Saturday, August 30, 2014

The problem with IVF supplements

Prescription placebos used in research and pra...


Lots of infertile patients take supplements in the hope that these will increase their chances of getting pregnant . Lots of doctors also prescribe these supplements, for many reasons. Some are designed to improve egg quality; others to improve endometrial receptivity; while others are supposed to boost sperm quality.

Most of these supplements are “natural products” which is why doctors are quite liberal about prescribing them . Also, the FDA does not need the manufacturer of these nutraceuticals and supplements to prove their efficacy. Most doctors and patients believe that since these are natural herbs, they are unlikely to do much harm, so why not go ahead and prescribe them. At least the patient is happy that “something is being done”, even if there is no proof that they help.

The problem is that some of these are extremely expensive . While they many not cost much on a daily basis, since the “course of treatment” lasts for many months, the costs add up very quickly !

Even worse, practically none of them have been proven to work. While it’s true that some patients will get pregnant after taking the supplement, this could very well be a placebo effect – and prescribing expensive placebos is hardly good medial practice !

No controlled clinical trials have ever been carried out to check the efficacy of these supplements . They are actively promoted by flashy websites , which do a great job of marketing by playing on the emotions of infertile couples. Many articulate women on bulletin boards will inadvertently promote these supplements by describing how they got pregnant after taking them.

The problem is that one swallow doesn't make a summer – and just because a supplement works for someone doesn't mean it will work for everyone.

The problem is that when women take supplements , they don't take just one – they take an entire box full, to cover all their bases ! It’s impossible to make out what worked and why, which means we do not learn anything useful from all these N=1 clinical trials women are carrying out on themselves.

The big danger is that anything which has helpful effects can also have harmful effects  ! This means that these supplements can actually reduce a patient's fertility , rather than increase it . We are seeing this in our practice. Thus, myoinositol is being actively promoted for treating patients with PCOD, where it has been shown to be effective. However, because it is being marketed under clever brand names such as Oosure, many doctors are mindlessly prescribing it for all patients who have ovulatory dysfunction – including those with poor ovarian reserve ! If doctors are confused as to which supplements to prescribe when, you can imagine the plight of the poor patients !

Patients get confused. When the doctor prescribes them with supplements such as DHEA to be taken for 6- 12  weeks prior to starting their IVF cycle in order to improve their ovarian reserve , they feel that if these supplements can improve IVF success rates, they may be able to help them to conceive naturally as well. They end up wasting a lot of time and money taking these supplements, and then get fed up and frustrated when they do not work.

This causes them to lose precious time – and the risk is that the false hope these supplements create may actually end up reducing the patient’s chances of having a baby.


Confused as to whether your supplements are helping you or harming you ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?







Friday, August 29, 2014

Hindi language content for patient education

Hindi
This is slowly changing. The launch of Devanagari script web addresses on Sunday, allowing people to use  .भारत domain names, was another step in the slow effort to bring about a multilingual Web. Already, Indian languages like Hindi – one of the most commonly-spoken languages on Earth – lag far behind. The move gels well with the new government’s effort to promote the use of Hindi, and its push to increase digital services available to all citizens. The next few years could well see a spurt in vernacular content online.

http://scroll.in/article/676475/can-domain-dot-%e0%a4%ad%e0%a4%be%e0%a4%b0%e0%a4%a4-spur-the-growth-of-the-vernacular-internet&utm_source=newsletter&utm_medium=email&utm_campaign=newsletter

Health is one of the commonest topics people search for information on. The government should take the initiative and  publish reliable, trustworthy updated information on health and illness for patients in local Indian languages, so they can take better care of their own health.

This would be a great way of ensuring that patients are well-informed; and this will help them to ensure that their doctors are providing them with the right medical treatment.

When IVF patients have unrealistic expectations



One of the major problems we have to deal with in IVF is the unrealistic expectations which many patients have about IVF success rates. 

Infertile couples will move heaven and earth in order to maximize their chances of having a baby. They try to cover all their bases by finding the best possible doctor and going to temples and churches to seek divine intercession.

Because there is so much riding on the outcome of the IVF cycle, they are understandably  distraught when the cycle fails. They let their emotions colour their logic, and start looking for alternative options.

Aggressive patients , who naively believe that medical technology can solve all problems , will look for more “ advanced “ and technically sophisticated solutions, such as PGD using CCS or NGS . Others who are more spiritual will go on fasts in the hope that their next cycle will result in a deeply longed for baby.

However , these are unrealistic expectations . There are no guarantees in life , and human reproduction remains inefficient , no matter whether it's done in an IVF lab , or in the bedroom . It’s important that patients learn to have realistic expectations , and understand that while we can control the process , we cannot control the outcome.

In a good clinic, we can ensure that the quality of care provided is of the highest level . However, the outcome is always uncertain . Even though Sachin Tendulkar was a great batsman, this didn’t mean that he always scored a century every time he went out to bat.

The problem with IVF is that it is fill of complex biological variables which we still don't have a good handle . A far more realistic and sensible approach is to focus on the process , and accept the fact that once you've done your homework and performed the process properly, you have no control over the final outcome . This is true for patients and for doctors as well , and once we learn to be humble , it's easier to deal with the ups and downs of an IVF cycle.

The problem is that patients are very vulnerable and they don’t want to listen to the truth. They want guarantees, and it’s very easy for unethical doctors to exploit these hopes by overpromising, so that they sign up for the IVF treatment.

Want an honest opinion about your chances of IVF success ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?







Thursday, August 28, 2014

Heparin Does Not Reduce Pregnancy Complications, and May Create Some

For the past 20 years pregnant women with an increased risk of developing blood clots have often been prescribed a common blood thinner to prevent serious complications from the clots, including preeclampsia (high blood pressure in the mother), disruption of the placenta, low birth weight and loss of the fetus. The largest randomized clinical trial to examine the therapy finds that the drug—low-molecular-weight heparin—is not effective. The find, reported in The Lancet, is the result of a dozen years of analysis of patients across five countries.

Doctors are very happy to overtreat - and here's an excellent example of how they often end up doing harm rather than good.

