Friday, October 31, 2014

Personalised IVF care at Malpani Infertility Clinic


•    We will try not to make you feel rushed when we meet with you. Yes, we are busy, but when we are seeing you, you are the focus of our attention !
•    We will try to make you feel comfortable , so that you feel free to ask any question you like. We will do our best to clear all your doubts, so that you never feel that any of your questions are stupid
•    We will respect your preferences and allow you to make your own decisions . We will treat you like intelligent adults
•    We know all our patients by their name – we will never make you feel like a number. We do not employ assistants and interact with you directly, so that you are sure you are always in safe hands
•    We will give you a shoulder to cry on, when you need it. We will help you maintain a positive attitude during the hard times.
•    We will never give you false hope and will always tell you the truth . We will always be available  for you
•    We will be open and transparent, so you are in control of your life
•    We will use technology to help you to help yourself
•    We will share information with you to educate you about the IVF process


Thursday, October 30, 2014

IVF success story at Malpani Infertility Clinic


Hi to all the couples who want to graduate into parenthood.
It can be really traumatizing to not conceive naturally and the first question is why us??

I felt equally low and was in denial for quite sometime to accept there is something wrong.
Obviously after sometime we started looking for medical help.

Me and my husband fell under the category of unexplained infertility for my first child.
We went ahead for IUI and I conceived in my very second cycle ( at that time we lived in the USA). I was 31 years old when I delivered my first baby.
Everything looked pretty simple and we had our first baby.
Soon after that we moved back to Mumbai.

As soon as my baby was 2years we started trying for our second baby but to our luck we were once again not able to conceive naturally. ( contrary to everyone saying second baby is always quick)

We consulted Dr Malpani in August 2013 and he suggested we try naturally for a couple of months but if things don't workout to do some blood tests and get back to him.
In Dec I came back to Dr with my reports which indicated low AMH levels.
He straight suggested us to go for IVF.
I was just not ready for it and was again in denial that my first baby is IUI so I should def be able to conceive by the same treatment plan.
He was categorically clear it will not work.
I consulted other doctors and they said u don't need IVF.
I took 3 cycles of IUI but no luck.
I was then suggested to go for laparoscopy, that's when I realized I am being taken for a medical ride.
I went to Dr Malpani and we started our treatment.
I conceived in my second cycle of IVF.
He was clear since this is your second baby we will not transfer more than 2 embryos.

The complete process was stress free. The staff at the clinic is Superb.
There is a positive Aura in this clinic which makes everything so easy.
Dr Aniruddha & Dr Anjali just put you to so much ease that you feel relaxed in your mind, which is so important for conception.
No guilt trips for your weight, food habits etc etc.

I am thankful to both of them and their team from the bottom of my heart.
Their approach to the whole process is extremely professional and extremely compassionate.

God Bless Always!

Tuesday, October 28, 2014

Can you afford not to do IVF ?



A common concern  which lots of infertile couples have is whether they can afford to do IVF or not.

Everyone knows that IVF treatment can be expensive  ! IVF doesn't have a 100% pregnancy rate, which means patients may need 2 to 3 cycles before they get pregnant. Trying to budget for this open-ended expense can be a major challenge ! This uncertainty often puts infertile couples off because many are not comfortable taking such a big financial risk when the outcome is uncertain .

However , I think couples need to remember that sometimes they cannot afford not to do IVF ! IVF is the one treatment which maximizes an infertile couple’s chances of getting pregnant . Irrespective of whether they actually achieve a pregnancy or not, attempting an IVF cycle will give them peace of mind that they followed the right process and did whatever was humanly possible to try to have a baby.

If they fail to make the attempt , this is something which they will most probably regret later on. We rarely regret the things we do , but we often regret the things we didn’t !

It’s true that there is a financial and emotional risk in attempting IVF. However, the emotional risk of not attempting it will often leave a lifelong scar . While the money spent on an IVF cycle can always be earned again, the opportunity cost of not doing IVF when you are young is irreplaceable.

The truth is that there is a price to be paid – whether you do IVF, or you don’t. This cost is both financial and emotional. While it’s easy to measure the financial burden, it’s hard to quantify the emotional pain – and as you get older, the pain of never having tried at all can become a huge burden with the passage of time.

As John Greenleaf Whittier eloquently put it — 'Of all sad words of tongue or pen, the saddest are these, 'It might have been.'

When you are 50 and looking back at your life , the last thing you want to be doing is beating up on yourself because you missed a golden opportunity. It can be hard to live with this regret which gets magnified as tie goes on. You may end up kicking yourself what you failed to do whatever was humanly possible in order to maximize your chances of having a baby !

Not sure if IVF is the right choice for 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!

Monday, October 27, 2014

Public health and personal health in India


The PM, Narendra Modi, inaugurated the  brand new Sir H N Reliance Foundation Hospital in Mumbai. He said,  When our country is compared to other countries, the health care system in our country shames us,” Modi said. He added, “Instead of focusing on  treatment of patients, the health care system must focus on preventive  care. It takes less to invest in preventive care than in treatment.” -

Sadly, the truth is that opening more hospitals is not going to solve the problem ! We need to focus on empowering patients  with Information Therapy, so that they can help themselves - both to remain healthy; and to get the best medical care, when they fall ill. The ROI on patient education for the Dept of Public Health is enormous, because this has been a completely neglected area so far.

Friday, October 24, 2014

Corporate hospitals versus small nursing homes


In the past, when patients needed hospitalization, their family doctor would refer them to the neighborhood nursing home , which was managed by a specialist who would provide care which was cost effective and affordable . For more serious problems, he would refer patients to a government or municipal hospital. In those days, there were no large corporate hospitals, and the care which patients received was personalized.

Today, however, the  scenario has changed completely. There are lots of five-star super deluxe specialty care hospitals coming up all over the country . These are extremely profitable ventures, and lots of corporate are now pouring money into these. They are marketed and branded very cleverly and because they are large sprawling structures , with the latest medical technology and lab equipment, with large teams of medical specialists manning them 24/7.

This means that today patients are presented with a dilemma if they need hospitalization. Should they go to the spanking brand-new , state of the art hospital, or should they stick with the local nursing home.

The truth is that most common surgeries and medical problems are best treated much more cost-effectively and efficiently in a well-managed, well-equipped small nursing home . Not only are they much cheaper, it’s much easier for the patient to establish a relationship with the doctor. The care is more hands on and personalized, and more convenient as well, because family members and patients
don’t need to travel long distances . It’s also a lot cheaper, because they do not have to pay the overheads for the unnecessary trappings which super specialty hospitals are fitted with.

However, the problem is that nursing homes vary widely in quality. While some are excellent, others can be death traps, because they are so poorly equipped and badly staffed. This is why patients often prefer large hospitals , without understanding the hazards associated with these. While large hospitals look very impressive and imposing, the sad truth that the care they provide can be pathetic – something to which even the doctors who work in the hospital will testify to !

The truth is that while patients are awed by the dazzling equipment and technology available in the new hospitals, the truth is that most of them will never need these. The danger is that once this equipment has been bought, the hospital has to justify the expenditure, which means the doctors are often forced to refer patients for unnecessary scans and tests, to generate income for the hospital. Thus, just because the hospital has invested crores of rupees on a robotic surgery device, their surgeons are now forced to use these. While surgeons are happy to play with these new gee-whiz toys, the truth is that they only add to the expense of the operation – without adding any value whatsoever to healing and recovery. It’s the poor patient ( or his health insurer) who is forced to foot the bills. Sadly, patients aren’t even aware that they are being subjected to avoidable procedures and treatments, which only help the hospital’s bottom line – not their care. However, it’s become a very competitive game, and hospitals spends large amounts of money in a one-upmanship game, to try to convince patients why they are better than the others. Patients are not sophisticated enough to be able to separate the wheat from the chaff, and most just accept whatever their doctor tells them as being gospel truth, without knowing that their doctor is pressurized by the hospital management to bring a certain amount of moolah on a regular basis, in order to meet the targets they set.

