the right track ! It's important that you have a detailed treatment summary of your IVF cycle, including photos of your embryos, so an IVF specialist can provide intelligent advise.

Malpani Clinic provides effective IVF treatment programs for patients from other IVF centers who have experienced a failed IVF cycle . Many of our patients come from other IVF centers due to failed IVF cycles. We can help you. We have helped many patients from around the world to have a baby despite previous failed IVF cycles.

What are the other things over which you do have control, and which you can change ?

You can use donor sperm, but with the availability of ICSI, the need to do this is practically zero today. In fact, we use donor sperm only for men with complete testicular failure. While some clinics will blame the poor quality of sperm for a failed ICSI cycle ( by claiming the sperm have high DNA fragmentation or abnormal DNA or abnormal morphology or very poor motility), none of these are issues which adversely impact ICSI fertilization rates in a good IVF lab. No matter how poor the sperm motility or how abnormal their shape or their DNA, in a good IVF lab, fertilization after ICSI is pretty much guaranteed ! Also, once the sperm have fertilized the egg, their task is accomplished. This may not seem intuitive, but boor quality sperm are usually never responsible for poor quality embryos, because embryo cleavage is dependent upon the energy provided by the mitochondria in the egg cytoplasm - not the sperm !

For a large number of patients with extremely poor ovarian reserve, donor eggs is often the best option to maximize success rates.This is especially true for older women. We know that one of the major factors contributing to in vitro fertilization failure is the high rate of chromosomal abnormalities in human embryos.As women age and their eggs get older, the incidence of chromosomal abnormalities in mature eggs increases significantly. The rate continues to increase with advancing age so that by the mid-40s over 75% of human embryos are chromosomally abnormal. This is mainly due to problems with the spindle apparatus in the egg nucleus, which is involved with properly lining up and separating the chromosomes as the egg matures at the time of ovulation. Older eggs have an inefficient cell division apparatus , as a result of which the chromosome pairs do not line up properly and "mistakes" are made when splitting pairs of chromosomes. This leads to eggs that do not have the proper balance of 23 chromosomes and results in a chromosomally abnormal embryo if fertilized. While using donor eggs to "treat" this problem is a fairly straightforward solution, this can be psychologically extremely difficult to come to terms with, especially for young women.

Many women will want to change the uterus when they encounter repeated IVF failure. They believe that their uterus is abnormal, and is "rejecting" their embryos. This reasoning seems logical, but is actually flawed, because the uterus is usually just a passive recipient, and surrogacy does not help to improve pregnancy rates if the woman's uterus is normal.

The trouble is that after a failed IVF cycle, patients want a scientific explanation as to why the cycle failed. They are not happy when the doctor tells them the truth - that it was random bad luck. They demand a diagnosis, because they believe that the doctor needs to accurately "diagnose" the problem, in order to find the right solution. Doctors are happy to trot out a glib diagnosis of "failed implantation" to keep their patients happy - and many will then order a battery of expensive tests to " pinpoint " the cause.

However, "failed implantation " is just a waste paper basket diagnosis, which doesn't provide any useful information. It's just a meaningless label which only describes what happened - that the embryos did not implant, that's all. Unfortunately, when a cycle fails, it's hard to think logically. Patients demand testing, and doctors order these to keep their patients happy.

This wastes a lot of time, money and energy. Even worse, the results of some of these tests come back as abnormal. These are just false positives, which have no clinical importance, but once a result is abnormal, the doctor is then obliged to "treat " it. This wastes even more time and money for the poor patient !

Think about it rationally for a minute. If these tests were really useful, then why would a doctor wait for the IVF cycle to fail before ordering the test ? He would order them before starting the first IVF cycle, if they did in fact provide any useful information.

IVF failures are one of the most depressing experiences a couple can go through in their IVF journey. Having experienced several failed IVF attempts can be very depressing and frustrating, especially when doctors cannot provide a suitable explanation for them. Please learn to be kind to yourself. Often the failure is not in your control.  At Malpani Clinic, we thoroughly evaluate you, before attempting another IVF cycle , so that correctable problems can be ruled out.

This is why, if your IVF cycle has failed, it's important that you have good-quality documentation of your failed IVF cycle ( including photos of your embryos ), so that you can get an intelligent second opinion to make sure you're on the right track !

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




Tuesday, March 25, 2014

How can we get doctors to improve ?


I sometimes despair when I see the deplorable state the medical profession in India today . Doctors are no longer held in the high regard which they used to be in . Even though patients still respect their personal doctor, lots of people feel that doctors are corrupt ( because they take money under the table) and unethical ( because they take cuts) and greedy ( because they over-test and over-treat in order to make more
money) . The reputation of the entire medical profession seems to be set on a downward spiral .

It's easy to blame the declining state of medical ethics on the fact that society as a whole is seems to put money before professionalism . Commercialism has become rampant and affects all of society, so why should we expect doctors to be immune to this. Also, because of the large number of private medical colleges set up by politicians to make a quick buck, new medical graduates will do their best to recover their fees by overcharging patients so they can get a return on the capitation fees they have spent in order to become doctors.

I see lots of examples of bad behavior on the part of doctors . They routinely demand money under the table ; do not provide the patients with receipts ; and not provide medical documentation of the treatment they have provided. Doctors can rationalize and justify their behavior – but the fact remains that this is wrong – and illegal.

So how can we get doctors to improve ? Passing laws never helps, because while passing them is easy and they look great on paper, they are practically impossible to implement in India in real life.

I think the real reason doctors don't improve is because patients allow them to get away with their deplorable behavior !

Sadly, Indian patients today routinely put up with the fact that

doctors perform underhanded activities such as demanding cash payments
doctors make them wait for hours on end ,
doctors are rude and uncommunicative
doctors don’t bother to explain what’s happening
doctors cover up and hide facts when there is a medical complication or error

It’s true that patients feel helpless and powerless ; and that there is a power imbalance in the doctor-patient relationship. When you are sick , the last thing you want to do is to challenge and confront your doctor. However, it is also equally true that by allowing doctors to get away with this behavior , patients are tacitly encouraging this, so that he continues to behave badly with other patients as well. As the Rabbis say - "It's not the rat that steals, it's the hole that steals". In other words, if the rat (aka the thief) would know that he wouldn't have a hole to conceal what he steals from others, he wouldn't steal.