Lots of IVF specialists have also started treating patients who have failed IVF cycles with LMWH ( low molecular weight heparin), claiming that this helps to improve the chances of implantation by improving blood flow to the uterus ( presumably by reducing the clotting tendency of the blood). Sadly, this has never been proven, and is used as empiric therapy, only because it makes logical sense.  The injections are painful - and expensive , and are best avoided , in my opinion.

What makes some IVF clinics better than others



For most surgical operations, the outcome of treatment is pretty much the same , no matter who the doctor is, and which hospital you select. Thus, most competent surgeons will perform routine operations such as appendectomy and tonsillectomy perfectly adequately , and patients will go home without any problems .

However , the situation seems to be completely different with IVF. This is because IVF is such a complicated treatment , which involves not only clinical expertise , but sophisticated IVF lab services as well. Because of the many biological variables involved in IVF treatment, the success rate amongst IVF clinics varies widely . In fact, the success rates in the best clinic can be upto four times as high as the worst.

There are lots of reasons for this wide variation .

The experience and the expertise of the IVF doctor makes a world of a difference. Good doctors have mastered the art of superovulating patients.IVF  success rates depend on the quality of embryos , and this in turn depends on the quality of the eggs which the patient grows. Expert doctors can coax even the failing ovaries of older patients to yield good quality eggs.

The expertise of the doctor may not make much difference for most young patients , who will grow eggs well, no matter which protocol is used. However, for difficult patients - for example , those with polycystic ovarian disease or those with poor ovarian reserve, the superovulation protocol the doctor uses can make the difference between failure and success .

The IVF lab has an extremely important role to play . Unfortunately , this is an area where lots of IVF clinics take shortcuts . Many don't even have a full-time embryologist ! Their equipment is often of poor quality and routine quality control measures ( for example, checking the temperature and CO2 level in the incubator ; and the pH of the culture medium) are never performed.

Many embryologists do not have the expertise to do ICSI properly – and lots do not have the confidence of being able to grow embryos to the blastocyst stage. Sadly, it’s easy to take ignorant patients for a ride, and these clinics take advantage of the patient’s gullibility.

The poor patients suffer, and end up failing multiple cycles , when all they need is to take treatment at a good clinic which has a good IVF lab , which can generate good-quality embryos for them.

Finally, the most important variable is proper patient selection . Some clinics will cherry pick patients, and treat only those who have a good prognosis, thus inflating their success rates. Others will treat everyone who comes to them, no matter how slim their chances of success, after counseling them , to make  sure they have realistic expectations . Finally, the worst ones will “ treat “ patients who have no chances of getting pregnant.  They go through the motions of doing IVF for them , just in order to generate money .

It can be hard for patients to make out which clinic is good and which clinic is bad . This is why it’s important for patients to educate themselves , so they can find out which clinic offers the facilities they need in order to maximize their chances of getting pregnant . This does require doing homework and putting in a certain amount of effort , but it's well worth it when the IVF cycle succeeds !


Need help in selecting the best IVF clinic ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?







Wednesday, August 27, 2014

When not to do IVF


Most infertile patients know that IVF is the treatment option which maximizes their chances of getting pregnant .

However, the problem seems to be that the pendulum has swung in the other direction , and lots of patients are being advised to do IVF, even though they do not need it. The truth is that there are many simpler treatment options available to treat infertility, and not every infertile couple needs IVF !

Thus, young patients with PCOD can easily be treated with medicines for ovulation induction. This is much less expensive than doing IVF – and it’s much more fun making babies in the bedroom than going to an IVF clinic.

It’s important that patients explore these simpler treatment options before moving on to IVF , which can be expensive .

The other group of patients who should not be doing IVF are the ones for whom the chances of success are extremely low . For these, treatment may be futile. Examples would include patients with Asherman syndrome , where the uterus has been completely damaged ; or patients with ovarian failure, who will not be able to grow eggs, no matter what we do.

These can be difficult patients to tackle . They are extremely desperate to have a baby , and are not willing to consider third-party options, such as donor eggs or surrogacy . So what is the poor doctor supposed to do ?

A good doctor will counsel patients that their chances of success are extremely poor. After doing so, if the patient has realistic expectations and still insists on going ahead , I think it's fine to do so, since the patient has provided informed consent . However, the danger is that often doctors are not very forthright, and they will hide this critical information from the patient . Some will go ahead with IVF treatment and transfer embryos into a uterus which such a poor lining, that the embryos do not have even the slightest chance of implanting.

Some IVF clinics will even transfer embryos which have arrested in the lab into the uterus, and thus fool the patient that they have received IVF treatment ! Others will go ahead with the treatment cycle, and then tell the patient at the last minute that since your embryos are of very poor quality, we need to use donor embryos in order to achieve a pregnancy. Because patients are so desperate at that point , they will go ahead and do whatever their doctor tells them to do, but this often results in long term unhappiness for the couple, who wasn’t mentally prepared to use donor embryos, and they may reject the child.


Tuesday, August 26, 2014

Is Malpani Infertility Clinic expensive ?


There are some patients who believe that we charge too much for IVF treatment . They compare the prices at Malpani Infertility Clinic with what their local clinic charges, and feel that we charge a premium. They feel this is unfair. After all, don’t all IVF clinics offer the same treatment ? Then how can we justify charging more ? Is it because we are greedy ?

While it is true that IVF treatment at a good clinic is expensive , it’s actually a bargain as compared to doing IVF in a bad clinic in order to save money .

There are many reasons why we believe our charges are cost effective. For one, they are open and transparent . Unlike the vast majority of Indian IVF clinic, we publish them in black and white on our website, which means patients do not suffer from sticker shock when they get the bill.

We pride ourselves in providing a high quality service, where patients come first. This means that our patients always have access directly to me, without having to go through assistants and juniors. We do not employ any assistants, and while this means we can provide care only to a limited number of patients, this also ensures that the quality of care is unsurpassed. This is also the reason we only have one clinic. We do not travel to any other clinic, and are always available in Mumbai for our patients.

