Monday, April 24, 2017

Do doctors charge too much ?


A doctor's income seems to have become an extremely sore issue in this day and age. Lots of people, right from the average citizen to the PM , feel that doctors charge way too much. Their belief is that medicine is supposed to be a noble profession,  and doctors should not allow their minds to be contaminated by base commercial considerations .  After all, doctors are highly educated professionals, and they should take delight in helping their patients to get better, rather than trying to maximize their income.
Lots of people believe that doctors have become too commercial and uncaring, and that their primary focus is on earning more, rather than providing good clinical care. This is why we are now seeing a backlash against doctors. They are getting beaten up by angry patients; the judiciary as well as the media are happy to criticise them; and  politicians are happy to pander to the masses by putting a price cap on procedures and medical equipment, so that they can make healthcare more affordable.
Doctors, on the other hand, feel very embittered that in spite of sacrificing the best years of their life burning the midnight oil in order to master medicine, they make a fraction of what corporate executives do. It burns them up that hot shot lawyers charge over 10 lakhs for making an appearance in court, irrespective of whether they open their mouth or not. They are knowledge workers, just as lawyers are, and yet people grudge them their fees. They can't understand why society uses such double standards when dealing with doctors. All a lawyer does is win a case, whereas a doctor can actually save your life - and how can anyone measure the worth of a life ? Doctors hare the fact that when a doctor messes up, judges are quick to  fine them crores of rupees, but when they perform life saving surgery, patients are reluctant to pay even a few thousand. Where's the justice in this ?
The problem is that we can't put a price on saving human life, which is why we expect doctors to be satisfied with compliments and gratitude. While these are great for enhancing a doctor's emotional income, how do they expect a doctor to survive on these ?
While an emotional income can be personally satisfying, how can the doctor use this to make a living ? He needs to pay money to buy a house to live in ; and send his children to school. Even if we wants to run a clinic to treat his patients, he still needs to buy the office space , the medical equipment, and pay the electricity bill.
The divide between doctors and patients is progressively widening. A doctor feels he gets grossly underpaid . No matter how many hours he may have spent in the middle of the night, struggling to save his patient's life, when the patient gets better, all he gets is gratitude. However, when the patient doesn't do well ( often for no fault of his) he becomes the patsy who is at the receiving end of the patient's ire.  This is why doctors feel they are getting an extremely raw deal.
There is no correlation between the amount of effort and time which he has invested in his career , and the return which he is now getting. This causes a lot of heartburn, and this is one of the reasons why doctors no longer want their children to become doctors anymore. They feel that all those years of hard work they have put in are never adequately compensated. Now it's not that doctors are greedy  - if they were, they would have become bankers - they are intelligent enough to have got into any profession of their choice ! They don't expect to roll in wealth , but they do want to make enough to be able to live comfortably.
I think we need to stop grudging them their fees. I agree there are a few greedy doctors, but by being miserly and by underpaying doctors, we're harming everyone in the healthcare system. It's because doctors are not paid well that they to resort to all kinds of underhand means in order to increase their income levels.
I think this is one of the problems we are seeing an epidemic of medical corruption today. It would be far healthier if doctors were paid freely and fairly for their professional services, and were given the value and the respect which they deserve.  Unfortunately, in India , we don't seem to value advice.  Thus, while patients are willing to pay surgeons a fat fee for doing an operation, they are not willing to pay family physicians for the advice they give , even though the advice may be far more valuable because it helps to save them from unnecessary surgery. Underpaying doctors just increases medical corruption because doctors can't live  on love and fresh air.

Saturday, April 22, 2017

All doctors need to become patientologists


Doctors take pride in mastering the scientific minutiae of medicine . On the top of the medical hierarchy are the super specialists - the ones who have a lot of technical expertise in a very narrow slice of medicine. They're usually looked up to by other doctors because they're the doctor's doctors. They know practically everything there is to know about their personal area of interest, and because they attract a lot of referrals, their depth of knowledge in their domain is enormous.

However, all this super specialization comes with a price. Because they are so focused on the little segment of medicine  which is of special interest to them, they sometimes fail to see the big picture. This is something which makes a lot of their patients extremely unhappy because they feel that these specialists have lost the human touch.

Doctors need to remember that while it's great to specialize - to be an interventional  cardiologist or a pediatric pulmonologist, they all need to be patientologists as well. They all need to specialize in learning how to take care of their patient's emotional needs.

Unfortunately, this key skill is often lacking. It's not as it doctors are not empathetic, it's just that this valuable trait is not emphasized during their training. In fact, residency can be very dehumanising, because the poor junior doctor is often made to work under conditions where he feels he is being treated like an animal. He is often sleep deprived, hungry, stressed, and subject to bullying by his seniors. It's high time we brought humanity back into the medical profession, and the first step in this direction is to handle young doctors more kindly, so that in turn, they also learn to treat their patients with tender loving care!

Thursday, April 20, 2017

Generic drugs vs branded debate



The recent move by the Modi government to make prescribing of generics compulsory has raised a lot of hackles. The objections have been pretty predictable. Obviously, the pharma companies are up in arms because they make most of their money from selling branded drugs. If this option is taken away from them, they're going to have to look for alternative means of generating revenue, and having to change a highly profitable business model is not easy for large corporates. Once the law gets teeth, it will no longer be business as usual, which is why they're upset. They are worried that their business will get commoditised and their margins will shrink. Since pharma CEOs are powerful , lots of observers are understandably cynical about the prospects of these new rules being implemented . Their belief is that they will be diluted so much that they will remain a toothless tiger.

Since the pharma companies guys can't complain directly that they are upset because this is going to eat into their profits, they are using doctors as their puppets. Doctors are upset with this move because they see this as an encroachment on their professional autonomy. They've been writing brand names for many years, and they don't see what they need to change an engrained habit. Yes, brand names are easier to remember, but the truth is that many of them get incentivized to prescribe a particular brand. They are obviously reluctant to say goodbye to this easy money. Also, they are worried that the locus of power has now shifted to the chemist, who will end up deciding which generic to dispense.

The general perception today seems to be that brands are of higher quality than generics. This is not true, since the active molecule in the drug remains the same - it's only the label which is slapped on it which changes. Yes, the government needs to make sure that the drugs are manufactured in a quality factory , and this is true for all drugs , whether or not they are generic or branded ! If you have a poor quality manufacturer, then whether he's marketing a generic molecule or a branded drug, its quality will remain equally poor . The FDA will have to become far more proactive , and as long as the medicines meet quality control standards, what the name on the box says makes no different at all to its therapeutic efficacy ! This is why private labels have become so popular in the FMCG industry - consumers are realizing that there is no point in spending extra on branding . This is as true for drugs as it is for FMCG products.

All pharmacology textbooks teach students and medical residents to prescribe generics. It's the active molecule which makes the drug effective, and this is what is drilled into the doctor's head during his training. The problem is that once a doctor starts practice, he forgets what his professors taught him, and gets influenced by the friendly medical representative, who is always welcomed because he comes bearing gifts.

There are many extraneous factors which come into play when a particular doctor chooses to prescribe a particular brand, but he never talks about this openly , because he's ashamed about the fact that he's not necessarily doing what's in the patients best interest. He needs to justify his actions, and the most convenient excuse is that brands are better than generics, even though he has no proof that this is true. He needs to salve his guilty conscience by bad-mouthing generics.