While patients may feel very safe in  these hospitals , because they have so much equipment , the care they provide is often extremely impersonal . Patients are often treated as numbers , and there is little continuity of care . It’s very hard to get hold of the Doctor when they want to talk to him, as a result of which many patients are extremely dissatisfied with the services these hospitals provide. However, they are so worried that their local nursing home is not adequately equipped to handle complications, in case these arise, that they prefer the sense of security which large hospitals provide. They are willing to pay the additional premium these hospital charge, because of the trust and confidence which they inspire, thanks to their ambience and façade. However, this trust is misplaced , and that a lot of medical care would be much better provided in small nursing homes , provided these are managed properly.

The trick is that you need to choose between a hospital or a nursing home based on what kind of problem you have . The best model is a blended one, where simple surgical and medical problems are handled in small nursing homes , because these are much more cost-effective . Only the more complicated problems needed to be referred to specialty hospitals . This is the way things would work in an ideal world. However, because both specialty hospitals and nursing homes compete for the same set of patients, and  because corporate hospitals have  so much more clout , the nursing homes are gradually being squeezed out of existence. This is bad for all of us, as medical care delivered in these corporate hospitals will continue becoming more expensive as time goes by.

Thursday, October 23, 2014

Please consult with the patient !

Conversation between doctor and patient/consumer.


When we talk about a doctor-patient consultation , we usually refer to the fact that when someone falls ill, they go to a doctor, who then tells them what to do. This is usually perceived as a one-way street,  where the doctor is the one in charge. He takes a history, does an examination, orders tests and makes a diagnosis and provides treatment .

However, a key component of the consultation needs to be the fact that doctors need to consult with the patient as well. Unfortunately , this is something which is often forgotten !

Thanks to advances in medicine, patients today have lots of choices . Each patient is different,   and depending upon their personality, world-view, religion and culture, each will select a different option. There is no single right answer, and doctors are not mind readers. They need to factor  in the patient’s personal preferences, and they can only find out what these are by talking to the patient.

Doctors cannot afford to guess – and they shouldn’t try to impose their choices on the patient either ! They need to be non-directive and non-judgmental, and allow the patient to decide. They need to ask the patient which treatment they would prefer. This is not a sign of weakness on the part of the doctor – it’s actually a sign of strength !

Sometimes patients get confused when the doctor asks them for their opinion . They believe that this means the doctor is confused and doesn’t know what to do , which is why he needs their advice ! In reality, this means that the doctor is a good professional, who is being respectful . He understands that it takes two to tango , and that patients need to provide inputs so that doctor can help them to make a decision which is right for them.

The only way to have a healthy doctor-patient relationship is when both contribute ! This will help the patient gets the best possible medical care . This might seem obvious , but it's amazing how rarely this advise is followed in real life.

The problem is that doctors are often so full of themselves , and have big egos - especially the big specialists in the big towns , who are brand names . They think they have all the answers and are happy to dish these out to everyone who comes to them. After all, when you have a hammer in your hand, all you see are nails !

In fact, this is a setup where problems are much more likely to occur . Specialists have a very limited perspective – and for a cardiologist, every chest pain originates in the heart, because he doesn’t understand anything about the stomach ! As long as everything is fine, patients have been socialized to meekly agreeing with everything the doctor says. They are passively compliant , but when things go wrong ( as they are bound to do in any complex biological system), they become angry and vengeful.

Medical decisions needs to be made on a shared basis, where both doctor and patient provide their inputs ; and take responsibility  for the outcomes. Sadly, many doctor’s still believe that shared decision making means -  Here's my decision, let me share it with you . Doctors need to respect their patients and their choices !

Tuesday, October 21, 2014

Why do you think you are not getting pregnant ?

Infertile couples who come to me for a consultation often bring fat files stuffed with their medical records. These contain copies of their earlier test results ; and summaries of the treatment cycles they have already been through. They pull these out , and then wait patiently , expecting me to study their records and then pronounce my verdict.

However, before I touch the file, I ask the patient, Why do you think you are not getting pregnant ? What have you learned from your earlier medical encounters ?

Many patients are puzzled when I ask them this basic question. Isn't it the doctor’s job to find out why they are not getting pregnant ? And isn’t the answer in their medical records ?

This is a very important question , because it allows me to assess how much they understand about their problem.  After all, if you need to teach someone, you have to start from their level of current understanding, and then take them to where they should be !

Some patients look confused, and I need to prompt them. I reassure them that this is an easy question to answer. After all, you only need 4 things to make a baby – eggs, sperm, uterus and tubes; and if they aren’t getting pregnant,  the problem  is either with the eggs; the sperm ; the uterus; the tubes; or we have not been able to identify it ( a condition we label as unexplained infertility).

If they cannot answer this simple question, this means they need a lot more counseling and time. I can judge how medically sophisticated the patient is from their answer, and I tailor my conversation accordingly. This is much more efficient and effective , and ensures that the patient and I are on the same page .

When I start going through the records, I ask the patient to explain key test results.  It’s not as if I am trying to test them  - it’s just to reassure them that they are smart enough to make sense of what seems to be complex medical gobbledygook ! If they get stuck, I clarify and help them to make progress. This approach reassures them that I will treat them as an intelligent adult; and that they don’t need to leave everything up to the doctor . This gives patients a lot of confidence that we can work together as a team.

Need help in making sense of your medical reports ? 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!




 

Monday, October 20, 2014

How to make better medical decisions - a guide for doctors



Physicians do get things wrong, remarkably often. Studies have shown that up to one in five patients are misdiagnosed. 

Yet people are very reluctant to challenge doctors, who are perceived as being experts.  Anxiety, stress and fear — emotions that are part and parcel of serious illness — can distort our choices. Stress makes us prone to tunnel vision, less likely to take in the information we need. Anxiety makes us more risk-averse than we would be regularly and more deferential.

If patients want to control their own destinies, they cannot afford to leave their brains ( and heart and spine) at home ! 

They need to go well-prepared for medical consultations, by arming themselves with Information Therapy.

http://www.nytimes.com/2013/10/20/opinion/sunday/why-we-make-bad-decisions.html?pagewanted=all&_r=0

Sunday, October 19, 2014

How patients can contribute to improving medical care


The NYTimes website has a great article called - Why Doctors Need Stories
http://opinionator.blogs.nytimes.com/2014/10/18/why-doctors-need-stories/?_php=true&_type=blogs&ref=opinion&assetType=opinion&_r=0

Narratives have always been important; and stories are great teaching tools. They are sticky and memorable, and medical students learn medicine by studying "around and about" their patients.

However, it's not only doctors who can contribute medical stories. Every patient has a story to tell, and patients can help to advance medical science by telling their own stories. A blog is a great way of doing so, which is why we encourage patients to keep a blog and share their experiences and their expertise, with other patients, and with doctors as well !

A great example of a superb patient blog is Manju's blog at www.myselfishgenes.blogspot.com

I hope her example will inspire other patients to keep a blog as well !
You can email Manju at manjupadmasekar@yahoo.com


Is Facebook exploiting young women by paying for their egg freezing ?


I was very impressed by the recent news that Facebook and Apple  have agreed to pay for egg freezing for their employees. I thought this was a very positive step, as it allowed young women more reproductive autonomy. By feezing their eggs , they now have more control over planning their life, and could choose to postpone childbearing, without compromising their fertility or increasing their risk of having a baby with a birth defect. I felt this was a very enlightened move, which would help to create employee loyalty.