How is the poor patient supposed to make out whether the IVF clinic they have chosen follows best practices ? After all, it’s very hard to judge the quality of medical services because they are intangible. Here’s a simple experiment you can try at your present clinic. Try to contact the head IVF doctor – the brand name doctor for whom you pay your fees, in order to get treatment from the best, and see how long it takes to get a reply.

In our clinic, we guarantee a reply directly from me within 24 hours. Isn't this confidence of always being able to get my advice invaluable? We store all your records electronically so we have instant access to them 24/7, and this ensures we can craft a personalized plan of action for you.

We have a highly qualified , experienced and full-time skilled embryologist ; and we use state-of-the-art equipment to provide cutting edge medical care. This combination allows us to provide high-tech high touch care to our patients. Because of our focus on quality , we ensure we provide personalized attention to all our patients, we don't cut corners .

Yes, it’s true that there are many clinics which charge less than what we do . However, we are not in the business of trying to compete with other clinics for offering the lowest fees. We are proud to compete as regards our quality of care and pregnancy rates. If we need to continue to provide a service which put patients first , we will not compromise on our quality of care by reducing fees , just in order to compete with other clinics. However, we do provide discounts and subsidized treatments to financially deserving patients.

Lots of clinics ( especially the ones which run national chains ) charge less than what we do. They try to compete on price, so that they can attract more patients . Sadly, the price the patient pays in order to save some money is that they often end up reducing their chances of getting pregnant significantly .
Many of these clinics will take short cuts and not follow basic IVF protocols such as documenting photographs of the embryos and providing these routinely and proactively to their patients . In fact, some of these clinics charge the patient a hefty premium for using an embryoscope, by claiming that this increases pregnancy rates. However, in reality they don’t do so ( the point of an embryoscope is that it generates photos of the embryos as these are dividing in the incubator) , and the poor patient is none the wiser, because of the lack of transparency. 

If you’d rather be treated in an assembly line clinic which has lots of doctors in white coats milling around, then Malpani Clinic is not the right place for you. On the other hand, if you’d rather be treated hands on by an IVF expert with years of experience, then we are a great choice.

Monday, August 25, 2014

What are my chances of getting pregnant ?



This is the commonest question the IVF specialist is asked – especially by someone who has failed an IVF cycle.

In one sense, it’s an easy question to answer. IVF clinics keep statistical records of the pregnancy rates we achieve in the women we treat, which means we can quote success rates in various groups of women ( for example, women under 35;  women over 40; and so on.)

The trouble is that these figures apply to groups of women . How can we intelligently extrapolate these to the individual patient sitting in front of you and asking the question?

Thus, not all 40-year olds are the same. Some have good ovarian reserve and produce excellent quality embryos; while others make embryos which are fragmented and which arrest in the lab. It’s not fair to lump apples and oranges together  when providing an answer, because it’s likely to be inaccurate and unreliable.

The truthful answer is more nuanced. It is – It depends upon how many good quality embryos you make – which in turn depends upon the egg quality.

Now while we do try to judge a patient’s ovarian reserve by checking her antral follicle count and measuring her AMH levels, these are fairly crude tests, with limited predictive ability. The final proof of the pudding is in the eating – and  its’ only when we actually superovulate her during an IVF cycle will be know how good her ovarian response is.

While the pre-IVF tests will give us some idea, these tests have limitations, and it’s impossible to predict how a biological system will behave.

The final proof of the pudding is in the eating – and finally it’s the number of good-quality embryos we are able to make which determine the chances of IVF success.

However, patients are not happy with this answer, even though it is accurate. They want a specific number, and would prefer a doctor who tells them - Based on my extensive experience , your chances of getting pregnant in my clinic are better than 56% ! This is a load of rubbish, but patients love this kind of pseudo-accuracy .

These doctors are very good at massaging figures , that selectively present the success rate in patients who have the best prognosis. Because patients are not sophisticated enough to read between the lines, they are suitably impressed and are happy to sign up.

Patients need to learn to ask better questions. Rather than push doctors to provide a figure ( which is often fabricated), the question they need to answer for themselves is – what is the magic number at which I will decide not to go ahead with the IVF cycle. Let me explain.

Suppose the doctor says your chances are 30% or 40%, if the patient has decided she will go ahead with the treatment if the success rate is better than 20% per cycle, then  the actual number the doctor quotes is unimportant, because it will not affect her decision. Of course, she may want to select a clinic which has a higher success rate overall , and these figures ( which are statistical averages for all the patients the clinic treats, and do not apply to individuals) are available online.

On the other hand, if she feels that if her chances of success are less than 10%, then she would rather not go ahead with the treatment cycle, because the slim chances do not justify her spending so much time, money and energy, then this is the key number she should focus on.

This means that the patient should then decide what particular success rate will allow her to make a go/no go decision ; and then share this information with the doctor,. so that he can answer the question a little more intelligently and honestly.

Remember that it’s just a question of statistics - it's also question of the individual patient’s personal preferences.  This is where both the clinic's overall success and the patient's decision-making process overlap.

Thus , we will have some patients where even if their chances of success are less than 5%, they are happy to go ahead, because 5% is better than zero ! They want to give it their best shot, because they never want to regret afterwards that they didn’t try. However , this is the kind of soul-searching the patient needs to do , even before asking the doctor the question - What are my chances of getting pregnant ?

Need help in getting pregnant ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?






Saturday, August 23, 2014

Doctors get paid too little


The general perception in society seems to be that doctors charge too much . They are seen to be greedy; loaded with money ; drive around in a Mercedes ; and play golf on weekends. They are perceived as being crooked because they make a lot of money on the side by : cheating health insurers by padding hospital bills; taking kickbacks from pharmaceutical companies for prescribing their brands; and from diagnostic centers for referring patients for expensive scans and tests which are unnecessary .

Ironically, people don't mind splurging money on luxuries ( such as going to dinner at a 5-star hotel or going for a holiday abroad), because they value the experience this provides them. However, they grudge having to spend money on their medical care. They feel this is money which was wasted , because all the doctor does is get you back to normal – it doesn’t leave you any better off than you were ! This is why going to a doctor is seen as a wasteful expense, rather than as a positive investment in your health.

