Friday, February 17, 2017

When infertile patients start obsessing over their test numbers


I'm a big believer in patient empowerment and feel that patients should do as much homework as possible, so they understand what their options are and can make well-informed decisions for themselves. Yes, this does involve a certain amount of effort, but it is possible for patients to decipher medical jargon and understand their options.

Lots of husband and family members worry when patients spend time on the internet trying to make sense of their results because they feel that half knowledge is dangerous and that these are decisions which are left to the doctor. Because infertility treatment is elective, there are so many variables involved and so many different options, I think patients need to apply their minds so they can express their personal preferences when deciding what to do next. As with everything else, you can carry this too far. Just like being completely ignorant about what's happening and leaving everything up to the doctor is not a good idea, I think looking at numbers out of context also carries its own sets of problems. This seems to be a very uniquely American problem where not only are the doctors completely obsessed with minor variance in test results, so are the patients as well.

Here's an example of a patient who sent me her report and what her concerns were.

Hello. I am 29 years old, my husband is 32. We tried to conceive naturally for around 6 months but due to luteal phase spotting, saw an RE who recommended clomid. We did 4 cycles of clomid with possible chemical pregnancy (highest b-HCG of 5.4). We have now completed fresh cycle of IVF (though we saved all embryos for frozen transfer). I had 32 mature eggs retrieved->19 fertilized->14 made it to day 5 and were frozen. Out of those we had genetic testing done on 8 and 5 are normal. I am preparing for a frozen transfer and noticed that my TSH level was 2.69 with Free T4 of 1.15 after my last cycle with clomid (that day beta hcg was also 2.6). Prior to that i have had my thyroid tested several times throughout the years and TSH has been between 1.1-1.9 with free t4 of 1.3-1.5. Should I be worried about this TSH? Could it be due to clomid? Or could the the b-hcg from trigger or chemical pregnancy have affected the value? Thank you!

Now this poor lady has been over-tested and over-treated and the problem is that he's interpreting her results all wrong. I agree that's not her fault. After all, she's not a doctor and I get that, but she also needs to be far more balanced in her approach and find a reliable doctor who will help to her to make sense of these rather than someone who causes her to worry unduly and creates a lot of anxiety in her head, especially when all these so-called abnormalities are just normal anatomical variance of no clinical importance. Otherwise she's going to drive herself crazy and most probably her husband as well, in her pursuit of the perfect numbers, whether this is a TSH level ... She's obviously been completely over-tested and over-treatment.

Again, this is a very uniquely American phenomenon which, unfortunately, Indian doctors seem to be adopting because it is far more remunerative for them to do as many procedures as possible irrespective of whether these procedures are helpful for the patient or not. The general tendency is this blind belief in technology where the rule seems to be, the more you do the better your results. Without realizing that a lot of these procedures may sound very logical but may actually turn out to be harmful and they've not been proven to improve pregnancy rates. Unless they're subjected to clinical trials, there's no reason for patients to subject themselves to being treated as guinea pigs, especially at their own expense, which is something which makes no sense to me.

As with everything else, do what Gautama Buddha said, "Follow the middle path."

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 to the right path  !





Wednesday, February 15, 2017

Why I love my work as an IVF specialist


In today's age , work is a very important part of the way society perceive us . Being proud of what you do also adds a lot to your self-esteem. I consider myself doubly blessed in the work which I do , because being an IVF specialist is extremely gratifying on multiple fronts.

We've been doing IVF for many years now, and I think it's one of the best jobs in the world , because we allow people to start a family - we help them to bring a new life into this world. Children born after IVF treatment are an asset to the country , because they are deeply loved. They are usually very well brought up, because their parents have moved heaven and earth in order to have a baby. When you help them to have a baby, not only have you transformed their lives, you've transformed the lives of all their family members as well , which means being an IVF specialist allows me to bring so much joy in people's life on a daily basis.

It also allows me a lot of professional autonomy . Our IVF clinic is a standalone clinic , and not part of a corporate chain. I don't need to be part of a large hospital , which means I can focus on doing what's right for my patients without having to worry about meeting financial targets or filling in paperwork and insurance forms. I can focus on doing the one thing I know how to do best - taking good care of my patients.

