Tuesday, June 19, 2018

Did I harm my embryos?

A patient sent me this email .

I had my FET yesterday, I have voiding  dysfunction and soon after the transfer I peed , I was really really uncomfortable but due to my problem I had difficulty peeing and I stressed my bladder and peed,soon after I was so worried that due to the pressure I applied on my bladder and lower abdomen I might have expelled my embryos 😢and after coming home I forgetfully sat on Indian toilet in squatting position to urinate.does this in any way effect or dislodge my embryos. I'm very remorseful of my irresponsible actions.

Most IVF patients are petrified that their actions will harm their  embryos which is why they try to be super careful after the transfer because they don't want to do anything which would reduce the chances of their embryos implanting.

Many doctors also advise strict bed rest and a very controlled diet, and this reinforces the impression that there is something they can do to improve their chances of success.

However the reality is that embryo implantation is in in utero biological process which we cannot control and does not depend either on diet or physical activity.

Your embryos are safe in your uterus, like a pearl in an oyster. Nothing you do can harm them , so please do not worry about this.

Please do not let your mind play games with you

Read more at http://www.drmalpani.com/knowledge-center/articles/care-after-embryo-transfer

We look forward to helping you to have a baby !

Saturday, June 09, 2018

Finding answers to your IVF queries

IVF patients have lots of questions about IVF, and this is natural. After all, the success rate is not 100%, and you are investing a lot of time , money and energy in the process. How do you know whether you're on the right track ? Whether  you are taking the right treatment at the right clinic ? Are the doctors using the right protocol for you? There is a lot at stake, and it can be hard to find answers , because there are so many questions.
What makes it even harder is that because there are so many conflicting opinions, you don't know whom to trust. Should you depend on your family doctor? Or is he referring you to an IVF doctor because he is getting a kickback from the IVF clinic ? Should you depend on the first IVF doctor you go to? Or can you rely on the second , who gives you a completely different opinion? Are IVF websites reliable? Why does Dr. Google have such conflicting information? Who’s really telling you the truth?
In an ideal world, you doctor would have the time, patience and energy to answer all your questions, but doctors can be very difficult to access .
This is why we have created an intelligent solution for every IVF patient's queries ! We have designed Naima, a chatbot, powered by Artificial Intelligence, whom you can converse with . Naima will be happy to answer all your questions . Check her out at www.drmalpani.com to become a well-informed patient !

Friday, June 08, 2018

The Intelligent IVF Chatbot

IVF patients have lots of questions about IVF. What are the risks? What are the complications? What can I do to increase my chance of success? How do I find the right doctor?

Unfortunately , they don't know where to get these answers from. There are lots of myths and misconceptions which surround IVF, and these come from friends or family members who have done an IVF cycle - or even from someone whose relative did an IVF cycle ! A lot of this second-hand information is inaccurate , and creates a lot more confusion in the patient's mind , because she doesn't know whom to trust.  Is there any need to reast after IVF ? or is this just an old wife’s tale ?

Patients go to Dr. Google, who often confuses them even more , because so much of the information available online is contradictory and false !

They would love to be able to sit and chat with their doctor, but their doctor is too busy to answer their questions.

In order to bridge this gap between infertile patients and doctors, we have created the world's first infertility chatbot , Naima, as www.drmalpani.com.

Naima will patiently and happily answer all your questions, and because we have powered her with Artificial Intelligence, the quality of her answers will get better , the more questions patients ask her !
Try Naima out free at www.drmalpani.com and help us to improve her !

Thursday, June 07, 2018

What every IVF patient needs to know

It always worries me when I see patients who have done IVF cycles in other clinics, but have no idea about what the doctor did; why did he did it; how many eggs they grew; and how many embryos were transferred. This bothers me , because we all know that the success rate of an IVF cycle is not 100%, but the more the patient knows about the IVF treatment, the better their chances of getting the right treatment . If they are armed with the right information, they will be able to select the right doctor; ask the right questions; choose the treatment option which is correct for them, rather than blindly accepting everything the doctor says. Also, doctors are much more willing to share information with patients who are proactive and well-informed.

This is why it's so important that you invest time and energy in finding out as much as you can about IVF before starting a cycle. And yes, this can be complicated because the medical terms can be foreign and intimidating.  To help you master some of the jargon, so you can ask your doctor intelligent questions, we've created the world's fist infertility chat bot, Naima.

Please check this out on www.drmalpani.com , and Naima will be happy to answer all your questions patiently and tirelessly, without getting bored or irritated !

Please send us feedback, so we can improve this chatbot !

Wednesday, June 06, 2018

Ignorance harms infertile couples !