When you are ill, you are willing to pay the doctor whatever he wants. When you recover, then you grudge him his fees !

This reminds me of the joke of the businessman and the doctor.

When the wealthy businessman choked on a fish bone at a restaurant, he was fortunate that a doctor was seated at a nearby table.

Springing up, the doctor skillfully removed the bone and saved his life.

As soon as the fellow had calmed himself and could talk again, he thanked the surgeon enthusiastically and offered to pay him for his services.

"Just name the fee," he croaked gratefully.

"Okay," replied the doctor. "How about half of what you'd have offered when the bone was still stuck in your throat?"

Be that as it may, how much should a doctor charge ?

This is a difficult question to answer, so let’s look at what our wise judiciary has to say about how much a human life is worth.

If a doctor is negligent, and a patient dies as a result of this, the court is willing to award damages in crores of rupees. Using the same yardstick, then the doctor saves the patient’s life, then why shouldn’t he charge 0.1% of the value of the life saved ? I am sure most doctors would be very happy with this !

We need to be consistent, and it’s unfair to pay doctors so little when they do their job well; and to then punish them so severely when they don’t !  Pediatricians would easily become the richest specialists, because of the number of quality life-years they add to a child’s life.



Friday, August 22, 2014

IVF emergencies and complications



IVF treatment is usually fairly straightforward . Patients are usually young and healthy, and the treatment usually goes smoothly as planned. This is why most IVF cycles are uneventful without any problems at all . However, sometimes there can be emergencies which patients need to be aware of.

The commonest medical emergency is ovarian hyperstimulation syndrome or OHSS. This occurs when the patient grows too many follicles, and if the doctor doesn’t know how to manage this problem , patients can end up with severe hyperstimulation which can be life-threatening . The good news is that hyperstimulation is a preventable problem , and can also be treated effectively by a knowledgeable doctor. We have lots of tools and techniques to prevent the problem , and to ensure that it doesn't become severe.

The other medical emergency IVF clinics have to deal with is that of ectopic pregnancy . Even though we transfer the embryos into the uterus in an IVF cycle, sometimes the embryos move out of the uterus in a a retrograde fashion into the fallopian tube, resulting in an ectopic pregnancy . In a good clinic, hCG levels are actively monitored routinely in order to make sure that the pregnancy is in the right location , If an ectopic is diagnosed in a timely fashion , it's very easy to treat this medically by giving a methotrexate injection which can kill the ectopic pregnancy. However , if the diagnosis is delayed or missed, then an ectopic pregnancy can rupture and be life-threatening.

In the past, a high order multiple pregnancy was a common complication of IVF because doctors transferred too many embryos in order to inflate their success rates. However, by restricting the number of embryos we transfer, this can be prevented.

There can also be complications during the egg collection, such as vaginal bleeding or infection. However, in a good clinic, these are very rare.

One of the vexing emergencies is that of a difficult embryo transfer , where the doctor has technical difficulty in depositing the embryos through the cervix into the uterus. This may be because of cervical stenosis; or a sharply angulated cervical canal. This can be extremely distressing for both doctor and patient, because a difficult embryo transfer does reduce the success rates. This is why many clinics will routinely do a dummy embryo transfer to prevent this situation from arising.

Finally, the commonest emergencies are the emotional ones , where patients break down when they find their beta hCG is negative and the IVF cycle has failed. This is best managed by an empathetic doctor,. who can provide patients with a shoulder to cry on , and explain to them that it's more important that they focus on the long-term perspective , rather than get disheartened just because one cycle has failed.

Need to learn more about how to prevent complications in your IVF cycle ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?






Thursday, August 21, 2014

Why personal attention from Dr Malpani for all patients at Malpani Infertility Clinic is guaranteed

The reason is remarkably simple.

It's because we don't have any assistants.
This means we have to provide hands on care to all our patients ourselves !

I answer all my emails myself - and patients are confident that they can get in touch with me directly, rather than having to go through assistants and juniors.

Most patients in other IVF clinics find it frustrating that they have to deal with clueless juniors and inexperienced assistants. The senior doctor is often unavailable or inaccessible. This is never an issue at Malpani Infertility Clinic where we take care of all our patients personally  - we don't delegate your care to anyone else !

Not all patients with Irregular cycles have PCOD



Many doctors and gynecologists misdiagnose and mismanage patients with irregular cycles.  Most of them seem to automatically jump to the conclusion that any young patient with irregular cycle has PCOD .  While it is true that the commonest cause of anovulation is polycystic ovarian disease , there are some unfortunate young women whose irregular cycles are because of poor ovarian reserve.

While gynecologists will think of this diagnosis when they deal with older women, they fail to consider this possibility in younger women. The problem is that once the woman has been labeled as having PCOD, doctors refuse to think about alterative possibilities.

This is heartbreaking, because it’s actually quite easy to differentiate between the two.   Women with PCOD have large ovaries with increased central stroma and with multiple small cysts on ultrasound scan. Women with poor ovarian reserve can also have cysts, but these are fewer in number and the ovarian stroma is not increased. However, unless the ultrasound scan is done by a doctor who is careful about continuing the number of antral follicles, it’s easy to jump to the wrong diagnosis. Sadly, when most gynecologists see ovarian cysts being reported in a young patient with irregular cycles, they assume this means she has PCOD.

It’s also easy to differentiate between the two by doing blood tests to check levels of the reproductive hormones, FSH, LH and AMH. PCOD patients have a high AMH level; and their LH:FSH ratio is increased, with the LH typically being twice as much as the FSH level. Patients with poor ovarian reserve, by contrast, have low AMH levels, and a high FSH:LH ratio.

The irony is that once the doctor has a preconceived notion that this woman has PCO , it’s hard for her to change this diagnostic label, and she receives the wrong treatment for many years, until she gets a second opinion.

