Friday, December 08, 2017

Why are IVF patients so reluctant to get a second opinion ?


If you are not happy with your IVF doctor, it's very logical that the next step should be to get a second opinion. However, most patients are extremely reluctant to do this .

For one, they have an existing relationship with their doctor , and they feel they will be disloyal and unfaithful to that doctor if they look for a second opinion - especially if they go behind his back ! (  Incidentally, this is not true. Every good doctor will encourage a second opinion because they want their patients to be happy with the care they are providing. They are confident that what they're doing is correct, and are quite pleased to allow another doctor to confirm this fact!) If your doctor doesn't want you to get a second opinion , or blocks you from doing this by refusing to give you your medical records, this in itself is a red flag !

Many patients are worried that the new doctor will make them undergo all the fertility tests all over again . Their experience has been that anytime they go to a new doctor, he badmouths the first doctor , and wants to repeat all the tests all over again,  because he doesn't trust the earlier laboratory. This consumes a lot of time; causes a lot of discomfort; and wastes a lot of money. This is why there is so much inertia, and patients usually prefer sticking to the known devil , rather than look for a new one. After all, what's the certainty that the new doctor will be any better ?

They are also secretly worried that if the new doctor points out that the quality of care their current doctor has offered is sub-par, this will confirm their worst fear - that they have wasted all their time, money and energy - and no one likes having their errors pointed out to them !

Ideally, if you want a second opinion, your doctor should be happy to give you a copy of all your medical records . In fact, he should be quite happy to reach out to the new doctor and help to facilitate the second opinion process , because he knows it's in everyone's best interests. Good doctors are professionals, and they understand that patients have the right to get a second opinion . They know that they are offering high quality treatment, and if the second doctor reinforces that fact, the patient will have even more confidence in them, and the trust will become even stronger.

Please explore the option of getting a second opinion - especially if you think your current IVF doctor is stuck and doesn't know what to do next !

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, December 06, 2017

How many IVF cycles should I do?


This is one of the commonest questions patients who have failed an IVF cycle ask when they come to me for a second opinion.
Is it worth doing another  IVF cycle?  What should I change ? Do I need to do anymore tests ? Should I expect to do three ? or four? How much stamina do I need? How much will this deplete my bank balance? Will multiple IVF cycles damage my health ?
Sometimes, with a lot of patients, you know that repeating the IVF treatment is futile, but many patients continue clutching at straws , because they're not willing to accept the truth.
Often they read about some fancy new research ( either in the newspaper or on a website )  which claims to dramatically improve IVF pregnancy rates . They some with this newspaper report or website printout, saying, "Can't you do this for me?" You then have to do through the details , and often you end up explaining to them that the research was done in a mouse laboratory, and has not been proven to be safe to use in humans,
Then they come after a few weeks , with a full page colour ad from a spanking new clinic that offers the "latest advanced technology" - and ask - Should I go to them, since they seem to offer much more than you can !
False hope can be cruel, but hope springs eternal in the breast , and if  it wasn't for hope, none of us would survive for too long. This is what makes things so difficult for both patient and doctor - it's no fund having to explain the limitations of modern technology to a patient who feels you have all the answers, and wants you to deliver a miracle.
A good doctor would tell the patient the truth that, "Look, a lot of these things which sound good on paper don't stand the test of time . New is not always better, and it's not a good idea to use yourself as a guinea pig."
However, patients need to make their decisions for themselves, and if they want to try something new, unproven and experimental, it's hard to stop them. After all, there is no medical risk when doing IVF - the risk is predominantly financial and emotional. If patients understand that and are still willing to go ahead, then perhaps a doctor should not stop them from doing what gives them peace of mind, even if this is illusory.
However, one thing which patients forget to factor in is the opportunity cost of doing repeated IVF cycles. After all, if you repeat the same thing, you're mostly going to end up with the same outcome - there's no logical reason for it to be different after you have done 4 IVF cycles .
The problem is that because you have locked yourself into repeated IVF cycles, you end up stopping yourself from enjoying all the other pleasures which life has to offer you. Also, this pig-headedness can stop you from exploring alternative options , such as adoption or third party reproduction - a decision which you may come to regret as you grow older.
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, December 05, 2017

How confusing sperm test reports end up confusing patients


A patient just sent me his sperm test report, and he was feeling very guilty that he had not been able to get his wife pregnant, because his report was so abnormal !

This is a great example of a bad report, because the doctor is providing a clinical opinion based on a lab report - something which a good pathologist will never do ! After all, interpreting the report and explaining it to the patient is the clinician's job !

Sadly, most gynecologists are completely clueless when it comes to making sense of a semen analysis report, and they also get confused with all the medical jargon this pathologist has stuffed his report with. All he has done is scare the poor patient !

He has also smartly suggested to the doctor that he should order additional expensive tests - which he is happy to do - at an additional charge, of course !

The fact that he says that normal counts can vary from 1 - 150 million means he is badly informed. However, because this is such an impressive report, both the referring doctor and the poor patient will get fooled.

Need help in making sense of your semen analysis report ? Read more at http://www.drmalpani.com/knowledge-center/resources/book/chapter4b

Why PCO patients should induce a period every month


Polycystic ovarian disease ( PCOD) is a common cause of infertility. Typically, most of these patients have irregular cycles because they don't ovulate regularly. Now, because they don't ovulate, they don't get pregnant , and they don't get regular periods either . This is because they produce a lot of estrogen, but there's no progesterone production at all, because of the lack of ovulation.

Now, this means that every time they miss a period, they're very hopeful that this time they could be pregnant. They wait and they wait, and after two months or three months they don't get a period, they finally go to a doctor who does a pregnancy test and then induces a period for them with tablets which contain progesterone. This happens once; then it happens twice ; and when it happens again and again , they start getting fed up and frustrated.

A lot of them are very scared of all these hormonal tablets which their doctor uses to induce a period , because they have been told that artificial hormones are dangerous ! They are worried that they will cause cancer; or will have side effects ; or that they'll get dependent on these tablets , which means their body will never start working properly. As it is they have low self-esteem, and this just makes it worse.  A lot of them believe that if these tablets are powerful enough to induce a period, then if they accidentally take the tablet when they are pregnant , they will end up miscarrying and losing the pregnancy.

This is why they waste a lot of time waiting to get a period. Not only does this false hope just add to their stress, it is also the cause of a lot of wasted opportunities. Until they induce their next period, they're not going to be able to ovulate,  and therefore won't be able to get pregnant. This means that if in an entire year, if they only get a period four or five times, their chances of getting pregnant on their own goes down dramatically.

