Thursday, June 30, 2016

Reviewing IVF doctor's online reviews



When patients select an IVF clinic, most go online to get more information about the clinic, so that they can make a well-informed decision.  They check out the website of the clinic, because this provides lots of useful information; and they also check out reviews about the doctor.  Patient reviews - what other patients have to say about the doctor , can  be extremely helpful when you are searching for the right doctor .  In fact we use customer reviews all the time for lots of stuff - for example, when buying a book on amazon; or selecting a restaurant on zomato.

 The trouble is that reviewing a doctor is very different from reviewing a book, and you need to be very careful when you analyse reviews about doctors. You need to look at lots of reviews on different sites in order to get a fair opinion.

Now, some patients will get put off when they read negative reviews about a doctor, but this is not always a very sensible approach. We all know that it's not possible to keep everyone happy all the time, and one disgruntled patient can post lots of negative reviews about one doctor on multiple sites because she doesn't like that particular doctor, and has a spiteful personality ( which often says more about her than about the doctor !)

This is why you need to take reviews with a pinch of salt, and just because one patient has had a bad experience doesn't necessarily mean that doctor is bad.

Similarly, you should worry a little bit about a doctor who seems to have all positive, glowing reviews. As we all know, it's possible to game reviews, and lots of doctors do this, because they know positive reviews can be very important in attracting patients. Thus, if there are lots of reviews which are written on the same date , or many of the reviews seem to be very similar to one another, you should be careful.

Of course, there are very sophisticated clinics which use PR agencies to write false reviews for them. This is an extremely clever ploy , which some IVF doctors use in order to get lots of positive ratings, and it can be very hard for the average patient to know how authentic or reliable some of these ratings are. This is why you should use ratings as an additional tool in your armamentarium when you're selecting a doctor, but don't get mislead by these ratings. As with everything else, they have pros and cons, and smart patients learn how to evaluate them critically.

Finally, do contribute your feedback as well, especially if you are happy with your doctor, in order to make these ratings more accurate and reliable. This will help other infertile patients to find the right IVF doctor !

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




Monday, June 27, 2016

The IVF gamble




Lots of infertile couples refuse to do IVF because they think of it as being a gamble. They think their chances of success are poor, and they don't want to risk spending a lot of money if the doctor cannot provide them with a guaranteed result. Of course, a guarantee in IVF is a very unrealistic expectation. It would be great if we could provide this, but we can't control biological processes , because doctors are human beings, just like their patients are.

Some patients would rather wait for a miracle , and they believe that their God will help them to have a baby. I think it's great to have faith in a higher power , and being spiritual helps you to cope with the travails of infertility, but if you want God to help you to win the lottery, you do need to at least buy a lottery ticket in the first place !

Patients need to understand that IVF is not like buying a lottery ticket  where everything is a matter of chance. It's much more like playing a poker game , where you can learn to improve your chances of success. 

In a lottery , you have no way of controlling what the outcome is going to be. However, there is a much greater element of skill in playing poker, where there is a big difference between a professional poker player and an amateur. Amateurs lose lots of money, because they get emotional and try to take shortcuts. A professional , on the other hand , will do his homework and study the maths, so that he is aware of the odds of success in each  hand he plays . He understands the laws of probability, and will not let his emotions cloud his judgment . He will not make wrong moves, because he knows what the traps and pitfalls are. While he knows that the outcome in any hand is uncertain, he follows the right process, so that he maximises his chances of success over time.

This is exactly the way a smart IVF patient will approach IVF treatment.  She has studied her chances of success; understands that there is a risk of failure; and will calmly and logically weigh all the pros and cons before making a decision. This is why it's extremely important that you find a good IVF clinic which is transparent, open and has your best interests at heart - after all, your chances of winning at poker are much better if you make sure you have been dealt a good hand !

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




Friday, June 24, 2016

Why do patients continue going to the same IVF doctor even after getting poor care ?


An infertile  patient just sent me this email.

Hello doctor,
This is my 3rd ivf cycle with donor egg  .. And my doctor does not provide any information about anything. My last 2 cycles failed ..in first cycle I bled on same day after ET . And in 2nd ET 1 frozen egg was transferred , which is also fail.. Now my doctor suggest me for 3rd cycle .. Today is my 13th day of period doctor tested my blood today  FSH and LH .. Which is very high Fsh is 86.4 and LH is 36.