Remember that doctors cannot survive without patients – and doctors don’t have a monopoly ! Patients need to learn to put their foot down , and say No ! If patients are willing to put their money where their mouth is, and refuse to tolerate bad behavior from doctors , things will definitely improve . It’s only when patients reward good doctors for good behavior and start punishing bad doctors for bad behavior will changes occur. The next you complain about your doctor, ask yourself – what did I do to fix the problem ? And if you are not part of the solution, you are part of the problem . If we refuse to take responsibility for our own actions , why should we expect things to improve ? The only reason doctors are on pedestals is because patients are on their knees !

When more is not better in IVF - PGS/CCS reduces IVF success rates


PGS and CCS seems to be the hottest new flavour of the month in IVF. Many patients come to us and ask that we do PGS/CCS for them. Typically, these are older women or those who have failed IVF cycles elsewhere. They have read about this new technique online, and want us to do it for them, because it is supposed to improve IVF success rates.

There is a good reason why PGS/CCS is so appealing. It allows us to screen embryos , so that we can selectively transfer only the genetically normal embryos. Isn't it common sense that doing so will improve IVF success rates ?  And since it's the newest technology around, it's being marketed very aggressively and cleverly !

Logically, we should be very happy to do so ( because we can charge more for these additional services). However, as professionals we also need to explain to them that while PGS will help us make more money, it will not help to improve their chances of success.

Sadly, most other IVF clinics do not bother to do so . And if a patient wants a new technology to be used for them, and is willing to pay for it, then why not pander to their request and comply ? It takes too much time and effort to say No to a patient's request - and it's hard to say No when you are turning away additional income. It's true that we lose these patients to other clinics, but other than educating them, there's nothing else we can do about this.

Because we are well off and very busy, we are in the fortunate position of being able to afford to say No when we don't think  the inappropriate overuse of technology is in the patient's best interests !

If you want to read why PGS/CCS does not help, please read the article, "Improved" Preimplantation Genetic Screening (PGS) Not Proven to Increase IVF Success Rates, at http://www.digitaljournal.com/pr/1801245

Monday, March 24, 2014

NK cell testing – yet another way to exploit the vulnerable infertile patient!


This is a guest post from our expert patient, Manju.

I get mails from patients saying that their NK cell number or NK cell activity is high and hence their doctor has asked  them to undergo  immunotherapy , using either IVIG infusion ; or intralipid therapy; Lymphocyte Immunotherapy (LIT) ; or tumour necrosis factor alpha blocking agents and steroids , or a combination of these, in order to 'treat' this abnormality.  They are advised that, by doing this, they can improve their chance of having a baby. Is this claim justified ? What are NK cells ? What are their functions in human body ? How are they connected to fertility ?  Do women who undergo this therapy improve their odds of having a baby  ? Does your doctor who asked you to undergo this test and therapy have  proof for its efficacy ? Is it wise to invest so much emotional, physical and financial energy in it ? There are so many unanswered questions and this article might help in answering them.

What are NK cells ?

Our body is attacked by bacteria and viruses constantly. Some cells in our body can become cancerous if errors occur in their DNA during cell division. In order to protect our body from microbes and from tumour causing cells, our body has developed a surveillance mechanism called the immune system  which consists of cells called white blood cells. These cells constantly scrutinize our body and remove the infected or abnormal cells.  Natural Killer (abbreviated as NK cells) cells are part of our immune system and are involved in early defense.  As the name suggests, their main function is to kill ! They have the ability to remove the microbe infected cells and genetically abnormal cells which might cause cancer. They do this by secreting a protein called perforin which makes hole in the infected cells. Then a lethal dose of enzymes are used to destroy the deleterious cells. In short, these NK cells function to protect our body against infections and cancer.  The name natural 'killer' cells comes from the invitro assay used to identify them (identifying NK cells by its ability to kill target cells). Please do not imagine NK cells as something which is waiting in the uterus to devour your much loved embryos !

Where are natural killer cells present in our body ?


NK cells are mainly found in the blood stream.  They are also found in liver, skin, lungs, thymus and uterus. They are the predominant type of maternal immune cells found in the uterine mucosa during the formation of placenta. They are also present in the endometrium of non-pregnant woman and accumulate at large numbers in the implantation site. Uterine natural killer cells are present in high numbers in early gestation.

Are peripheral NK cells and uterine NK cells similar ?

No they are not ! Both these cells are functionally as well as phenotypically different. NK cells are identified by the receptor they are carrying. The receptor used to identify NK cells are called as CD 56. NK cells which express less CD 56 are called CD 56 dim cells. These kind of NK cells are predominant in peripheral blood and show extensive cytolytic (killing deleterious cells) activity. The NK cells present in uterine mucosa carry more CD 56 receptors on them and are called CD 56 bright cells. Their cytolytic potential is comparatively less than the CD 56 dim cells.

If so, is studying peripheral blood cells in order to assess the number and activity of uterine NK cells justified ?

Definitely not !  It is analogous to counting  the number of people and studying their behavior in Africa in an attempt to study the same in Asia. Both are humans but neither the place they inhabit nor their behaviour is similar !

What functions do NK cells have in uterus ?

The truth is, the function of NK cells in uterus is not yet clearly defined. The NK cells in the uterus are thought to produce several angiogenic factors and thereby help in regulating the menstraul cycle. There is evidence that they play a beneficial role by helping the proper invasion of placental trophoblast cells into uterine decidua by secreting essential cytokines and thus helping to establish a normal blood supply to the fetus and placenta throughout pregnancy. NK cells do not kill trophoplast cells !

How are natural killer cells linked to infertility and why it is not a scientifically valid observation ?

It was shown that women with recurrent miscarriage had increased amount of NK cells in their peripheral blood circulation or in their endometrium and/or their NK cells showed increased cytotoxic property . It was hypothesized that, in infertile women, overactive (malfunctional) uterine NK cells destroyed the trophoblast of the developing embryo preventing implantation or leading to miscarriage.  But this observation had many flaws :

1. The method used to measure the number of NK cells varied in different studies. The results can vary a lot , depending on the technique used to measure NK cells.
2. NK cells in the blood of normal healthy individual can vary from 5% to 29% depending on the sex of the individual, ethnicity, stress and age. Inspite of this, infertile women who had more than 12% NK cells in their circulation are defined as having “ abnormally elevated “ NK cells and are ‘treated’ in the studies conducted. Moreover peripheral blood NK cells are different from uterine NK cells. Studying peripheral blood NK cells cannot throw light on the number and function of uterine NK cells.
3. When NK cells are collected from the uterus, they must be isolated from the same depth in all women because their density varies widely along the uterine mucosa. If not, the results can vary widely.
4. Well designed, sufficiently powered clinical trials with appropriate population selection and using the same NK cell testing methodology are lacking.
5. The cytolytic potential of NK cells are tested using cancer cells (K562 cells). It was shown that NK cells can kill cancer cells and not normal human trophoblastic cells invitro.
So there is no scientific rationale for these tests !