The wrong treatment ends up wasting a lot of time and money ; and when the patient finally realizes that they were misdiagnosed , they are angry and resentful and can't understand why so many different doctors ( including the sonographers ) couldn’t make the right diagnosis.

Even worse, many of these patients are then “ treated “ with ovarian drilling. This actually reduces their ovarian reserve even more, which means the chances of these patients getting pregnant even after IVF drop dramatically !

The problem is that once a patient has been mis-labelled, most doctors will not take the time and trouble to dig down deeper and find out whether the original diagnosis was correct or not. This is why patients need to do their own homework for themselves , because if you don't have the right
diagnosis , you are not likely to get the right treatment.


Need help ?

Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly!








Wednesday, August 20, 2014

Use patient power to tackle medical corruption

Educated and empowered patients make it much harder for corrupt practices to occur in the health system, writes Aniruddha Malpani in the BMJ.

Corruption (the abuse of power for private gain) seems to be a problem that afflicts healthcare systems the world over. A recent article in The BMJ described some of the problems in India.


It’s true that the Indian healthcare system is ailing. We have too many patients and not enough doctors to provide personalised care. The result is that patients see themselves as helpless, and some doctors and officials exploit this power imbalance to make money by unfair means.

Traditional solutions have not worked. Regulation is doomed to fail because the regulators themselves are often corrupt. Exhorting doctors to become more ethical is not helpful—good doctors don’t need to be told, and bad doctors will not improve because we preach to them.

Contributing to the stalemate is that we continue to consider the number of patients in India as a problem. Actually, they are part of the solution: patients are the largest untapped healthcare resource.

http://www.bmj.com/content/349/bmj.g5156

MY EXPERIENCES WITH I V F from a patient at Malpani Infertility Clinic

I am writing this at the request of Dr.Aniruddha Malpani with whom my wife underwent IVF procedure in November 2013 at it clicked at the first cycle by God's grace.
While I have tried to give the best analysis from my first hand experience,I have to mention that everybody's life and their situational factors are unique and there are no tailor made solutions to everybody's problem.
However, some points from my experience may be applied to their situation,and I would be happy if that helps the reader of this article.
OUR STORY
We had a very late marriage i.e when we both were above 35 years of age.
We got married in 1999.
After initial try by natural process for 2 years we went for check up with local gynac.in 2001.
All tests advised were taken.
We were shocked to know that we have crossed the hill and only can conceive with technological assistance.
After further consultations with other Doctors and medications we were unsuccessful.
This went on till 2002 when my mother became bed ridden and we had to abandon all our trials and take care of my mother, who subsequently expired in 2003.
Now the situation is we were at the early forties.
In 2005 we had to sell the house in which we were living, since it was ancestral property and the proceeds were divided amongst all legal heirs.This again took time and the attempt to get a child took a back seat.
We were not getting any younger.
However after settling in the new place we started trying vigorously but with little success..
It was then I consulted one good astrologer in Chennai who had to say that we were destined to have one child but only after we crossed fifty years.
Still we tried but did not succeed.
Then we consulted 2 more astrologers in Mumbai who also predicted exactly the same and they added that it would be only with technological help or we should go for adoption.
However we had crossed the legal adoption age and that was not possible. .
Hence we abandoned all our efforts for the time being.
However we consulted a dietician to keep our health in good conditions from all points of view and saw to it that we were fit otherwise.
NOW THE OPERATIVE PART
From our experience we believe that the following factors are very crucial for success in IVF 1)HEALTH CONDITION OF BOTH THE PARTNERS  esp. the female who is going to bear the child.More importantly they should not suffer from diabetes/B.P./ thyroid problem/other chronic ailments.While this is equally applicable to normal conception this is more important in IVF conception.since the couple must have already failed in the attempts of normal conception and age is against the constituents.
Preferably all such problems should be sorted out before undergoing IVF.
2)TIMING OF IVF
 From our experience it is preferable to consult some good astrologer to get the knowledge of favourable period from this point of view and carry out the procedure in the good period rather than trying out again and again and getting mentally and emotionally drained out.
3)SELECTION OF A GOOD IVF DOCTOR
This is very very crucial from all points of view There are very good Doctors in this field and there are also fly by night operators.who take you for ride.
WHY WE WENT TO DR.MALPANIS
DR.MALPANIS ARE A WELL KNOWN  HUSBAND AND WIFE TEAM WHO PRACTISE IN ASSISTED REPRODUCTIVE TECHNOLOGY...
We were reading Dr.Malpanis' interviews in Times of India way back in early 2000 when we had no idea that one day we will undergo IVF at his clinic.
Further we had attended one lecture about wheat grass therapy in Dr.Malpani's library somewhere near Pedder road way back in 2004. and got to know about the Doctor's other medical help activities apart from the main one.
We first visited Dr.Malpani's clinic in 2012 for initial consultation and found out that the Doctor's explanation is (though fast) very lucid.They follow a need based approach on case to case basis which is very important.
The atmosphere at the clinic in general is quite good and the staff and nurses are very helpful and ever ready to help you out with your problems.
Apart from this,it is well known that Dr.Malpanis are in this line for a long period and their technical expertise is of highest quality.
4)PRE IVF CONTROL ON FOOD AND EXERCISE.
This is very important.It is better to avoid outside food at least 6 to 8 months before going in for IVF since we do not know what are the ingredients that go in to make the food at the outside eateries and hotels.
HOME COOKED FOOD IS THE BEST.
Also it is necessary to understand that one should cook the food and eat it within 2 hours so that all the vitamins are in tact in the food that we eat.
The more we delay eating the food the less vitamins we get from the food.
Also from our experience one should avoid too much spicy or oily food as far as possible.
REGULAR EXERCISE IS ALSO  GOOD FROM ALL POINTS OF VIEW.
5)POST IVF CARE
Now we come for the final part.
After following all the above steps i.e.choosing a favourable timing,choosing a good Doctor, taking care of your health and getting rid of toxins in your body etc.we go for this crucial step.
We underwent the IVF procedure in November 2013.
At the time of doing IVF I had no idea as to what food food we had to eat etc to make it a success.
It was then I asked this question to Dr.Anjali Malpani.
Her answer though laconic had set my mind thinking.
SHE SAID -1) YOU CAN GIVE HER NARIYAL PANI  AND 2)YOU APPLY YOUR MIND.
It was then I started thinking deeply.
I started giving nariyal pani to my wife daily.In addition food that had lot of watery contents viz.DHUDI, SAFED BOPLA, PODWAL etc. were given in the first 25 days till Beta HCG tests(for confirming
pregnancy) were taken.
The thinking and analogy was just as plants/flowers require water to grow so also the human embryo requires watery food to grow.(Plants grow fast in cooler atmosphere).
Also you have to avoid too much spicy or oily food ( only home cooked food).
Regular food intake is essential.Adequate water intake is very essential.
Avoid food that has contracting capacity.
Preferably avoid Ajwine,Hing etc
Also avoid pain killers and tablets like gelusil etc which is normally in ordinary times used to control gas.
All medications should be strictly under medical supervision.
Cut down on coffee/tea and other beverages.AVOID ALL COLD BEVERAGES AND COLAS.
Have good sleep and rest but be sure that you are physically otherwise active.
DO NOT LIFT ANY HEAVY OBJECTS.NO HARD LABOUR.DO NOT BEND TOO OFTEN UNLESS IT IS ABSOLUTELY NECESSARY.
IF POSSIBLE VISIT VARIOUS WEBSITES TO GET KNOWLEDGE( THOUGH SOMETIMES THIS MAY BE CONFUSING) BUT THEN YOU HAVE TO TAKE AN INFORMED DECISION.
THE IDEA IS KEEP CONSTANTLY THINKING WHAT BEST TO DO, GIVEN THE CIRCUMSTANCES.
Once pregnancy is confirmed via the relevant tests, immediately consult a good gynac.
Follow all advice of the Doctor.Take all medications regularly EVERY DAY IS A FRESH CHALLENGE.
DO NOT BE OVER CONFIDENT AS WELL AS DO NOT BE OVER CAUTIOUS.
BE NORMAL IN YOUR DAY TO DAY LIFE.
Our baby was born in July 2014.
God has blessed us with a girl child.
6)POWER OF PRAYERS AND DIVINE HELP.
Whatever activity we do,divine help is necessary.Prayers do help us to improve our mental balance and calmness.
In this context regular prayers do help a lot.
However over indulgence like fasting etc. should be strictly avoided.
For those who DO NOT believe in God.my advice is -be good to fellow human beings.That itself is Godliness.
Hope this write up is useful to the readers.
BEST WISHES.