Please advise me should i go for it ?
        Thank you

It can be very hard to advice such a patient.

She knows she is getting very poor quality care, but inspite of this, she continues her treatment with the same doctor !

Is it because this doctor provides cheap medical care ?  While it is true that patients do have financial constraints, and that IVF can be expensive, she is just throwing away her money by going to a bad clinic. Now I can understand that it's hard for a patient to differentiate between a good clinic and a bad clinic before they do their first IVF cycle. But when they have experienced poor quality treatment when doing th first cycle, then why do they persist in wasting time with the same doctor ?

Some clinics lock patients in by taking their fees in advance for a 3-cycle package. While this can seem to be an attractive option, because it reduces costs and offers the patient more hope, if the clinic is a bad clinic, she will just continue wasting precious time. What's worse is that this will deprive her of the chance to find a good clinic - and this is an opportunity cost she really cannot afford to fritter away ! Because she has burned her fingers with one IVF clinic, she will now distrust all IVF clinics, and will not have the confidence to try afresh with a better IVF clinic.

It's obvious that the doctor is taking advantage of her ignorance, and taking her for a ride - but why is she allowing the doctor to do this ? Shouldn't patients take responsibility for their decisions, rather than passively leave everything upto their doctor ?

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







Wednesday, June 22, 2016

Red flags when selecting an IVF clinic


All IVF patients know that which clinic they select for doing their IVF treatment can have a big impact on the outcome of their cycle, and this is why they spend a lot of energy and time in shopping around for the right IVF doctor. Unfortunately, a lot of them are not really sophisticated enough to be able to differentiate a good doctor and a bad doctor, and most will end up going to whichever IVF clinic their family doctor sends them to.

In the past, you could trust that your family doctor would send you to a good clinic, but as we all know, this is no longer a reliable method for selecting an IVF clinic , because the medical profession is riddled with corruption. This is why you need to do your own homework and your due diligence before blindly trusting anyone. It's a good idea to check out the IVF clinic your family doctor goes to, but please also check out at least one more.

Here are some red flags you should look out for when you are selecting an IVF clinic.

If you go to a clinic which makes you routinely wait a long time, that's a red flag, which means they don't respect your time and they're not well organized.

If you don't get a chance to talk to the main doctor, that's a cause for concern as well. Lots of clinics make you talk to the junior doctor, who will take a history which the senior doctor glances at, so that you have maybe three or four minutes to talk to the main doctor. This works well if you have routine run-of-the-mill problem, but if you want individualized, specialized, personalized care from the senior doctor, then this is not such a great method.

You should worry if everyone is put through the same battery of tests. This is a " mindless medicine" protocol where one size is made to fit all, because the senior doctor does not want to apply his mind to tailoring the treatment for the individual patient.  This is never a good idea , because every patient is different . If you are asked to do tests, there should be an explanation for what tests are being done; why they're being done ; what the doctor expects to find; and how this will change your treatment options.

You should especially wary when the tests are very expensive;  or when you're forced to go to a particular lab for the tests. Often there is a hidden agenda as to why the doctor is sending you for a particular test.

Some doctors do certain unproven tests for everyone - for example, a hysteroscopy or PCR tests for endometrial TB.  You should also worry if the doctor routinely asks for multiple tests to rule out a particular disease. Thus , some doctors have a bee in their bonnet about genital tuberculosis as a cause for infertility , and some will treat everyone with anti-TB medicines , irrespective of whether the tests are positive or negative ! I don't think this is good quality medical care and these anti-TB medicines can be toxic, have side effects, and make you waste a lot of time and money.

It's a good idea to talk to other patients in the clinic while you are waiting ( and sadly, there will be a lot of waiting in most IVF clinics ). This can be a good opportunity to compare notes, so you can compare your experiences with those of others.

Similarly, if you have a doctor who seems to be too trigger happy , and does a laparoscopy and hysteroscopy for every patient, this can be a red flag as well.

At the end of the day, I'm not asking you to become a doctor when you're evaluating a doctor . However, it's a good idea to do your homework and get a second opinion , so you can ask more intelligent questions and select the right doctor for yourself.

Online reviews about the clinic are useful , and this is something which should be explored as well. There are lots of sites which allow patients to review doctors , and they will give you a good sense of what other patient's experience with this doctor has been. Unfortunately, there are problems with reviews as well , and I'll be discussing this in the next post.