This is why PCO patients must induce a period once a month , so that they have a better chance of getting pregnant Once they've induced a period, they can then try to induce ovulation in the next cycle. The tablets which  are used to induce a withdrawal bleed contain a hormone with the unpronounceable name , medroxyprogesterone acetate ( MPA for short).

The good news is that these tablets are  extremely safe. These are natural hormones, the same hormones their body would normally have produced if they'd ovulated on their own . Because it's a natural hormone, it has no long-term side effects . Of course, the tablets only act in the month in which they take them . This often confuses them, because they feel that they have become "dependent" on the tablets.  The truth is that the underlying disease remains - after all, the progesterone doesn't treat or cure the PCOD - it  just induces a period , and that is it's only role.

The beauty about progesterone is that it's very safe during pregnancy. This means that even if they take it inadvertently when they're pregnant, there is absolutely no risk to the baby. 

Taking progesterone to induce a monthly period is something which PCO patients need to learn to do for themselves - and a good doctor will teach them how to do this, so they don't have to go running to the doctor every month every time they miss a period. Patients need to learn more about their chronic disease , so they're empowered enough to be able to manage it for themselves. There are a lot of simple things that they can do for themselves, so they don't have to seek medical attention unnecessarily , or waste a lot of time in their quest to have a baby.

Even if PCO patients don't want a baby,  they should still induce a period every month. Otherwise, the continuous unopposed estrogen exposure will cause their uterine lining to build up, and endometrial hyperplasia can be a premalignant condition if not treated properly.

You can read more about how we treat PCOD at
http://www.drmalpani.com/knowledge-center/the-infertile-woman/how-to-manage-your-pcod







Friday, December 01, 2017

Poor quality IVF treatment

I received this tearful email from a patient.

I have a very sad medical history .  I used to get extremely painful periods (I got my first periods at the age of around 14-15 years) where medical help was always required by me. The doctors in my home town could not understand the problem and we were completely relying on the best doctors of our city. I was treated for depression, epilepsy, abdominal TB, hormones, etc. etc. because they believed that my symptoms were similar to any of these ailments.
After years of treatment but no relief (around 11 years of treatment with no solid diagnosis, no reports nothing), I got married at the age of 28 and there after when I was not able to conceive my husband took me to SCI International Hospital in February 2016. After proper diagnosis they told us that I was suffering from endometriosis. I had my laparoscopic and hysteroscopic surgery in October 2016 at Indraprastha Apollo Delhi. I got my next periods in around Feb-Mar 2017 after surgery.
Thereafter it was followed by two IUI failures and two IVF failures. My last negative HCG report I received on 28th November 2017. My doctor says everthing was good. She said it was magical that I had good number of eggs during both my IVF cycles, with two Grade A and one grade B each time. So everytime they put in three embies in me and everytime it did not exist.
The doctor says probably it is not God's will otherwise they had tried their best. I am not much satisfied by blaming God and myself. If everything was good then why did I have so many failures. There must be some reason behind it? The reason is yet undiscovered. If the problem is with eggs then why did I get grade A embryos each time and if the problem is with uterus then even donor eggs cannot help me...
I strongly believe that if there is a problem, there will be a solution to it. The only thing is 'a right person who can given right suggestion is required'. I request you to kindly go through the reports that I am attaching with this mail and provide your valuable suggestions.
I replied, asking for more details about her IVF cycle, so I could offer suggestions. After all, I need more medical details, so I could guide her properly.

Can you send me more details about your IVF cycles ?
DO YOU HAVE PHOTOS OF YOUR EMBRYOS ?
You can see what embryos should look like at http://www.drmalpani.com/knowledge-center/ivf/embryos
What were the  meds which were used for
superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood at the time of the HCG trigger ? What was the endometrial thickness ?
How many embryos were transferred ?
What was the embryo quality ? 
Can you please send me the printed treatment summary from your IVF clinic ?
Her reply was

Thanks for your kind response. I do not have any photos of my embryos. Should I ask my doctor to share it with me? I mean I was not aware that photos of embryos are also taken during the treatment but if it is taken during the procedure, please confirm, I will then speak to my doctor about this. 

This is a patient with a complex problem, whose IVF doctor has not been transparent and open with her.  Anyone who says the embryos were Grade A , without specifying the number of cells in the embryo and giving embryo photos , is not being completely honest. Of course, part of the problem was she didn't know what questions to ask, as a result of which her doctor did not bother to share the basic details with her.

If she had done her homework before starting her IVF cycle, she would have learned that the only tangible product an IVF clinic can deliver is embryos , and all good clinics provide embryo photos proactively and routinely to all their patients, to document they have delivered high quality medical care.

Sadly, she has learned the hard way that she can't leave everything upto the doctor either - and she needs to be a well-informed patient, if she wants to get the best 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 !








Why pregnancy rates are better with single Day 5 embryo ( blastocyst) transfers

Logically, one would expect that the pregnancy rate would be better if we transferred two embryos at a time, as compared to putting back only  one .  Yes, this is true if you calculate the success rate per transfer, but not true when you calculate the cumulative pregnancy rate - the total chances of getting pregnant after transferring all the embryos back.

Let's assume you have 2 top quality blastocysts, and that each blastocyst has has a 30% chance of implanting if we transfer it in an optimally receptive endometrium.

Now if we put two embryos back at the same time, each of them has that 30% chance,  and the limiting factor will be endometrial receptivity. If the endometrium is optimal, then there is high possibility that both may implant, which is why the twin pregnancy rate is high after IVF.  Sadly, our technology for assessing endometrial receptivity is still crude, and we are forced to depend upon the endometrial thickness and texture as measured on the ultrasound scan to judge this , because the new generation ERA ( Endometrial Receptivity Assay ) tests are a waste of time and money.

Now the reason why only one implants ( and the other doesn't, even though the uterine lining is receptive) is because one of the blastocysts has a genetic problem ( which we cannot test even with PGS, because PGS only allows us to count the number of chromosomes) , and this prevents it from implanting. This is why transferring two blastocysts has a better pregnancy rate than transferring just one  when you calculate the success rate per cycle - you are improving the chances of transferring a genetically normal embryo by putting back two instead of one.

On the other hand, it's possible that when we transfer two genetically normal blastocysts,  neither of them will implant because there's a problem with endometrial receptivity. This means no matter how many blastocysts we transfer in that cycle , none of them would implant. If we put two together , we have wasted both these precious embryos . On the other hand , if we put one at a time, each embryo has its own chance of becoming a baby, because the endometrial receptivity may be better in one cycle as compared to another. This way, we are maximizing the probability of achieving a pregnancy for these women , because we are making the best possible use of these blastocysts.  I agree this sounds very hit and miss, but sadly these are the current limitations of IVF technology today, and ERA and PGS do not help in overcoming these.