I was therefore very surprised to read that some health activists felt that this was a retrogressive step. They were painting it as being anti-feminist, because they believed these companies were interfering  with their employees plans to start a family. These people felt that companies wanted to manipulate young women so as to extract the most of their productive working years, by asking them to postpone child-bearing . It was being positioned as a " artificial reproductive technology to boost capitalistic productivity" versus " natural reproduction  " debate. They claimed that the move was ethically wrong, as children needed mothers who were young; and that  asking women to bear children at a later age would lead to more medical complications as well.

I believe this is a very good move , and is very ethical as it allows women more control over their reproductive options. Egg freezing allows women to ensure that biology is no longer destiny ! Just like birth control allows women more control over when to have babies and how many to have , egg freezing allows women more options as to when to have a baby. It allows them more flexibility in having both a career and a baby, so that they can have their cake , and eat it too.

In fact, not allowing them this option is unethical in my opinion. Why should women be forced to have babies at a particular age ?  Our poor grandmothers were forced to have baby after baby , because she did not have the option of using birth control ! Just like contraception allows women more control over their life, so does assisted reproductive technology.

Also, older mothers are often better mothers because they are more mature; more stable; financially better off; and settled in life. The organisation is not interfering - it is simply allowing women the freedom to choose for themselves. After all, they aren't forcing them to freeze their eggs !

Since the eggs are young, the risk of pregnancy complications are not increased, as long as the woman is healthy. Her calendar age is not an issue - it's her physical health

I think these critics are falling into the trap of underestimating these women. They are very smart
( after all, they are working at Apple and Facebook ! ). They are very capable of making up their own mind and this is an empowering move in my opinion ! These are very personal decisions which are best made by the women involved themselves - and we should respect their right to do so !

Saturday, October 18, 2014

The embryo scope as a marketing gimmick




 Most doctors unfortunately are quite happy to take advantage of the fact that patients are dazzled by medical technology. They are easily lured by claims of the “newest and latest” advance, and lots of doctors take pride in the being the first to offer the newest IVF toy, claiming that using this will improve success rates dramatically. Patients have short memories, and there is a new technology being promoted every few years, depending upon what is fashionable.

The flavour of the month seems to embryoscopy, and many IVF clinics are proudly promoting this, saying that this is now the “state-of-the-art” technology which will improve IVF pregnancy rates.

So what is the embryoscope ? It’s a type of incubator that has a built-in camera, which is capable of taking pictures of your embryo several times an hour. These pictures are then combined to create a time-lapse video showing the embryo’s development at every stage, so that the embryologist can assess embryo development more precisely and select the best embryos for transfer.

An embryoscope is expensive, and in order to recover the cost, IVF clinics feature their latest buy prominently in their advertising materials and on their website. They use this in order to differentiate themselves from the competition, by offering technology which is “more advanced” than the others. Patients are quite clueless, and are easily swayed by these claims because they are not sophisticated enough to separate the wheat from the chaff. They happily cough up Rs 30000 more , so that the doctor can use the embryoscope for their embryos, with the hope that this will improve their chances of success.

The dirty secret is that these clinics cheat patients by claiming to use the embryoscope for them, but never do so in reality. Let me explain.

Each EmbryoScope has the capacity to culture only up to 72 eggs or embryos from a maximum of 6 patients at a time. These need to be observed over a period of 5 days ( for a blastocyst transfer) which means that one embryoscope can typically be used for only one patient every 5 days.  Thus, if there are 3 egg collections daily, the embryoscope will be fully blocked in a 2 day period for a total of 5 days. This means that the embryoscope cannot be used for another patient who is cycling at the same time.  Embryoscopes are expensive, and most clinics have only one.  This means that if a busy clinic is telling all the patients who are cycling at the same time that they are using an embryoscope for each of them, they are clearly lying !

How can you make sure you are not being taken for a ride ? Remember that the purpose of an embryoscope is to take a video of your embryos as they develop in vitro. If the clinic tells you that it is using an embryoscope for you ( and charging you extra for this), then you need to insist that they give you a video of your embryos, so you can verify this. The embryoscope automatically provides a video output, and you should ask for a copy of this, so at least you have documentation that an embryoscope was actually used for your care ( even though using this does not improve your pregnancy rates). This  is a simple method by which you can ensure your doctor is not charging you extra for a procedure they are not using for you.

Want to make sure you are not being taken for a ride by your IVF doctor ? 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, October 17, 2014

When your IVF cycle fails


When your IVF cycle fails , a major source of distress is seeing all your hard earned money go down the drain. Even worse is the fear that your dream of having a baby may never come true. After all, if IVF – the treatment of last resort for infertile couples - has failed, then what else can you do the next  time ? Your hopes come crashing down and life seems bleak.

If you feel that way, you are wrong. You do not have to give up on your dream of having a  baby just because your IVF cycle has failed. You always have the ability to change your reproductive destiny.
But it will take a bit of time and patience. And it will require that you change some of the thoughts and feelings you have about medical treatment .

First, accept the fact that you alone are completely responsible for your IVF treatment. This might seem to make no sense ! How can a patient be responsible for IVF ? Isn’t this the doctor’s responsibility ?  The key is that you need to stop thinking of yourself merely as a passive participant in your treatment – after all, you aren’t a guinea pig!

By taking responsibility for your treatment, you also assume responsibility for your future.  You start taking ownership of your problem, rather than leave everything upto the doctor.  Let’s not forget – you are the one who has the most as stake. ! Now this doesn’t mean that you need to join medical college or start an IVF clinic. What it means is that you need to accept that patients can be powerful – and you need to assert this power  if you want to maximize your chances of IVF success.

Second, set realistic expectations. We see many patients who give up after taking IVF at a poor quality clinic. They didn’t do their homework before starting the IVF treatment and went to the nearest ( or cheapest) clinic.  They are very naïve and believe that all IVF clinics are the same. They trust the doctor and leave everything upto him. They wake up only after their cycle fails. When they then start doing their homework, they find they were shortchanged, because the doctor did not share any information with them and did not give them photos of their embryos. They are understandably angry and resentful, and refuse to trust any other doctor after this bitter experience. They end up throwing the baby with the bath water !

While the outcome of any IVF cycle is always uncertain, finding a good clinic which follows the right processes will maximize your chances of success. Other patients refuse to do IVF unless the doctor can give them a 100% guarantee. I feel sorry for these patients, because they are setting themselves up for failure.  They are likely to be cheated by a glib, smooth-talking doctor, who gets them pregnant by fooling them by giving them a HCG injection which causes their pregnancy test to become positive !

The great thing about setting realistic expectations is that you can prepare yourself for failure before you start, so that it’s easier to cope with the emotional roller coaster ride of IVF.

Realize that the journey to your baby is taken one day at a time.  A step in the right direction will help you reach your goal, but you cannot fast forward the process or take a shortcut.

Need help in bouncing back when your IVF cycle fails ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you as to what you can do to maximise your chances of success in the next attempt !

Thursday, October 16, 2014

How Google has disrupted the family doctor



In the past , the family doctor’s life was pretty simple . When someone fell ill, they would first try home remedies ; and if these didn't work, they would go to their family doctor. The doctor would make a diagnosis, and since most medical problems are self-limited , the majority of patients would get better. Because of the natural history of most diseases , where the body heals itself, the most important role of the doctor was to rule out serious problems ( which are rare and would need referral to a specialist ) and reassure the patient and hold his hand till he got better.