You can also get a good sense of the doctor's philosophy when you visit his website. Does he want to educate you  about infertility, so you know more about your problem , and can make well-informed decisions ? or is the website all about the doctor and is  celebrity patients ? While it can be great when you know that the doctor has lots of success stories, ultimately the focus of the doctor should be on the patient,  and you want a doctor who's empathetic and patient-centric.

You can learn a lot when you finally meet the doctor. Is he in a rush ? Or is he willing to sit down and discuss your concerns ? Does he address them all ? Is he optimistic and hopeful ? Is he willing to share information? Is he willing to empower you?

Money is always an important issue. IVF can be an expensive treatment, and there is no certainty whether the treatment will work or not. While it's true that the most costly clinic is not always the best, you should worry if a clinic charges too little, because it's quite likely that they may be cutting corners in order to reduce their costs. This may turn out to be much more expensive in the long run.

There are lots of unethical practices as regards payment, and you need to be on your guard. If the doctor asks for cash payments; or money under the table; or does not give you a receipt for your payment, then you need to worry. No  honest doctor will do this - and if the doctor is willing to cheat the government, why do you think he won't be willing to cheat you as well ?
Another common problem is that the doctor asks for additional money mid-way during your cycle for additional procedures ( without having discussed this with you when you signed up), when you are not in a position to say no. If this happens, then it's quite likely that you are being taken for a ride. 

Finally, how well does the doctor treat you at the end of your cycle ? Do they provide you with complete documentation proactively and routinely ? Do they provide embryo photos ? Or do they abandon you if your cycle has failed ?

If you feel you have received bad medical care, then please do speak up. You should provide feedback to the doctor, and to the hospital management as well. If you feel that they are ignoring you, then do this in writing. It's also a good idea to post your reviews online. This can help to protect other patients from unethical doctors.


 All this can seem to be a lot of time and trouble and effort. Isn't it just much easier to go to the first one who you pick or the one who's closest to you or the one you've read about in a newspaper article? Yes, it's easier but can often be the wrong decision, which can prove to be expensive.

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





Sunday, June 19, 2016

What Indian pharma needs to do to engage with doctors



This is based on a talk I gave recently to Mylan Pharmaceuticals.

Indian pharma needs to reinvent the way it connects with doctors. It's high time we broke the doctor-pharma nexus and started developing ethical ways of engaging doctors, so that everyone in the Indian healthcare system - patients, doctors and pharmaceutical companies, all benefit, without adopting underhand practices.