Because we've been doing this for many years, we've got very good at it. We have a high success rate, which means patients come to us from all over the world . This is very gratifying , because being able to help them to succeed after they have become despondent because they have failed IVF cycles in other clinics can be very exhilarating.

Our website allows me to share my knowledge with infertile couples from all over the world, and we try to help patients to make well-informed decisions. Our patients are well-read and intelligent, and they teach me a lot about how to cope with life's adversities, as they battle with their medical problems. Being infertile can be emotionally very stressful, and I learn how to remain graceful and unflappable even when life is unkind and unfair.


The beauty of IVF is that it is a superb blend of science and technology; medical therapy and surgery; advanced imaging; as well as counseling . All these facets are equally important, which helps me to become well-rounded. When I do a consult, I need to understand what the patient's going through , so I can empathize with her. We need to deploy advanced technology in our IVF lab , to be able to create high quality embryos. We have to do precise surgery , such as egg collections and embryo transfers. We need to interpret ultrasound scans to monitor the cycle; and we need to make sense of blood tests and design treatment protocols customised to the patient's specific problems. IVF is one of modern medicine's success story , and allows us to make babies for patients whom we would never have been to help even 40 years ago.

Finally, IVF allows me to work with my talented wife , Dr Anjali. She is much more caring than I am, and has far better clinical sense and intuition. This means we can combine our strengths to provide the best care to our patients.   Would you like to share this with your colleagues? Email Be the first one to share this post

We need to stop medicalising IVF treatment



IVF is an extremely effective form of therapy for infertile couples . It is the final, common pathway for any couple with an infertility problem, because it allows us to bypass whatever hurdles nature may have put in their place. For example, whether the tubes are blocked , or the sperm count is low, IVF allows to do with the lab what is not happening normally for that infertile couple in the bedroom. That's why IVF is an ART, which stands for Assisted Reproductive Technology and not Artificial Reproductive Technology.

A big problem today is that everyone seems to have medicalized IVF. They think of it as being abnormal or artificial . Thus, some patients are worried that the sperm selected for IVF may be weak , as a result of which the baby born may be abnormal. It's high time we put to rest these myths and misconceptions.

IVF has now been around for more than 40 years. Millions of babies have been born worldwide after IVF and it's been proven to be safe and effective, both for the babies who are born as well,  as their mothers. This is quite intuitive , if you stop to think about it . Effectively, all we are doing in an IVF cycle is what would normally happen in the fallopian tube in the woman's bedroom if she were having sex normally , and she were fertile . In IVF, we do exactly the same process in the petri dish in the incubator - we are just replacing the fallopian tube with a test tube ! Once we've made the embryo, it's exactly like any other woman's embryo.

There is absolutely no difference between an in vitro embryo and in vivo embryo , and this is the reason why an IVF pregnancy is exactly like any other pregnancy . We need to reassure our patients that what we are doing is safe , and that an IVF pregnancy doesn't require any special care or precautions. Thus , after the embryo transfer, they don't need bed rest or dietary restrictions.
After all, women doing IVF are not patients ! They're normal women , and we're just helping them to kickstart their pregnancy.

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, February 14, 2017

Worst case scenario planning for IVF patients


For most IVF doctors and patients , failure is a taboo word.

It's something which no one wants to talk about, because everyone wants to discuss only the chances of success. This is obviously far easier to do and much more pleasant, but I don't think evading hard issues really makes a lot of sense. I think it's always important to protect your downside before considering the upside.

Not only is this far more sensible, it helps you create a safety net. Being prepared for the worst improves your emotional resilience and ensures that you don't go to pieces in case your cycle fails.  Some patients think their world will end if their IVF cycles fails. However, the truth is that life continues even after IVF failure .

If you fail to prepare for failure, and put all of your eggs in one basket (pardon the pun), then if that cycle does fail, you're likely to be so emotionally devastated that you may just give up completely and refuse to do another cycle.  Ironically, repeating the IVF cycle would actually be your best option, but because you were not emotionally prepared for failure, you deprive yourself of your best chance of having a baby . You cannot afford to go to pieces just because the cycle fails.

The good thing about planning for the worst case scenario in IVF is that there is no medical risk to  IVF failure - the failure will not damage your ovarian reserve, increase your risk of cancer, or harm your physical health . The risk is predominantly financial and emotional , and because these can be anticipated , you can plan for them.