Why is it unlikely that uterine NK cells will attack the embryo ?

Progesterone is considered as one of nature's best immunosuppresant. It was shown that progesterone at the concentration present at the materno-fetal interface inhibits NK cell activity. The placenta also secretes several factors which act as immunosuppressants. Even the human embryo has been shown to produce certain chemicals which stimulate the maternal system to produce Early Pregnancy Factor ( EPF) which acts as an immunosuppressant too. Trophoblast cells also express certain receptors which prevent NK cells from attacking them. Hence it is highly unlikely that uterine NK cells attack your embryo in vivo.

What is the NK cell activity assay and how useful is this assay ?

In order to find out whether NK cells show abnormal cytotoxic activity, the NK cells (mostly from peripheral blood) are removed from our body's natural environment where progesterone, placental factors and other natural immunosuppressants are present in plenty. Then an in vitro assay is carried out using k562 cells as a target . k562 is a myelogenous leukemia cell line. The percentage of k562 cells lysed or killed by NK cells gives an idea about how active your NK cells are. Using the result of this NK cell cytotoxicity assay , some doctors decide whether a particular woman should undergo immune therapy or not.

There are certain important points to be noted here: K562 are cancerous cells and such cancerous cells are readily recognized by healthy NK cells. It is the normal function of NK cells to kill cancer causing cells. The use of the K562 lysis assay to determine whether your NK cells have the capability to attack your embryo is a very crude, vague and controversial method. Even if a particular woman’s NK cells are active against cancer cells (K562) , this doesn’t necessarily mean that her cells will behave the same way against her embryo's trophoblast cells. So why don’t labs test NK cells activity against trophoblast cells in vitro ? This is because NK cells in such invitro assays do not kill human trophoblast cells !

It must be kept in mind that the in vitro environment is extremely different from in vivo conditions. Uterus environment (in vivo environment) is extremely rich in natural immunosuppressant (like progesterone) and when a competent embryo enters the uterus , it signals the maternal system to secrete immunosuppressants. How can an assay conducted without simulating a natural in vivo environment be used to predict NK cell cytotoxicity against human embryos ? How could one correlate activity against a cancer cell line with activity against human trophoblast cells? How many studies were done to determine the cut-off value for determining NK cell cytotoxicity?  Very few studies have been done , and most of them were published in low-ranking journals , which means they lack enough power !

What are the ‘therapies’ available to ‘treat’ malfunctional NK cells and how useful they are?

It is believed that by using intravenous immunoglobulins , intralipids, lymphocyte immunotherapy or by using tumour necrosis factor - alpha blocking agents and steroids the ‘raised’ or ‘malfunctional’ NK cells can be ‘ treated’ by dampening the immune response. Such therapies have no scientific validity and can pose significant health risks to the patients. Intravenous immunoglobulin is a pooled blood product and can result in anaphylactic response, fever, flushing, nausea, and headache and pose an increased risk for the transmission of infectious diseases. Intralipid therapy and IVIG, can dampen the immune response and make one prone to infectious diseases.

If this is true; why do many REs offer NK cell testing and therapy?

There are many reasons for this :
1.    Money – many doctors are not ashamed to make money out of your desperation and vulnerability.
2.    Doctors are humans too and are prone to cognitive biases. They conveniently forget the 9 patients who failed IVF after undergoing such scientifically invalid therapy , but they remember that one patient who had 8 failed IVFs and who achieved success after being treated for malfunctional NK cells! They remember their sensational success stories and crave credit for it. As a result many become vocal advocates for pseudo science!  Many REs do not maintain proper records of the treatment they offer and hence have no chance to make a valid statistical analysis of the treatment they offer. They value their personal experience much more than the knowledge accumulated by several scientists after careful research over a period of time.  As a result they forget that evidence based medicine is the golden standard of good medical practice.
3.    Patients, out of desperation, believe all the sensational media news which is based on anecdotal evidence (for example read this: http://www.dailymail.co.uk/femail/article-2361112/Mayonnaise-miracle-babies-150-IVF-attempts-controversial-egg-yolk-oil-jabs-theyre-mums-last.html - very impressive, beautiful pictures, right). Extensive coverage of anecdotal success stories by the media creates a bandwagon effect. Because of their lack of scientific knowledge , patients are unable separate the wheat from the chaff.  As a result, they believe that by using the therapy they read about on a website or in an article in the newspaper ( which may actually just be a press release) they can get their much desired baby. This kind of blind expectation of patients in the efficacy of new, unproven treatments pushes many REs to offer them these treatment, irrespective of their scientific validity. Patient pressure forces doctors to do stuff they may not believe I because they are scared they might lose their patient to some other doctor who offers them !
5.    Many doctors find it difficult to understand the rationale behind these tests. They get duped by the diagnostic and pharmaceutical companies who promote these tests and therapies.

Stop to think for one minute . If NK cell testing was really useful, then why wouldn't all IVF clinics offer this testing ? Don't all IVF clinics want their patients to get pregnant ? If NK cell testing was of proven value, then why does the ASRM advise against it ?

How do you explain all the success stories of women who have failed 5 IVF cycles and then got pregnant after treating their high NK cell activity?


Let me ask you another question: how will you explain all the failure stories , even after the high NK cell activity was “treated” ? Just because your friend or a blogger says that they achieved success after taking treatment for their high NK cell activity  doesn’t mean that the observation is scientifically valid . Anecdotes are not proof of efficacy! We humans are social storytelling animals and we learn by the experience of others  -  this is how we are hardwired. That is why our mind gives undue importance to such stories , instead of looking for valid scientific proof. Another important thing we must realize is that patients who benefit from a particular treatment are more likely to boast about it than the patients who didn’t get success, who are resigned to their fate. So for every five women who succeed, there might be another fifty who failed , but you do not get a chance to know about them. This is why anecdotal evidence is not reliable. In order to test the effectiveness of a particular treatment, a randomized clinical trial with sufficient power must be conducted. At present , there are not enough RCTs to prove that NK cell testing and therapy really benefits infertile patients.