The truth is that each blastocyst is worth its weight in gold , and should be given the best possible chance of becoming a baby. The best way of doing this is by transferring one single blastocyst at a time in an optimally prepared endometrium. Yes, this does have disadvantages , because it does mean that the patient needs to come back again for the next cycle, in case the first one fails.

However, the good thing about transferring frozen embryos after thawing them is that this is a simple procedure , which is not expensive. The patient doesn't need to take any injections and it can be done in a natural cycle as well.  Because we can focus on optimizing both the embryo as well as the endometrium , because we're doing these independently, the overall chance of achieving a pregnancy is much better. Sometimes, less is more !

Rather than just calculate pregnancy rate per transfer, patients need to focus on the cumulative conception rate, so that their chances of taking a healthy baby home is maximized.

Is your doctor suggesting you transfer more than one embryo in one cycle ? This suggests he has no confidence in his IVF lab, and you should look for another IVF clinic !

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, November 30, 2017

Was your IVF failure because of bad luck ? or because of a bad clinic ?

We all know that IVF does not have a 100% success rate, but when an IVF cycle fails, you are never sure what the reason for the failure was.

Was it because of plain bad luck ? After all, why good looking embryos do not implant is still one of those things we do not understand - it is one of medicine's unsolved mysteries ! We know that human reproduction is not very efficient, and even fertile couples take time to make a baby in their bedroom, which means sometimes all patients need to do is be patient and try again.

Or was it because the IVF clinic was not good enough ?

How is the poor patient meant to decide what to do next ? Should she  stick with the same doctor ? Or should she change clinics ?

This is the million dollar question, and  the answer depends upon doing a careful analysis of your failed IVF cycle - preferably by an independent IVF expert, who can tell you if the quality of care you received was upto the mark.

The good news is that there are only two simple questions you need to answer to make a well-informed decision !

1. Did the doctor do a blastocyst ( Day 5) transfer ?
2. Did he give you photos of your embryos before transferring them ?

If the answer is No, then this is red flag, and you should strongly consider changing your clinic !

The only tangible product an IVF clinic can deliver is embryos !  All good clinics provide embryo photos proactively and routinely

Any clinic which does not provide embryo photos is a poor quality clinic.

Please find a better clinic if you want to maximise your chances of success - one which does only blastocyst transfers and provides embryo photos routinely to all patients !

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, November 26, 2017

Why didn't my egg fertilise after ICSI ?

A patient just sent me this email.

We had our 1st cycle in July this year with ICSI as I had just turned 45 years and my partner is same age, we had a very good grade 1 embryo put back but didn't implant.

So we have just now had another cycle on the 24th November this month, I had a mature egg follicle size was 19 mm sperm was good they done ICSI again but this time they said it didn't fertilize ?

They told us the egg was good and the sperm was good but it just didn't happen.

How can I have a good egg and sperm but didn't fertilize using ICSI . I could understand it if the egg wasn't a good one or sperm, and how come we had a grade one embryo few months ago and now nothing?

Does this sound right to you ? ICSI with a good egg good sperm but no fertilization I cant get my head around I've been so upset.

This was my answer to her.

Yes, this is frustrating, but it's quite common to have failed fertilisation after ICSI when women are more than 40 years of age

This is because the egg may look good, but because it has aged, the mitochondria ( the energy powerhouses of the cell)  in its cytoplasm do not have enough  ability to be able to power cell division

This is why a woman's fertility drops as she gets older !

The limitation with IVF technology today is that we cannot test the mitochondrial competence of the egg .

What can you do when your IVF doctor does not agree with you ?

Infertility presents a number of unusual challenges .  

It is caused by a medical problem -  for example, blocked fallopian tubes,  or a low sperm count - and this means we can offer medical treatment for it, but the truth is that childlessness is a social label. This is why treatment for infertility is elective - and patients have to decide for themselves if they want to do IVF or not. 

This is why there really is no right answer or wrong answer as to what kind of treatment IVF patients should be taking. For example, the medical treatment which would give the highest chances of success for an older woman with poor ovarian reserve (a reduced AMH level and a low antral follicle count ) would be to do donor egg IVF.  In all other areas of medicine, the doctor would advice her to do the treatment which maximises the chances of a good outcome. However, if she wants to try IVF with her own eggs, how can you refuse her this option ?  As a doctor you know that her chances of getting pregnant with her own eggs are extremely poor , but if she still insists that she wants to use her own eggs , you have to respect her personal choices. You know there's a high probability that both the quantity and the quality of her eggs will be  poor, so you try to explain to her that her chances of having live birth chances are low, but she is still the final decision maker, since it's her baby. She is using you to provide her with technical assistance , and wants to make her own choices for herself.

 Now from a purely scientific point of view, this may be an irrational decision, because using donor eggs will increase her chances of having a baby enormously , and after all isn't that what she wants - a baby ? So why not suggest that she uses only donor eggs?  However, for something which is so personal and private as reproduction , these are decisions which patients need to make for themselves. These are usually emotional decisions, which they then justify for themselves by using logic, saying, "Well, even a 1% chance is better than a 0% chance. So why don't I at least give it my best shot?" 

This can be very hard for a doctor . Where does one draw the line between offering what seems to be futile treatment , as compared to respecting the patient's autonomy and allowing her to decide for herself ? 

There are no easy answers , and this is a bit of a problem , because there are greedy doctors who will take advantage of the patient's desperation . They are happy to offer any kind of treatment the patients wants , because they're quite happy to charge the patient an arm and a leg for fulfilling her desires , even though they know that the treatment is doomed for fail, and she will just end up wasting a lot of money.

However, when there is so much money at stake, it's sometimes hard for a doctor to stick to the higher moral ground. It's very tempting for him to say, "Yes. I know the chances are poor, but after all, I need to do what the patient wants me to do. Why should I discourage her ? If I say no, I don't earn anything at all - so why refuse the income ?  In any case, even if I say no, she'll just go to some other doctor, so isn't it better that I offer her the treatment myself, rather than reject her and send her to my competitor?" 

Reproductive medicine is not just science - it also involves art and commerce , and this is why it can be extremely challenging for doctors to make the right decisions for their patients. This is why respecting the patient's decisions can be so difficult - especially when you know that they are just deluding themselves, and you don't want to be a party to offering them false hope.

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, November 23, 2017

Is it safe for me to postpone having children for the next 4 years ?

I just received this email from a young 31 year old woman.