Saturday, June 18, 2016

All you wanted to know about egg freezing



Why should women consider egg-freezing?
Every woman is born with all the eggs she will ever have; when I tell my patients this in the course of their consultation, many of them are genuinely shocked. Men are able to produce new and viable sperm right through their life; by contrast, a woman’s eggs start aging even before birth, and this process of depletion continues until they are finally  exhausted at menopause.
Today a number of career-minded women  put off motherhood and the fact that they have a depleting egg count  can be downright  terrifying to them. But that’s not how it needs to be. Modern day reproductive technologies have made possible various options that enable women to have children much later in their life.  The key lies in knowing your options, so you can exercise them intelligently.
Egg freezing is now one of the simplest ways in which a woman can radically slow-down her biological clock; this option is one I recommend to young women who are concerned about their fertility.
When is the best time for egg-freezing?
 Its best to freeze your eggs when you are in your 20’s & 30’s. This is because younger eggs are of better quality, which means they will withstand the freeze and thaw procedure better. They also have a much better chance of fertilizing, because their mitochondrial energy levels are higher, which means they provide you a better chance of having a baby.
The trouble is that when women are good candidates for egg freezing –  between the ages of 30 to 35, they have so much going on in their life, and rightfully feel that their chances of finding the right person and getting married are so high , that they still not willing to consider the possibility that they may have difficulty having a baby in the bedroom when they want one. The biological clock is still quite muffled at this stage in a woman’s life ! This is why it’s usually when they start crossing 37 that they start exploring all these additional options. They may have heard stories from their friends, who needed to do IVF to have a baby. This is wake-up call for them, and they are prodded into exploring their reproductive desires much more closely. While we are happy to do egg freezing for any woman, no matter what her age, the reality is that they may not have such a great success rate, and it would have been much better for them to have done it earlier, rather than to have postponed making this decision for so long.
How is the egg-freezing procedure like?
The egg freezing process isn’t all that complex. Once you qualify as a candidate for egg freezing, we will then plan a cycle around your menstrual cycle. As soon as it begins, we begin administering fertility hormones. These are in the form of daily injections and you are required  to take them for about 10 days ,  after which your eggs will be extracted at the clinic. The 30 minute procedure is  done under light sedation, is quick and painless. Your eggs are then frozen by the embryologist in the IVF lab, using a flash freezing ( vitrification) protocol. Survival rates are nearly 100%.
Will freezing my eggs now make me run out of them later?
This is a misconception, and a very common one at that. This is because we are  only freezing the eggs which you would otherwise have lost. Typically, only one egg gets ovulated each month, but 30-40 follicles start the maturation process. These normally die every month, because they undergo atresia. With the fertility hormone treatment, we are effectively disrupting this loss , which means we are saving those eggs  which would have died under natural circumstances. You also need to keep in mind that the hormonal injections we use are natural hormones, which get excreted promptly, and don’t have any long-term side effects.
What are the success rates of having a healthy baby through frozen eggs?
The success rates of having a healthy baby depend upon many variables, including: the number of eggs frozen ; the quality of the eggs; and the experience and expertise of the IVF clinic doing the egg freezing.
The younger the age at which your eggs are frozen, the better your chances of having a healthy baby with them
While it’s hard to provide precise success rates for an individual woman, the rule of thumb is that a woman less than 35 should freeze approximately 20 frozen eggs to have a chance of about 80% of having a healthy baby. While the survival rate of frozen eggs after thawing is excellent, we need to remember that human reproduction is not an efficient enterprise – and this is true both in the bedroom and in the IVF lab . Thus, about 60% of these eggs will fertilise after thawing when ICSI is done; and about 40% will form Day 5 embryos ( blastocysts). When a blastocyst is transferred, it has about a 30% chance of implanting and becoming a baby. Since each frozen egg is worth its weight in gold, it’s a good idea to freeze extra eggs, to make sure your safety net is robust – and in case your want more babies in the future !  This means you may need to do 1-3 egg freezing cycles, to give yourself a good chance of having a baby. This will depend upon your ovarian reserve, and whether you have conditions such as PCOD or endometriosis. The rule is simple – more is better !
How long will my frozen eggs last?
Theoretically, forever! The eggs are frozen at -196, which means they are in a state of suspended animation, and will remain here until we thaw them, because all their metabolic activity has been stopped at this low temperature. The technology has been used for over a decade now and there are healthy children from eggs which have been frozen for 5-9 years.
Are babies that have been  created using  frozen eggs as healthy as all other babies?
Regardless of whether IVF babies have been created using fresh or frozen eggs ( or frozen sperm or embryos for that matter) , they are as healthy as any babies that have been born naturally.
What are the complications?
It’s very important that you take all these medications the way they have been prescribed by your doctor. You may also be asked to avoid sexual intercourse for a certain period of time.  The symptoms you should be wary about are:
•    Temperature above 39°C
•    Severe abdominal pain/swelling
•    Severe nausea/vomiting which doesn’t go away
•    Heavy vaginal bleeding (though light -bleeding is normal)
•    Difficulty urinating/painful urination
•    Fainting/dizziness
Any final words of advice for the readers of EggChill?
It’s great that advances in reproductive  technology now offer so many additional options to women, so that they can now control their own reproductive destinies, rather than depend upon the vagaries of nature. Biology is not destiny, and we need to make sure women are made aware of their options, so they can make well-informed choices for themselves

This article first appeared at http://eggchill.com/dr-malpani/

Want to know more about egg freezing ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !




 

Friday, June 17, 2016

Endometriosis - what's the right treatment ?


Endometriosis has always been a tricky problem . We still don't understand who gets endometriosis ; what causes it; and why there is such little correlation between the extent of the disease and their patient's symptoms. There are still lots of unresolved questions, which is why there are so many controversies about the impact of endometriosis on fertility . This is why patients with endo are so confused about which is the right treatment for them. After all , if doctors are confused , it is highly likely that patients are going to be completely perplexed as well . This is why patients find that they get diametrically opposite advise , depending on which particular doctor they go to.  Thus, is a patient with a chocolate cyst goes to a general gynecologist , she is likely to advise medical therapy by putting her on Lupron depot , in order to suppress her menstruation , which will offer her pain relief . If she goes to a laparoscopic surgeon , he is likely to advise laparoscopic conservative surgery , to remove the chocolate cyst. And if she goes to an IVF specialist for a third opinion, he is quite likely to tell her to do IVF so that she can get pregnant quickly , which will cause the symptoms to get better, and will often cause the endo to  regress as well.