The healthcare industry needs to get back to basics . Pharma should focus on producing high-quality drugs at a reasonable cost, and stop wasting money on " marketing ". Once generics become mainstream, they will no longer need to employ an army of medical representatives to cajole and induce doctors to prescribe their brand - most of which are just "me-too" variants. This will help to reduce their marketing spends, because companies will not have to waste money on competing with other pharma companies for which particular brand the doctor chooses to prescribe. This is a step in the right direction , and we should all be pleased , because it'll make quality drugs more easily available to patients at an affordable cost. As with anything else, any time you change the status quo, some people are going to get upset, but over time this move will help to make sure that medicine is practiced more rationally and ethically in this country.

Pharmaceutical companies will now focus on improving the quality in their manufacturing plants, rather than wasting money on branding and marketing. Also, since they will no longer have to spend on cajoling doctors to prescribe their brands, they will be able to deploy this towards educating patients, so that patients are better informed about what medicines they are taking, and why.

Tuesday, April 18, 2017

How digital patient profiles can help doctors to understand their patients better


Service industries such as hotels use customer relationship management ( CRM ) systems extensively  in order to track the personal preferences of their clients , so they can provide them with high-quality services, tailored to their  individual tastes . Guest Experience  Management Systems allow them to delight their customers, allowing them to create guest loyalty. In order to do this efficiently, they need to capture a lot of  data about their customers, so they can learn more about their customer's needs and wants.  This is true even for websites like Amazon, who collect a lot of data about the past purchases of their customers, so they can customize what they display to each individual.
Why can't we apply these same lessons to medicine ? After all, patients are the healthcare industry's customers, and the more we know about our patients, the better the services we're going to be able to provide for them. Isn't it logical that we should have all this information about our patients at our fingertips whenever we do a consultation?
Ideally, whenever a patient signs up for an appointment, the EMR should be able to scrape online publicly-accessible databases and provide a summary about what her likes and dislikes are, so that the doctor is better prepared for the visit . Not only will the doctor be armed with the medical details about her illness, but will also have a better idea about what kind of  individual she is, and what her personality is.
Today, a good nurse or clinical assistant provides this information to the doctor just prior to the consultation , and this helps the doctor to create a personal connection with the patient. Over time, as we establish a relationship with our patient, we are able to understand our patients as unique individuals, and this allows us to create trust. Patients are comfortable with their doctor because they feel that he knows and understand them.
Why should it take multiple visits to create this bond?  We need to use technology intelligently  to help doctors to connect better with their patients , by helping them to understand their personal desires, wants and needs. This can help to strengthen the doctor-patient relationship, because the doctor will be able to see his patients as more than just someone who has a medical problem which needs treatment - he will see them as a fellow-human.  Wouldn't you be delighted if your doctor asked you about how your son was doing in school, because his EMR informed him that you had recently posted a photo of him winning the Math Olympiad on your Facebook page ?
Doctors today are often seen as impersonal and uncaring. Additional personal details about the patient will  make the doctor-patient interaction much richer, because it will help the doctor to connect better with the patient. It will encourage small talk and this kind of social lubrication can reduce the barriers  which impede doctor-patient communication. Most patients want to try to create a personal connection with their doctor, so that he will be more empathetic - let's help doctors to do this as well.  This is what made the family doctor of the past so special - he knew a lot about the family, and was often considered to be a part of it. We can use technology to create this same kind of magic again.
Interestingly, this kind of background information can help the doctor to provide better medical care. He can explore whether there is family support available at home; and who the caregiver is, so he can involve them in the treatment plan as well.
Perhaps when we ask patients to take an appointment, we should encourage them to fill in some of their personal details in the intake form, so we have a better sense of what their interests are. For example, they could add a link to their Facebook page, and this would help  doctors to improve their bedside manner by helping them to break the ice with their patients , since they now have some background information about their patient.
As William Osler  “The good physician treats the disease; the great physician treats the patient who has the disease.” Technology can help doctors to learn more about their patients !

Monday, April 17, 2017

When more is not better in IVF - IVF "add-ons" can harm patients

Finally, Dr Raj Mathur, consultant gynaecologist at Manchester Fertility and St Mary's Hospital, started by acknowledging that there does indeed appear to be a problem. Clinics advertise their use of add-ons as markers of quality or innovation, he said. With this comes a duty, however, to advertise responsibly, for example by placing the technique in its context and offering full information about it. Dr Mathur said that clinicians have a responsibility to protect their patients, who are at a heightened sensitivity and may be overly receptive to the claims linked to add-ons, and should take great care not to exploit unproven treatments for profit. - 

Read more at http://www.ivf.net/ivf/fertility-treatment-add-ons-do-they-add-up-o9895.html

Sunday, April 16, 2017

Is this a good quality embryo ?



We routinely show patients  their embryos before the transfer, and this can be quite an emotional moment for them. The commonest question they ask is - "Is this a good quality embryo?"
Of course, what they really want to know is if that embryo will become a baby, but they do realise that doctors aren't very good at predicting the fate of an embryo once we transfer it.
As a scientist , it's easy to explain to what a top quality blastocyst looks like; and that a eight-cell embryo with no fragments on Day 3 is a good quality embryo. However, from the patient's perspective , the only good embryo is one which becomes a baby !

The problem is we just cannot determine with today's technology which embryo will implant successfully and become a baby.

IVF technology has limitations , and both patients and doctors need to accept this gracefully. Thus, sometimes great looking embryos on day three will arrest on Day 4 and not form blastocysts on Day 5 in the laboratory. Conversely , we have embryos which look terrible on day three , and yet form good quality blastocysts.

The problem is that when we grade an embryo in the IVF lab, we have to depend upon eyeballing it - what does it look like ( the scientific word for which is morphology) .  How many cells does it have ? Are these cells equal and regular ? Does it have  fragments ? How fast does it divide ?  This grading allows us to select better looking embryos as compared to the ones which don't look so good, because we know the ones with better morphology have a higher chance of implanting. However, we still can't predict the fate of an individual embryo as yet. The problem is that implantation is a complex multifactorial biological process, which is affect by many variables which we can't tease apart. This is hardly surprising, given the fact that we are trying to follow the fate of a living ball of cells which we have put back in the uterus.

This is not for lack of trying. Thus , scientists have developed  additional technological tools such as PGS and CCS, where we biopsy the embryo to check its chromosomal constitution, because we know that aneuploid embryos ( those with chromosomal abnormalities ) have a lower chance of implanting.  Similarly, some labs use time-lapse technology in order to get a real-time video of how the embryo develops in vitro. However, while these tools provide additional data, none of them is clinically helpful , because it still doesn't answer the patient's million-dollar question  - will this embryo become a baby or not.

This can be frustrating not just for patients, but for doctors as well. Thus, we can say, "Okay, this particular embryo looks the best on day five." However , after we transfer it in the uterus, we can't track its fate, so that if doesn't implant , we can't pinpoint why it failed to do so . Did it stop dividing on Day 7 ? Or was the endometrium not receptive ?