" I have an exciting job in a bank, and want to pursue by career. I am married, but want to postpone having a child for the next 3-4 years, as I am on a the fast track to cracking the glass ceiling. However, my mother is insisting that I put my career on hold, and have a baby  now. She is worried that I will find it hard to conceive if I put this off any further - and that I won't be able to enjoy my baby if I get older. What are my options ?"

This has become an increasingly common dilemma for young professional women today. Like their male colleagues , they too want to have a baby and pursue their career , but are unsure about how deferring child-bearing will affect their fertility - especially if they want to have more than 2 babies.  How can they have their cake and eat it too ?

It can be very hard to set priorities, and women are often torn between growing their families , or growing their career.

There are no easy answers, and each woman needs to find her own solution.

It's a good idea to check your ovarian reserve, so you have some idea about how much time you have left before your ovaries let you down.

The easiest test is a simple blood test which checks your AMH level , and you can read more about this at http://www.drmalpani.com/knowledge-center/infertility-testing/amh. While a single level will not provide a fool-proof answer, measuring your ovarian age by checking your AMH level is much more useful than just going by your calendar age ! Equally importantly, you can test this on an annual basis, so you can track your ovarian reserve over time.

Also, testing your antral follicle count by doing a vaginal ultrasound scan ( read more about this at http://www.drmalpani.com/knowledge-center/articles/afc) provides valuable information about how much time you have left to safely postpone childbearing.

Yes, you can do IVF if you get older, but IVF does not turn back the biological clock, and if you have poor quality eggs, then the pregnancy rate with IVF is poor, and you maybe forced to use donor eggs to have a baby. You may then bitterly regret your decision of postponing having a baby !

One option which is worth exploring is social egg freezing, so you can store your young eggs in an egg bank, and use these when you are ready to start your family - one way of having your cake, and eating it too !

Please share your favourite doctor story !


Most of us trust our doctors, and are grateful to them when they help us to get better.

However, we rarely get a chance to express our thanks.

Please share your story about your favourite doctor at www.mydoctormyhero.com !

We are offering a prize of Rs 1000 for the best story of the week !

Why you should transfer only a single blastocyst !

Today, our standard practice is to freeze all your embryos at a blastocyst ( Day 5) stage, and then transfer them after thawing them in the next cycle, one at a time. Here's why we think this is the best method for optimizing your chances of having a healthy baby.

Let's start off with why we don't advise doing fresh transfers.  The chances of getting pregnant depend on two variables - 1. the quality of the embryo, and 2. endometrial receptivity.

In a natural cycle, endometrial receptivity and the embryo are synchronized perfectly, which is why fertile women  get pregnant in the bedroom so easily. However, in a fresh IVF cycle, because we're super-ovulating you, our focus is on getting you to grow lots of good quality eggs. However, this often means that the price we pay for this is that your endometrial receptivity gets impaired. The truth is that it's hard to have your cake and eat it too, which means we need to compromise when doing an IVF cycle.  This is why, even though we get great quality embryos, they may not implant. Now this is true even though the endometrium looks fine on an ultrasound scan , and this is because its receptivity at the molecular level has taken a beating , because of the high levels of hormones to which the endometrium has been exposed to during the fresh cycle.

This is why we think freezing all the embryos, and then transferring them later on, is a better option. This allows us  to focus on one thing at a time. In the first fresh cycle, we focus on your super-ovulation protocol, to get lots of eggs and good quality embryos. Then, in the second thaw cycle, we can focus on your endometrial receptivity , because we already have good quality frozen embryos , and we just need to transfer them. Thanks to our embryologist's extensive experience and expertise with vitrification, our success rates with freezing and thawing embryos is practically 100%, which means no harm is done to your precious embryos as a result of the freezing and thawing.

Why do we prefer transferring a single blastocyst , as compared to transferring two embryos ? I think we all should agree that transferring more than two is irresponsible , because it just increases the risk of a high order multiple pregnancy. This is dangerous for the babies, because of the risk of prematurity ; and doing procedures like selective fetal reduction to salvage the situation often means that you may end up miscarrying and losing all your babies - something for which you will never forgive yourself !

If I had to pick between one and two, I would still advise one. Now, this, again, is not intuitive because lots of patients say, "  A twin pregnancy is fine - it's actually a bonus, because I get an instant family   ! What's wrong with putting two back?"

Let's look at this logically. Each embryo has its own independent chance of getting pregnant.  Let's assume that if we put one top quality blastocyst back in an optimally receptive endometrium, it has a 30% chance of becoming baby.

Now if we put two embryos back at the same time, each of them has that 30% chance,  and the limiting factor is endometrial receptivity. If the endometrium is optimal, then there is high possibility that both may implant, which is why the twin pregnancy rate is high after IVF.  Now the reason why only one implants ( and the other doesn't, even though the uterine lining is receptive) is because one of the blastocysts has some kind of genetic problem, which prevents it from implanting. It's impossible to identify this in the lab, and this is why transferring two blastocysts has a better pregnancy rate than transferring just one - you are improving the chances of transferring a genetically normal embryo by putting back two instead of one.

On the other hand, it's possible that when we transfer two genetically normal blastocysts,  neither of them will implant because there's a problem with endometrial receptivity. This means no matter how many blastocysts we transfer, none of them would implant. If we put two at a time, we have wasted both these precious embryos. On the other hand , if we put one at a time, each embryo has its own chance of becoming a baby, because the endometrial receptivity may be better in one cycle as compared to another. This way, we are maximizing the probability of achieving a pregnancy for these women , because we are making the best possible use of these blastocysts.  I agree this sounds very hit and miss, but sadly these are the current limitations of IVF technology today, and ERA and PGS do not help in overcoming these.

The truth is that each blastocyst is worth its weight in gold , and should be given the best possible chance of becoming a baby. The best way of doing this is by transferring one single blastocyst at a time in an optimally prepared endometrium. Yes, this does have disadvantages , because it does mean that the patient needs to come back again for the next cycle, in case the first one fails.

However, the good thing about transferring frozen embryos after thawing them is that this is a simple procedure , which is not expensive. The patient doesn't need to take any injections and it can be done in a natural cycle as well.  Because we can focus on optimizing both the embryo as well as the endometrium , because we're doing these independently, the overall chance of achieving a pregnancy is much better.

I think this is what patients need to focus on - the cumulative conception rate, so that their chances of taking a healthy baby home is maximized.

Is your doctor suggesting you transfer many embryos ? This suggests he has no confidence in his IVF lab, and you should look for another IVF clinic !

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, November 22, 2017

When IVF Patients Make Irrational Decisions


Infertility presents a number of unusual challenges for doctors.  It is caused by a medical problem -  for example, blocked fallopian tubes,  or a low sperm out - and this means we can offer medical treatment for it, but the truth is that childlessness is a social label. This is why treatment for infertility is elective - and patients have to decide for themselves if they want to do IVF or not.