Life has become much more complicated now for the family physician, because he is being disintermediated by Google. Thanks to the internet , patients routinely do a Google search on their symptoms. They usually do this before going to the doctor, which means in a few minutes, they are quite likely to know more about the doctor about their possible diagnosis and treatment options. The trouble is that they then starting thinking of themselves as being well-informed, whereas often they are misinformed, because so many sites are unreliable and plain wrong. Even Google has realized this, which it is why it is now offering Google chats with doctors, to help patients make sense of the information they have unearthed.

The role of these virtual visits is still unproven. Meanwhile, what additional value can the real life doctor add to the patient’s life? Doctors are extremely pressed for time , and confronting a well-informed patient can create a lot of pressure on the doctor, who is now ironically at a disadvantage as compared to the patient, regarding his medical knowledgebase. The doctor’s knowledge is often outdated, and there is no way he can keep abreast of all the advances in medicine. He may have to read more about the problem to update himself, but he cannot afford to do this in front of the patient, as he does not want to lose face.


When patients realise that they know more about their problem than their doctor does, they are quite likely to lose confidence in his expertise. They then want to use the family doctor purely as a sounding board, to get a “second opinion” and confirm they are on the right track. They will often demand a referral to a specialist, because the doctor seems to be out of his depth. Presumably the specialist will know more about the disease, because of his years of experience and expertise.


Google has made the doctor’s life much harder , and that’s why many doctors get irritated by patients who come to them with the results of their internet search. The truth is that a lot of these search results are complete rubbish, because patients are not sophisticated enough to separate the what from the chaff. While they can acquire the information easily, making sense of it requires a lot of sophistication which many patients lack, because they do not have the ability interpret it in the right context.


While google is great at providing knowledge , to transmute that knowledge into wisdom and then convert it into actionable advise still requires the maturity of a doctor. Family doctors are great at this, because they know the patient and understand his background and personal preferences. The problem arises if patients don’t have a family doctor, because it takes time and trust to develop a healthy doctor-patient relationship. If this is missing, then this information asymmetry ( where the patient thinks he knows more than the doctor) can only create friction and unhappiness, for both doctor and patient.


Wednesday, October 15, 2014

Facebook and Apple pay for egg freezing and IVF !

Silicon Valley's biggest companies have long offered cushy perks to attract top talent and keep workers happy logging scores of hours on the job. But beyond day-to-day luxuries, Facebook and Apple will now give up to $20,000 in benefits to help employees pay for infertility treatments, sperm donors and even to freeze their eggs. The move comes amid stiff competition for skilled engineers, and as many of the biggest firms try to diversify their male-dominated ranks to include and appeal to more women.

"Anything that gives women more control over the timing of fertility is going to be helpful to professional women," said Shelley Correll, a sociology professor and director of the Clayman Institute for Gender Research at Stanford University. "It potentially addresses the conflicts between the biological clock and the clockwork of women's careers: The time that's most important in work, for getting your career established, often coincides with normal fertility time for women. This can potentially help resolve that by pushing women's fertility into the future."

http://www.startribune.com/lifestyle/health/279195791.html

Patient Education Simplified! DVDs in Indian regional languages



There is a major dearth of patient educational materials in Indian regional languages. In order to fill this gap, Mr Parag Vora started PEAS ( Patient Education and Awareness Services), in which I am an angel investor.

I am very excited that patients and doctors can now buy PEAS videos online from India's first exhaustive patient education DVD library online store at  http://store.peasonline.com/

These are Medically Accurate, High Definition Animated Videos available in Indian regional languages - Hindi, Gujarati, Marathi, Tamil, Telugu, Kannada, Malayalam, Bengali.

Technical skills versus bedside manner

English: A thoracic surgeon performs a mitral ...


Let’s assume you need to have cardiac surgery and you have a choice between two cardiac surgeons – one whose complication rate is 10% and the other's is 5%. The one with the lower rate is known to be a jerk who is rude and takes money under the table. The other one is a thorough gentleman. Whom would you pick ? And why ?   When you're selecting a specialist , should you choose one who's technically extremely competent ( but rude) , or one whose bedside manner is excellent ( but whose technical skills are not as good) ?

In a perfect world, all doctors would be both technically superb as well as deeply empathetic . This is the ideal combination which all of us are looking for in our doctor ( and if you're lucky enough to find a specialist who has both these skills, count yourself extremely lucky , and hold on to him for dear life ).

However, it's extremely rare to find this kind of doctor , and this is why patients are often forced to choose between technical competence and bedside manner . This is a complicated issue  - and there is no easy answer. Everyone makes a different decision, and the answer depends on the kind of patient you are , and what kind of medical problem you have .

Lots of patients are quite happy to settle for a surgeon whose technical skills are superb, and they do not care much if he provides any hand-holding afterwards, as long as he is a technical wizard in the Operation Theater. Others will focus on the doctor’s bedside manner. Their belief is that the technical skills most doctors have is similar; and they use his bedside manner as a surrogate marker for his medical skills, based on the assumption that if he has taken the trouble to cultivate a good bedside manner, he will be professionally competent as well.  They will refuse to go to a “star” surgeon who is rude, because they feel that a doctor who does not respect his patients is not a professional they would be willing to trust. They believe that it hardly matters whether the hernia surgery takes 10 minutes or 15 minutes – how could this affect wound healing ? As long as the doctor is proficient , they would rather have someone they can talk to, who will be there to hold their hand after the surgery, rather than someone who's just a technical wizard .

There will be others who will say – What do I care if he holds my hand after the surgery, as long as he does a superb job in the OT ! This is why patients will often have such diametrically opposite opinions about the same surgeon. Some will swear by him, while others will swear at him !

Ideally, doctors who had good technical skills would also work on polishing their bedside manner , because they understand the importance of both of them. This is the hallmark of a really great medical professional , but if you cannot find a doctor who has this rare combination , then you are going to have to select which of these two is more important for you. An enlightened doctor will understand his weaknesses and will try to correct them by employing juniors who have complementary skills. Thus , a senior surgeon may employ juniors as assistants and delegate the job of talking to patients to them.

Remember that there are no right answers – it’s just that you need to be clear in your own mind as to what’s more important for you, so that you can find the doctor who is right for you . The chemistry between doctor and patient needs to be right,  and this is extremely important . Patients need to understand that they often have a choice in the matter !





Tuesday, October 14, 2014

Social media in healthcare - conference in Mumbai

Pharma marketing in India still seems to be stuck in a time warp. The standard technique seems to be try to influence doctors so that they prescribe their products. It's high time pharma realised this model is broken . They need to start adding value to the life of doctors by helping them to become more productive; and to patients by helping them  manage their illness better. Social media allows pharma to reach out to doctors and patients directly, and it's heartening to see that Indian pharma companies are finally waking up to the potential  this channel has. It's early days , which means there are still lots of challenges - and opportunities as well !

IVF Pregnancy Calculator and the 2 week gap – When is My Baby due ?



The moment you find out you are pregnant, the next question is – when is my baby due ? This is true, whether you get pregnant in your bedroom, or after doing IVF !

There are lots of pregnancy calculators online , which allow women to calculate their due date. The principle is quite simple – they just need to key in their LMP ( first day of their last menstrual period) and the calculator will tell them their due date ( by adding 40 weeks do the LMP, a rule of thumb called Naegle’s rule).

One would think that calculating the due date after IVF treatment should be much easier, because we know the exact date on which the eggs were retrieved and the embryos were transferred ! However, it can be more confusing, because of the difference between menstrual age and embryonic age. This is why many couples feel lost. Doctors often make matter worse, especially when they do HCG tests and ultrasound scans. Too much data can confuse the poor patient, because you just want to know when your bundle of joy will be with you. 