You need to know exactly how much you are going to have to spend; and how much you are willing to spend in your pursuit of a baby. If there are limitations , you need to think of creative solutions so you can work around these. For example, you can talk to your doctor , and ask for a discount, or opt for shared risk program which reduce your financial risk.

Exactly the same reasoning applies to the emotional risk of failure as well . Rather than start catastrophising if the cycle fails, or sugar coating everything by assuming that your cycle will succeed, you need to be hard headed and realistic enough to accept the fact that it may fail.

You need to put the IVF treatment in the right perspective. It's not an emergency treatment, and you can take your time until you are mentally and physically prepared to go through an IVF cycle. Even if the cycle fails , you will always have peace of mind you did your best, if you do your homework and make a well informed decision.

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





Monday, February 13, 2017

Aamir Khan as a social entrepreneur


Celebrities have a lot of power .  Because of the adulation which they attract , they are often used as brand ambassadors to lead social campaigns. They have the power to do a  lot of good because their actions catch the eye of the public.

Lots of people are quite cynical about some of these celebrity endorsements. They believe these "go-good" activities are used by them as vehicles to improve their public profile and popularity. Every once in a while however, you come across a celebrity who uses not just his face and his goodwill, but also his brains to be able to do something to make the world a better place.

A great example of this is the work which Aamir Khan is doing with the Paani Foundation, which is battling the water shortage in Maharashtra by systematizing watershed management.

Watershed management to tackle drought has been around for many years. What makes Aamir's initiative praise-worthy is that he is leveraging his public persona intelligently.  He realises that the impact a celebrity has can be quite transitory , which is why the Paani Foundation insists that the villager do the work themselves - they need to take ownership of the solution if the changes need to be long-lasting.

He has tied up with his friend, Satyajit, and they make a great team. I learned more about their unique model at fundraiser hosted by Motilal Oswal on 8 Feb 2017.

For one, they've decided that their foundation needs to self-destruct ! They believe that if they do a good job, then the Paani Foundation will become irrelevant in five years. Secondly, they're not disbursing any money to the villages themselves, which means they have stayed away from a potential source of corruption and allegations of favouritism.

They are creating competitions , and awarding prizes to the villages which do the best job at water harvesting and conservation - an excellent example of gamification ! They are using Marathi TV channels and the government to create awareness, and invite villages to compete for these prizes.

Their role is to educate villagers about  what needs to be done, but I love the fact that they're not doing the work - they are getting the villagers to do it themselves. This is what makes their model so magical - it can be scaled up exponentially ! They propagate watershed management knowledge - and then it's upto the villages to implement this themselves.  This way, even if the villages don't win prizes, they still end up as winners because they have more water than they had in the past.

Equally importantly, they're tying up with the Maharashtra government, because they realize that  this movement needs governmental support. The government has far more muscle, far more reach, and far more money - and the Foundation is amplifying this very cleverly by using Aamir Khan's clout to attract villagers to take part in these competitions.

Since the villagers themselves need to do all the work, they are the ones who need to take the initiative to fix their own problems - the Foundation only acts as a catalyst.  It is this sense of ownership which makes the Paani Foundation so unique. If the villagers create the check dams , bandhs and tanks themselves, they are fully  invested in making sure they remain functional, which means they will continue to maintain them year after year.  This is in sharp contrast to projects done by the government, which typically decay over time because of a lack of ongoing support and follow up.

Also, since the villagers are intimately aware of their local geography, they are much better informed about what  needs to be done and where it needs to be done, as compared to a government engineer who is on a 4 year posting.

Far more importantly, this movement has the potential to become a great catalyst for social change. Because all the villagers need to get together on a single platform, they need to be able to overcome their local differences and unite - something which can be surprisingly hard, given the barriers which have characterized traditional Indian society for so many centuries.

Once they taste success, villagers get a sense of empowerment -  We did it ourselves ! This can then be the first step in a long line of social changes, because they have now learned that they are not helpless - they can do lots of for themselves if they get together. This can set off a positive virtuous cycle.  Once they have enough water and don't have to fight drought on a regular basis, they will have enough food, which in turn leads to an improved economy. This will then allow them to address their other social needs, such as education and health , without having to depend on government largesse.

What's great is that it's not just a top-down approach or a bottom-up approach - it skillfully combines both  !