ss36909@gmail.com

Tuesday, August 19, 2014

Please do not waste your money




I often see patients who do not require any medical intervention at all.  For example, I just saw a couple where the wife is 26 years old, the husband is 30, and even though they have been married for 3 years, they have been trying to have a baby only for the last four months . They are now under a bit of social pressure to start their family, but since prima facie everything seems to be five, it’s hard for me to justify doing tests for them, since they are not infertile.

The probability of the test results coming back as normal is extremely high , and their chances of making a baby on their own in their bedroom without any testing or treatment is extremely good.

This is the kind of patient who just needs reassurance and does not need any testing. When I tell them to just continue trying in their bedroom, and not to waste their money,  some couples are mature enough to realise that I am giving them sensible advise – and that talking a “hands-off” approach is in their best interests.

I just need to explain to them that human reproduction is inefficient; that it can take time to make a baby in the bedroom ; and I teach them about their fertile time.  Many are willing to wait and see what happens; and are grateful that I have not wasted their money on unnecessary testing and treatment. These patients just need reassurance , and for many of them, verbal reassurance from a senior specialist is good enough.

However, some patients are not satisfied with this. They want to know how I can be so confident that they do not have a medical problem. The truth is that I cannot, and if my verbal reassurance is not enough for them , then I order the basic fertility tests for them, to provide them with more tangible reassurance that everything is fine !

For this group of patients, I am forced to do the testing , because they need to see some concrete proof in the form of medical test results and reports that everything is in fact fine.


Monday, August 18, 2014

The do nothing consultation



The last few consultations I have done have been what I call “ do-nothing consultations “. This is when I tell the patient that they do not need my help in order to get pregnant  ; and that their best course of action would be continue trying in their bedroom.

This might seem to be very unusual advice coming from an IVF specialist . Because I am a senior specialist, most patients come to me for a second ( and often third ) opinion , in order to have their tests and investigations reviewed by an expert. Often they have been advised surgery by a gynecologist or infertile specialist, and they need to make sure they are getting the right advise.


The first patient was woman who wasn't trying to get pregnant , but had done an ultrasound scan ( as part of a super-deluxe corporate health check up scheme which her company had paid for, since she was a senior manager). This showed she had a 2 cm cyst, and her doctor had advised her that this could possibly be endometriosis , and that she needed a laparoscopy in order to confirm the diagnosis; and treat it. She had scared her that if it was left alone, it could rupture or spread and cause her to become infertile in the future.

The second patient had gone to her gynecologist because she was having a lot of vaginal discharge . Her doctor suspected “ PID” or pelvic inflammatory disease, ( a wastepaper basket diagnosis, which means precious little) and had asked her to do a pelvic scan to “diagnose” this. The scan showed she had a little bit of fluid in the pelvis. Now it’s quite common to find fluid even in normal women, but her doctor felt that the presence of this confirmed her diagnosis. She then did a blood test for TB ( an extremely inaccurate and unreliable test which checks for TB IgG and IgM antibodies) and when this came back as positive, she was triumphant that her clinical suspicion had been vindicated, labeled her as having “silent genital TB” and promptly put her on a 6-month course of anti-TB medicines !

The third patient was a 26 year old, who had gone for prepregnancy counseling to make sure she was normal. Her doctor picked up a small 5mm uterine polyp on the vaginal ultrasound scan can advised her that she needed to do an operative hysteroscopy to remove it. She warned her that the polyp would prevent her from getting pregnant – and that even if she did manage to conceive, the polyp would cause a miscarriage.