Basics of Your Due Date

Your due date is usually calculated based on a 40 week average gestational age. This is an estimate , calculated from the first date of the last menstrual period. Now we know that a woman cannot not pregnant before she ovulates – and ovulation , fertilization and conception occur about 14 days from the start of the menstrual cycle. Therefore, if a woman with a 28-day cycle had her last period on January 1, her due date is 8 Oct . However, the baby was probably conceived around January 14. This means on 1 Feb, while the embryo’s age is only 4 weeks, the doctor will say she is 4 weeks pregnant !.   This is a clinical norm we use, which refers to the menstrual age, and not the actual age of the fetus. The reason for this is that most women don’t know on which date they ovulated; or on which day they had sex which led them to get pregnant. However, since the vast majority know their menstrual cycle well, it’s easy and convenient to use menstrual age for dating the pregnancy in clinical practice , in order to simplify matters. 

Calculating IVF Birth Date

When you do IVF, you do not need to use the date of  your last menstrual period to calculate your due date – you have far more information , which is much more biologically reliable.  The trouble is that if you calculate your gestational age from the date of the embryo transfer or the date of fertilization, your obstetrician will get confused, because he is used to calculating the age of the pregnancy in menstrual weeks – not the embryonic age. This means that even though you are actually being more scientifically accurate, you will have to follow the norms which clinicians use.

So how do you convert the date of your embryo transfer to menstrual age ? This is surprisingly simple . The key reproductive event you need to focus on is ovulation ! It makes much more sense to talk about the pregnancy in terms of DPO ( days post ovulation), rather than the menstrual age or the day of the embryo transfer. This is because we can use this landmark for all situations ( including IUI pregnancies; for Day 3 embryo transfers and Day 5 embryo transfers ; and frozen cycles as well !)

Since every IVF patient knows the date they ovulated ( = the day of egg collection), it's easy to calculate your menstrual age. Just subtract 14 from your date of ovulation. This is your " corrected LMP" ( last menstrual period) . This means ( Corrected) LMP = Date of egg collection minus 14.  The reason we do this is simple - it's because text books assume the follicular phase is exactly 14 days ! Once you know your corrected LMP, it's then easy to use this as the anchor, based on which your OB can calculate your gestational age.

This means that the menstrual age will always be 14 days more than the actual age of the embryo.

Confused ? Let's look at an example.

Let's suppose your LMP was 5 Jan; and your egg collection was done on 24 Jan ( let's assume you took a long time to grow eggs); and your embryo transfer was done on 29 Jan ( Day 5 transfer). The HCG pregnancy test will be usually done about 14 days post ovulation ( DPO), which is 7 Feb. If it's positive - say 120 mIU/ml, the doctor will confirm you are pregnant ! This means that even though you are only 14 DPO ( and your embryo's age is only 14 days ) , he will calculate your corrected LMP as 10 Jan ( date of ovulation , 24 Jan, minus 14 days) - which means your clinical gestational age ( or menstrual age) will become 4 weeks ( 28 days) ! Once you understand this " 2 week gap" and the rationale behind it , you'll find it much easier to date your pregnancy !

The way labs report HCG results just makes matters worse ! If you remember the above rules, it’ll be much easier for you to make sense of your HCG results and date your pregnancy.

Ultrasound scans are another minefield. While the sonographer can measure the baby very precisely, and the machine uses a computer to calculate the age of the baby ( and based on this, it reports your expected due date), please do remember that even though the ultrasound machine uses a computer to do its calculations, these are only estimates, and not as precise as the date you calculate based on the date of egg collection !
 Ultrasound measurements cannot be taken as standard , because embryos grow at different rates.

Do also remember that babies born between 37 to 42 weeks from the last menstrual period are also considered to be full term.  In real life , only a small number of women give birth precisely on their calculated due date. If you have a multiple pregnancy, the chances of reaching the magic due date go down quite a bit.



Monday, October 13, 2014

IVF in India – Are you in the Wrong Clinic ?


IVF has become a popular choice with infertile couples who have been trying to have their own baby without success. Often  couples become so desperate, that they reach out to the first IVF clinic they hear about . Every IVF clinic in India claims to be the best !  Sadly, many couples are not sophisticated enough to check the veracity of these claims. They unwillingly become victims to marketing gimmicks and tall claims. This can be very costly, both emotionally and financially. Therefore, before choosing an IVF clinic in India, it is always a good practice to first check the clinic out thoroughly. This is especially true for couples who are travelling to India from overseas for their treatment.

It is not always easy to identify if an IVF clinic is good or bad. They all seem to look the same – and many of them even go so far as to copy the content on our website at www.drmalpani.com !  While imitation is the best form of flattery, just copying our content does not allow them to copy our high success rates, because they cannot replicate our expertise and experience !

Here are some tell-tale signs which can give you some indication of the clinic's quality.  When you need to find out more about the clinic, it is best to keep the following points in mind.   There’s nothing wrong with doctor-shopping if it helps you maximise your chances of success !

What are the Signs of a Bad IVF Clinic in India?

•    A bad IVF clinic makes many claims on their website and in their printed advertisements, but when it comes to showing you around the clinic, they are not willing to do . A refusal to give you a guided tour of the facilities and equipment used should be a cause for alarm.
•    You should ideally have a single doctor to take care of you throughout your treatment. You don’t want to be treated as just another number or “ the case with blocked tubes” !  The same doctor who does your consultation should take care of you through the entire IVF treatment cycle – from history taking to formulating the treatment plan; from scans to embryo transfer.  You should worry a lot if you are asked to see a new doctor every time you come to the clinic. You should get a dedicated doctor , and should not have to consult with assistants or nurses every time you visit. 
•    Do they store your records properly? Or is the doctor completely clueless about what they did for you during your last visit ? or in the last treatment cycle ? If they do not have easy access to your records, your doctors would end up wasting a lot of time in determining how your cycle is progressing and what they need to tweak . In many cases, they are completely blank and it appears they do not remember anything about you – even your name. Often they have to rely on the information you relay to them in order to take the next step.
•    Interview the other patients in the reception area, as to what their experiences with the clinic are. Experienced and senior patients can provide a very frank and forthright perspective !
•    Do they offer comprehensive services?  Blood tests ? scans ? a full-service embryology lab ? Or do they make you run around from pillar to post for your tests and medications ?
•    Check the qualifications of the doctor ! Is the clinic registered with the ICMR of the Govt of
India ? If not, you should worry a lot, because this means they have not been able to satisfy even the basic requirements which the ICMR demands.
•    Do they have to batch patients because they do not have all the required expertise in house ? This can cause serious problems because the doctor will need to manipulate your cycle, and this can reduce your ovarian response in the IVF cycle.

Undergoing IVF is not easy and you should spend a lot of energy in finding a good IVF clinic .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!






Saturday, October 11, 2014

IVF is not artificial



Many patients are still scared of doing IVF because they think it is an “artificial” process . They worry that babies made in the lab by artificial processes will be weak or abnormal. Others ( who are a little more sophisticated) are concerned that since the embryos are being artificially inserted into the uterus by the doctor, they need to rest in bed after the transfer, because they embryo may “fall out” if they do not do so.

There are still many myths and misconceptions about IVF, especially about the care which patients need to take after they get pregnant. Many of these get propagated thanks to bulletin boards and online forums.  It's quite easy to understand why these myths are so prevalent – they make a lot of intuitive sense. After all, if the doctor is putting the embryos into the uterus through the cervix , doesn’t it follow that the same embryos can easily fall out through the cervix when the woman coughs or sneezes or strains ?

This is why there are so many precautions women are advised to take after the embryo transfer . Some of these come from the doctor, while others are advised by friends and family members – or other IVF patients ! They want to maximize their chances of success and want to ensure that nothing bad happens to their embryos .

We need to keep on reminding our patients that no special precautions are needed after IVF – there’s no need to create a list of do's and don'ts . Nothing they can do can reduce their chances of success – or increase them either.