It's not been an unalloyed success, and they have had setbacks and failures. I like the fact that they are dreaming big, but starting small. They're not in a rush, and are deliberately being systematic and slow , so they can grow properly and organically. They're making mistakes, and have the humility to acknowledge these , so that they can learn from them. They are happy to partner with funders , NGOs , geologists and water management specialists, so that they can scale up successfully.

Interestingly, they're not raising money for themselves - Aamir is independently wealthy and they have enough to run their Foundation. They're raising money in order to help villagers to accomplish stuff  which they cannot do for themselves. For example they need machines to do some of the heavy duty  construction work, and the donations they are raising are being used to hire the earth moving machinery for the villages. Also, since they do not want to handle the money themselves, the funds are being routed through an NGO , which has been certified by TISS as being eligible for CSR funding.

I like their thoughtful approach. They have been designed as a learning organisation, and are agile enough to deal with the problems and pitfalls they may encounter.

While many funders are happy to throw money at them, so they can replicate their work in other states of India, they have remarkable focus - as proven by their ability to say No to these requests. They don't want to bite off more than they can chew, and they want to be sure that their model is sustainable and scaleable . They are happy to share their SOPs with others, but don't feel they have the bandwidth to venture outside the state, because they don't want to dilute their impact.

Do you want to help ? They do have a list of scientific and technical problems they need help with tackling ( for example, using technology to map aquifers) , and your insights would be welcome !

Friday, February 10, 2017

Why transferring a single blastocyst at a time improves pregnancy rates


Lots of IVF patients and doctors are very confused about how many embryos to transfer. The general belief is that the more the embryos you put back, the better your chances of getting pregnant. This is why many IVF doctors still put back as many embryos as the patient has. If the patient happens to end up with a multiple pregnancy , they are happy to do an additional procedure called a selective fetal reduction, to reduce this to a twin pregnancy. This practice is so rampant, that some ultrasound clinics do 3-7 fetal reductions daily  !

Patients also contribute to this push for transferring more embryos. This is especially true when they have failed multiple cycles . They feel that if all the embryos which had been put back so far haven't implanted, then why not transfer even more , to increase their chances. They naively believe that their chances of ending up with a high order multiple are very low, so they feel that they will cross that bridge if and when they get to that stage.

This is something which IVF doctors encourage as well , because they want to boost their success rates. They want as many of their patients to get pregnant as possible, because a pregnancy is an IVF specialist's endpoint. If it does turn out to be a multiple pregnancy , then that's really the obstetrician's problem, not theirs ! They can tell the patient - I did my bit - I got you pregnant , which proves I am a good IVF doctor ! They want to artificially inflate their IVF success rates, because this allows them to trot out statistics which keep on getting progressively better, even if the live birth rate suffers. This is especially true in clinics where pregnancy rates aren't very good, because their laboratory conditions are sub-optimal, which means their implantation rates are poor.

The good thing about IVF technology is that it advances relentlessly. Our ability to grow embryos to the blastocyst stage is now excellent , and high quality blastocysts have a very good chance of implanting and becoming babies. Even better, our ability to freeze these blastocysts  has become so good ( as a result of vitrification ) that we never need to waste any of these precious embryos.

In the past, because the IVF lab wasn't robust enough to grow embryos to blastocysts reliably; because freezing programs weren't good; and because implantation rates were poor , a lot of clinics would transfer three, four, and even five embryos on day two or day three. It was pretty much a spray and pray approach. Since IVF was a hit and miss affair , the attitude was  - let's put in whatever embryos we have , and we'll see what to do in case she gets pregnant. If she ends up with a high order multiple, we'll handle the complication if and when it occurs.

Over time, as the embryology laboratory kept on improving, high order multiple births became so common, that IVF clinics realised that they had to do something to prevent this problem. This is why many clinics are now moving to transferring only two embryos on day five.

In fact , our suggestion to our patients is to transfer only a single embryo - less is more ! Suppose you have  two high quality blastocysts. One choice is to put both these blastocysts back together . You could get twins, which is perhaps not such a bad outcome , but twins do have a higher complication rate as compared to singletons. The other alternative is to transfer one in the fresh cycle; and freeze one. Finally, you could freeze both.