This is why there really is no right answer or wrong answer as to what kind of treatment IVF patients should be taking. For example, the medical treatment which would give the highest chances of success for an older woman with poor ovarian reserve (a reduced AMH level and a low antral follicle count ) would be to do donor egg IVF.  In all other areas of medicine, the doctor would advice her to do the treatment which maximises the chances of a good outcome. However, if she wants to try IVF with her own eggs, how can you refuse her this option ?  As a doctor you know that her chances of getting pregnant with her own eggs are extremely poor , but if she still insists that she wants to use her own eggs , you have to respect her personal choices. You know there's a high probability that both the quantity and the quality of her eggs will be  poor, so you try to explain to her that her chances of having live birth chances are low, but she is still the final decision maker, since it's her baby. She is using you to provide her with technical assistance , and wants to make her own choices for herself.

 Now from a purely scientific point of view, this may be an irrational decision, because using donor eggs will increase her chances of having a baby enormously , and after all isn't that what she wants - a baby ? So why not suggest that she uses only donor eggs?  However, for something which is so personal and private as reproduction , these are decisions which patients need to make for themselves. These are usually emotional decisions, which they then justify for themselves by using logic, saying, "Well, even a 1% chance is better than a 0% chance. So why don't I at least give it my best shot?"

This can be very hard for a doctor . Where does one draw the line between offering what seems to be futile treatment , as compared to respecting the patient's autonomy and allowing her to decide for herself ?
There are no easy answers , and this is a bit of a problem , because there are greedy doctors who will take advantage of the patient's desperation . They are happy to offer any kind of treatment the patients wants , because they're quite happy to charge the patient an arm and a leg for fulfilling her desires , even though they know that the treatment is doomed for fail, and she will just end up wasting a lot of money.

However, when there is so much money at stake, it's sometimes hard for a doctor to stick to the higher moral ground. It's very tempting for him to say, "Yes. I know the chances are poor, but after all, I need to do what the patient wants me to do. Why should I discourage her ? If I say no, I don't earn anything at all - so why refuse the income ?  In any case, even if I say no, she'll just go to some other doctor, so isn't it better that I offer her the treatment myself, rather than reject her and send her to my competitor?"

Reproductive medicine is not just science - it also involves art and commerce , and this is why it can be extremely challenging for doctors to make the right decisions for their patients. This is why respecting the patient's decisions can be so difficult - especially when you know that they are just deluding themselves, and you don't want to be a party to offering them false hope.

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 !





Saturday, November 18, 2017

Egg freezing - how old is too old ? The limits of IVF technology


While the Times of India article about a celebrity carrying a twin pregnancy after egg freezing will help increase awareness about the option of social egg freezing as a method for preserving fertility in older women, I am very concerned about the misleading message this is going to  send to most  women!
They are going to start believing that IVF specialists are magicians  who can get anyone pregnant - and that a woman's biological age does not affect her fertility. Women will delude themselves that they can happily postpone having a baby for as long as they like , but this is false ! There is a price you pay when you try to have your cake and eat it as well, and the bitter truth is going to create a lot of unhappiness when they find out the truth.  When have a biological clock, and while egg freezing is a sensible option for women in their 30s, to try to offer it to women in their 40s is foolhardy.
This particular story itself is a little hard to swallow. The success rate of freezing eggs at the age of 41 is exceptionally low  - and then to get pregnant with twins with these frozen eggs requires one to suspend their credulity. Human reproduction is not efficient, and there is a lot of wastage and attrition even during IVF. Yes, we can make a 40 year old grow follicles, but many of these will not contain eggs; many of these eggs will not fertilise; and very few will form good quality blastocysts which are worth transferring.
Yes, we can get older women pregnant easily, but they have to be willing to use donor eggs , and this is not an easy decision. Of course, clever older women who use donor eggs to get pregnant can now claim that they got pregnant with their own eggs which they had frozen when they were younger - and no one's going to challenge them !
The facts are that the ovarian reserve for a woman drops off dramatically after the age of 38, and the pregnancy rate with IVF even with fresh eggs after the age of 40 is less than 5% per cycle. The live birth rate is even lower, because embryos from older eggs  have a much higher rate of  genetic anomalies !
The right age to freeze eggs is less than 35, because it gives women a good chance  of having a baby. Most IVF clinics will agree that doing this after the age of 40 is futile.
On second thoughts, maybe I shouldn't complain about this misleading article , because all IVF clinics will now get lots more  referrals from older women who want us to freeze their eggs, but giving patients false hope is hardly the right way to practise medicine !

Wednesday, November 15, 2017

Please don't do a laparoscopy !

Many doctors routinely do a laparoscopy and hysteroscopy for all infertile women.

They justify this by saying it's a simple diagnostic procedure, which will allow them to confirm that there is no anatomical problem.

They also say it's "minor surgery", which just involves a "small cut" and a few hours stay in a hospital.

What they don't tell the patient that there's absolutely no need to do a laparoscopy at all ! Let's not forget that the safest surgery is the one you don't need to do !

The truth is that laparoscopy does not provide us with any useful information which we cannot obtain with simpler non-invasive tests, such as a HSG and a vaginal ultrasound scan. Even more importantly, it really does not change the treatment options for the infertile couple.

The biggest danger is that it can actually reduce your fertility. Once the doctor puts a telescope inside your belly, he often gets "itchy fingers", and will do a procedure which is not called for at all !

If you doctor tells you to get a laparoscopy, just say No !

Wednesday, November 08, 2017

IVF failure - what next ?

After an IVF cycle fails, the first question patients ask is - What do we do differently the next time ?

The answer to this question depends upon analysing the failed cycle systematically. After all, in order to move forwards, we first need to look backwards, so we can plan the next IVF cycle more intelligently.

This is why it's so important that you insist that your doctor give you photos of your embryos and your medical records at the time of the transfer ! This information is worth its weight in gold 

Monday, November 06, 2017

How to judge the quality of your IVF doctor at the time of your first consultation

Most patients naively assume that all IVF doctors are equally good, but this is completely false.

There is a world of a difference between a good doctor and a bad doctor, and this affects your chances of getting pregnant enormously !

Please don't get misled by advertisements - you need to do your own research to make a well-informed decision.

The good news is that it's easy to assess the quality of an IVF doctor the first time you meet him, provided you have done your homework properly.

Is the doctor well-organised ? systematic ? Does he have a well-defined process ? Is he happy to answer your questions ? Does he spend time talking to you, or are you forced to deal with assistants ?