We remind patients that ART does not stand for artificial reproductive technology – it stands for assisted reproductive technology. This means that when we do IVF, we are simply assisting nature ! IVF only allows us to perform in the IVF lab what is not happening naturally in the bedroom for couples who suffer from infertility.

While it’s true that eggs and sperm are being fertilized in vitro in the lab under our supervision, all we are trying to do is to mimic the natural in vivo process ! Instead of it happening in the fallopian tube ( as it does for normal fertile couples), it is now happening in the test tube in the IVF lab, that’s all.

Also, once the  embryo has been transferred into the uterus, it doesn’t matter whether it spent three days in the fallopian tube , or three days in the lab ! Once the embryos implant, the pregnancy is just like any other normal pregnancy. Once the embryos are in the uterus, they follow the completely natural biological process of in utero implantation, which means that the final common pathway remain the same. You can think of IVF as a technique which allows us to take a slight detour, in order to bypass  the obstacles which the eggs and sperm of infertile couples encounter in the bedroom .

Want more information about IVF ? 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, October 10, 2014

The doctor-patient relationship - trust is not enough


Trust is an integral part of the doctor-patient relationship . We need to be able to trust our personal
physician , and finding a doctor they can trust is an important goal for all patients. We need to believe that our doctor will do what‘s right for  us , and will be available for us in our time of need .

However , while trust is a necessary part of the doctor-patient relationship , my point is that it's not sufficient . The reason is that no matter how technically competent the doctor maybe , and however ethical , honest and upright he is , he cannot read your mind.  While he may be a competent professional, he doesn’t know what your personal preferences are. This is why the treatment he may select for you may not be the one which you would have chosen if you were aware of all your options . For example, if you have chest pain, he may have a very aggressive personality , and may want to do surgery, while you may be much more conservative, and are happier to let nature to take its own course. In medicine there are no black-and-white easy answers – there are only shades of grey. Each patient needs to find the path which is right for them, so that they are comfortable with this, and can live with the outcome of their decision, no matter what the final outcome maybe, because it’s always impossible to predict this.

This is why a healthy doctor-patient partnership is so powerful . No matter how good your doctor is, you cannot afford to blindly trust him and make all the decisions for you. In fact , a good doctor will go out of his way to explain to the patient what their options are . He will try to be as neutral and nonjudgmental as possible , so he can listen to the patient's input . Interestingly, the more willing the doctor is to discuss options with the patient, and to share the limits of medical knowledge, the greater the trust his patients will have in him !

Patients who are actively engaged make far better decisions in partnership with their doctor, as compared to the patient who meekly does whatever their doctor orders him to. This engagement takes time and effort on the part of both patient and doctor, but this is a very worthwhile investment !

Thursday, October 09, 2014

How some Indian doctors exploit the ignorance of IVF patients


For lots of gynecologists , IVF seems to be an extremely lucrative super-specialty , which is why many of them in small towns are now starting their own IVF clinics . They attend a one-week training workshop to get a " diploma " or certificate ; buy equipment ; arrange for an embryologist and an IVF specialist to fly down from the nearest large city once a month , and start offering IVF to the patients in their own town. Patients are delighted, because now they don't have to travel long distances to do IVF, which means the treatment is affordable.

Now if their success rates were good, this would be perfect. However, the tragedy is that they often do a poor job at doing IVF. For one thing, they are not registered as an ART Clinic with the ICMR
( Indian Council of Medical Research, New Delhi) which means they are not authorized to do IVF.

Second, they batch their patients so that they can do the egg collection on the date the embryologist will be visiting their clinic. As one would expect, the pregnancy rate is dismal, given the fact that they do IVF on a sporadic basis; there is no quality control in place; they have to depend on external expertise ; and are forced to group lots of patients together on order to make it cost effective for them to fly the embryologist down and to pay for his services.

If you lump apples and oranges together , you end up getting fruit squash of poor quality. Some patients will grow eggs slowly while others will grow faster, but  because the embryologist is down for only 1-2 days, they are forced to finish treating the entire batch of patients within the limited amount of time the embryologist is in their clinic. The doctor is forced to manipulate the cycles , so as to time everyone’s egg collection on the same day. The problem is that it’s not  possible do this well for all the patients in the batch, with the result that the superovulation protocol is not optimized for each individual patient. While this may not matter too much for young women who are good responders, older women will often end up with few eggs of poor quality. The doctor will then advise them to use donor eggs ( and usually these are taken from the other women who are cycling at the same time, without their consent !)

Because the embryologist has to complete so many cases in a short amount of time , he’s often tired and fatigued. It’s not possible to offer blastocyst transfers , because the embryologist usually spends only 1-2 days in the clinic; the documentation is very poor; patients are not given photos of their embryos; and they are not able to freeze the supernumerary embryos, which are wasted or donated to other patients ( without the patient’s consent).

Even though the pregnancy rate in these satellite IVF clinics is poor, they use various clever tricks to ensure that they don’t lose their patients to better equipped IVF clinics in the larger cities, even though these usually have much better equipment; a full-time embryologist; and a much higher success rate.

Because they live in the same town as the patient, they have a personal relationship with the patient, and they exploit the poor patient’s ignorance. Because patients are so emotionally vulnerable , it's easy to take them for a ride.

Thus, they scare patients by telling them it’s a bad idea to go to a IVF clinic in Mumbai. These are some of the flawed arguments they use.

1.    If you go to Mumbai, when you travel back after your transfer, your embryos will fall out of your uterus and you will never get pregnant, because you need strict bed rest after the embryo transfer.
2.    If there is a complication after your IVF treatment, how will your Mumbai doctor be able to help you ? They scare them with tales ( many of which are fictitious) of patients who have had problems after taking IVF treatment in other cities
3.    They claim that their success rates are as high as those of Mumbai clinics – and it’s easy to fool patients with these tall claims, because patients don’t demand proof.
4.    They hold on to their patients even after an IVF failure, by telling them that it’s better to do IVF cycles back to back, as this will increase their chances of succes.

It’s easy to fool some of the patients some of the time, but when patients find out that the information which was given to them was inaccurate , they are angry and resentful – and all IVF doctors end up getting a bad reputation.

IVF patients need to insist that their IVF clinic is registered with the ICMR before they agree to sign up for IVF treatment. While this is not a guarantee that the clinic has a high success rate, at least they know that the clinic has been inspected by a regulatory authority, which means it meets at least the basic standards needed.

Want to be sure you are getting high quality IVF treatment ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion,  so I can guide you!






Wednesday, October 08, 2014

Ruptured ectopic after IVF = bad IVF doctor

English: removal of an ectopic pregnancy out o...


When I see how badly some IVF patients have been managed , my blood boils . I recently saw a patient who had a ruptured ectopic pregnancy after an IVF treatment cycle . This is a definite red flag which means that patient has been mismanaged and that the quality of medical care provided has been extremely poor . A ruptured ectopic after IVF treatment often means that the care has been negligent.

Once  a patient gets pregnant after IVF, it’s the duty of the doctor ( and the patient) to monitor the  pregnancy to make sure that it is progressing well . This can be done easily by checking hCG levels , and doing an ultrasound scan when the HCG level is more than 1000 mIU/ml. This is simple to do and not expensive.

If the HCG level is more than 1000 mIU/ml, and we cannot see a pregnancy scan inside the uterus, this means the patient has an ectopic pregnancy. It’s very easy to treat an ectopic pregnancy when it is diagnosed early ( as it should be after IVF treatment). The doctor just needs to give an IM methotrexate injection to kills the pregnancy and prevent it from growing.