This is what I call the " T plus 1" problem. While we can grade the embryo on that day, we don't know what will happen to it on the next day. Will it continue to grow well ? Or will it arrest ? Will the cells start fragmenting ? In the IVF lab, we have to live one day at a time, and there is no getting around this limitation as yet. In a perfect world, we would be able to grow the embryo to a baby in the lab, and then hand this over to the mother - a process called ectogenesis. However, we have not reached this level of sophistication as yet , except in science fiction

Having said this, it's still important that you have photographs of your embryos for documentation , so you can judge their quality. Other doctors can also look at your embryo photos and grade their quality. However, you do need to understand that not all good quality embryos will become a baby. Conversely, just because an embryo is of poor quality doesn't mean that it won't become a baby - and if it does, these babies are perfectly healthy and normal.

Need help in assessing the quality of your embryo ? 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, April 13, 2017

Fed up of being treated by assistants at your IVF clinic ?


I received this email from a doctor recently.

Dear Sir
I'm Dr BG, an orthopedic surgeon.
My sperm count is just 1 million per ml.
We have had 3 failed ICSI cycles.
In the first cycle , 10 eggs were retrieved and 5 embryos formed and day 5 blastocyst transfer  of 3 embryos was done. No embryos were frozen Second cycle 18 ova were retrieved, we got 8 embryos and 3 were transferred at blastocyst stage day 5.
In third cycle we changed our doctor, We got only 7 eggs 2 embryos and day 3 transfer was done
In all 3 cycles beta HCG was almost Zero.
Please guide us about what next can be done?
I'm very frustrated about the fact all the work in our cycles was done by the assistants of IVF experts. We felt that we were being treated by the assistants , and the IVF experts were just having an overview of treatment.
I'm very concerned about the fact that an IVF expert was not present at all the stages of cycle ; and was never actually involved in the process.
Please guide me and my wife about what we should do next.
Thanks and regards
Dr BG

Doctors are usually VIP patients, and get extra care and attention when they seek medical treatment for themselves. Imagine that if this is the way a doctor is being treated , how the other patients must be being mis-managed.

Sadly, this is the typical experience of most patients in IVF clinics today.

This is why we have made a conscious decision not to employ assistants. We provide all the treatment ourselves. We are  very hands-on, and this explains why our success rate is no high.

You can read about how we pamper our patients at http://www.drmalpani.com/knowledge-center/articles/pampered-ivf-patients

Is your IVF doctor always missing in action ? Are you looking for an IVF expert who will treat you himself ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !




I am 43 - can I get pregnant naturally?


Since I provide free second opinion on my website, I get lots of queries from patients.  One of the common inquiries I get is from older women who want to know what their chances of getting pregnant are. Now, this is an easy question to ask, but as with a lot of simple questions, it can be extremely difficult to answer.
What a doctor needs to answer intelligently is the right context , and for this he needs more information.  The answer to whether a particular 43-year-old can get pregnant in her bedroom or not depends on many variables, such as : how long has she been trying to have a baby ; what the results of her fertility tests are; whether she's taken treatment before; and whether her cycles are regular or not.
This is why my usual response to this question is: I need more information ! I can answer intelligently only if I have more data, for which the patient needs to do some basic fertility tests. Remember that it's never the calendar age of the woman which matters - it's the age of her ovaries.  We know that as a woman gets older, her eggs start getting older, which is why her fertility drops, but there is no simple correlation between age and declining ovarian reserve , because every woman is different.
The problem is that individual women aren't interested in generalised statistics - they don't care about what happens to the other hundred 43-year-old woman who ask me the same question. They only want to know what's going to happen to them.
Our limitation is that doctors aren't fortunetellers , and we really can't predict for the individual patient what her future reproductive outcome is going to be - and this is true, whether she tries in her bedroom , or does IVF.
However, we do provide her with intelligent advice, customised to her situation, based on basic information such as what her antral follicle count and AMH levels are.  With this information, we can discuss her options with her. I do not censor information and try to be frank and forthright, but lots of patients aren't very happy with my bluntness . No one wants to hear bad news, but I think it's far better to be prepared so you can intelligently choose the option which works best for you, rather than waste time pursuing futile treatment. False hope can be very cruel !
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, April 12, 2017

Why being an IVF specialist is the best job in the world !


Patients need to use Dr Google wisely


Most doctors don't like patients who search for information on the internet . Their experience has been that because there is so much unreliable information on the internet , these patients get lost and confused; and are always trying to second-guess their doctor's advice. This is why they tell them to stay away from doctor Google ; and many doctors get irritated when patients bring a huge sheaf of printouts from dozens of website. Many doctors are convinced that all this online research is a waste of time, because patients don't have the maturity to be able to interpret the information they unearth. Not only do they lack context , a lot of the information they retrieve is of poor quality and outdated . The standard party line amongst doctors is that patients are worse off by going on the internet . They should instead just trust their doctor to do what's right for them.

In a perfect world , patients would be able to trust their doctor blindly, but we all know that this is not going to happen, because doctors have frittered away the trust patients used to repose in them. Also, the internet is always available , and it's perfectly natural that patients are going to use it, so it's quite silly to prohibit them from doing so.


When we tell our patients not to go on the internet, we are doing them a disservice, because we are throwing the baby out with the bath water.  All we need to do is to help our patients to learn to differentiate good sites from the bad ones . Patients also don't enjoy spending hours digging up medical information  when they go online - they'd much rather be watching movies on Netflix if they had a choice !  Patients will often get a headache when they try to do their research on their own, because they get confused when the come across conflicting information n different websites. They aren't sure whom to trust, and they resent the fact that their doctor is not willing to help them to separate the wheat from the chaff.

Doctors need to guide patients to go to  reliable websites - for example, those from Harvard Medical School; or Johns Hopkins; or the NIH ; or the UK NHS. This way both patients and their doctors confident that the information they will get will be updated, trustworthy and reliable. They should use these sites as the bedrock of their homework , and then build on this if they need more depth. This way they won't waste their time - and their doctors - by going to unreliable sites.

Yes, there are lots of unreliable sites online , but why do you need to worry about them if you're going to focus only on the reliable sites , which empower you with trustworthy information?

Need reliable information of IVF ? Check out www.ivfindia.com !

Monday, April 10, 2017

How to choose the best doctor


I am an IVF specialist , and when our patients get pregnant , they ask us to refer them to an obstetrician. The commonest question is, "Which obstetrician should we go to?" This is completely reasonable - after all , they trust me, and want me to refer them to a good doctor. Now , these obstetricians are my colleagues and friends, but I'm very reluctant to tell them whom to go to.
To get good care from the obstetrician during pregnancy, the most  important ingredient is the doctor- patient relationship, and the chemistry between the two should be just right. Rather than give them a name, this is the process I tell them to follow.

"Just assume for a moment that the technical competence of most gynecologists who have the right professional qualification is comparable . The key is that you need to find a doctor whom you feel is right for you. Make a short-list of at least two doctors . You can do this by doing a google search, or asking your friends for recommendations.  You then need to interview both these doctors. Pay for a consultation , and then pick which one you prefer . "

Do you like the ambience ? Is it close by ? Is parking easily available ? How communicative is the doctor ? How friendly is the staff ? Do the other patients in the reception area look happy ? How long do they make you wait ? What vibes do you get ? This should give you enough information to be able to pick and choose the one who is right for you."