While every doctor will tell you the advantages of the treatment option they are offering,
unfortunately they will not tell you the disadvantages of each of their treatment modalities . Thus, while medical therapy will suppress the periods and stop the pain , it will not affect the chocolate cyst , which will remain exactly the same . This means that when you stop the Lupron Depot,  the pain will comes back and the adhesions will also remain exactly the same . This means that all you can do with medical treatment is to buy time. Also, Lurpon can be quite an expensive injection , with some nasty side effects , and you can't keep on taking it again and again .

While laparoscopic surgery is very good at a removing the chocolate cyst , the surgery cannot stop it from recurring . Again , over enthusiastic surgery will reduce ovarian reserve , because normal ovarian tissue is also removed along with the cyst wall, and this can make the patient's infertility worse.

While IVF maximizes the chances of getting pregnant quickly , it is an expensive treatment, and it's better to try simpler options first.

This is why the patient's persona; preferences are so important . Patients need to consider three key variables when making a decision. These are: the presence of a chocolate cyst; pelvic pain ; and infertility . Some patients may have all three, and while they are correlated, they each need to be analysed separately. 

Only those chocolate cysts which are more than 30 mm need to be considered when formulating a treatment plan - and only if this increases in size on serial vaginal ultrasound scans . Lots  of cysts can be left alone. Sadly, a lot of the surgery which is done for cysts is completely inappropriate , because patients are scared into signing up for surgery by being told that the cyst may rupture, and cause complications. It's perfectly acceptable to be conservative, and leave an asymptomatic chocolate cyst alone . It cannot be monitored on serial ultrasound scans to see whether it remains the same size, since we cannot predict the natural history of the cyst in patients. Also, surgical treatment does come with a price - that it can reduce fertility; and will also not prevent the cyst from recurring. Medical therapy has no role to play , because it will not cause the cyst to change in size . There are non surgical options for treating the cyst, such as a vaginal ultrasound guided cyst aspiration . This is a simple procedure which can be repeated, but because it does not remove the cyst wall, the cyst can refill quickly, which means it's usually just a temporising measure.

A major issue for some patients with endometriosis is pelvic pain, and this can sometimes be chronic and disabling. The priority for this group of patients is relief from their pain, so they can carry on with their life.

The third common symptom is infertility, and often the diagnosis of endometriosis is made during the workup for infertility.

We need to remember that we need to treat the patient's problems - the reason she came to the doctor in the first place. Thus, if the cyst was an incidental finding during the infertility workup, then the primary focus should be on helping her to get pregnant ,rather than treating the cyst. We should not be treating images on an ultrasound scan - we should be solving the problem for which the patient came to you ! After all the patient doesn't come to you and say, "Hi doctor, I have a chocolate cyst and this needs to be treated." The cyst is diagnosed only after doing a scan, and good doctors only  do a scan when the patient has a problem.

Thus, if the primary presenting problem is pain, then this is what we need to focus on. This is why the patient's medical history and personal preferences are so important . Doctors need to sit down with the patient , and ask her what her priority is. Thus, her treatment options will vary depending on whether her goal is to be pain-free, or to have a baby.  This means that we cannot use a "one size fits all" approach, and the treatment plan needs to be tailored to the patient's needs. Thus,  a 5 cm chocolate cyst will be treated completely differently, depending upon who has it. If it's an older patient , who doesn't want to have babies anymore , and whose biggest problem is pain , then removing the ovaries makes a lot of sense , because this will provide her with dramatic pain relief , without any chance of it recurring again.

On the other hand if another patient has a 5 cm cyst as well as severe pain, but wants to have a baby more than anything else, then perhaps IVF is the best way to go. Once she has a baby, she will be happy and not only will she be pain-free during her pregnancy , her cyst may resolve as well . If we chose to do surgery first to remove the cyst , she might get some pain relief , but this would also reduce her ovarian reserve and damage her future fertility.