The tragedy is that doctors often fail to consider the diagnosis of ectopic. This is unforgivable ! If the diagnosis is not made on time, the pregnancy keeps on growing. It may start leaking blood, and can even rupture. This can be a life-threatening complication .

The biggest tragedy is that this is a completely preventable complication ! Doctors need to be aware of the fact that IVF pregnancies need to be monitored ; and patients need to insist that their doctors monitor them carefully . Otherwise, they will end up as one of those unhappy statistics of a ruptured ectopic after IVF , which will reduce their fertility even further.

Want to make sure you don't end up as an unhappy statistic ? 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!





Tuesday, October 07, 2014

Govt funded IVF treatment for Parsis

A Parsi wedding portrait, 1948
At a time when the government is promoting birth control measures, the city got its first set of Parsi twins - a boy and a girl - born last week with the help of a government funded fertility treatment scheme. Jiyo Parsi, the unique initiative of the Central government, comes as a welcome change as every new birth matters for the rapidly declining community in the city.
http://www.mumbaimirror.com/mumbai/others/City-gets-1st-Parsi-twins-under-govt-scheme/articleshow/44570592.cms

While it's great that IVF treatment is being funded, I have 3 major issues with this

1. The Parsis are a rich community. They have the highest per capita income in India. If they are worried about their declining numbers, why can't the community pay for the treatment themselves ? Why do they need government subsidies for this ?
2. Why should non-Parsi Indian taxpayers subsidise this treatment ? And why should this scheme be selectively for Parsis only ? Isn't this unconstitutional ? Aren't all Indian citizens entitled to the same rights ?
3. Why can't the government mandate that IVF treatment be covered by health insurers ? This would be much fairer for everyone.

Why I sometimes get angry and upset with IVF patients


When I see patients who have received poor quality IVF care, my heart breaks . I am upset that my medical colleague ( who is my professional peer) has done a bad job. However, what also gets my goat is the fact that the patient has taken such little interest in their treatment . It bothers me that patients leave everything up to the doctor and are not willing to take the time and trouble to be more actively engaged in their treatment . Now I can pardon uneducated or illiterate patients , but if patients who are educated and well-informed don’t do their homework , then this is much harder to forgive.

There is a lot an active and engaged patient can contribute to their medical care, and it’s only when patients start partnering with their doctor that doctors will start shaping up and improving . It’s the patient’s lackadaisical attitude  and willing to passively put up with whatever the doctor dishes out) which actually contributes to the carelessness and lack of attention to detail which doctors display so routinely.

It’s true that patients cannot change their doctor’s behaviors . If they are lucky and find a good doctor who is conscientious and professional , then they are fine. However, if they are not so fortunate, and end up with a sloppy doctor, then blaming the doctor after the cycle fails, or complaining about the medical profession no longer cares about patients really doesn’t help anyone.

It’s the patient who suffers the most damage – and the biggest tragedy is that a lot of this could be prevented if patients were more proactive and involved.  I care for my patients, and it bothers me when I see this happen and this is why I get upset and angry.

The traditional way of addressing the problem has been regulating doctors , to try to make sure they follow basic professional standards and guidelines. However, this approach has its limitations – especially in a country like India, where it’s hard to enforce some of these rules.

Helping the patient to help themselves can be  a far more constructive approach. There’s no need to treat patients as being stupid and passive. It makes a lot of sense to focus on what the patient can do himself to improve the care he receives. A good patient can change his own behavior , and by making sure that he's well-informed and has realistic expectations of what a good IVF get clinic can deliver , the chances of his being taken for a ride by an unethical doctor go down dramatically . This is why I get extremely upset when I find that patients are clueless about the treatment they have received, and have chosen to be passive participants , who have left everything up to the doctor. Doctors are not Gods, and patients need to invest time and energy in doing their homework and finding the right doctor, who respects them, so that they can ensure that the treatment is progressing as it supposed to.

I'm not trying to make excuses for incompetence on the part of doctors . While doctors should be held responsible for providing poor quality care , at the end of the day , it takes two hands to clap , and patients also need to take responsibility for the quality of care which they receive. This is especially true for IVF treatment, which is elective , and where patients are healthy , can think clearly , and can make decision for themselves.

Educated intelligent IVF patients need to learn to be proactive. Not only will this help the to get better medical care, it will also help them to improve the standards of care their doctor provides to other patients, so that everyone benefits in the long run.

Need help in making sure you have done your homework properly ? 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!





Monday, October 06, 2014

Empiric therapy in IVF



Lots of patients who have failed an IVF cycle ( either in our clinic or elsewhere) want us to try something new and different for their next cycle. Common requests are - Can you please prescribe steroids for me ? IV immunoglobulins ? Intralipids ?

They spend a lot of time online, trying to research their treatment options . Maybe there’s something which we didn’t do in the first cycle which can help the second cycle to succeed ? Patients who have failed an IVF cycle can become quite desperate and are happy to clutch at straws. When they read about “the new and latest “ treatment advance, they want us to try this out for them.

The trouble is that a lot of these treatments are empirical. Empirical therapy is one which is based on experience. They have never been proven to be effective in controlled clinical trials . These are supported by lots of anecdotal case reports of success, where some patients have benefited as a result of trying that particular treatment intervention . Now just because there is no clinical trial does not mean that these treatments are not useful – it just means that a clinical trial may never have been done. On the other hand, just because there was a pregnancy after the treatment does not mean that the pregnancy was a result of the treatment . This is a natural bias and this logical fallacy is called the “post hoc, ergo propter hoc” fallacy. Sadly, it’s very easy for patients to fall prey to this, which is why there are so many accounts online of patients who swear that taking IVIg therapy helped them to get pregnant. These are very emotional stories, and it’s easy to conclude that if a patient who has failed her first IVF cycle gets pregnant in her second cycle after taking intravenous immunoglobulin , that it was the intravenous immunoglobulin which caused the second cycle to succeed . However, this is false. If this were true, then doctors would routinely start using IV immunoglobulins for all their IVF cycles – why would they wait for the cycle to fail before using a therapeutic intervention which has been proven to improve pregnancy rates ?

While I have nothing against empiric interventions , I think patients also need to acknowledge the limitations of these . Not only can they be extremely costly , they also have hazardous side effects . For example, the overuse of steroids can cause hip necrosis , and actually harm the patient .

Unfortunately, there is a lot of pressure to treat - not only for patients, but for doctors as well. Doctors have a natural bias to want to something different – even though it’s not been proven to be better. Patients are easily influenced by the success stories they read online – even if these accounts are not scientifically valid . Thus , if 100 patients have taken intravenous immunoglobulin , the ones who get pregnant after taking it will wax eloquent about how effective the treatment is – while the ones who don’t get pregnant will keep silent – or will go one to trying something different. This is why the documentation about the failures of empiric therapy is so poor. The major risk is the false hope they create in patient’s minds and hearts.

I'm perfectly okay with using empirical therapy, provided patients understand that it is unproven ; and if it is inexpensive and safe . Thus, I think it’s fine to use interventions such as acupuncture , DHEA , vitamin D and other supplements - but for a lot of the other stuff ( such as IV Ig) which is expensive, risky and unproven, I would say no, unless the patient twists my arm. As a scientist, I am forced to depend upon reliable scientific evidence, but patients are not bound to follow scientific principles, and are free to do as they please. I am happy to honour patient preferences, provided they do no harm.

Failed an IVF cycle and not sure what to do next ? 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, October 04, 2014

Acupuncture for IVF patients in Mumbai, India


Acupuncture is still not very popular or easily available in Mumbai. We invited Dr Jasmine Modi, our consultant acupuncturist, to educate patients about acupuncture.