Patients need to understand that doctors are not fortune-tellers . They can't always predict what's going happen ; and often have a bias towards labeling everything they see which is out of the ordinary as being “abnormal” and needing intervention, because they have a bias for looking for problems and “ fixing “ these. They are worried that if they ignore an abnormal finding and this later turns out to be a serious problem, the patient may sue them for negligence. This is why they prefer practicing defensive medicine. They will never get sued for overtreating !

Also, it’s much easier to just “treat” every abnormality. This is much more  profitable ( because doctors get paid for performing interventions);  and ironically, this takes less time. If you tell a patient they can ignore the abnormality, it takes much longer to counsel the patient as to why masterly inactivity is the best course of action.  This is because the first question patients will ask is - How could that be possible ? After all, all the other doctors advised surgery ! How can you be so sure you are correct and they are wrong ? Isn’t it better to be safe rather than sorry ?

I have to explain to the patient that while it is possible that a small polyp on the ultrasound scan may reduce fertility, it is much more likely that this is an innocent bystander which is not causing any mischief and can be left alone. I have to explain that polyps are quite common in young women  and many fertile women also have small polyps ( but are blissfully unaware they have these because they have never needed to get an ultrasound scan done !) In fact, sometimes over-enthusiastic surgery can cause harm by causing scarring and adhesions. I also explain that if she fails to get pregnant in a few months , then we might consider intervention after an appropriate period of time .

Suppose the patient with the polyp comes back after six months, saying I am still not pregnant, and then she gets pregnant after removing the polyp, she is likely to resent the fact that i did nothing for six months, and wasted six months of her life in watchful waiting. Similarly, if the small ovarian cyst does not resolve but instead becomes bigger, she will think I was a bad doctor because I chose to ignore the“ abnormality” .


The problem is much worse when you consider genital TB. Most gynecologists in India seem to think that tubercle bacilli are lurking in the pelvis of every Indian woman!  The variety of tests done to diagnose“ silent TB “ in India are mind-boggling !  These include: blood tests for TB IgG and IgM; TB GOLD blood tests; tests for checking interferon levels; PCR tests – the list seems to be endless ! Most of these tests are not available anywhere else in the world, because they are unreliable and untrustworthy.

However, gynecologists merrily order panels of these tests  left, right and center. Many of them come back as positive, and the poor patient ( who does not have TB at all) is then subjected to 9 months of “treatment” with toxic antiTB antibiotics. Not only do these have side effects, they also waste precious time, thus reducing her fertility.


It takes a long time to explain the concept of “false positives” to patients – and why nothing needs to be done even if the test is reported as being “abnormal”. Patients are understandably reluctant to not to anything. They are worried that their “latent” TB is like a time bomb, which will spread and cause further damage if it is not treated promptly ! They also refuse to believe me when I tell them the tests are not reliable. After all, isn’t the fact that the doctor ordered the test and that it was done from a “reliable “ lab conclusive proof that the test is valid ?


The problem is that I am not a fortune –teller – but then neither is any other doctor ! All I can do is counsel the patient, and explain to them why doing nothing is often far better than doing something ! Not all patients are mature enough to understand this is approach , but masterly inactivity is an absolutely appropriate course of medical action , even though this is something which only senior doctors have the wisdom and confidence to advice .

This is why it is especially gratifying to see the relieved smile in the face of the patient when I tell her I don’t need to do anything at all for her. She is very happy that she doesn't need to go through even more tests and investigations in order to chase up what is most probably a red herring. Getting this kind of reassurance from a senior infertility specialist gives them a lot of reassurance that all is well. When I tell them that they can get pregnant in their own bedroom, and when they prove me right, the box of chocolates they gift me is the best reward which any doctor can get !

Sunday, August 17, 2014

Doctors taking kickbacks


Why do doctors prescribe a branded drug when its generic variant is easily available at a fraction of the price ?

NDTV's hidden camera expose proves that doctors blatantly violate this guideline in exchange for kickbacks from pharmaceutical firms.

http://www.ndtv.com/article/india/caught-on-camera-for-bribes-doctors-will-prescribe-you-anything-574334

While sting operations like these are useful in highlighting the black sheep in the medical profession, they can backfire as well.

All this bad press means that even good doctors feel pressurised . They feel unappreciated and unloved. Rather than treat their patients with care, they will start treating them as customers, leading to a worsening of a negative vicious cycle. Doctors will defend themselves by practising defensive medicine - and this will lead to costs further spiralling out of control.

From a happy patient





Dear Aniruddha,

I assume our birth announcement arrived in good order :)

Yes, everything went well, I made it to full term,  38 weeks minus one day and had an elective Cesarean. The boys were still very comfortable in my belly and didn't make any rush to be born, despite of my short cervix.... obstetrics stays a big mystery to me and the doctors...

I did develop diabetes gravidarum during the pregnancy and hence the birthweight of Finn, almost 9 pounds !!! (poor me)
Finn did have some starting issues hypoglycemia, and spitting, but it resolved in a few days.

The pregnancy has been a very very difficult one, mentally as well as physically. It took a great toll on me. I lived from week to week, I was afraid all the time, and bedrest sucks by the way! :) 

The relief is enormous and we feel so blessed! Our family is complete, 3 beautiful children, and one in heaven, forever in our hearts.
After 13 years my IVF journey has come to an end. It's been a rough ride but it enriched my life enormously.

I send you the picture of our little ones, our pride and joy.

Thank you, dear Aniruddha for your guidance in this process. You, your clinic and India have a very special place in my heart. 

I will update my success story as soon as possible :) 

with warmest regards,

Karolina, Peter, Fay, Finnegan and Benjamin

Saturday, August 16, 2014

How do I track my " fertile time " ?


Do you know what this image means ? If you cannot, you need help !

Most couples know that women can get pregnant only at a particular time during their  menstrual cycle - when they are ovulating. However, because ovulation is not visible, most women don't have a clue as to how to track their ovulation.

This is true even for women who are educated. The ignorance which surrounds this topic is mind-boggling !

I think it's because of 3 reasons.