In the past, we would say - Go ahead and transfer both . However, our recommendation is to transfer only one and freeze the other. If an embryo is going to implant, then it will - putting two together at one time doesn't increase the chances of implantation - it just increases the risk of a twin pregnancy.

Transferring two blastocysts together doesn't improve the chances of either implanting, because each embryo is independent . Transferring more than one does not have an additive effect.  Think of each blastocyst as being a 5 carat diamond solitaire - each solitaire is best mounted separately, because it shines better on its own. This is why egg and embryo pooling is such a stupid idea.

Even if the single embryo doesn't implant , then at least you have a second shot at getting pregnant by transferring your frozen embryo in the next cycle. And there's no reason to think that transferring two would have improved the chances of a pregnancy. In fact, if the cycle failed, then you would have ended up losing both, and would not have anything in reserve to fall back on.

The additional cost of a frozen cycle is so much less than a fresh cycle, that it's far more cost effective to use this approach. In fact, for mature patients , we are now going one step further and saying - Freeze all your embryos , and then transfer only one embryo back at a time. Transferring frozen embryos actually has a better implantation rate because we can prepare the endometrium so that it's optimal for receptivity.

This way, patients get multiple chances to get pregnant from just a single egg collection. This means their cumulative conception rate over multiple cycles with these frozen embryos is far better. The only downside is that it takes longer to get pregnant , because the patient needs to come back for her frozen cycles. However, not only do the overall pregnancy rates improve , the chances of her taking a baby home increase as well, because the risk of obstetric complications is reduced with a singleton pregnancy , as compared to a twin.  Also, if she gets pregnant, she can use her frozen embryo to have a second baby in the future as well , thus completing her family !

Paradoxically, a single transfer if even more important in patients with poor ovarian reserve, who have very few embryos. Each embryo is worth its weight in gold, and should be transferred individually. Even if she has only a single top quality blastocyst, a freeze all is the best approach. Of course, this is applicable only if your IVF clinic has a high quality lab and a robust vitrification program. This is why selecting a high quality IVF clinic makes such a big difference to your chances of having a baby !



Thursday, February 09, 2017

Ask the IVF Embryologist

Most patients are clueless about what happens in the IVF lab, even though the lab is the heart of IVF treatment. The IVF lab is where all the action occurs  because this is where we make your embryos !

Embryologists are the unsung heroes of the IVF clinic.

If you have questions about your embryos, you can now ask Dr Sai, the Chief Embryologist at Malpani Infertility Clinic.

Read more at http://www.drmalpani.com/knowledge-center/ask-the-embryologist2

Dreams do come true !

Ever since I was a young girl, I knew I was extremely lucky in every path that I walked - parents, schooling, childhood, education, money, family, marriage…everything was just so perfect….till the point when suddenly I found out I wasn't being able to get pregnant. That's when I started feeling unlucky….It was the time when I started believing God doesn’t give everything to everyone…

There were only coping mechanisms which I could think of -  leave it or live with it…Leaving it was more difficult than living it. People around you don’t let that happen. Every function that you attend, people wouldn’t care how well I was doing in my life - they were concerned - or pretended to be concerned - about me having a baby. Special thanks to the great Indian mentality of interference and giving opinions even if they are not asked for. It was painful for me to attend naming ceremonies, birthdays of friends’ kids and walking in there without a kid. Especially when I had seen friends doing abortions for whatsoever reasons, I used to get highly upset. It was very easy for them to end a pregnancy and they never knew how hard some people have to try to just start a pregnancy. But everyone owns their life and all I had to do was own mine and take some steps.

Being educated and well aware of medical advancements and our poor lifestyle leading to stressful life, we never were embarrassed to go to the infertility doctors. Checking our reports, they said everything looks normal except for my low AMH levels. We had lots of tests, hysteroscopy etc. as a part of the preparation. One of those very renowned doctors told us to attend his lectures if we wanted answers to our queries, as he was too busy to answer them one on one. It was my last day in that clinic.

Another doctor didn’t have time for anything - only a few minutes which they could give us - and everything was handled by  her juniors. We underwent 1 IUI and 2 IVF cycles out of which one was successful but ended around 8 weeks. The amount of medicines and injections that I had to take was horrendous. The worst part hit us when the doctor refused to attend our calls when we were so paranoid and panicked as we were losing our baby.