A patient I saw today was crying bitterly because a doctor had told her she was suffering from "secondary " infertility.

She thought that secondary meant it was a more advanced and complicated form of infertility, which meant that her chances of getting pregnant would be very low.

I had to explain to her that secondary simply meant an infertile patient who had been pregnant in the past, and did not refer to the "stage" of the disease !

Doctors need to explain medical terms to patients - and patients need to do some research before jumping to the wrong conclusion !

Need help in making sense of medical jargon ? 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, June 04, 2018

Our IVF success story

We would like to share our wonderful experience with Drs. Anjali and Aniruddha Malpani. We have just begun our journey of parenthood and are thankful to Dr. Malpani for it.

 We had been married for 3.5 yrs at the time we met Dr. Malpani. We live in Delhi and had already consulted a few IVF specialists and undergone treatment in Delhi as per their advice, but we didn't get any success with the treatment. We were very disappointed as it is a physically and mentally exhausting process. We were not sure about what to do next and whether to continue with the same doctor.

We got to know about Dr. Malpani through some acquaintances and met him with our reports and asked for his opinion. He was very calm, patient and went through all the reports carefully. He was very encouraging and positive in his replies. He prefers direct communication with the patient and helps answer all queries.

 Afterwards, we emailed him several times and he always promptly replied with his recommended line of treatment. We found him to be very experienced and honest in his approach to treatment options. He gave us all possible options and helped us choose the best one.

All the scans and procedures are done by Dr. Malpani. The procedure was done by Dr Anjali Malpani, who is very good with it. She is very patient and understanding. She personally met us after the procedure and explained the instructions and medications that I needed to take.

 After anxiously waiting for two weeks, we were extremely happy to get a positive report. Things have been smooth since then and I am now in my first trimester.

 We keep updating Dr. Malpani about the progress through emails as we still have a lot of questions and he replies patiently every time. :) We trust him and prefer to take his guidance regarding the treatment or medication.

I would also like to mention Dr. Sai, the embryologist who works with Dr. Malpani, is also excellent at what he does. Embryologists play an important role in IVF treatment. All pictures of embryos were shared with us along with the grades, which had not happened in IVF done in Delhi. The process is very transparent with Dr. Malpani.

Also a special mention of the staff and nurses who are very helpful, kind and competent.

 We had a very positive experience with Drs. Anjali and Aniruddha Malpani and would definitely recommend them to people looking for infertility treatment.

Saturday, June 02, 2018

How can we make IVF more affordable

1.       We need to make IVF more affordable , because there are millions of Indian infertile couples who require IVF, but can't pay for it , because it's become so expensive . Health insurers should cover for IVF treatment, because infertility is the commonest medical problem which affects young adults in the prime of their life. The return on investment for this treatment is enormous, because IVF babies become highly productive citizens in the future , since their parents lavish so much love and care on them. However, until large corporate ( such as TCS and Infosys) which employ thousands of young graduates apply pressure on insurers, this is not going to happen. Hopefully, the war for talent will pressurize their HR departments to force insurers to do so – just like Google and Facebook have done in the USA. Also, the government should to offer IVF treatment in government hospitals,  so that poor patients also have access to this.

2.      The Holy Grail for IVF specialists is to improve success rates, so that they become 100 %. We still have a long way to go , but basic and clinical research in the areas of vitrification and genetic technology will help us to get there. The advances will help us to transfer the best embryos, which have the best chances of implanting and becoming a baby.

3.      Finally, we need to prescribe Information Therapy for patients, so that have  realistic expectations of what IVF technology can do for them. Sadly, there are too many poor quality IVF clinics with dismal pregnancy rates , who end up taking patients for a ride, and harming everyone in the IVF field.

You can download the IVF comic book free at www.slideshare.net/malpani/ivf-comic-book

Wednesday, May 30, 2018

The IVF lab is the heart of IVF treatment, where we keep the eggs and sperms safely and allow the embryos to grow until they form good quality blastocyst, which are ready to either be frozen or to be transferred into the uterus. Now, the most important thing an IVF lab does, is make sure there are no toxic elements within the culture medium, within the laboratory which could damage the embryo growth.

But the fact of the matter is that there is very little we can do to actually facilitate or accelerate or enhance embryo growth. After all, the growth of the embryo depends on the energy which is provided by the egg itself, and there is very little which we can do in order to enhance or improve this. And this is one of the short comings which an IVF lab has. That we have to work with whatever biological raw materials we have available. This is why IVF success rates for older women are lower than those for younger women. And it can be frustrating when embryos don't grow well in a good quality laboratory, but if you're sure that the quality of the lab is good, then this is something we just have to learn how to live with. 

