Thursday, September 28, 2017

The futile quest for certainty in IVF treatment.


Every couple who does IVF wants to get pregnant in the first cycle, and of course, every IVF doctor wants their patients to get pregnant in the first cycle as well ! It's very fulfilling to be able to add so much happiness to your patients' life by giving them a deeply loved baby, and if we had a 100% success rate, our life would be much easier !

Unfortunately, our IVF technology still has a long way to go .While we're good at doing certain things, there are lots of gaps in our knowledge . This is especially true after we've transferred an embryo back into the uterus. This is literally a black box , and we have no idea what's going to happen to the embryo in utero.

Implantation is a biological process which we cannot study in vivo . Since you're putting a live embryo back into the body , we have no non-invasive way of being able to monitor its progress or track its fate .

We need to be mature and accept the fact that our technology has limitations. We don't have answers for all our questions, , and we need to learn to live with this uncertainty .

However,  this is something which patients are unhappy about. They desperately want answers, and they will often ambush doctors into providing these answers. They will often unknowingly push their doctors into ordering lots of completely pointless and unnecessary tests. Doctors then add insult to injury, by offering " treatments " based on these " abnormal" test results.

It's easy to justify these tests saying, " These tests will give us more information," but the bitter reality is they don't provide any useful clinical information at all , whether it's PGS ( preimplantation genetic screening)  or ERA ( endometrial receptivity assays) .  While these maybe useful research tools, they  should be used only during clinical trials, and patients should not have to pay for the privilege of serving as guinea pigs !  Some Indian doctors are so creative that they offer tests which are available only in India ( such as PAMP testing) because these have never been validated anywhere else in the world !

While these tests may seem to make  a lot of scientific sense, sadly many of the equally logical treatments  touted widely in the past have failed to live up to their original hype - and this includes treatments such as paternal lymphocyte immune therapy;  or intravenous immunoglobulins ( IVIg);  or NK cell testing  -  it's a long list of useless tests and wasteful treatments.

This is why patients should be extremely careful before accepting the justifications which doctors trot out for justifying the use of these tests. The standard reply is - In my experience, it's helped other patients, so let's try it for you ! Any treatment can be justified by calling it empirical treatment - treatment based on experience, but not on evidence.

Fads and fashions come and go in medicine, and they change every few years, but the reality is that none of these treatments have been proven to be of any value at all. I think it's unfair that doctors use their patients as guinea pigs and try out  all these expensive and unproven experiments on them. Even worse, they charge their patients an arm and a leg for carrying out treatments which have not been  proven to be effective.

Yes, doctors would also love to attain certainty, and this is great if you're a researcher in a laboratory where you want to explore reproduction and embryo implantation in a mouse model - after all, that's the job of a researcher. We need to advance our understanding in the laboratory so we can apply this in the clinical setting.

However, clinicians should not be doing this kind of research outside of clinical trial, and it's completely unfair to patients who are being used as subjects of clinical trials.

Doctors add insult to injury by charging them for interventions which have not been proven to be effective in clinical practice, Not only do doctors need to shape up and improve by being more open and transparent with their patients, patients also need to start pushing back when doctors suggests these tests and treatments ! Please ask for medical journal articles from reputed medical journals, which prove that the .treatment being offered has been proven to work in a controlled clinical trial !

Want to make certain your doctor is giving you good advice ? 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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