We had tried 3 different doctors in this field, who were supposed to be top-notch, and we felt we were being treated as a widget in a factory. It seemed to be an assembly line approach, with no human touch. I should say it was a BUSINESS in true sense with only commercial approach. I agree it’s their means of living but for god’s sake they were handling the feelings of emotionally fragile people. To do IVF, one has gone through a lot , and is already very vulnerable - I wish they understand this. And I gave up , both emotionally and physically.

Taking a foreign posting was one of the major reasons to go away from all this. In office abroad, when I said I don’t have a kid, the reaction was usually one of sympathy. No one tried to pry into our personal life, and this was such a great blessing . However, away from home, and away from family,  the emptiness started hurting more. All thoughts started coming to me including adoption, surrogacy and many more.

And one day I was travelling in train and vaguely remembered our family doctor referring to Dr Malpani to my parents as they were discussing about we not having a baby yet. All I remembered was Dr Malpani and Colaba. I immediately googled it and started reading his website. The first thing which I remember clearly was second opinion. I found that so interesting and all the information on website was so helpful. I decided to send an email and before even I could imagine I got a reply from the doctor himself. This was the first positive vibes I got and I felt very touched. We took his appointment and the first meeting itself was so positive and assuring. I never met such a doctor who speaks so nicely, to the point and is not tired of responding your questions. We had done our earlier IVFs with my own eggs though AMH levels were low. We discussed this with the doctor and egg donor option was discussed. I know it is a big step but at least one of the genes will be of your partner and you can feel the motherhood has much more positive points as compared to when you will go for an adoption. It was my fight with my mind but one needs to be practical in life.

The entire process was seamless and support of the staff is remarkable and we felt like a family. It was beyond the expectations on how you would like to get treated especially when you are on an emotional roller coaster. From reception to the OT, all were just so nice to us. Even after the procedure, every email was answered immediately. This proves that this is much more than just a medical treatment for the clinic . I cannot thank Doctor Malpani and his team enough for making the process so satisfying and making our dreams come true…..



Monday, February 06, 2017

An infertile patient's secret thoughts, worries and fears

This is a guest post from a very thoughtful patient of ours.

It describes very eloquently the worries and fears which prey on an infertile patient's mind. It's very hard to discuss them with anyone, and bottling them up just makes things worse !

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Isn't it a paradox that when India and world's population is exploding at alarming rate; here I am ,struggling to have a single child for 5 long years and with no idea when the struggle will really end.

I am being treated at Malpani's and yesterday the doctor urged me to write down my thoughts... He said that many others are in same state and articulation  of our thoughts on paper may make us feel better. And in the process of doing so I may end up empathizing and helping others.

Right now, I am in no mood for doing any general good ... nor do i care which parts of it the doctor picks for his blog....  I have decided to write down each and every thing I feel and think these days in selfish interest and honest hope of feeling better myself.

For today, I am just going to list down all my irritating thoughts .... my worries . In no particular priority .. honestly all negative things (which is all I think I am left with.. to offer)!

1) the Age is passing  and the constant hollow feeling...

I will be 34 in May and have been married for 7 years. Being an MBA from one of  top schools ... i could put a lot of positive and constructive energy in building a noteworthy career for myself...BUT ...In reality, all my energies in these 5 crucial  years have been sucked up by this one issue of unexplained fertility. Waiting 60 long months for a resolution ... my life is stagnating !

I try to put the professional and personal things in different wagons but at end of the day, several failed attempts of being a mother are making my professional achievements seem hollow and meaningless.

2) I have healthy genes otherwise !

From the age I have memory ... I don't remember going to a doctor for any other reasons.
I don't think before marriage since childhood if I had been to our family doctor for more than 5 times.
I always had 1 other persistent health issue... sometimes I get breathless for which I take aerocort inhale once in month.
But other than that I don't get headaches .. no allergies .. no reactions...no aches no pains... I haven't seen a doctor for any other reason....
It's very irritating that I keep seeing fertility doctors and await a cure and find no solution for 5 years !

Sometimes I also fear that with so many fertility treatments most of which are hormonal . . I may be posing myself to a higher risk of cancer of some kind in future.

