Wednesday, December 13, 2017

The caring doctor

Patients often criticize doctors for being unemotional and distant . Because we are taught to maintain a professional barrier , we may seem to be cold and uncaring, but the reality is that doctors have a heart too - we're human after all !
Ironically, sometimes it's this humanness which backfires. Thus, we will often identify with some of our patients - especially when they're of the same age group, or come from a similar background. We sometimes need to break bad news to them , and when they start crying on hearing this, we get emotionally upset as well.  We may then end up saying things to try to console the patient, which he may then misinterpret . This can come back to haunt us , because the patient feels that the doctor was too frank and overstepped his professional boundary.
I recently had a patient who got pregnant after IVF , and I sent her to an ultrasound clinic for a viability scan at 6 weeks, to confirm her pregnancy was progressing well.  Her sonographer was worried that she couldn't see a beating heart, and told her - There is a possibility that this may not be a healthy pregnancy.  The patient broke down and came running to me in tears the same evening , saying - The radiologist told me my baby is dead !
Interestingly, the sonographer is an extremely good doctor who is normally very careful . Because she's a radiologist, she would never provide a clinical interpretation to a patient. Her standard answer is, "I have done the scan and my job is to report what I see on these ultrasound images . It's your doctor who's the clinician , and he will tell you what this means." Interpreting the image in a clinical context is the clinician's job, not the radiologist's, and good radiologist are acutely aware of this fact . So why did she bend the rules this time ?
She could see that the patient was very worried and agitated. The patient had read online that the inability to see a fetal heart at 6 weeks gestational age may mean that the pregnancy may not be healthy. She tried to calm the patient down by giving her some additional information , which the patient then misinterpreted, because she was so upset.
Yes, in one sense, the sonographer over-stepped her professional bounds , but she did that because she's a human being - a  good doctor who is empathetic and who cares for her patient.
I wish patients would appreciate how hard it is to be a good doctor ! It's hard to know where to draw the boundary between being compassionate and being detached. It's much easier being professional and maintaining a distance . We are warned by our professors that we need to be cold and objective if we want to practise properly, but we don't leave our hearts at home when we enter the clinic . When we try to be caring and connect with our patients, sometimes this backfires , as it did in this particular case.
I called up the doctor and told her what had happened. I needed to provide her with feedback , and I reassured her that what she'd done was in good faith, so she shouldn't feel bad about it. Her intentions were good , and her heart was in the right place, but sometimes even well meaning actions backfire. What she had said in order to alleviate the patient's anxieties and reassure her ended up causing the patient even more anxiety, because it's easy for emotional patients to misinterpret what a doctor means. When these messages get distorted, it causes a lot of harm to everyone.
I had to reassure her that it's often hard to draw a final conclusion so early in pregnancy, and that we need to wait and repeat the scan again in one week to check whether the pregnancy is healthy or not.
Patients forget how difficult it can be to be a doctor ! Handling patients who are crying in front of you can be tricky, because you want to be objective, but you also want to do your best to take their pain away - after all, this is why you chose to become a healer in the first place !






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 !

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