My RE says experience is as important as knowledge and assures that he has seen it work in his practice!

Just because your RE has seen it work in his practice doesn’t mean it really works ! Again your RE is telling you a story , and this can only be considered as his individual view about the treatment – just more anecdotal “ evidence” . As I have already mentioned, your RE is a human too with cognitive biases , and hence his judgments can be flawed too.

I read a RE’s blog where he defends his approach of providing treatment based on anecdotal evidence , by giving an elephant trail adage. He quotes this:
Elephants in Africa migrate hundreds of miles each year to reach their ancestral feeding grounds. The journey requires that they cross mountains, ravines, jungles, turbulent rivers and unforgiving desert terrains. They always follow the same path, one that over time has proven to be the least challenging and the most productive.  Indeed, in the beginning they must have made many costly directional and topographic errors, but over time they eventually defined the best way to reach their destination safely. This is how I learn too – from my experience, over years of trial and error.

Humans are rational animals! They need not have to subject themselves to risks which animals have to go through. As humans , we can form a hypothesis and test its validity by conducting proper research - we don’t have to believe anecdotal evidence alone.  The  RE equates his patients to experimental rats , and claims that everyone learns by mistakes , and that errors do happen. If someone wants to experiment on their patients, it has to be done with informed consent , and not by exploiting their vulnerability. If an experimental procedure is tried on you, why should you pay them a huge fee for the treatment? Is it even ethical? He claims that he has no scientific evidence to prove intralipid therapy is effective but he knows that it works by his experience! If doctors can judge correctly by their experience alone, then there is no need for pharmaceutical companies to spend millions on performing  RCTs and extensive research !

What should I do now ? Why shouldn’t I take a chance and try the therapy (I am desperate to have a baby!) Who know, it might work for me!

After hearing all the rational arguments , if your heart still says that you must give it a try, then you can go ahead.  But please understand the following :

Try to see whether you can enroll yourself in clinical trials which are conducted to assess the therapy’s validity. If not , ask your RE whether he could provide the treatment free of charge, since it is not a proven treatment and is based on anecdotal evidence. This way, you get the treatment and he gains knowledge – a ‘win-win situation’ (I bet no RE will agree to this unless and until they themselves are involved in conducting a clinical trial for the same)

Please educate yourself about the risks involved in such treatments and be aware of the emotional risks such treatments carry! There is also the opportunity cost to consider.   By barking up the wrong tree ,you may waste a lot of time and tons of money.

If you are a woman of advanced maternal age , please understand that it is your oocyte competence which is the most important factor in influencing implantation – not your NK cell activity ! Please do not subject yourself to such unproven therapies – they are very unlikely to help !

Take home messages
1.    NK cells are not proven to kill your embryo by attacking the trophoblast. They do not kill trophoblast even in the invitro assay used to assess its activity !
2.    The tests available for measuring NK cell number and assaying its activity are highly variable and do not yield consistent results.
3.    Your NK cell number in peripheral blood can vary a lot,  depending on stress, age, ethnicity etc
4.    Peripheral blood NK cells are very different than that of uterine ( uNK) NK  cells; studying them will not shed light on uNK cells.
5.    The therapies offered for NK cell malfunction have many side-effects, please be well-informed about these.
6.    Your RE’s personal experience and observation (plural of anecdote is not data !) cannot replace good clinical research data.
7.    In your quest for a baby , do not get desperate and allow the idiosyncratic personal practices of some physicians to exploit you !

Confused ? Not sure if you should need immune therapy ? 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 older newly married couple and infertility


We are now seeing a different kind of patient in our clinic these days. These are couples who are older and have got married recently , so typically the wife is more than 35 ; the husband is more than 40. They are usually professionals who have had very busy lives and fulfilling careers . They are doing very well for themselves ; and chose not to get married for many years because they couldn't find the right person. Now that they have finally found the right person ( often online , thanks to sites like shaadi.com; or through friends, neighbors, relatives),  when they finally hook up with someone they then need to decide whether they should start a family or not.

This is when they come to grips with the fact that their biological system no longer functions as optimally as it would for a younger woman ; and this can be a bit of a rude wake-up call for lots of these older women. These are typically very successful professionals who are used to doing everything for themselves and succeeding in life . They have high-profile lives and high-profile careers and most of them have been able to climb the rungs of their profession to get to whatever stage they wanted to.

They also automatically ( and naively) assume that once they have found Mister Right , they’ll be able to have a baby when they want to, because they have always been able to get what they want in life , as a result of their hard work and determination.  However, when they find out that their eggs maybe too old for them to be able to get pregnant , this comes as a bit of a rude surprise and shock , because no one ever prepared them for this eventuality.

What can be very disconcerting for some of these women is how strong their craving to have a baby can be – baby lust can be a very powerful force indeed !  These are the kind of women who would have never thought of the possibility of becoming moms or thinking of themselves as taking care of babies or toddlers when they were 30, who now find that at the age of 36 that this has become the major obsession in their life.

These are very interesting patients to work with because they're well read and well informed and have done their homework . They are mature and have seen quite a bit of life , as a result of which they are very capable of making their own decisions for themselves .

Many of these women come with many regrets and a lot of emotional baggage. ( I wish I had decided to have a baby earlier ! I wish I hadn’t put it off for so many years. I wish someone had told me about the biology of ovarian aging !) It’s quite challenging to explain to them that even though IVF technology has advanced significantly , there are still limits as to what we can do when we deal with women with poor ovarian reserve.

Many of them are worried that they are now too old to be good parents and are concerned that they will not have enough energy to be able to bring up a toddler.  I remind them that while their parenting style will be different from a 25 year old mother’s, in some respects it will be much better. They are likely to be much more laid back and mature; and since they have more money, they are in a better position to provide their child with a lot of life’s luxuries. Also, since they are spending so much time, money and energy on getting pregnant, they are likely to do a stellar job with bringing up their baby, who will not lack love and attention.

Fortunately, not all older women will have poor ovarian reserve ; and some of them will very happily get pregnant in the first IVF attempt itself , so that it makes all the efforts we put on their behalf very worthwhile.

Are you an older couple ? Are you worried about your biological clock ticking away ? 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, March 23, 2014

The noncompliant doctor


A lot has been written about patient compliance . Lots of doctors ( and pharmaceutical company executives) believe that if patients learn to be compliant and follow the doctor’s instructions , they will get better. Patients are expected to do what the doctor orders them to and doctors believe that patients will follow their instructions.