Assisted reproductive technology (ART) has improved greatly in recent years, and increasing numbers of couples have benefited from the scientific advances. At the same time, more and more people are turning to Acupuncture, either alone or in conjunction with their Western treatments to improve their chances of conceiving and delivering healthy children.

Acupuncture consists of gentle insertion and stimulation of thin disposable sterile needles at strategic points near the surface of the body. Over 2000 acupuncture points on the human body connect with 14 major pathways called meridians. This meridians conduct qi or energy between the surface of the body and internal organs. It is the qi that regulates spiritual, emotional and physical balance. When the flow of qi is disrupted through poor health habits or other circumstances, pain and/or disease can result. Acupuncture helps to keep the normal flow of this energy unblocked, thereby increasing a couples chance to conceive. Acupuncture is holistic, seeing the interconnectedness of all the body's systems. When healthy and balanced, you are more likely to get pregnant and produce a healthy child. The goal of acupuncture is to return your body to a state of health. The effects are cumulative; they take time; the results get better and better.

  
THE TREATMENT PROTOCOL

If you plan to combine Acupuncture with infertility treatment, the treatment begins 3 months before fertility procedures commence and continues throughout your treatment. Ideally, patients come twice a week.  While this is ideal, many people come in just prior to starting IVF, or during an IVF cycle, and they have still had improvement.

If a woman is undergoing IVF, woman should get treated on the day of the transfer, before and after, or as close as possible. Women are also encouraged to continue with treatment after a positive pregnancy test once a week for the first trimester to help prevent miscarriage. Women who have more difficulty getting pregnant have a slightly higher rate of miscarriage.

Procedures other than acupuncture that might be included are: cupping; electric stimulation; and moxibustion. Herbs are also a very useful and an important component of Acupuncture. Acupuncture points and protocols vary from patient to patient because each person has different needs. For example, with a woman suffering from endometriosis, we would focus on moving the blood, whereas with a woman who is not ovulating, we would concentrate on nourishing the blood. Treatment is completely designed for you as an individual, depending on the factors noted above, your health and your goals.

“The goal of an infertility treatment from acupuncture perspective is not just to get pregnant but to stay pregnant and to have a healthy baby."



Dr Jasmine Modi.
(Acupuncturist).
9819350976.
www.jasminemodi.com


Friday, October 03, 2014

What infertile couples need to do to get over their fear of IVF




Do you dread attempting IVF , even though you know that this is the one treatment which maximizes your chances of having a baby ?

Quite likely your major fear ( which is completely normal) is that IVF does not have a 100% success rate, and you are scared that even after spending all that money, you may end up with nothing in your hands to show for all your efforts and expenses. This often paralyses patients into inactivity .

You are emotionally vulnerable, and the possibility that even the most advanced medical treatment may not actually give you the baby which you desire so deeply gives you nightmares and sleepless nights. Many couples are not willing to even think about the possibility that they may be forced remain childless all their life – just like most humans are unwilling to confront their own mortality.
This makes a bad problem even worse , because when you become emotional , you can't think straight and are not capable of making the right decisions . This impasse is often exacerbated by the fact that your spouse may not agree as to which treatment option is best for you . Thus, for example , the husband may be willing to consider adoption , while the wife may refuse to do so, because she is worried about whether their family will accept their adopted child. Men tend to oversimplify problems , and look for shortcuts, whereas women  are better able to take a long-term perspective and weight pros and cons.

The social pressures to which infertile couples are subjected to just makes matters so much worse. There are 50 different people telling you 50 different things , and you don’t know whom you can trust.

The only effective solution is to move forward by taking action . This needs to be a well-informed exploration of their options - not just action for the sake of doing something . This means you need to do your homework ; explore all your options ; and come to terms with the fact that the outcome of any action is always uncertain – all you can do is follow proper process. This way, no matter whether you get pregnant or not, at least you will have peace of mind that you did their best.

The problem is that infertile couples are often so frustrated and mentally upset that the default action is often that of inertia - doing nothing . This is the worst possible action for you to take !  You need to listen to both your head and your heart. You need to follow a logical systematic framework ; make a list of all your options and work your way through that list , finding the option which appeals the most to you.

Being infertile is an extremely emotional experience . It affects your self-esteem , and makes you feel bad about yourself . It often shakes up your faith in God , and causes marriages to break up as well . There is no doubt that the price one pays for being infertile can be considerable. On the other hand, if you think of it as a challenge and learn to overcome this, the strength which you can derive from this battle can be a very healing experience. Infertility can teach a lot of life lessons – it’s up to you to decide which lessons you want to learn !

Not sure if you should do IVF or not ? 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, October 02, 2014

Overtesting versus thoroughness - more is not always better in IVF !

When an IVF  doctor orders lots of tests, most patients are very impressed. The feel that this doctor is being extremely meticulous and thorough , which means he is doing his best to find problems and solve them. They believe this approach will maximize their chances of getting pregnant , and they admire doctors who routinely do a series of tests ( such as hysteroscopy , TB PCR testing, NK cells testing, sperm DNA fragmentation and so on) . The more expensive the tests, the happier the patient is. This is especially true if the doctor tells them that they need to send the sample overseas for the test ! This just confirms that this doctor is extremely sophisticated and is using the latest cutting edge technology to help them to have a baby. Doctors will often play a game of one-upmanship to demonstrate to patients how they are better than the rest – and the more esoteric the test, the easier it is to play the game and score points !

There is still an aura of mystique about medical testing , and patients are awed by reports which are full of medical jargon. After all, any doctor who can makes sense of so much gobbledygook must be a real expert !

Doctors are more than happy to order more tests – after all, ordering tests is profitable for them . Not only do they get a cut from the lab fees ( which the lab offers to lure them into sending more tests) , it’s also a mathematical certainty that the more the tests you order , the more the abnormalities you will find ! This now gives the doctor an excuse to order  even more tests ; provide additional “  treatment”; and refer the patient to colleagues and specialists. This means the patient ends up spending a lot of money even before they actually start the IVF treatment cycle ! Some patients end up wasting over six months in  testing and consultations – and the cost of these is nearly as much as that of the IVF cycle. However, since the costs are incremental, they end up spending  a pretty penny, in bits and pieces . By the time they realize how much time and money they have wasted, it’s too late to do anything about it, as they are now committed.

Patients need to remember that quantity and quality don't always go hand-in-hand . Overtesting is often unnecessary – and the only person it helps is the doctor because it helps to increase their profits. Lots of these tests yield abnormal results , which are false positives and have no bearing on the patient’s fertility at all. Most don’t change the patient’s treatment options , which means a lot of this testing is extremely wasteful . Because insurance companies don't pay for IVF treatment , this hard-earned money comes from the patient's pocket . This means that not only does the patient waste a lot of valuable time and money on these unnecessary test results , they also spend so much on “treating” the so-called abnormalities , that they often cannot afford to do more than one IVF cycle .

The list of wasteful tests is extremely long – and varies depending upon which part of the world you are in. Patients need to get back to basics and push back when doctors order too many tests . Remember that IVF is pretty basic straightforward treatment – all we are trying to do is to achieve in the lab what is not happening in the bedroom . All we need for IVF is eggs, sperm and a uterus !

It's possible to overcomplicate this by doing a lot of fancy tests - for example , for checking sperm quality by doing " sperm function tests" , or testing for  whether the endometrium is receptive or not by doing an "endometrial receptivity assay" . While these tests make theoretical sense, they should be used only in a research setting, because we still don’t know if they are clinically useful or not . A lot of these tests are experimental and unproven . Most do not affect pregnancy success rates or treatment options , and if your doctor insists on doing lots of tests , you should definitely get a second opinion ! Tests are not always as harmless as they seem !

Not sure if the tests your IVF doctor is ordering are needed or not ? 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 ?





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