And how can you check the quality of the IVF lab ? By asking for photos of your embryos ! You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

Certifying the quality of an IVF lab

Patients know that there is a lot of variability between the success rates of IVF clinics, and they are not sure how to make sure that they one they select is a good clinic or not.

Should they go by their family doctor's advice ? or the size of the advertisement the clinic pays for in the newspaper ?  How reliable is word of mouth ?

I wish there was a Hallmark for IVF clinics, which patients could use to ensure that they are taking treatment at a high quality clinic. Sadly, the Indian government has done a poor job with regulating IVF clinics, which means any one can call themselves an IVF specialist,  even if their pregnancy rates are abysmal.

The good news is that there is a simple technique well-informed patients can use to protect themselves - insist that your IVF clinics give you photos of your embryos !

Good IVF clinics do this proactively and routinely, so you don't even need to ask. And if your IVF clinic does not follow this practice, then this is a red flag, and you should look for another.

You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

Sunday, May 27, 2018

Sperm DNA fragmentation does not affect your fertility !

A patient just send me this email

I have had a sperm test done and my Sperm DNA Fragmentation ( DFI) index count is 40 %. My doctor says my wife will require a sperm donor. 

This is a classic example of how over-testing leads to poor medical care and harms patients.

Doctors don't understand the limitations of the newer medical tests, and are quite happy to order the "latest and most expensive " tests when treating their patients - especially when they have no idea what's going on ! They cloak their ignorance with the garb of sophisticated scientific test results - and the poor patient gets misled !

The reality is that there is no correlation between  sperm DFI and male fertility. Lots of fertile men will have  a high sperm DFI , but they have enough sense not to go to a doctor to get it tested ! There's too much overlap in the sperm DFI results in fertile men and infertile men to make the test meaningful or useful.

However, doctors don't understand that these tests are riddled with the problem of false positives, and are very happy to "treat" the abnormal test result ( because they forget that they should be treating the patients, and not the lab report !)

So what role does sperm DFI testing have to play ? It should be used very selectively, only for couples who plan to do IVF. Studies should that if a couple needs IVF, if the man has a high sperm DFI, they should opt for ICSI rather than IVF , because the fertilisation rate with IVF is lower as compared to ICSI in these men, that's all !

The only way to protect yourself from clueless doctors is by investing in Information Therapy !

You can read more about sperm DNA fragmentation tests at 

Saturday, May 26, 2018

Is there any connection between Grade C embryos and the risk of birth defects ?

A patient asked me this question.

Can Grade A embryos result in abnormalities in the baby ? Or do only Grade C results in abnormalities ? 

Sadly, there is still a lot of misunderstanding  about embryo grading . Most embryologists are not skilled enough to be able to grade embryos properly, and because many IVF specialists have never set foot in the lab , they don't really understand what embryo grades mean. And if the IVF doctor is so confused, it's hardly surprising that patients are completely in the dark.

Embryo grades are basically lab shorthand for describing the appearance of the embryo - how it looks under the microscope . There is no correlation between birth defects and the grade of the embryo . Top quality embryos have a better chance of implanting and becoming a baby , but even if a poor quality embryo does implant, the risk of that baby having a birth defect is not increased !

This is why IVF patients should insist that the IVF clinic give them photos of their embryos, so they understand on what basis the grading is being done . Sadly, most IVF lab don't bother to provide photos, and their grading is very arbitrary, because they can say what they like, and they know they can get away with this !

Thus, they tell the patient - we have transferred 3 Grade A embryos for you - without even telling the patient how many cells the embryo had ! The poor patient is forced to trust the doctor, because they don't know any better - and it's too late to do much about this now, because you've already paid your fees !

All good IVF clinics provide photos to all their patients routinely and proactively, because it helps to increase the trust their patients have in them.

Being able to see your embryo photos allows you to compare them with an atlas of embryos, so you can check the grading for yourself - and no, you don't need to become an embryologist to do this ! This transparency will your upgrade be without even providing basic information as to how many self the embryo hearts and just missed you a lot of confusion and misunderstanding for the poor patient.