Interestingly, while the traditional  belief was that compliant patients did better than those who did not follow their doctor’s orders, we now know that noncompliant patients are of two different kinds . One doesn’t follow instructions because they cannot afford the prescribed medicines or are unable to understand the doctor’s complex instructions. However, there is a subset of noncompliant patients who actually do even better than compliant patients. They have a mind of their own and when they disagree with the doctor’s advise they will chart out their own path. These patients are not aggressive, but they are assertive, and will not blindly do whatever the doctor tells them to.

Just like most doctors expect patients to be compliant, most patients expect their doctors to be compliant as well ! When they request the doctor to prescribe antibiotics for their cold or order an X-ray for their back pain, they expect their doctor to acquiesce. A compliant doctor does what ever the patient asks him to. This is why pharmaceutical companies spend so much money on advertising branded drugs to the public – they know that most doctors will agree to do what their patient wants them to.  Now this does not mean that doctors are puppets in the hands of their patients. This fact just recognizes the reality that because it is much easier for them to comply, most doctors are not willing to take the time and trouble to explain to patients why their patient’s requests are wrong.

Most doctors are quite happy to be compliant because it’s so much easier to take the path of least resistance. Saying yes to the patient saves them a lot of time, so they can move on with seeing the next one.  It also keeps their patients happy , so why rock the boat by saying no ?

However, there is a subset of noncompliant doctors who are far better than compliant doctors. They take the time to think through and process the patient's request . When they think it is medically inappropriate , rather than just accept what the patient wants , they will push back , and explain to the patient why their request is flawed. They will offer an alternative solution to the patient, which they feel is better and more effective.

Sadly, most doctors don't have this kind of time to spend with the patient. Few have the energy or the inclination to argue with the patient – after all, taking the approach that the “customer is always right” is much easier ! However, this kind of doctor is a better doctor, because he makes sure that his patient gets the right amount of medical care - not too much , and not too little .

It is the noncompliant doctors who are the true professionals – they have the patient's best interests at heart . They respect their personal professional abilities , and would rather do what is right for the patient on a long term basis, rather than try to curry short term favour by keeping the patient happy . Few doctors have the self-confidence to do this. They are worried that if they do not agree with the patient's request,  the patient will go off to another doctor and he will lose his patients to someone else . He does not want to lose income , and will therefore buckle down to patient pressure ( much of which is created and cleverly manipulated by seductive advertising by pharmaceutical companies and medical devise manufacturers). 

By contrast, wise doctors have the maturity to understand that if they take the time to explain to their patients what the right course of action is , intelligent patients will appreciate their advise and efforts – and are likely to be far more loyal in the long run. Good doctors know that it is far better for them fire patients who have unrealistic demands and who do not value their professional opinion ! They understand how to talk to their patients,  and educate them, so they become smarter patients !

Saturday, March 22, 2014

Infertility in Hindu Mythology - Dr Devdutt Pattanaik



This is a guest post by my friend and renowned mythologist, Dr Devdutt Pattanaik

Having children has always been important since time immemorial, and the continuity of the family unit has been of major significance in Hindu culture. Infertility is a social stigma even today, and Indian mythology is full of stories about what couples have done in the past to overcome their problem of infertility.

Ancient tales hold the key to the unconscious desires of a people. They help us appreciate the fears and insecurities of people who visit state-of-the-art infertility clinics. In this article, sacred narratives from ancient scriptures are explored to understand the importance of fertility in the Hindu worldview.

Debt to Ancestors
The following story of sage Agastya from the great Hindu epic Mahabharata (written 2000 years ago) tells us why Hindus, in particular, and Indians, in general, are so obsessed with children. Besides social factors like ‘someone to take care of me in my old age’, it directs our attention to a profound religious demand for a child, especially a male one.

The sage Agastya wanted moksha­, liberation from the endless cycle of rebirths. So he broke all social bonds, went to the forest, meditated and performed austerities. He believed that by refusing to succumb to any desire, by refusing to yield to the illusory pleasures of the material world, his soul would break free from the prison that was his body. He spent years mortifying himself. Liberation eluded him. Then, one night, he had a vision: he saw his ancestors hanging head down over a gaping hole. They were crying, “We are trapped in the land of the dead. And there is no hope of escape.” “What can I do to help?” asked Agastya. They replied, “Father children, so that we can be reborn. Help us return to the land of the living so that we too can work towards our moksha. Or else, you will land up in the hell known as Put and suffer there for all eternity. Repay the debt you owe your ancestors.” Thus admonished, Agastya returned to his village, got married, fathered children, and only after they had become independent did he return to the forest.

Hindus believe that all men come into this world burdened by a debt – the pitr-runa (pitr = ancestor; runa = debt). The only way to repay this debt is to father a male offspring. During funerary rites, known as shraadha, Hindu males are reminded of this debt. In the Dharmashastras, Hindu law books written between 500-1000 A.D., it is said that those who fail to repay this debt end up in the Hell known as Put where they suffer for all eternity. Since the birth of a child, preferably male child, liberates a man from his debt, the Sanskrit word for son is putra (deliverer from Put). The daughter or putri is also a deliverer from Put, but to a lesser extent.

Dharma and Karma
Two words that play a crucial role in the understanding the Hindu (as well as Buddhist and Jain) attitude towards life are dharma and karma.

Dharma is essentially duty that must be performed for the sake of social as well as cosmic stability. Failure to do so leads to social anarchy and cosmic chaos. Duty is traditionally defined by one’s inherited caste (teacher, protector, provider, servant) and by one’s stage in life (student, householder, senior citizen, hermit). Producing a child is one’s biological duty applicable all human beings. Those who wanted to renounce the world were only allowed to do so after they had fulfilled all worldly duties.

Men who could not fulfil their biological obligations because of a physical problem (impotence) or a mental quirk (homosexuality) were termed rather derogatorily kliba or napunsaka, sexually dysfunctional non-man. In the Manu Smriti, an ancient Hindu law book, such men were debarred from sacred rituals and from inheritance. Only by producing children, were a man and woman considered biologically fulfilled. It must be remembered, that only after marriage was a man in Hindu society given the right to enjoy worldly pleasures and possess worldly wealth. A king could not be king unless he was married. And an impotent man or a man who could not father a child was not allowed to be king. Hence, in the Mahabharata, when the king Pandu learns that he will die the moment he has sex with his wife, he renounces his crown – his inability to father a child debars him from kingship.