3) my ankle fracture :
We decided to start a family 1 year into marriage but I had an ankle fracture then. It took me 9 months to heal and I must have undergone 15 ankle X rays at that time(Nov 2010-Aug 2011)
I still carry some metal screws and rods in my left ankle which the orthopedic had asked me to have removed in August 2012. But I started visiting the gynacs since Nov 2011 month after month in the hope of getting pregnant and did not wish to expose my body to Xrays at early pregnancy stage. I have been postponing the surgery thinking I will do it while I am on maternity which unfortunately has not happened.

4) I will make a sick parent :
Had everything got resolved fast... I would have been in happy state of mind ... But 5 long years of constant tension...wait .. anxiety and negative feelings... I fear I will make a mentality sick parent to my child (for whom I am going through so many struggles)
Or with age I may lose the vigour or energy to parent a child.

5) the umpteen alternate therapies.....None of which seem to work !
I keep googling each day with a hope to find that one magical solution which will make things work for me ... but none of it has helped me as yet and I don't know which ones to pursue for how long !

I have experimented with acupuncture ... ayurveda .... massages ... spiritual chants ... music.. castor oil packs..hot showers ..chakra healing..random advices on diet... and none of it have given me results. I have quit after few tries and felt guilty many times of not being determined enough or not being a thorough believer... and have strayed and flipflopped too many times to know what went wrong ...

For now what i know is....I will continue with ayurveda massages as I feel relaxed after that.

5) Diet and PCOS
I love food and although i eat everything without complaints ...it's a torture to constantly follow some or other advice when it comes to food. Be it portions or variety.... I feel a constant pressure while eating as it may add to my weight which is linked to PCOS or increase my body heat which as per ayurveda is not good for conception.

For example : I loved sea food( clams .. prawns, shellfish , crabs etc.) ... but I don't remember last when I have eaten it to my heart's content in last 5 years... Sea food is supposed to increase body temperature as per ayurveda


6) appearance and advices
I am 70 kgs and that provides everyone an opportunity to tell me exactly what I should be eating to be slimmer....
And since I don't have a child  7 years into marriage ... the itch to advice me multiplies many folds and its everyone's birthright !

I fake ultra confidence to scare these well-wishers away but they find ways  to  whisper all sorts of advice to my mother or MIL which then is added to "our invisible rule book to get pregnant faster".... this book haunts me for days each month when I have learnt my pregnancy hasn't worked.

6) were my ovaries dysfunctional  or is my  uterus dysfunctional ?
I was detected with PCOS in Nov 2011 but was told it's not severe and many ladies concieve with no troubles in spite of acute PCOD.
So I kept thinking it's my ovaries who need to produce good quality eggs...

My AMH is above 4 (i.e. 1 level below perfect) which says I am not menopausal...

And when you do IVF .. ovaries anyways don't have a role beyond producing many good quality eggs at the start.

My uterine lining wasn't growing for 9 months post embryos were formed in 2nd fresh IVF cycle. And when it grew to the doctor's satisfaction and we did a transfer.. I got pregnant with ectopic. This the highest BHCG i have had :  6000 levels and i saw it on ultrasound too. Which means the one embryo which managed to travel to a tube implanted well. My tubes were fertile and embryo was good.
But what happened to the one embryo which remained in the uterus... I think that got killed...  same way the one embryo we transferred last month too got killed. Also the 5 embryos we transferred 2 years back in my first IVF fresh and frozen cycles have got killed.
Now my analysis says the real issue is that my uterus is dysfunctional.
And for many years in the past .. I kept assuming PCOS was the big issue... not knowing the real issue wasted around 4 years my crucial fertile age.

7) measuring the period flow :
For a few months in the past .. I haven't got my periods witout medication... I have taken medicines such as mesoprostol etc which are given to empty uterus contents in case of pregnant women. It is the last thing in oral medicines which can be given to abort pregnancy.

That was the only time and after ectopic pregnancy I had good flow in periods. I.e. 3 days of flow.

Else these days I get flow only on day 2.ie only for 1 day.
I am not sure whether that's causing my lining to not grow properly for the next cycle.