As with everything else in life, when there are multiple complex variables involved, it's important to factor all these in before making a decision . It's important for the doctor to understand what is most important to the patient.  This require a mature patient , who understands her disease ; who has studied her treatment options; and who is assertive , and is willing to articulate her personal preferences.  It also requires an empathetic doctor who is willing to sit down with the patient, explain to her what her options are, and in what sequence they should be done, so she maximizes the benefits of medical treatment.

With this approach , it's possible for to have her cake and eat it too, otherwise she may end up damaging her fertility in her pursuit of "treating" a cyst which could perhaps have been safely left alone. It's only when patients are aware of these trade offs that they can make well informed decisions , so that they have peace of mind they have received good quality medical care.


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






Thursday, June 16, 2016

Why doing a D&C after a miscarriage is a bad idea



One of the hardest things for an infertile couples to deal with is a miscarriage after an IVF cycle . While not getting pregnant can be heartbreaking , losing a pregnancy after getting pregnant is far worse . Sadly, IVF does not provide any protection against miscarriage , and just like a natural pregnancy has a miscarriage rate of about 10% , so does an IVF pregnancy . The loss is far more acute, because this is such a deeply desired pregnancy . A miscarriage can often be the last straw which breaks the camel' s back , and many patients will give up after this. This is a shame, because the fact that you have got pregnant ( even if you did miscarry) means your chances of having a healthy baby have actually improved !

Most pregnancy losses ( whether after IVF or after sex in the bedroom) occur in the first trimester - usually in the first 8 weeks. They are called missed abortions  - perhaps because the embryo is missing on the ultrasound scan . The HCG levels rise as expected, but when the doctor does the scan at 6 weeks, this shows that there is a pregnancy sac. but it's empty - there is no baby.

Patients can't understand how they can be pregnant without there being a baby. The reason is that pregnancy consists of both the embryo , as well as the placenta - the extra embryonic tissue which is needed to support the pregnancy. It's the placenta which produces the HCG, which is why the HCH levels rise well, even though there is no embryo ( the medical term for which is anembryonic pregnancy).

The commonest for an early miscarriage is a genetic problem in the baby , and this is why many doctors advise patients to do a D&C ( dilatation and curettage) after a missed abortion , so that they can send the pregnancy tissue (called the products of conception ) for chromosomal testing , in order to document this. This seems quite logical at first blush,  but is actually a completely pointless test , especially if this is your first miscarriage. This is because the test result does not change your treatment options for the future at all.

Let me explain . Just because the karyotype report  is normal,  this does not mean that the reason for the miscarriage is not a genetic problem . Remember that all a karyotype can do is to count the number of chromosomes and check their shape - it cannot test for all possible lethal genetic defects, because it's such a crude genetic test. Also, even if the karyotype is abnormal, this makes precious little difference for the future, because most chromosomal anomalies are because of random defects, and are very unlikely to recur in the next pregnancy.

Just because there is a chromosomal error in this pregnancy, this doesn't mean that the patient is at increased risk for a chromosomal defect the next time she does IVF. Also, do remember that the IVF procedure itself does not increase the risk of the embryo having a genetic defect - this defect is usually completely random.

Chromosomal testing of the fetus (using either cell culture or genetic sequencing techniques) is expensive, and we don't learn anything useful from it . What's much worse is that doing a D&C can actually harm the patient's future fertility.

Often the doctor needs to do a lot of scraping in order to completely remove the fetus after a missed abortion, and this can cause intrauterine adhesions , which reduce your chances of getting pregnant in the future.

If you are unlucky and do end up having a missed abortion after your IVF treatment, you need to be emotionally resilient ; terminate the pregnancy with medical therapy ; and learn to look at the glass as being half-full. The fact that you have got pregnant means your chances of having a healthy baby are actually far better and someone who's never been pregnant at all - and if you can carry to 8 weeks, there's a very good chance you can carry to 8 months as well !

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




Tuesday, June 14, 2016

Why don't Indian doctors listen to their patients ?


A very articulate patient was complaining to me that doctors in India just don't listen to patients. She had a  cyst in her ovary and had been to see 3 gynecologists. She said - Most of them don't even bother to take a history ! They refuse to answer my questions, or explain my options. It's usually - This is my advice - take it, or leave and find another doctor !

Why do patients feel that Indian doctors don't care about their perspective ? I think this is because doctors have such different worldviews about their patients.