1. Old wife's tales. There are lots of myths about fertility and you can find many of these floating around on the internet. Some people believe that the woman's best opportunity to get pregnant is 5 days after the period. There is no scientific basis for these opinions, which get bandied about regularly on bulletin boards, based on the "personal experience" of the couple

2. The ignorance of the couple. Many couples, no matter how sophisticated they are, refuse to seek help . Not only is it an embarrassing topic, they are reluctant to display their ignorance. They feel that since everyone else in the world knows such "basic " facts, they would lose face by showing that they do not know. They are therefore forced  pick up their information from completely unreliable sources ( such as their girl friend, or cocktail party chatter).

3. Clueless doctors. Many doctors still advise patients that the best time to have sex is 3 days before ovulation - and 3 days after ovulation. They do not know that once a woman ovulates, she becomes infertile ( because her cervical mucus dries up). They also do not educate the woman as to how she can calculate her fertile days. They just tell her that she ovulates on the 14th day. However, this is true only for  women with a regular 28 day cycle. For women whose cycle is not 28 days, the ovulation day is not Day 14 - but they do not teach her how to calculate her personal ovulation date. Even worse, many couples do not even know how to calculate the days of their menstrual cycle. Some believe that Day 1 is the day their period ends !

Many couples who are trying to conceive in their thirties may not have the luxury of time to let nature take its own course. Human reproduction is not very efficient, and for these couples, time is at a premium.

If you are not sure how to track ovulation, you can calculate your fertile days by using our free
fertility calculator at www.myfertiletime.in

Friday, August 15, 2014

Police shut down IVF clinic in Thailand


Police and health officials have raided and shut down an obstetrics and gynaecological clinic in Sathon on suspicion it has been operating as an in vitro fertilisation (IVF) clinic without authorisation. 

http://www.bangkokpost.com/news/politics/426783/police-shut-down-new-life-clinic

I think it's great that the Thailand government is cleaning up its system. This will help to protect patients.

My prediction is that we are going to see the  same scenario play out in India as well. There are many fly by night cowboy clinics, which are out to make a quick buck in India as well. There are at least 1300 so-called IVF clinics in India - of which only about 200 are registered with the Indian regulatory authority - the ICMR.

The trouble is that these unrecognised clinics will cut corners and take short cuts to make a quick buck - and in the regulatory overzealous backlash which will be triggered off when their misdeeds come to light, good IVF clinics ( and their patients as well !) will suffer.

What can you do as a patient to protect yourself ? Insist that your IVF clinic shows you their ICMR ART registration certificate. If they refuse to do so, you should smell a rat !

Did I harm my embryos by sleeping on my stomach ?


I recently got this email from a patient.

    Dear Dr, Please help me because I am very worried. I had embryo transfer two days ago and have since slept on my stomach. This morning I awoke with one arm underneath, across my belly and abdomen, squashing it in. I thought maybe this should not be done, and so I looked it up online and there are lots of woman and even clinics who say very strongly you should NOT sleep on your stomach/front after embryo transfer. Have I ruined everything? I so don't want to stop implantation because I slept on my front, with my arm across my stomach. Thanks

Sophisticated patients may laugh when they read this email. The truth is that after the embryo transfer, your embryos are safe in your uterus, like a pearl in an oyster. Nothing you do can harm them , so patients do not need to worry about their physical activity; diet; posture; or stress levels. They can lead a completely normal life without obsessing over minor inconsequential issues

The 2ww takes a long time, but there's no point in letting your mind play games with you !

The trouble is that women are unsure, they will turn to the internet to find out answers to their questions.  They are scared to ask their doctor , because they think their questions are "stupid" and they don't want to waste their doctor's precious time.

The trouble is that there is so much rubbish written online by poorly informed patients, that old wives tales and myths and misconceptions are rampant. Sadly, the internet which could potentially be a powerful tool to educate and inform patients and reduce their worries, ends up causing a lot of harm by spreading misinformation.

Because it's not possible to regulate the internet, this is why patients need to spend time and energy in educating themselves, so they don't get misled by wrong information.

Confused ? Not sure what to believe ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?








Thursday, August 14, 2014

Patients - be aware– not beware !


The Times of India is doing a good job with highlighting the problems which plague the medical profession today .  The health care system is ill, and it’s important to talk about burning issues such as medical corruption , rather than bury them under the carpet.

The big downside to these articles is that while they are great at highlighting problems, they do not provide any concrete solutions to the reader. They end up creating an atmosphere of distrust and suspicion , which harms both patients and doctors. In order for the patient to heal , it is important that he be able to trust that his doctor is acting in a fiduciary capacity , and is doing what is best for him by acting as a trusted professional .

As result of these article, the entire medical profession has been tarred with the same brush. Every doctor, no matter how good he may be , is treated with suspicion . The patient is on his guard in every clinical encounter. This means that it’s much harder today for even good doctors to earn their patient’s trust.

Rather than create a confrontational situation , where patients are pitted against doctors, the media could make much more productive use of  its clout by creating a “ Be Aware” campaign for patients , rather than the present “ Beware” campaign they are running.

This would involve educating patients as to what the right medical care is , for their particular medical problem , using the well-established principles of evidence-based medicine . This information would be trustworthy , and would be provided online, so that it's easily accessible to patients . Once patients are aware of their treatment options , they can make their own decisions, in partnership with their doctor. Patients would be easily able to verify that the advise which their doctor was giving them was right – and this would allow the doctor to earn their trust!

While it’s true that educational campaigns do not attract as many eyeballs as  articles which highlight malpractice and corruption ( which are far more interesting to read about, because they raise the reader’s ire), this kind of campaign would be much more constructive .

It would help to enhance the doctor-patient relationship , and heal the healthcare system. Providing Information Therapy makes a lot of business sense for the  media , because everyone spends hours scouring the net when they fall ill.  If this information is available on a trusted website, they would be happy to read it here, rather than waste hours on Dr Google.

This would be a long-term investment, which would pay off handsomely in the long run, because it would help to ensure that patients and doctors stop thinking of themselves as being adversaries , and start respecting each other as partners.


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