8) my 64 month long infertility ordeal
Oct 2011: went to doc for a random missed period and wish to start family
Put on progynova and Gestin treatment for 4 months with oral multivitamins to help concieve
Nov 2011 : sonography showed 2 intramural fibroids and PCOS
Apr 2012 : histosalphingography
Tubes found patent
Nov 2012: 2 IUIs done.. advised IVF but scared so changed gynac
Feb 2013 : laproscopy done with PCOD drilling done
Mar to Nov 2013 : 5 IUIs done advised IVF again by the doctor
Nov 2013 : did acupuncture + ayurveda oral + ayurveda massages
Jan 2014 : clinical pregnancy highest BHCG 952.
Jun 2014 : Hysteroscopy done. Some infection at the mouth of the uterus freezed and cleaned using cryo****(don't remember the term)
Sept 2014 : first IVF fresh cycle (BHCG 150)
Mar 2015: frozen cycle (BHCG 50)
Contemplating doctor change
Visited dr indira hinduja.. Kiran Coelho ... rediscussed if fibroid removal is an option. But refused by both . Kiran agreed hesitantly and with risk caveats .

Jul 2015 : landed @ Malpanis ..given vit D / DhEA / etc
Oct 2015 : ovum retrieved . 21 eggs 5 d5 embryos formed
Ovaries enlarged so fresh cycle canceled.
Dec 2015 - July 2016 : lining unsatisfactory to do a FET
July 2016: FET with 2 embryos. Ectopic BHCG: 6000
Jan 2017: FET 1 embryo . BHCG:0

9) vitamin D and B12 deficiencies : whenever I have tested these in interim .. I have been deficient. Not sure if this is causing the failure to implantation.

10) the toll on my marriage and other responsibilities : We seem to be blaming each other for small issues these days.
We hardly have sex and don't seem to be attracted to each other.
We want to do it some times but think time / ovulation .. basically it's hardly  mood driven and very infrequently spontaneous.

Also our families are so consumed by this problem that my in laws or parents don't discuss their health issues with us thinking they will burden us more .. but this attitude makes us further guilty of being selfish and not being there for our parents when they need us.

11) social withdrawal : we wish everyone good but do not enjoy being at birthday parties or baby showers. We do not like outings where we know there would be kids. This is taking us away from some of our good friends / cousins who we use to hang out with regularly.

12) gods and abstinence : I have been sincerely worshipping around 26 gods whom I use to not even know existed. I am abstaining/following foods /customs which promise faster results.

13) at astrologer's mercy : an astrologer who has good repute in our family has predicted we will have a child. According to him , it's time we do. In dire states , I keep telling this to myself and being hopeful.















Friday, February 03, 2017

IVF failure rates vs IVF success rates


The commonest question a patient asks an IVF doctor is, "What are my chances of success?" What are the pregnancy rates in your clinic?"

This is perfectly natural - after all, the patient has come looking for a baby , and they want to know how well the doctor can gratify this desire for them. Doctors are happy to talk about IVF success rates, but the problem is that this creates a framing bias . This is because when you talk about successes , you tend to gloss over the possibility of failure.

The danger is that this sets up unrealistic expectations, which means patients are very optimistic and hopeful when they start their IVF cycle.  They are sure their IVF cycle is going to succeed, and when it fails , this creates a backlash. Patients are extremely upset, and they will often vent their anger on the doctor . Now it's not that the doctor was responsible for the failure, but because he didn't discuss this possibility explicitly with the patient up front, he set up the patient for unnecessary heartbreak and disappointment.

It's completely normal and natural for IVF doctors to talk about success rather than failure. After all, who wants to be a wet blanket? Who wants to take the risk of putting the patient off by disheartening   her ? She may think you are a very negative doctor, and will go off to the competing clinic across the road  . Few patients have the maturity to appreciate a doctor who is blunt, frank and forthright - they'd rather go to someone who promises them hope , even if this is false!

This is why IVF doctors are so sweet at the time of the first consultation.  They want the  patient to come to them for treatment, which is why they frame the situation in a manner which increases the chances of the patient signing up with them, rather than with another doctor. Now, while this might be good for the doctor's practice, it's self-serving, and doctors need to be aware of their personal prejudices when counseling their patients.

I believe doctors don't need to prepare IVF patients for success ! After all, if the patient is successful, she's going to be extremely happy with you,  and will send lots more patients to you. However, you do need to prepare the patient for failure. if you fail to do this, then in case the cycle fails (which it often does), then she doesn't go to pieces, and is able to be resilient and bounce back.

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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