Some doctors feel that patients are not very smart , and that they should just leave all medical decision-making about their disease to the doctor, who's the medical expert. They often get irritated by patients who do internet searches , and don't like having to answer questions put to them by patients. They hate patient who bring long lists with them, and will often put these patients in their place by either tossing their questions in the waste paper basket , or by patronizing them by saying things like, "Just leave everything to me, and don't worry about it."

At the other end of the spectrum are doctors who respect patients who ask intelligent questions , and they try to empower their patients with information.

Here are some reasons for the differences in these kinds of doctors.

Part of it is related to their training. Typically, doctors who have trained overseas are far more likely to be empathetic, and much more willing to respond to their patients' queries. Doctors who have trained only in India are often more paternalistic , because they absorb the behavior patterns of their teachers and seniors.

The patient population the doctor treats makes a big difference as well. Thus, if you work in a government hospital , or if most of your patients are poor, this colors your perception , because these poor patients are often treated as second-class citizens. Often, they're not very articulate or well organised. They may have lost their old records because they live in a slum, and often they cannot provide a cogent medical history because of poor literacy.  In government hospitals, there is a huge mass of patients waiting to be seen , which means that the doctor doesn't have the luxury of time to be able to sit down and have leisurely conversations with these patients .

I think the age of the doctor makes a difference, as well. Senior doctors are more likely to be patronizing, because this has been their default behaviour , and this is what they think their patients expect from them - to be told what to do. The younger generation of doctors is more willing to encourage questions.

The specialty of the doctor also makes a difference . Thus, pediatricians and psychiatrists are much more willing to spend time talking to their patients, as compared to surgeons, who would much rather be in the operation theater, rather than in the consulting room , listening to their patients' litany of complaints.

Finally, the doctor's behaviour depends upon his personality . Some doctors position themselves as being authorities , and will not brook any questions from anyone. Others are much more willing to learn from their patients, because they know that they are not omniscient.

I agree that this is an overgeneralization, but this framework will help patients to understand the differences between the different kind of doctors whom they see. Ultimately, patients get the doctors they deserve, so you need to find a doctor whose consultation style is in sync with yours , so that you're both comfortable with each other, and you can trust him.

Need help in finding a doctor who listens to you ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !





Sunday, June 12, 2016

How an innovative artist portrays an embryo !






Each cell of this embryo contains an image of a flowering tree - the spring of life ! Gina Glover is a truly remarkable artist. You can see this poster at the Guy's Hospital IVF clinic.

When a picture is worth a 1000 words !

Gina Glover is the creative artist, who used ties to demonstrate what sperm can look like. This highly original work of art is at the Guy's Hospital IVF unit in London !

Friday, June 10, 2016

Why PGS Testing is a waste of time and money


I gave a talk at the CUPART Conference in Goa on why PGS testing for aneuploidy testing to try to improve IVF success rates in older women is a waste of time and money

Thursday, June 09, 2016

Helping children to learn by tinkering

I am an angel investor in Bibox. Check out the cool stuff they are doing at www.bibox.in !

How we prevent errors in our IVF clinic


The biggest nightmare for any IVF patient ( and doctor) is an accidental mix-up of eggs, sperm or embryos. After all, they all look the same, do how do we make sure that there are no errors ?

IVF is as prone to errors as any other treatment because it is provided by a host of people working together – doctors, nurses, receptionist, ultrasonographers, lab technicians and embryologists. It requires lots of coordination, and there are few treatment processes for which a team approach is more important than for assisted reproduction. Close, continuous communication is required at many levels to ensure everything goes as planned.

Communication matters

Regular interaction is required to assure that infertile couples are adequately prepared, and that scans, blood tests, egg collections and embryo transfers are performed seamlessly. IVF offers a wide variety of mix-and-match treatment options, because there can be multiple sources of eggs, sperms, and uteri; and lots of different physicians are involved, including reproductive endocrinologists, urologists, anesthetists and counselors.

All of these can produce an environment of controlled chaos that must be managed. Important to the issues of patient safety and the integrity of an ART program are the ways in which a program handles the difficult issue of medical errors. Total freedom from error is only possible in theory. Response to errors, when they occur, reveals the integrity of the program and should be based on established processes.