Karma means both action and fate. Hindus (as well as Buddhists and Jains) believe that every action leads to a series of reactions. All creatures are obliged to experience the repercussions of their (conscious and unconscious) actions, either in this life or the next. Thus, every event is the result of past actions. If one is barren, it is because of events that occurred in the past, either in this life or in the one before. A folk story based on the Mahabharata illustrates this point. At the end of a great war, queen Gandhari is informed that all her hundred children are dead. She weeps and seeks a reason for this unfair situation, to which a sage replies, “In your last life, you sat on a stone under which there were a hundred turtle eggs. The eggs were crushed. So the mother-turtle cursed you that you too would experience the loss of hundred children.”

A situation in governed by karma, but one’s reaction to is governed by free will. Astrology helps understand what karma has in store for us. The result of karma can be either endured or it can be modified by certain occult rituals, by the power of holy men or by the grace of god. This is the reason why childless men in India visit temples, go on pilgrimages, seek the intervention of holy men or perform elaborate rituals.

White seed and Red Seed
Why a male offspring is more important to a Hindu (besides social factors) can be traced to certain beliefs. In the Mahabharata, it is said that the soul of a man lies locked in the semen. Semen is the medium through which ancestors slip into the land of the living. The soul in semen is embodied in the womb.

According to ancient Hindu seers known as rishis, within the womb is the red seed known as rajas (the counterpart of the white male seed known as shukra). The rajas wraps the soul in flesh and blood. The shukra, besides being a medium for the soul, is also the source of bones. Thus all living creatures come into being because of the father’s white seed and the mother’s red seed. The former generates consciousness and transforms into the skeleton while the latter creates the flesh.

There is an interesting story in this regard from the Padma Purana. A king had two wives but no children. He asked some sages to make a potion that would make his wives pregnant. He died before the potion was ready. The two widowed queens did not want to waste the magic potion. So the elder queen drank it while the younger queen made love to her ‘like a man’. In due course, the elder queen gave birth to a child, but it was only a lump of flesh. The sages said, “Since no white seed was part of the conception, the child had no bones and no consciousness.” They appeased the gods and the child was ‘repaired’.

Power of the white seed
Indian men are known for their obsession with virility. Virility here refers to many things, physical strength, mental agility, sexual energy as well ability to father a male child. So when an Indian says, “I have less strength (takat kum hai),” he could refer to malaise or lethargy or impotence or inability to father a male child. Here again is an ancient belief that physical strength is reflected in semen strength.

The ancient seers believed that food consumed is transformed in the body into sap (plasma), then flesh, then blood, then bone, then marrow and finally seed (Hence the traditional Indian belief that out of a thousand drops of blood comes one drop of semen). The seed can produce a new life or if retained can transform into a magical substance called ojas that gives a man superhuman strength and occult powers. It also helps man escape from the cycle of rebirths.

In women, the red seed is shed every month. Hence, women are considered to be the weaker sex – they cannot attain ‘spiritual’ status because they have no access to ojas.

Men on the other hand can retain their white seed and become ‘holy’. This is the reason given to explain the presence of greater number of holy men than holy women in India. This is also the reason why powerful warrior gods like Hanuman and Ayyappa are associated with both virility and celibacy.

In the Mahabharata, it is said that a male child is born when the white seed is stronger than the red seed. Thus a virile man (one whose semen is strong) fathers only male children. When the red seed is strong, the child is female. When both white and red seed are equal the child is neither this nor that (this was the traditional explanation for transexuality and homosexuality). This belief perhaps explains why, despite modern genetic data on X and Y chromosomes, it is the woman in India who is ‘blamed’ for the feminization of the fetus and why she is given special diets to make the fetus male. This also explains why men feel angry and ashamed when they father daughters. The sex of the child is linked to their virility, or lack of it.

The fertile period
According to the Dharmashastras, though sex for pleasure was permitted, greater importance was given to sex for procreation. Men who had to father male offsprings were advised not to waste semen. They were advised to have intercourse only when the woman was in ‘season’. This period was known as ritu and it roughly corresponds to the fertile period, the days in the menstrual cycle when a woman is most likely to conceive. Women were advised to make themselves beautiful and present themselves to their husbands after their periods.

If a woman who was in her fertile period approached a man for sex, he was obliged to have sex with her, the reason being – a fertile period should not be wasted. Every time a fertile period was lost, an ancestor lost his opportunity to be reborn. When a woman menstruated, she was held responsible for the opportunity last. She was equated with ‘death’ and hence considered polluted. She was asked to isolate herself during her periods, just as men who cremate the dead are isolated from the rest of the community.

A man who turned down a woman who approached him during her fertile period was described as a eunuch and held in disdain. In the Mahabharata, there are tales of women who approached men who were not their husbands during their fertile period because their husbands were unavailable. This was legally sanctioned. The sage Aruni was horrified when his guru’s wife approached him for sex. She explained, “Your guru has gone on a pilgrimage. Asking you do fulfill his biological obligations is a lesser sin than wasting this fertile period.”

The time when men and women had sex affected the nature of the child conceived. In the Bhagavata Purana is the story of Diti who approached her husband, the sage Kashyapa, for sex in the evening, a time reserved for prayers to ward of malevolent spirits. As a result, she conceived children who were demons.

When a man approached a woman, before intercourse, he was expected to invoke the gods, especially Vishnu, the god who sustains natural order, and Tvastr or Vishvakarma, the god who makes things. Only through their blessings, was it believed that a child could be conceived. This was known as the garbhadhana sanskara, or the rite of conception.

The sterile man
When a man could not produce a child on his wife, he was given the benefit of the doubt and allowed to marry again, and again. If despite this, he failed to father a child, it was concluded (but never explicitly stated) that he was sterile. In such circumstances, the Dharmashastras suggested that another man be invited to cohabit with the wives. This practice was known as niyoga or levirate.

In the Mahabharata, when king Vichitravirya (vichitra = odd; virya = virility) dies, his mother invited the sage Vyasa to produced children on his widowed daughters-in-law. Children thus produced were called children of Vichitravirya (the legal father), not the children of Vyasa (the biological or surrogate father).

It is alleged that this practice of niyoga is followed (rather clandestinely) even today, whereby sterile men make their wives cohabit with relatives or with holy men. Though religiously sanctioned, this practice is socially frowned upon and hence no one talks about it openly.