"If you're still not sure , ask both of them this one question. "Why should I come to you as compared to going to doctor X?" Some doctors may take offense at this question , and that in itself is a red flag. After all , this is a perfectly valid question to ask , and patients do deserve an answer.

A good doctor will be happy to answer, and the right response is, "Yes, Doctor X is a good doctor , and there are lots of other doctors who will also take good care of you. However, I feel this is what makes us better. " This thoughtful response shows that he is mature; will not bad-mouth other doctors ; and is service oriented and keen to have you as a patient. This is the kind of doctor who you are likely to be happy with.

This is exactly the same model you should use when you are looking for the best IVF doctor 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 !





Saturday, April 08, 2017

IVF patient versus IVF doctor - when your doctor refuses to listen to you


IVF patients are often faced with a dilemma when their doctor refuses to listen to their personal preferences, and they don't agree with their doctor's advice Thus, there are older patients with DOR ( diminished ovarian reserve) who want to try IVF with their own eggs, but their doctor discourages them from doing so, by saying that the chances with their own eggs are very poor . The doctors pushes the patient into using donor eggs, saying this would be a far better option, because it has a much higher pregnancy rate. 

This can create a lot of angst, and sometimes patients aren't sure what to do - whether they should follow their own heart, or obey their doctor. They've been taught (especially in India ) to defer to their doctor's advice - after all, he is the expert in the room , and they're supposed to follow whatever he says.  However, this is not a good idea for an elective treatment such as IVF.

Because using donor eggs and other third party reproductive options is such a highly charged emotional decision, patients need to be very careful when agreeing with the doctor's suggestions. While it's very easy for the doctor to provide the advice, it's the patient who needs to live with the consequences of that advice.   That's why you need to think through some of these decisions very carefully , and discuss what your concerns are with your doctor. He's not a mind-reader, and you need to tell him what your preferred choices are. Now, he may or may not agree with you - after all, he is a professional , and he may not want to provide what he thinks is futile treatment, and that's fine. Nevertheless, it's important to have this discussion. 

You should feel heard and respected , and you should be able to trust your doctor. You should never get the feeling that he's trying to force a particular treatment option down your throat , simply in order to make more money. You need to have enough confidence that he has your best interests at heart , and is putting your  personal preferences first. 

You need a doctor who's willing to be open-minded and nonjudgmental - someone who's willing to discuss your options with you.  You don't want someone who crams his opinion down your throat simply because he happens to be the doctor , and "knows best". This is why mutual respect and trust in an IVF doctor/patient relationship is so important.

The fact of the matter is that there are never any right answers. There are always going to be options, and it's impossible to predict what the outcome of any option is going to be for an individual patient. A doctor can provide you with medically accurate information - but this only applies to groups of women, and he is not a fortune teller. 

For example, if your AMH is low, he can tell you that your chances of getting pregnant with your own eggs is about 5%, whereas, if you use donor eggs , your chances will go up to 50%.  However, whether to then still go ahead with the 5% option because you're not comfortable using the donor egg option is a decision which only you can make. You cannot abdicate that responsibility , and you cannot outsource it - you're the one who needs to be comfortable with it, because this is your life.

The bottom line is that if you're happy with whatever decisions you make, you will keep your child happy, and everyone else around you happy as well. You need to be selfish and put yourself first when thinking about some of these things, because if you are miserable, you will create unhappiness in the life of those you love as well . This is why you need a doctor who will give you the permission and the freedom to discuss all these options openly with him - and this needs a mature doctor, who is willing to spend enough time with you, so you can explore your options thoroughly, and do what your head and heart tell you is right for you.

Looking for an IVF doctor who will respect your wishes ? 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, April 07, 2017

How your personal beliefs will change your IVF treatment options



Patients from all over India come to our clinic for IVF treatment. They come from different backgrounds, which is why they have such varied beliefs. Part of it is related to their educational status, which means illiterate patients don't understand the nuances of IVF , and still have lots of misconceptions about "test tube baby" treatment.

Many of their views about IVF treatment are strongly related to their religious beliefs. Thus, people who are deeply religious are much more accepting of the outcome of the IVF treatment, and even if it fails , they're much less likely to blame the doctor. They're much more willing to accept that the failure was written in their fate - what they think of as their kismat - and attribute it to their karma , or the will of God. They intuitively accept the limitations of what a doctor can do, and are less demanding and more forgiving .

This is why it's much easier for them to counsel these patients if their cycle fails, because they accept the fact that doctors have their own limitations. They understand that humans don't have all the answers, and no matter how hard we try , we can't control human biology.

The trouble is that this same trust can be a problem if they end up in a poor quality IVF clinic . These doctors exploit the patients' trust , and take advantage of the fact that they're clueless about the medical technical details of IVF. They conveniently blame the IVF failure to divine will, when in fact it is actually a result of their medical incompetence and poor quality equipment . Thus, instead of acknowledging the fact that the reason for the IVF failure was poor quality embryos because the laboratory wasn't enough , they will attribute the failure to an unkind god. Sadly, patients are often not able to differentiate between doctor who's telling them the truth and one who is not.  It is this fatalistic attitude which allows so many poor quality IVF clinics to prey on the ignorance of these gullible villagers.

Strongly held religious beliefs also affect which treatments certain couples are willing to accept. Thus, most Muslim patients will refuse to accept donor eggs or donor sperm under any circumstances . This can be a particularly thorny issue when the husband and wife don't see eye to eye . The wife may be willing to use donor eggs , because she's so desperate to have a baby, but when the husband puts his foot down and refuses on religious grounds, this can create a lot of friction.

For some highly educated patients , coming to terms with IVF failure can be much harder. They are very used to controlling everything , and have very unrealistic expectations of medical technology.  These patients are willing to pay whatever the doctor charges , and naively believe that money can buy IVF success. They expect that doctors should know everything, do everything, and be able to control everything - all they need to do it to pay the medical fees. They cannot understand why perfectly good looking embryos do not implant, and when the cycle fails , they're much more likely to blame the doctor . They attribute the failure to medical incompetence, rather than understand that no matter what a doctor does, we can never be sure what the outcome of an IVF cycle will be .

Unfortunately, these patients are not willing to be understanding. No matter how much you counsel them , or how much documentation and information you provide, they're always very suspicious about what is going on.  They believe that only US labs are of good quality, and that all Indian doctors are sub-standard.  While it's great that they want to be informed and actively involved in their treatment, I think sometimes they just make life much harder for themselves . They are not willing to accept that medical technology has limitations, and they push the doctor into doing even more tests and treatments   ( even if these are unproven and untested), in their quest to control the outcome. They expect perfection from their doctor, and when the cycle fails, they vent their anger and disappointment on the 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, April 05, 2017

The zero OHSS clinic

While IVF is usually safe , one of the dreaded complications of IVF treatment is ovarian hyperstimulation syndrome ( OHSS.)  If not managed properly, it can lead  to hospitalisation in the ICU, and even death. This is why it's so important to prevent it.

Step number 1 is to identify patients who are at increased risk for developing OHSS. These are typically patients with PCOD - those with a high AMH level and a high antral follicle count.
For these patients, we use the 3-step " antagonist downregulation-agonist trigger-freeze all  " protocol to prevent OHSS. This means we have become a Zero OHSS clinic.

How does this work ?