Selecting the right IVF doctor is a critically important decision, so please listen to your gut when making this choice !

What are my chances of getting pregnant with IVF ?


This is one of the commonest questions patients ask, but it's actually not a very helpful question for many reasons.

1. While clinics can share their success rate. remember that this percentage figure applies to a group of patients they have treated in the past, and this is not something you really care about. What you really want to know is what your chances of getting pregnant are  - and it's impossible for anyone to predict this for an individual patient !

2. For an individual patient, the percentage figure is meaningless, because the outcome for you is binary  - you either get a baby or you don't, which means the final answer is either 100% or 0 % !

3. For many Indian clinics, the figures they quote are not reliable, so take these with a large pinch of salt !

In any case, a far better way to think about this is in terms of delta , or difference.

The key question should be - How much will doing IVF improve your chances of having a baby, as compared to doing nothing ? Thus, if you have blocked tubes, you know that your chances of having a baby without IVF are zero, and you may decide anything is better than zero ! However, this is a very personal decision, and you need to make this for yourself, so you have peace of mind you did your best, and have no regrets later on.

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 !





Saturday, November 04, 2017

Has your IVF cycle failed ?

Instead of allowing your doctor to subject you to a battery of useless tests which will just send you off on  wild goose chase, first make sure you review your medical records, and photos of your embryos.

This is invaluable information, which will guide you what to do next !

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, November 03, 2017

Should I use donor eggs to have a baby ?

It's hard to have to accept that you may need to use donor eggs in order to have a baby - after all, we all want to pass on our genes to our children !

You might find this classic poem by Kahlil Gibran useful in guiding your decision !



On Children
 Kahlil Gibran
Your children are not your children.
They are the sons and daughters of Life's longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them,
but seek not to make them like you.
For life goes not backward nor tarries with yesterday.
You are the bows from which your children
as living arrows are sent forth.
The archer sees the mark upon the path of the infinite,
and He bends you with His might
that His arrows may go swift and far.
Let your bending in the archer's hand be for gladness;
For even as He loves the arrow that flies,
so He loves also the bow that is stable.

Sunday, October 29, 2017

Why is it so hard to interpret a semen analysis test?


The sperm test is the simplest and commonest test done for evaluating an infertile couple. It allows us to evaluate a man's fertility, and because it's cheap, it's the one which is done first.

However, its apparent simplicity conceals how complex interpreting this test really is !

Because it's a routine test, one of the biggest problem is that lots of laboratories do it , and most of them have no idea how to do the test properly ! The technician does not have enough experience, and will often not have the right equipment ( such as a phase contrast microscope; or calibrate sperm counting chambers) .
This is why a lot of men end up with very unreliable reports, which their doctor cannot interpret intelligently, because they can't be trusted. This creates a lot of confusion ! This is why we see many men whose sperm counts fluctuate all the way from 5 million per ml to 60 million  per ml, depending on which particular laboratory they do the test from ! The irony is that all the reports are most probably wrong.  To add insult to injury , doctors will start "treatment" based on these reports - and it will be impossible to assess whether the treatment is helping - or harming !

Thus, it's very common to find round cells in the semen and these are usually sperm precursors, which are quite normal. However, these are often mis-reported as " pus cells ", and the poor man is treated for months on end with antibiotics to treat the " infection " !

Similarly, most labs are just not capable of staining the sperm to check their morphology - the proportion of normally shaped sperm in the sample, and these numbers are just cooked up by the technician.

The problem is not just poor quality labs however. Often men don't do the test properly because they have not been given the right instructions. There needs to be at least a 3-day abstinence period ;  the man needs to make sure that he collects the entire ejaculate in a clean container ; and the sample should be delivered to the lab within an hour or so . Unfortunately, lots of men don't follow these instructions , and sometimes they are too embarrassed to tell the lab that they have spilled the sample !

Another  huge problem is that gynecologists don't have the expertise to interpret the semen analysis report properly . Gynecologists are specialists in taking care of the health of women, and never see a man in their professional practice. Yes, they can figure out if the report is normal or not, but unfortunately they're not good at being able to understand the nuances of an abnormal sperm test report. This is why they often end up confusing the patient , and send him for all kinds of "advanced" sperm function tests ( which are promoted by the sperm testing laboratories  because they generate extra revenue for them!)  These tests serve absolutely no purpose at all, and make a bad situation even worse, because they don't provide any useful clinical information at all.

Often gynecologists will refer men with an abnormal report to a urologist or an andrologist, and this just compounds the problem,  because the left hand has no idea what the right hand is doing, and the treatment of the infertile couple gets fragmented and uncoordinated !

The truth is that there is very little effective treatment a male infertility specialist can offer, but because he needs to demonstrate his expertise, he will ask for a whole new batter of additional tests ! These include all kind of pointless , expensive and embarrassing tests, such as a colour Doppler to check for varicoceles ; and transrectal scans to check for ejaculatory duct obstruction. As part of the panel of tests which are ordered to be "thorough" with the evaluation, many doctors now also order hormonal blood tests ( FSH, LH, prolactin, testosterone); as well as chromosomes studies - all of which are a complete waste of time and money. The poor patient ends up going from one doctor to another , and since no one has a clue what is happening, he loses confidence in all the doctors.
It's not just a limitations with doctors - the truth is that medical science still doesn't know what a normal sperm test report is ! Many decades ago, a normal sperm count used to be considered to be 60 million per ml.  A few years ago, it was 20 million per ml. Currently, the "new normal" is 15 million per ml. It's hardly surprising that infertile men are going to say, "Hey, if science doesn't even know what a normal sperm count for a fertile man is, then how can they help me to interpret my particular report?"

The dirty little secret is we can't. We can tell a man with a zero sperm count that he can't father a pregnancy in the bedroom, but we can't really tell a man who has sperm in his semen whether he can get his wife pregnant or not !

This might seem surprising ! After all , isn't that the purpose of a semen analysis ? Yes, that's what an ideal sperm test would do, but a semen analysis is an extremely crude test , and doesn't provide us with that information. Yes, it does tell us what the sperm count is, and whether the sperms are moving or not, but that's not the question which the man is asking ! He wants to know, "Can I get my wife pregnant or not?" This is a completely different question , and because it's much more complex , it's not possible for us to answer this as yet.

After all, the fertility of a couple doesn't just depend on the man's sperm count or motility - it also depends on his wife's fertility ! This means that it's possible that if he had married a younger, more fertile woman, then he would have been able to get her pregnancy even with a very low sperm count !

This is why infertile men often end up getting such a raw deal - and this is why it's best for them to go to an infertility specialist , who deals with the infertile couple as a unit - and not just either a gynecologist ( who has no idea how to deal with infertile men) or an andrologist ( who has no idea how to treat infertile women!