In the Kathasaritsagar, a collection of stories written in the 11th century A.D., there is the story of a king who makes an offering of rice balls to his ancestors. As he about to throw the offering in the river, three hands reach up – one of a farmer, one of a priest and one of a warrior. The oracles revealed, “The farmer is the man who married your mother, the priest is the man who made your mother pregnant and the warrior is the man who took care of you.” The king is advised to give the rice ball to the farmer because scriptures describe him as the true father. Thus was the practice of surrogate fatherhood established.

Artificial insemination
There are tales that suggest that the ancients were familiar with the ‘idea’ of artificial insemination. For example, we learn of ‘magic potions’ being created by sages for queens of childless kings that makes the women pregnant. What were these magic substances? Could they be ‘fertility drugs’ or could they be metaphors for ‘donated semen’?

One story states that the god Shiva once spurted semen when he saw Vishnu in the form of the celestial enchantress Mohini. Sages collected this semen and gave it to the wind-god Vayu who poured it into the ‘ear’ (a common mythical metaphor for the womb) of Anjani, a monkey, who gave birth to Hanuman, the monkey-god. Devoid of the mythical aura, one might say that the tale refers to the practice of artificial insemination: semen is transferred to the womb without sexual intercourse).

The surrogate mother
In the Bhagvata Purana, there is a story that suggests the practice of surrogate motherhood. Kans, the wicked king of Mathura, had imprisoned his sister Devaki and her husband Vasudeva because oracles had informed him that her child would be his killer. Every time she delivered a child, he smashed its head on the floor. He killed six children. When the seventh child was conceived, the gods intervened. They summoned the goddess Yogamaya and had her transfer the fetus from the womb of Devaki to the womb of Rohini (Vasudeva’s other wife who lived with her sister Yashoda across the river Yamuna, in the village of cowherds at Gokul). Thus the child conceived in one womb was incubated in and delivered through another womb.

Serpent power
In India today, when a couple does not have children, they often visit shrines and pray. Some visit holy men. Others offer cradles and dolls at shrines of mother-goddesses. Still others visit serpent shrines.

Serpents in many ancient cultures have been associated with fertility ( don’t forget that the serpent continues to be the symbol of medicine). There are many reasons for this. Probably because the serpent could slough its skin, it was believed to possess the power of rejuvenation. Probably because the serpent lived under the earth, it was believed to be the keeper of the secret that transforms seeds into plants. Farmers in India worship serpents in the hope they have a good harvest. Women worship serpents so that they are fertile and their husbands, virile.

In modern times, these practices may seem silly and superstitious. But for centuries they have offered hope to a people who believed that producing children was their biological duty. They offer the psychological support that today counselors provide. While these support structures can turn into crutches, their place in culture demands the be understood rather than be summarily dismissed.

Friday, March 21, 2014

The perfect IVF doctor !


If you want an IVF  doctor who:
1.  Answers all your questions
2.  Responds to your email ( usually within 24 hours)
3.  Doesn't force you to come in for every little problem
4.  Treats you like an intelligent adult, and invests in patient education and information therapy
5. Is open and transparent and provides clear documentation of all your IVF treatment
7. Provides a receipt for 100% of your payments
8. Has a high success rate
9. Uses proven technology
10. Does not over-test or overtreat
11. Is focused on doing IVF because he does only IVF treatments and nothing else
12. Is always available because he has only one clinic and does not go anywhere else
13. Doesn’t have assistants and does everything himself
14. Is empathetic
15. Takes pride in tackling difficult patients

Then come to Malpani Infertility 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 !




Thursday, March 20, 2014

Why do doctors order so many tests ?


One of the things doctors do most commonly is order tests. The uncharitable explanation for why they do so many tests is for financial reasons. It’s an open secret that the diagnostic laboratories and scan centers often give doctors a kickback (commission ) on each test, which means that it makes financial sense for them to do lots of tests . However, there are lots of ethical doctors who do not get kickbacks , and yet they order lots of tests. Why is this so ?

One of the reasons is a very common psychological fallacy most of us are fooled by. We often believe that the more the data we have , the more accurate will be our diagnosis . Doctor confuse more information with more accuracy.

Actually, this seems to make a logical sense . After all, isn’t it common sense that more information should give lead to more accuracy ? This is why when doctors encounter patients with a complex problem, they order more tests to get more information. They hope that the test results will give them more insight into the right diagnosis.

However, psychologists have shown that more information does not always improve accuracy . In reality, more data has the pernicious side effect of increasing the confidence levels of the doctor in his diagnosis. This is not a problem which is unique to doctors - it actually applies to experts in all fields , including financial advisors. Because lots of doctors are not aware of this common cognitive bias , they over-order tests when they are stumped, in order to try to improve the accuracy of their diagnosis, without realizing that they are not doing much good !

Another reason why doctors order tests is because this is what patients demand and expect ! Most patients are no longer satisfied by a  clinical examination ( even though this is far more valuable than any number of tests ! ) Today’s patients seem to have more confidence in scans and computer printouts. They need technology in order to be satisfied that the doctor has done a good job - and sometimes it is just to keep the patient satisfied that the doctor orders tests. Patients will often question a doctor’s efficiency if he does not do tests – and some feel the doctor was not thorough or careful if he did not order tests !

This is ironic , because only a very confident and competent doctor will actually refuse to order tests. A dirty little secret is that many of these tests can actually be harmful , because they lead to a lot of unnecessary overtreatment . More is not always better !  However , patients are not sophisticated to question the doctor. The key question they need to learn to ask when the doctor orders a test is simple – How will this change my treatment ?

Because they do not do so, the explosion of new technology means that the number of tests a doctor can order has grown exponentially ! Also, when doctor attend conferences, they want to learn “what’s hot and what’s new”. They are seduced by attractively produced presentations, which tom-tom the accuracy and efficiency of the newest tests – and no one bothers to highlight their limitations, because these key note speakers are usually sponsored by the company which is selling the tests.

Let’s look critically at the newest test which is being marketed for IVF patients today. This is called the endometrial receptivity assay, or the ERA. This uses genetic markers as an endometrial function test , to test if the endometrium will allow an embryo to implant. This is a very new,  sophisticated test, which is very expensive and is offered by only one company so far. Since failed embryo implantation is such a distressing problems, IVF specialists are very happy to order this tests for patients who have failed IVF cycles. However, because doctors understand precious little about genetics, they end up fooling  themselves - and their patients. Thanks to a lot of slick marketing, with tons of genetic gobbledygook which doctors don’t understand, it’s surprisingly easy to take doctors for a ride !