We superovulate you with gonadotropin injections, such as Gonal F; downregulate you with GnRH antagonists ( such as Ovucet or Cetrorelix) from Day 7 onwards; and then, instead of using HCG as a trigger, we use GnRH agonists ( such as Decapeptyl) to trigger ovulation.

Your eggs are collected after 36 hours, and all the embryos are frozen on Day 5 ( blastocysts) . No transfer is done in the fresh IVF cycle; and the frozen blastocysts are then  transferred in the next cycle, one at a time. With this protocol, the chances of developing OHSS are virtual zero. This allows us to collect lots of eggs safely, and then transfer the frozen embryos , one at a time after thawing them in subsequent cycles. This offers a lot of safety; and maximises the chances of your having a healthy singleton live birth , which is the holy grail of IVF treatment.

This is what the protocol looks like.

IVF/ ICSI treatment starts from Day 2 of your cycle. Day 1 = Day of bright red bleeding. If the bleeding starts after 6 pm count the next day as Day 1. Ignore the spotting.
On Day 2, we do an ultrasound scan at our clinic to confirm there is no ovarian cyst, and to count the number of antral follicles. We then start your superovulation .
Inj Gonal-F ( 75 IU FSH ), 2 amp ( 150 IU ) daily from Day 2. The dose of Gonal-F (  FSH) will depend upon your ovarian morphology and your antral follicle count.
From Day 7, we start Inj Cetrorelix/Ovucet/ Orgalutron/ Antagon, 0.25 mg daily . This is a GnRH antagonist. The Gonal-F continues.
We do the next scan on Day 7, after which you would have to be in Bombay for about 10 days. Your husband is needed on Day 12-Day 14 ( the day of the egg pickup). All the treatment is performed at our clinic, which means you never have to go elsewhere.

This is what the daily schedule would look like.

Day 1. No action
Day 2. Vaginal ultrasound scan to confirm there is no ovarian cyst. If there is no cyst, we can commence superovulation.
If there is a cyst, we aspirate ( puncture) it and continue with the treatment.
Day 2 . Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 3 Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 4 Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 5 Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 6 Inj Gonal-F ( 75 IU), 2 amp ( 150 IU ) sc daily
Day 7. Vaginal ultrasound scan to monitor follicular growth. If the response if fine, we continue with the same dose of Gonal - F; and add the GnRH antagonist
 Inj Gonal-F ( 75 IU), 2 amp (150IU ) daily. Inj Cetrolix, 0.25 mg daily
Day 8 . Inj Gonal-F ( 75 IU), 2 amp (150IU ) daily. Inj Cetrolix, 0.25 mg daily

Day 9 . Inj Gonal-F ( 75 IU), 2 amp (150IU ) daily. Inj Cetrolix, 0.25 mg daily
Day 10. Vaginal ultrasound scan to monitor follicular growth
The Gonal-F and Cetrolix injections continue until the follicles are mature ( approx Day 12).
Then a GnRH agonist ( Triptorelin, Decapeptyl, 0.2 mg sc) injection is given as the trigger , and eggs retrieved 36 hours after this.

These are fertilised with your husband's sperm, and all  your embryos are frozen on Day 5 ( blastocyst). We provide you photos of these.

You can travel back 3 days after the egg collection.

You then come back after one month for the transfer of your frozen embryos.

Did you develop OHSS in your earlier IVF cycle ? Want to make sure you don't run that risk again ? 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, April 04, 2017

Ask the Embryologist


Even though the IVF lab is the heart and soul of the IVF clinic, most IVF patients are clueless about what happens in the IVF lab. Many IVF doctors take advantage of this ignorance, and keep their patients in the dark about their embryos.

This is a tragedy.

Dr Sai is the Senior Embryologist at Malpani Infertility Clinic and will be happy to answer your questions, if the embryologist in your IVF clinic is inaccessible.

He says - The IVF lab plays an extremely important role in the success of your IVF treatment, and we are very proud of the work we do in helping you to have a baby.
I'll be happy to answer any queries you have ! Please email me at ivflab@drmalpani.com

When we show our patients their embryos in our lab, this is often a highly emotional moment for them.
Here are some of the common questions they ask. I'd like to share my answers.

1) How do you grade embryos ?
Grading Multicellular Stage Embryos (Day 2 and Day 3 embryos) :

Sunday, April 02, 2017

Why patients feel abandoned by IVF doctors when their cycle fails

I just got this email from a patient.

Dear Dr Malpani, I have read your article online and am very much interested on any updates on your article or challenge to Clear Passage Therapy .

I have seen this Clinic referred to me by Natural Fertility online and so I went to their website and started the application process including the submission of my medical history.  I have gone thru 3 failed IVFs (2 fresh (w/ DNA bx of embryo) and 1 FET cycles), 1 natural pregnancy in between 1 IVFs, all miscarried on 5th week, 10th week, 0 pregnancy on my last IVF w/ DNA.  I was diagnosed by my Fertility Doctor at Kaiser with Right Blocked Fallopian tube (middle) thru HSG.

When I read about how to naturally unblock your FT using the KIT that can be purchased in Natural Fertility website, I immediately looked into it and was about to try to purchase it.  Along their email, they also recommended doing the natural massage therapy at CPT. So I looked into it and I got very excited, although I didn't expect it to be that pricey ($6,000 for 5 days), almost like the price of IUI.

I thought to myself "Oh well, what else is new, how people take advantage of people in need" - this is the sad reality of life.

I am hoping I can unblock my tube naturally and thus have a higher chance of getting pregnant again.  Me and my husband have been trying for almost 8 months now naturally using the OVIA kit plus Fertility Acupuncture, still unsuccessful.

Then I saw your article, different from the success stories that were on the first few top articles when you do a review of the IVF Clinic search in Google.

That's why I'm reaching out to you personally so I don't get ripped off again by Clinics who, as you mentioned, just accept patients, even if they really don't see that it's going to work for them, as long as they can pay.  That's how I felt with all my IVF doctors.  I didn't feel any bit of concern, empathy from any of the Clinics. To them I am just any other patient (patient #X), didn't really study my case well, didn't really give me best treatment. They are all so nice to you in the beginning and during the process. And when it didn't work, all of a sudden, boom, the doctor didn't seem to like remember you or just acts so indifferent.

So, going back to the reason of this email, has Clear Passage Therapy Clinic reached out to you and acted upon your challenge? Is it ok if I get any updates on this and I would thank you so much for helping me decide what's best for me and my husband in our continuous journey of trying to build a family.

God bless and I sincerely hope to hear from you.

Does your doctor refuse to answer your questions after your IVF cycle has failed ? 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, April 01, 2017

Our Bonus Baby - Our Success Story at Malpani Clinic


We are from Bangalore and had been trying to conceive from past 10+ years without any success. We had seen  multiple doctors here and tried stimulated cycles, couple of IUIs and one round of IVF at highly reputed clinics here. We even tried alternative medicines like homeopathy, ayurveda etc.. In these past 10+ years, I conceived naturally 4 times but miscarried before 9 weeks.

When we decided to do IVF at the end of 2012, I contacted Dr. Malpani for second opinion and his feedback gave me a lot of confidence to go ahead with IVF with a local clinic, but it was not a success. The tremendous stress I went through this IVF made me take a break from all sort of treatments. So we leaned towards alternative medicines because I was able to ovulate and produce embryos in previous IVF.