You can see what a sperm test report should look like at
http://www.drmalpani.com/knowledge-center/resources/book/chapter4b

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, October 26, 2017

Prenatal Testing: What is a Nonstress Test?


Expectant mothers always have this constant worry about their baby’s health, especially since congenital birth defects can possibly happen to some. Good thing there are prenatal screening tests that can be done, usually within the first and second trimesters, to rule out this possibility. Once a screening test shows a positive result, diagnostic tests will then provide a conclusive answer.
Some prenatal tests may be required for pregnant mothers as routine procedures, while others may be offered additional screening exams, especially those with higher risk of bearing a child with certain health conditions. One of these additional prenatal exams include a fetal nonstress test.

What to know about a nonstress test
Also known as a fetal heart rate monitoring, a nonstress test (NST) is a common prenatal exam to check on the baby’s health. The procedure involves a monitoring of the baby’s heart rate in response to his movements. The test is termed “non-stress” since it is noninvasive, meaning there is literally no stress placed on the fetus over the duration of the procedure.
During a nonstress test, the healthcare practitioner checks on the baby’s heartbeat on two occasions: while the baby is at rest and while he is moving. Normally, the baby’s heart rate increases when he is kicking or moving, just as our heart beats faster when we are active.
Nonstress test for high-risk pregnancies
Generally, the goal of a nonstress test is to evaluate the baby’s oxygen supply based on how his heart rate responds to his movements. But when is it really necessary?
Your doctor may recommend a nonstress test done if the mother is already past her due date, or if she is having a high-risk pregnancy a month or two leading up to her due date. Specifically, you may need to undergo a nonstress test if you have a pregnancy-induced high blood pressure, type 1 diabetes, or a heart disease.
You are also likely to need this screening test if you have had a history of complications during a previous pregnancy, Rh sensitization, oligohydramnios or a low amniotic fluid, or if your baby is shown to have decreased fetal movements or growth problems.
What to expect during an nonstress test
Before the procedure, the doctor may advise you to grab a meal to hopefully stimulate your baby to move during the test. It may also help to use the bathroom prior to the test, as you will remain strapped to a monitor for the next hour or so.
During the procedure, you will be asked to lie on your left side. Then, two fetal monitor pieces, an ultrasound transducer and a toco transducer, will be placed on your abdomen with elastic belts holding them in place. The ultrasound transducer measures your baby’s heart rate while the toco transducer keeps track of the uterine activity.
The results of an NST may either be reactive or nonreactive. It is reactive if the fetal heart rate increases when the baby moves, which should happen at least twice in 20 minutes. To stimulate the baby, the nurse may have you drink water or juice.
However, if the baby’s heart does not beat faster upon movement, or if he is not moving, the test will show a nonreactive result. But a nonreactive result should not be a cause of worry just yet as this could only mean the NST has not given enough information that you need. During such time, the doctor may recommend additional tests such as a contraction stress test or a biophysical profile to further check on the baby’s condition.

Prenatal testing is important to ensure that the baby is growing and developing normally. Although such screening tests and procedures may indicate undesirable results, the good thing is that certain measures can be done promptly to guarantee a safe and healthy delivery of your child. 

Saturday, October 07, 2017

Why IVF patients need to be optimistic !


Most IVF patients are extremely optimistic that their IVF cycle is going to work for them. If every patient didn't think in their heart of hearts that the cycle was going to be successful, no one would ever have the courage to start one. After all, a failed cycle causes a lot of heartache and heartburn . Patients are putting a lot on the line when doing IVF - not just in terms of money, but also in the form of hope, time and energy .
 
 They know that a lot rides on the outcome of the cycle , and because IVF gives them the best chance of having a baby , they're gather up all their courage and start off on a cycle. Of course, they're also very worried that the cycle may fail, and the ones who are realistic and well-read and have done their homework understand that the odds are stacked against them. After all, human reproduction is not efficient, and embryo implantation is a biological process which no doctor in the world can control. 
 
Even after knowing that the chances of failure are more than the chances of success in a single cycle, the fact that they're still able to go ahead does mean that they need to be highly optimistic. And even if this optimism may seem to be irrational, it's often the only thing which allows them to start a cycle. 
 
IVF is not an easy ride , and tests the emotional resilience and maturity of a patient. Lots of them are never be able to start another cycle when the first cycle fails because they had so much hope invested in the first one. That's why it's important to find the right degree of balance between optimism and realism when starting the treatment.  Patients need to be prepared that it can take 3-4 cycles to have a baby, and these patients will have the courage to bounce back and give it another shot even if their cycle fails.
 
I agree this is not easy, and every patient needs to find what works best for them. Yes,  it's important to hope for the best, but it's equally important to prepare for the worst , so you don't go to pieces in case the cycle fails.  This is why it's important to step back and take a long-term perspective . Even though an individual cycle may fail, we still have the ability to learn a lot from that failed cycle, and can use this information to improve your odds of success for the next cycle. 
 
It's important to think of IVF as a process which may take three or four cycles before it gives you the deeply-loved baby you want , rather than think of it as a single shot affair. Of course, in a perfect world , every IVF cycle would work, but then patients wouldn't need any counseling at all ! IVF technology has not brought us to that point as yet, so you need to be able to shield yourself from the possibility of heartbreak.

Unnecessary testicular surgery for the infertile man


A common fashion these days in some IVF clinics is to do TESE-ICSI for men with severe oligoasthenospermia ( low sperm count).

This is justified by saying that these men with " abnormal sperm"  have  high sperm DNA fragmentation, and this will result in poor fertilisation and poor quality embryos.

The solution they propose is extracting sperm directly from the testes, by doing a TESE, the theory presumably being that testicular sperm will not have as much DNA fragmentation because they are "fresh".
Of course, it also goes without saying that doing an additional procedure allows the IVF clinic to charge more !

This is complete rubbish, and TESE should only be done for men with azoospermia ( zero sperm count).

If there are sperm in the semen, then these should be used for doing ICSI - there is no need to use testicular sperm at all

Please don't let the doctor assault your testes for no rhyme or reason !

IVF scams never seem to end !


I am always impressed by how creative IVF clinics are - at cheating their patients !

The latest scam is " Biologically Active Peptide Concentrate or BAPC , to improve a thin uterine lining ! This is completely untested and unproven, but is being "sold" to patients as the latest and most advanced treatment !

It's scary how easy it is to take advantage of a gullible infertile patient's emotional vulnerability. All you need to do is to coin a clever new acronym, and start selling your product ! Pay the doctor a hefty kickback, and he'll be happy to "treat" his patients using your clever new innovation - even if it's no better than sterile water!