Because doctors want to be “one-up” on other doctors, they are happy to order the “latest tests” – which are often much more expensive, because they are new. This newness  also means they are much more unreliable, because we don’t have enough clinical experience with them !

Ironically, patients don’t seem to mind paying for all these unnecessary tests. In fact, most of them are quite happy when the test results come back as normal, because they naively believe that these means they are fine!  They don’t seem to consider the money spent on the test as a waste ! Actually, the purpose of tests when used judiciously is to confirm or rule out a clinical diagnosis, based on the doctor’s clinical examination. It cannot be a hunting expedition, where the doctor uses a “spray and pray” approach to try to find an abnormality , which may be of no clinical importance !

However, doctors, like most people , generally believe that the more information they have the better their decisions will be . This is why they often pursue information that is inconsequential to their final decisions . However, the reality is that more knowledge can reduce the accuracy of prediction of uncertain outcomes , and simultaneously increase the doctor’s confidence in their  incorrect  predictions.  As the Nobel laureate Daniel Kahneman pointed out, "Overconfident professionals sincerely believe they have expertise, act as experts and look like experts. You will have to struggle to remind yourself that they may be in the grip of an illusion." Doctors need to learn from his wise words - “Be honest with yourselves! Admit what you don’t know!”

A common cognitive bias doctors suffer from is the “illusion of validity” . How do patients distinguish the justified confidence of experts from the sincere overconfidence of professionals who do not know they are out of their depth? Overconfidence arises because people are often blind to their own blindness.
The bottom line which doctors need to ask themselves before ordering a test is – how will this change the patient’s treatment options ? Let’s not lose sight of this in our enthusiasm for ordering  tests ! ( And if the doctor does not ask this question, the patient needs to learn to do so !)

Confused about why your IVF doctor is ordering so many tests ? 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, March 19, 2014

How the fear of failure hurts IVF patients



It is often the fear of failure which causes many infertile patients to stay away from exploring IVF treatment.  This fear can be a major emotional hurdle, which stops them from exploring IVF. Even though they know that IVF is the one treatment option which has the highest success rate, they will refuse to consider the option. They prefer keeping it “ in reserve” – as a last resort, in case everything else fails. However, this decision to defer IVF does carry a major opportunity cost , because ovarian reserve declines the longer the decision is postponed.

This is the reason many infertile couples will keep on changing gynecologists  and keep on repeating IUI cycle after IUI cycle, without being able to build up the courage to see an IVF specialist.  Their fear ( which often remains unarticulated ) is that if the IVF cycle fails, then they will have nothing else to fall back on.

This fear of failure is extremely irrational . Just because there is a possibility of failure , this is not a sound reason to never even attempt IVF. It’s is true that it can take more than one cycle to succeed, but this is far better than wasting time pursuing ineffective options which have a much lower success rate.

It is this emotional overreaction to the possibility of failure that puts them off.  Research has shown that, people overestimate the impact of negative events , and psychologists call this impact bias. Women are scared that if their cycle fails , they will go to piece and that life won’t be worth living anymore. However, the truth is that we all have a mental health immune system. Just like our physical immune system , which protects us from invasion by bacteria and viruses, this plays a very useful role in helping us to cope with life. However, because it cannot be seen, most of us are are not even aware that we possess one ! Fortunately, this works extremely efficiently , and helps us to cope with the disappointments of daily life , which we all have to live with .

We all suffer from cognitive biases and prejudices , which explain why we do this. We underestimate our ability to be able to cope with disappointments. Many For example, studies have shown that lots of people believe that if they developed paralysis because of an accident , life would no longer be worth living. In reality , when the happiness levels of paraplegics is tested about one year after the accident, most are reasonably happy and well-adjusted .  This is why the four wisest words are – This too will pass !

While it is quite reasonable to fear failure , often the bigger failure is the failure to act . Many studies have shown that we often regret the things we don’t do in life, as compared to the ones that we do, even if they don’t succeed. From a purely logical point of view, even if the IVF cycle fails, you are no worse off than when  you started. You didn’t have a baby before the IVF cycle , and you still don’t. But you do have the peace of mind you tried your best, and this feeling can be invaluable.

Otherwise you will always be haunted all your life by the possibility that maybe if you had tried IVF, you might have ended up with a baby ! This kind of “ What if” doubt just adds to your stress levels, and detracts from the quality of life for infertile couples.

One way of reducing your fear of failure is by maximising your chances of success !

Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

You can talk to some of our patients by email at http://www.drmalpani.com/success-stories.htm

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

Tuesday, March 18, 2014

Dealing with the risks of IVF



One reason patients find it so hard to start an IVF cycle is because of the risks associated with IVF. The good news is that the medical risks are very low – and in a good clinic, these are virtually zero. The major risk is financial , and this can be a major hurdle for many patients, However, it can be quantified and patients can make a well-informed decision as to whether or not they want to take on this risk .

The major intangible risk which puts many patients off IVF is the emotional risk – how will I cope if the cycle fails. Patients are often not able to express this risk , because the fear of failure paralyses them into inactivity.

They are very reluctant to gamble all the time, money and energy which needs to be invested in an IVF cycle, when the outcome is so uncertain. This is why many patients are not able to analyse this risk logically , because their heart takes over their head.


Because they are not able to deal with this in an intelligent and rational fashion , they end up making the worst possible decision – not doing IVF , without even understanding why they are reluctant to do it.  While it’s true that it's not compulsory for every infertile patient to do IVF, I think every patient who chooses not to do it should have a clear , logical , unemotional reason for why they are opting out of exploring and doing IVF.

They need to do this explicitly and make a list of logical reasons why IVF is not right for them. If they do not do so, then as time goes by , they may regret their decision . They may feel that this was an opportunity which they failed to pursue - and this regret often comes back to haunt them when they are older. All of us have taken risks in life at some point – and as grownup mature adults , we are capable of handling these risks.

You need to take risks if you want to achieve your goals . It’s a trade-off, as with so many things in life. Patients need to think about it dispassionately and unemotionally , in order to make the right decision for themselves. A simple trick is to pretend that you are making the deciding for your younger sister . Stepping outside of yourself will help to give you clarity and make a better and more thoughtful decision !

Need help in putting the risks of IVF in the right perspective ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

LinkWithin

Related Posts Plugin for WordPress, Blogger...