At the end of 2015, I pulled all my courage again and decided to do another round of IVF, but this time only at Malpani Clinic in Mumbai. My husband also agreed on the same. I immediately contacted Dr. Malpani by mail and got response within 12 hours. Amazing !!! He asked me to do couple of blood tests and SA for my husband. With these test results, we already had our treatment plan prepared by the doctor from day #1 of the cycle. But we wanted to meet him in person, so we met him in first half of 2016.

Our first experience at the clinic was awesome and we both immediately felt that we made a right decision and we are in right hands. In our first appointment, doctor explained the success rate of each IVF cycle and no false promises were made. Based on my age (late 30s), low AMH value and history of recurrent miscarriages, success rate would be maximum 5% with  my own eggs per cycle; and if we opted for donor eggs, it will be 40% – 50%.  This was a rude shock for us, and we told the doctor that both of us need some time to make a decision . We returned  home.

After applying a lot of logical, rational thinking, we decided to go with the donor eggs option.  My husband’s genes will be carried and I will be carrying the baby for 9 months. The comparison was with surrogacy and adoption and we felt this was a far better option.

Past experiences has taught us lot of lessons like time is so precious , so  go for the best available. We informed doctor about our decision and very quickly our donor had been identified. It was decided to go for the donor egg cycle in  mid-2016.

From day #1 of cycle till the end, the treatment plan was shared with us by mail. I did initial scans locally and shared report with doctor by mail. On Day#10, we reached Mumbai to stay for 10days. We stayed very close to the clinic and we never felt any pressure/tension to go to the clinic for  a scan/procedure. We got total 14  grade A embryos!:)

Dr. Sai (Embryologist) showed us the beautiful embryos before we headed towards the transfer. It was a very touching moment to see those embryos thanks to SCIENCE. Two day#5 grade A embryos were transferred by Dr. Malpani in the presence of my husband.

Here I should praise  Dr. Malpani and their entire staff’s manners and commitment to their work. They made me so comfortable in OT for embryo transfer  and all the time doctor was checking on me whether I was comfortable or not.  That kind of human touch and empathy with patients makes for a GREAT doctor. Before transferring the embryos, doctor asked us to pray to our GOD. Post transfer his instructions are simple: lead a normal life, we have done our job and let nature take care of the rest.

We returned home with lots of hopes after 3 days of transfer. That cycle didn’t work out. We took break for a couple of months before our first frozen embryo transfer cycle. This cycle went smoothly and again two top quality blastocysts were transferred. I was in the clinic only for 3 hours during the entire cycle. To the dot, the treatment plan was shared and executed by doctor so well.

After 12 days of transfer, I did beta HCG and the value was close to 2000. The value doubled and then quadrupled in consecutive tests. At 6w2d, we went for our first scan and found two beautiful heartbeats. Yes...both the embryos are implanted and today I am 12weeks pregnant with TWINS!!!

Till date, I e-mail the doctor with all my silly questions and he answers all of them. Whatever my local gynec says I want approval from Dr. Malpani. Experience and trust matters a lot !!!

I'd love to say a lot more about Dr. Aniruddha and Anjali Malpani and their clinic, but whatever I say will not be enough to express our gratitude.  They are really a blessing to the infertile couples to fulfill their dreams of having a baby.  We are so thankful to Dr. Aniruddha Malpani, Dr. Sai              ( embryologist and the CREATOR), our donor (whoever she is  GOD BLESS HER and her family) and entire staff at Malpani clinic.

For any personal queries, you can reach us at ourquestforbaby@gmail.com

Friday, March 31, 2017

Why IVF patients get confused


I received the above email from a patient. As you can see, he is a computer engineer, is doing his homework, and is very well organised !

This image highlights the fact that there is so much variation in the advice which IVF doctors give.
To add insult injury, except for the AMH level, all the other tests advised are useless and wasteful !
No wonder patients are confused !

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 !




The IVF doctor's dilemma


I was confronted with an interesting dilemma recently. The patient had recently got married to an older man who already had three children from his first wife. This was her first marriage and she wanted babies, but she was already 39 . When she did a blood test , she found out she had ovarian failure , and would need to use donor eggs. She was quite comfortable with the idea because she wanted a baby desperately, but her husband put his foot down and said he wasn't willing to consider using donor eggs under any circumstances, because this was against his religious beliefs. She was extremely unhappy , and did her best to cajole him, but she wasn't able to persuade him.

She came back to me after a year's time and said, "This is what I plan to do. I'm going to ask him to deposit and freeze his sperm sample in your lab. I'm then going to come to Mumbai without him, and tell him that you superovulated me, collected my eggs ; created embryos with my eggs and his sperm; and transferred these embryos into me. In reality, you can use donor eggs instead of my eggs, and he will be none the wiser, because he will believe that the embryos were made with my eggs. This way, I'll get pregnant and have a baby; he'll be happy; and I'll be able to save my marriage."
She made it sound like a sensible solution , because it keeps everyone happy. After all, if he doesn't know we've used donor eggs, then why will he object ? After all, she is an adult, and is simply asserting her right to use donor eggs to have a baby.

The problem  is far more complicated, because she is married to him. We need informed consent when we do IVF treatment, which means both the husband and the wife need to sign the consent form.  I told her that if we don't get the husband's signature , we can't go ahead.  She said, "But he lives in Lucknow, and it's not convenient or possible for him to come down just to sign a form.  Why don't you give me the form , and I'll get his signature , and you can then proceed with  my treatment."
I have a suspicion she is going to do some hanky-panky, because she is so desperate to have a baby. She may forge his signature, and I can't countercheck whose signature it actually is - I am not a notary ! Once I have a signed consent form , I can then go ahead with the treatment, because I have complied with all the regulations.

However, I am worried that she is not being truthful with her husband. Now it's true that she's doing this in order to save her marriage , and she's not hurting him in the process.  When I asked her what happens if he finds out the truth after six years, she sensibly pointed out that the chances of his doing so are close to zero.

Doctors are confronted with these complex ethical dilemmas when we practice medicine, and it's very hard to find the right solution. It's easiest for me to refuse to help her. I can put my interests first, and turn her away, because her husband does not see eye to eye with her. This would protect me, but it would not be the best solution for her, as she would be doomed to remaining childless all her life.
I could also say - " I have an informed consent form, which means I have complied with the letter of the law . I can go ahead with the treatment and help her to have the baby she so deeply desires". But would this be ethical ? Now I can justify my actions by saying I am doing this in the patient's best interest - having a baby would add meaning and joy to her life, and would help her to save her marriage. On the other hand, the counterargument could be that I'm doing this just in order to earn more money !

How does one sort these things out? How does one parse them? If things go well , there's never a problem, but what happens if they have a dispute and need to go to court after five years ?  No matter how good my intentions may have been, no one willing be willing to accept that I treated her without any selfish interest. Both the lawyer and the judge will paint be as being an unethical, greedy doctor, and give me a hard time.  Why should I take on that risk , for no personal benefit at all, other than the fact that I want to help my patient?

Wednesday, March 29, 2017

The difference between a chemical pregnancy and a false pregnancy.