What can patients do to protect themselves ?

Tuesday, October 03, 2017

Why an IVF doctor is an active angel investor


I am a full time practising IVF specialist, which is why people sometimes wonder why I am investing in startups so actively. Why do I want to wear a new hat at this stage of my life ?

There are many reasons why I am very glad I have gone down this path.

I believe you remain young as long as you keep on learning new stuff, and while I know a lot about IVF, there's lots of stuff I don't know about many other fields. I am curious and I like learning more, and a great way of learning is by investing in start-ups . These founders are domain experts, who have the courage to have a contrarian point of view. They  think they can do a better job than the existing incumbents, which is why they're willing to challenge them. This requires a lot of conviction, and I learn a lot about the domains I invest in, thanks to them.  This makes life much more interesting , because practically everything I read is grist to my mill, and can be of use to one of my founders.  I need to be interested in what is happening in many domains, rather than be myopic and think only about what I need to do for my IVF patients.

I believe in the T-shaped model of leading life, which means you acquire a lot of expertise and depth in one particular niche, and then apply it to other fields. Angel investing allows me to do this. If you want to be a good angel , you need to be a well read philosopher ! Because I invest across many different domains, I need to keep up to date on what's happening in all of them, so I can have intelligent discussions with entrepreneurs. This is why investing is the last liberal art !

Neither of my daughters  is a doctor, and  while one is doing her MBA at Stanford, the other is working in a clean-tech startup in San Francisco after completing her Masters in Environmental Management in Yale. I need to be able to understand what they are doing, and I don't want to lose their respect just because I cannot decipher cash flow statements. Angel investing allows me to keep up with them !

One problem with being a doctor is that you tend to hang out only with other doctors, and as doctors get older, they get a skeptical and cynical. They are always complaining about how people don't respect doctors anymore; and how patients are always on the internet,  trying to second guess their doctors. They keep on reminiscing about the good old days, but these aren't going to come back, so there's no point in wallowing in nostalgia ! The problem with hanging out with pessimists is that you become pessimistic yourself, and start thinking that the world is going to the dogs.

It's much more interesting to think about the future, and what we can do to make it better. Entrepreneurs have to be optimistic , because they're willing to invest time and energy on tackling complex challenges. My hope is that their optimism will rub off on to me as well !

Life has been kind, and because I have been lucky to have a friend like Rakesh Jhunjhunwalla ( India's Warren Buffett), I have more than enough money to be contented and happy.  Making more money is not going to change me or my lifestyle, so I would rather invest in startups, even though they are a riskier asset class. My investment in them has the potential to create much more good, especially because I have a soft corner for social impact investing. If I can help the next generation of entrepreneurs to make the world a better place by funding them, this is the best use I can find for my money ! This is why I find angel investing  very rewarding, and look forward to being an active angel investor in the future as well.

My next post will be on why being an IVF specialist helps me to become a better angel investor ! Stay tuned...




Monday, October 02, 2017

The poor infertile man


Male infertility is common, and is usually responsible for about 40% of all infertile cases. The commonest reason is the low sperm count, also known as oligospermia.

What breaks my heart is the poor quality of treatment which these men get. Typically, they go to a gynecologist who has no clue about how to deal with men , because all they do is deal with women. However, when confronted with something they don't understand, like most doctors, they mindlessly tick off lots of boxes on a laboratory order form, to "investigate" so they can make a "diagnosis". They usually order a panel of tests , including hormone levels ( such as FSH, LH, prolactin, tesosterone); karyotype                   ( chromosome test ) ;  and a doppler ultrasound ( to check for a varicocele). However, none of which these are any use whatsoever in a man with a low sperm count ! The very fact that the man has some sperm in his semen means all his tests are going to be normal ! Most minor abnormalities are of no clinical importance.
Even worse, these results don't provide any actionable information , because there's nothing we can do to increase the sperm count ! However, doctors are never happy just prescribing tests - they love to " treat" as well ! They advise a lot of lifestyle modification measures, such as eating a healthier diet; doing more exercise; taking cold water showers; wearing boxer shorts; reducing stress levels; taking holidays; as well all kinds of empirical therapy , such as antioxidants . All this expensive rubbish doesn't help with improving the man's fertility at all, but just ends up making him feel persecuted. Yes, a man's sperm count will occasionally increase , but this hardly helps - fluctuations in the sperm count are very common, even without treatment.
However, all this therapeutic meddling makes the poor man's life hell. As it is, he feels inferior and inadequate, because he can't get his wife pregnant - something which any normal man should be able to do with ease ! His low self-esteem just gets worse, and he blames himself for being the cause of his wife having to suffer taunts from the rest of the world.

Even after complying with all the onerous restrictions placed on him ( no social drinks, and not even an occasional smoke), most of the time there is no improvement in the sperm count at all. This is when he loses confidence completely in all doctors.

The man with a low sperm count should just accept the fact that there are lots of things doctors don't understand. One of these is why men have a low sperm count, which is why we can't do much to increase it.
If you are one of those unfortunate men who does happen to have a low sperm count, please stop beating up on yourself. Make sure you repeat the test again, preferably from another more reliable lab , to confirm the diagnosis. However, if the results  remain persistently poor, then your options are limited.

Some gynecologists and IVF centers will refer you to an andrologist , who's supposed to be a specialist in treating male infertility. However , the reality is there's very little this specialist can do for you.  Good andrologists will be honest and tell their patients, "Look, there's no point in wasting your money taking all the empirical therapy we're going to give you. It's far better to just go on and do ICSI".

However , this is not something which most patients want to hear, and they often pressurize the doctor into writing medicines for them. When the doctor can see the patient twist his arm for a prescription, he is happy to write this, so he can move on to the next patient , rather than wasting his time on these hopeless cases , for which he knows he really can't do anything. However, this means that another three months of the poor patient's life is wasted, and his poor wife keeps on getting older !

Sadly, the torture doesn't stop even after starting the right treatment, which is IVF/ICSI . If the embryo is of poor quality and the IVF/ICSI  cycle fails, many doctors blame the failure on the poor quality of the sperm, and suggest to the man that they use donor sperm the next time ! This is plainly ridiculous, since the only reason for doing the ICSI in the first place was the poor sperm . When doing ICSI, we need only 1 sperm to fertilise 1 egg , and it doesn't matter how poor quality the semen sample is at all !

The reason for poor quality fragmented embryos is much more likely to be a poor quality lab, but the doctor blames the man for this, and does even more pointless tests, such as sperm DNA fragmentation, to prove to him that the "fault" is his, and that it his poor sperm which are responsible for the IVF failure !

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