The errors

IVF programs can be madhouses of activity, and the possibility of an error creeping in is every IVF clinic’s nightmare. There are two primary types of errors in IVF:

•    One, in which the eggs or sperm are mistakenly used with the gametes of another person ; or the wrong embryo is transferred to a patient
•    The second, which leads to the loss of sperm, eggs, or embryos (for example, because of a power failure as a result of which the incubator malfunctions).

IVF mix-ups are every patient’s and doctor’s nightmare, and lots of high profile cases have been described where this has happened. The trouble is that eggs, sperms, and embryos look exactly the same under the microscope !  Errors can be avoided by:

•    Obsessive labeling
•    Double witnessing, where a second person double checks the identity of all the dishes in the lab can help reduce this risk
•    Electronic witnessing, using coding and RFID (radio frequency identification) technology has also been introduced to prevent gamete mix-ups.

If a mix-up does occur and is noticed, this must be brought to the doctor’s attention immediately.  Even if the embryo has not been transferred, the patient should be informed, so they can decide on a course of action they are comfortable with.

The second type of error may or may not lead to a reduced chance of reproduction. A loss of part of a sperm specimen or improper handling of immature oocytes may not result in a dramatic change in the outcome of the cycle for the patient. Although there can be a difference of opinion about whether this should be disclosed, the ASRM Ethics committee states that it’s best to disclose even minor mistakes that have potentially adverse effects for patients.

"If, on the other hand, there is clearly no adverse effect and if disclosure may unnecessarily compound the stress of patients, disclosure may not be obligatory." However, the perception of dishonesty resulting from attempts to cover errors is often worse than the actual medical error.

Maintaining transparency is important

Good IVF clinics have policies and procedures in place that deal specifically with medical error. These should include definitions; statements about who should be informed, when, and how; and mechanisms for determining the cause of the error and preventing its repetition. Policies should encourage a culture of openness, address the ill effects of trying to cover up errors, and very importantly, include corrective actions to minimize future errors.

They should be based on the understanding that errors can and will occur, and that a better assessment of errors will improve the mechanisms for preventing and correcting them. This has a positive effect on staff morale, which further enhances safety. A mechanism for reporting both within the clinic and the laboratory allows for analysis of near misses. Incidents that do not result in harm should also be reported to allow process optimization that can prevent serious errors.

Process mapping

IVF care is a complex clinical process, and the clinical activity needs to be categorized into compartments. This allows us to depict them as flow diagrams that allow study of sources of error or risk. This promotes the ability to streamline the interaction of multiple complex tasks performed by different clinical and administrative units such as nursing, laboratory, and billing departments.

In addition to reducing effort, which in turn can decrease the sources of error, the process map gives all the staff members an overview of the complete treatment cycle, so that the right hand finally knows what the left hand is doing. This improves coordination and communication, and allows each staff member to put patients first. Because they can see the big picture, the staff is now no longer just focused on doing their individual job, but understands that their goal is to help the patient along her IVF journey.

Flow process diagrams allow us to assess the risk of error at each step in a clinical process. For example, what would happen if the lab did not report the estradiol value in a timely fashion to the doctor when he is timing the HCG trigger shot? The systematic evaluation of risk points can lead to an action plan that results in minimal errors in the future.

Establishing metrics and tracking provides a means for following the success of error reduction over time. Parameters can be as simple as checking to see what percentage of patients are phoned the day after egg collection to make sure they are comfortable and are not developing OHSS. Such simple proactive measures can help to make IVF safer for patients.

We use an EMR ( electronic medical record) to document that we have provided treatment correctly and safely. This allows team members to communicate with each other, and with the patient as well.

The laboratory is the last stop in the complex process of IVF treatment and laboratory personnel must confirm that all consents are current and complete for the intended treatments. In the absence of these documents (whether paper or electronic), the embryology laboratory should not perform the procedures.

Improving safety is not the responsibility of only the clinic staff.  Thus, drug manufacturers have started to provide the medications which patients need to self-inject daily in pre-filled syringes, so that their chances of making a mistake in taking the injections is reduced.

The patient is the final line of defense against errors. Making sure the patient knows what is supposed to happen next is the best way of reducing errors.  This is why we have created the free My Fertility Diary app (www.myfertilitydiary.com); it allows patients to track and monitor the progress of their IVF cycle. If they know what’s going on, they are empowered to speak up when the cycle does not progress as planned.

LinkWithin

Related Posts Plugin for WordPress, Blogger...