We often see patients who have done an IVF cycle elsewhere, and who get a positive pregnancy test result. They are ecstatic  when they are told by the doctor that they're pregnant. However, their HCG levels are usually between 30 mIU/ml - 100 mIU/ml or so, and they never cross more than 100 mIU/ml.  They may increase a little bit , and they then drop. The ultrasound scan never shows a pregnancy sac, and they never end up with a baby.

This is the story line their doctor feeds them.  You had a chemical pregnancy.  What this means is that your IVF cycle was successful, and the embryo we transferred for you did implant, but unfortunately, you miscarried. This was a very early pregnancy, but the fact that you got pregnant means my IVF treatment worked ! Don't worry  , we will do another cycle for you, and I am sure it will work this time.  We will run some special tests to find out why you miscarried, and change your treatment accordingly , so you have a better chance  of having a baby the next time. They then order expensive tests such as  ERA (  endometrial receptivity assay ) , NK cell tests; PAMP tests and TB PCR tests , to convince patients that they are on the right track.

The tragedy is that it's very easy to cheat patients by exploiting their ignorance, which is what these doctors are doing. When I review the medical records, I find that these doctors routinely give all their patients HCG injections ( such as Sifassi , Choragon  and Ovitrelle) after the embryo transfer .
Now if you give the patients an HCG injection and then do a blood test to measure her HCG levels, of course the HCG test is going to be positive. We could her husband pregnant as well by giving him the HCG injection !  This is not really a pregnancy, and it's definitely not a chemical pregnancy. It is what I call a false pregnancy or a pseudo-pregnancy - a pregnancy which is created artificially by giving an HCG injection in order to fool the patient .

Please don't get taken in for a ride. If your doctor wants to give you an HCG injection and then do the HCG test, you should worry a lot  !

Not sure your IVF doctor is giving you good advice ? I am happy to give you a free second opinion to help you ensure you are getting good medical care . 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, March 28, 2017

The insecurity of poor quality IVF clinics

A patient asked me for a second opinion after a failed IVF cycle .

I asked her to send me photos of her embryos, so I could provide personalised advice.

She sent me this email.

I tried to get the photos, however this is the reply from the embryologist. Should I be concerned about continuing at this clinic?

 We do not have any pictures of the embryos. We did not have to hatch either embryo because they were already hatched for PGD. When we thaw the embryos we only take pictures if we hatch because it is the same machine. We do not want to keep the embryos out any longer than they have to because we do not want to expose them to any outside influences that can effect them such as pH changes, temp changes, and large amounts of lights.

This is not a good answer. All good IVF clinics take embryo photos routinely. Even when the embryologist looks at them , they are being exposed to the same " large amount of light", so this reason makes no sense to me Patients need to start getting more proactive if they want to make sure they are taking treatment at a good IVF clinic.

Want to make sure your IVF clinic is following best practices ? 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, March 26, 2017

How can we prevent doctor bashing ?


Now that the doctors have gone back to work, everyone is breathing a sigh of relief. The government is very pleased that they have averted a crisis, and that patients are being looked after once again; and the junior doctors are pleased that they can go back to completing their education and getting their degrees. One more storm has been weathered successfully.

However, what's very disappointing is that no one is stepping back to look at the big picture. No one has bothered to do a root cause analysis as to the reason for this simmering anger against doctors; and there has been practically no public support for these young residents, who have been hung out to dry for having the courage to demand protection for themselves - something which is their basic right, and which they should be able to take for granted.
The tragedy is that strikes and agitations by junior doctors have become recurrent events . I remember that when I was a resident 30 years ago, we had also gone on strike , and the government broke us by wearing us out and threatening us . They are playing exactly the same game again - it's just the names of the players who have changed.
All the junior doctors asked for is that the administration provide them with enough security , so that their personal safety is not endangered during the performance of their duty. Is this too much ask for ?

To add insult to injury, even the High Court Chief Justice threatens the doctors when they sought protection ! She  said - Public will hit you': Resume work or face termination, Bombay HC tells striking resident doctors. It's very sad that a judge is suggesting that it's OK for citizens to break the law and beat up doctors!

Things have gone from bad to worse in the last 30 years . The living conditions the government hospitals provide for these junior doctors remains deplorable. The support infrastructure is completely lacking ; junior doctors are chronically overworked and sleep deprived; and they are made to do a lot of useless scut work , because the hospitals refuse to spend money on the ancillary staff required to provide good patient care. It is the poor junior doctors who are saddled with this additional burden - something which is not part of their curriculum or job description, because it doesn't involve delivering clinical care to the patient. The tragedy is that because these young doctors are conscientious and responsible , they are willing to take on these additional duties, even though they shouldn't have to, simply because they want to make sure that their patients get better.

Thus, they waste hours carrying blood samples from the ward to the laboratory ; or collecting reports from the x-ray department , rather than learning at the patient's bedside . This is stuff that should actually be done by ward boys, assistants and clerks, but because the hospital doesn't have the budget to employ them, it's the junior doctors who are treated as beasts of burden, and forced to do these mundane administrative tasks. What's really appreciable is that they do this unquestioningly and uncomplainingly, because they respect their seniors and professors, and will do whatever they ask them to.

No junior doctors ever says, "No, this is not my job , and I refuse to do it " - though they would be well within their rights to do so. This is also partly because of inertia - this is what their seniors did, and this is the way things have always been. However, the truth is that this is a broken system, and we cannot continue like this.

The underlying reason for this sad state of affairs is that the government loves to make populist declarations as regards medical care. Thus, they promise to provide free health care to everyone, even though they don't have enough hospital beds and doctors to be able to do so . This sounds great on paper , and gives the ministers a lot of press coverage. However, the problem is they don't put their money where their mouth is. They don't back up their promises by spending money on employing additional staff in the hospitals; or providing the hospital dean with a budget which is sufficient for him to be able to ensure that the aging medical equipment in these hospitals continues to work properly. Even basic medicines are not available in the pharmacy, and patients are made to run around from pillar to post. It's easy to see why patients in these government hospitals lose their temper - the system is so badly designed, that anyone is bound to get agitated, upset, and frustrated trying to navigate it. However, patients can't vent their anger on the people who deserve their ire - the politicians and administrators, because they are inaccessible.

This is why it is the junior doctors who end up serving as punching bags whenever anything goes wrong. It's high time that we accept that these problems do not arise because junior doctors are careless ; lazy ; or don't want to work. Let's not forget that medical students are our academic creme de la creme - they are the best and the brightest our educational system produces, and they have worked hard to get into medical college. They continue to be willing to slog hard, and do so no matter how adverse their working conditions are.

The reason for the doctor bashing is because the system is dysfunctional and broken ; and unless we are willing to spend enough money to make sure that the citizens of this country get good quality health care at an affordable cost, things are just going to progressively become worse. The reality is that the administration continues to ill-treat them with impunity, just because they can do so easily. They are a floating population, who are very vulnerable, because they know that their careers are at stake, and they don't want to risk this.

My big worry is that the government doesn't seem to understand the long-term consequence of ignoring the legitimate claims of doctors. Bright students will no longer want to join medical college after seeing how badly doctors are treated by the administration, the media , and by angry relatives. A medical college seat used to be highly coveted. It will now go to the B-graders, because the A-graders will look for greener pastures and opt for other careers. Most parents will also discourage their students from taking up medicine - a very far cry from the past, when parents would be exceptionally proud if their children secured admission in medical college because this was so highly competitive.

Please stop and think. The message are we conveying to these young doctors is that we don't care about your personal safety - you have to go back to taking care of patients, no matter the risk to your life and limb . If we treat them so inhumanly, how can we expect them to become humane doctors and care for their patients when they graduate.

Instead of allowing the poor doctors to remain convenient scapegoats, we need to speak up and make sure the government authorities are held answerable for improving medical infrastructure . The government has more than enough money - it's just that corrupt officials and bureaucrats pocket it , as result of which patients are deprived of basic medical facilities. This is what we should really be agitating against - but because affluent citizens like you and me get our care from private medical facilities, we don't care if the government allows the public hospitals go to the dogs.

Today, tempers have cooled, and the medical associations and the government have come to an understanding. We've weathered the crisis for now, but I think it's just a matter of time when it will blow up again. The next time another doctor gets beaten up by angry relatives , we will have a sense of deja vu, but whether this incident will occur in the next week, or the next year, I cannot predict.

Friday, March 24, 2017

Iatrogenic infertility - when infertility doctors cause infertility !


Being infertile is bad enough, but it's a hundred times worse when the infertility is actually caused by your doctor. This is what we call Iatrogenic Infertility and it is of two types. One is permanent , where your fertility is damaged irreversibly because of something which the doctor does. The second is temporary, where your fertility takes a beating because of the medical intervention he advises.

Permanent damage is usually because of surgical procedures. The three commonest offenders in this regard are
hysteroscopic metroplasty;
laparoscopic ovarian drilling;and
laparoscopic surgery for treatment of endometriosis.

Let's look at these one by one.

A hysteroscopic metroplasty is an operation which is done only by Indian gynecologists . For some weird reason, they feel that infertile Indian women have a small uterine cavity , and they make cuts in order to increase the size of their uterine cavity. This is completely ridiculous, because every woman, no matter how fertile she is, is obviously going to have a small uterine cavity when she is not pregnant. Nature has designed the uterus so that the cavity will automatically grow once she gets pregnant, so this is a completely pointless procedure. However, it's become extremely popular, simply because most gynecologists have itchy fingers - they are happy to put in telescopes wherever they can, including the uterus. It's easy to convince the patient to do this hysteroscopy procedure, because they call them " minimally invasive" , thus giving the impression that there's very little risk involved. Once they put the telescope inside, they always want to do additional procedures so they can charge more, and the commonest "add-on" is a metroplasty. This is done for the flimsiest of pretext, "Oh, the cavity doesn't look fine. It's a little bit narrow. I can't see both the cornu, so let me make a few cuts to fix the problem - all kinds of funny reasons. The harm is that these unnecessary cuts can cause scarring , and damage the endometrium. The irony is that these scars cause the cavity to shrink, so that patients become infertile because of a procedure which they didn't need to do in the first place !

The second common offender is laparoscopic ovarian drilling, where doctors drill holes in the ovaries for women with polycystic ovarian disease. Now, if this is done sensibly  ( restricted only to women who have large ovaries, with increased stroma; and performed conservatively ( only 3-4 drills per ovary), it can be helpful. However, many over-enthusiastic doctors end up burning and destroying too much ovarian tissue in these women. They end up causing ovarian failure in these poor unfortunate women , who started off having lots of ovarian reserve , but are now doomed to being infertile because their ovarian reserve has been damaged. That's especially true when some doctors repeat the surgical drilling , because they don't think the earlier doctor did a good job !

Finally, laparoscopy for endometriosis often causes a lot of harm. It's especially tragic because these patients don't require a laparoscopy in the first place ! The trouble is that in their enthusiasm to destroy the endometriosis, they often remove normal ovarian tissue, causing the woman to become infertile , and pushing her from the frying pan into the fire.

Temporary infertility is usually because of medical interventions.  The commonest problem is when women are put on anti-TB treatment because of a positive TB-PCR tests. They end up taking these toxic drugs for nine months. Often patients get so fed up , that they drop out of infertility treatment, thus depriving themselves of their chances of having a baby. This is also true for patients who are subjected to multiple IUI cycles . Every new doctor wants to repeat the old IUI treatment once again , either because they don't have anything better to offer , or because they feel that the IUI done by the earlier doctor wasn't good enough. By wasting a lot of the patient's precious time, they reduce her ovarian reserve because she ages, and this ends up compromising her fertility. Most of these patients are not willing to do an IVF cycle, because of the repeated IUI failures, as a result of which they have no confidence left in infertility doctors. Even if she does finally screw up her courage and do an IVF cycle, her ovarian reserve has dropped because she has become older, and this reduces her chances of getting pregnant even with IVF.

If you want to make sure that your infertility doctor does not add to your infertility problems, you do need to do your homework !

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, March 23, 2017

Why junior doctors in India are running scared

Protecting doctors against medical terrorism

Futile overtesting after an IVF cycle has failed.


A failed IVF cycle can be extremely traumatic for the patient because you do it with a lot of hope knowing that that's your best option. It's the court of last resort after all, and when the cycle fails you're world goes to pieces because you're not sure what to do next, you really don't have a backup option. This is why when a cycle fails, the first question every patients asks is, "Why did it fail?" The doctor in an obvious knee-jerk reflex response will say, "Okay fine, we'll run some tests in order to find out."

Now this seems very logical, but actually this is a very poor quality question which ends up resulting in a lot of over-testing and a lot of over-treatment, because the fact of the matter is, we really don't have very good tests to be able to find out which embryos implant, and which don't. This is hardly surprising because you're putting a microscopic ball of live cells into the uterus, it's very hard to track it's fed. Ideally, doctors should be honest with patients and say, "Look we can't answer that question" but obviously patients don't want to hear that question, and very few doctors are mature enough to be, respect their patient's intelligence and share the truth with them, so therefore they will come up with all kinds of possible reasons such as immune rejection, or NK cells, and do all kinds of fancy, exotic, expensive esoteric tests. Which then lead the patient up the garden path because not only do they make a waste a lot of money, obviously these test results are abnormal as they often will be, they then need to be treated.

The irony is really doing anything for any of these abnormalities doesn't really increase the chance of the patient conceiving in the next cycle. Patients need to understand that's easy to ask questions but sometimes the right answer is "We don't know" and in one sense it really doesn't matter because often, all we need to do is to repeat the cycle, make sure the embryos are gorgeous, the endometrium is fine, and the transfer is easy. If we do this a sufficient number of time, the chance of finally getting pregnant are going to be excellent. But it does require a lot of patience, both on the part of the doctor, as well as the patient, and it requires a lot of maturity on the part of the patient to be willing to accept that technology doesn't necessarily have answers.

This of course makes patients very uncomfortable because they want a doctor who's omniscient, who can answer all their queries, and it's not very comfortable knowing that there lots of things which are not in a doctor's control, but we need to accept that human reproduction is not efficient and we need to learn to live with this reality.

I always tell patients, "If there really were a test which would help me to find out why your cycle failed, don't you think I would do the test before the cycle failed, so that I could optimize your chance of getting pregnant and increase your chance of success, rather than wait for the cycle to fail and then do the test?" This is why all these tests after a failed IVF cycle are completely futile and wasteful.

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 !




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