You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

Friday, May 25, 2018

The limits of IVF technology

The IVF lab is the heart of IVF treatment. We keep your eggs and sperms safely in the incubator, and your embryos grow in the IVF culture medium in vitro, until they form good quality blastocysts, which are ready to either be frozen , or to be transferred into your uterus.
The most important thing an IVF lab does is make sure there are no toxic elements within the culture medium or the laboratory , as these could damage the growth of your embryos. We want to keep them happy, so they thrive in vitro, until they are ready to go back into your uterus !
However, sadly there is very little we can do to actually enhance the growth of your embryos. This is because the growth of the embryo depends on the energy provided by the mitochondria in the cytoplasm of the egg, and there is nothing we can do as yet to improve this.
This is one of the limitations an IVF lab has to live with - we have to work with whatever raw materials we get. After all, IVF is an ART - an assisted reproductive technology, where we given nature a helping hand. Yes, it can be frustrating when embryos don't grow well in a good quality laboratory, but if you're sure that the embryologist is an experienced expert, then this is something you have to learn to accept.
This is why it's so important to make sure your IVF lab gives you photos of your embryos - so you can make sure they have been nurtured with tender loving care in the lab !
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 !

World's first infertility Chatbot !

We have created the world's first infertility chatbot, to help infertile patients learn more about their problem.
Naima is an intelligent digital medical assistant, who will help you find what you need to know !

Check her out at www.ivfindia.com

This is a beta release, and your feedback will help us enormously in improving how she answers your   queries ! Please be kind - this is a work in progress

Thursday, May 24, 2018

The difference between IVF outputs and IVF outcomes - what every patient needs to know !

What every patient ( and every doctor) wants from every IVF cycle is a happy ending -  a baby. It's great when we can achieve this happy outcome, but sadly IVF does not have a 100% pregnancy rate, which means many IVF cycles fail.
While this is heartbreaking, the patient then needs to plan what to do next, and this is why it's so important to differentiate between output and outcome.
The output is the end-result of the IVF treatment , and this is something which a doctor can control. This is tangible, in the form of top quality blastocysts.
However, once we transfer the blastocyst back into the uterus, we have no control over whether this will implant or not, which means we cannot predict what the final outcome ( a baby) will be.
Patients need to check the quality of the IVF treatment they receive based on the output - the embryo quality - rather than the outcome.
This is why it's so important to ask for photos of your embryos.
All good clinics provide these routinely and proactively
You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

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, May 19, 2018

How can we make IVF more affordable in India ?

I often see lots of infertile patients who could get pregnant if they did IVF treatment. Unfortunately, they just cannot afford to do an IVF cycle for financial reasons, and they end up without a baby. It fair to say  that  this causes them a significant amount of  frustration and heartburn when you know that IVF can help you get pregnant; but you can’t, because you just can’t afford the treatment.

Can this be changed?  
But it’s not just the patients who are affected; IVF specialists also go through a lot of anguish when this happens. It’s very difficult to come to terms with the fact that   though there is a medical solution, you are unable to offer it to a patient, simply because she can’t afford it. This isn’t the case only in India, but across the world, there are people who have to forgo IVF because of the cost factor. So what can be done to make the treatment more affordable?

In India, it would make a big difference if the government accepted the fact that family planning and welfare does not just mean limiting family size, but also helping couples to achieve their desired family size. If government hospitals & medical colleges began offering IVF programs, they would easily be able to afford to this in a cost-effective manner.
Our medical colleges are churning out a large number of M.D. gynecologists who haven’t really had any exposure to IVF treatment; it’s a shame that these gynecologists are under qualified. If IVF is offered at these hospitals, both the purposes would be served. Infertile patients would get quality care, and there would be an entire generation of gynecologists who are being trained properly!

Insurance companies say “no” to IVF
Health insurance companies don’t cover IVF treatment. The excuse they give is that infertility isn’t a medical disease and that it’s no more than a lifestyle illness which doesn’t make it eligible to be covered under insurance. Patients don’t have the means to fight back and the companies get away with it.
The simple solution is that infertile patients should form an NGO which would establish that infertility is a medical problem and that it should be covered by insurance just as any other medical treatment would be.  This would make the treatment much more affordable for a number of couples.
So, why is IVF so expensive?
One of the main reasons is because doctors inflate their charges by saying that their years of training, the expensive IVF equipment, the disposables etc, make it very expensive. This is true to a certain extend; however, if they use economies of scale, they will be able to provide more affordable IVF treatment to patients.
 If they start treating a larger number of patients and use innovative technology (like vitrification for freezing), it will improve their success rates and inexpensive IVF treatment can be much more than a pipe dream.

Not happy with the attention you are getting from your IVF clinic? Need more information? 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, May 18, 2018

Why didn't this blastocyst implant ?

The truthful answer is - We don't know !

This doesn't mean we are stupid or ignorant - it just means medical technology has its limitations, and we need to learn to live with them, by having realistic expectations of what IVF treatment can accomplish - and what it can't !

So what do we know ?

We know that human reproduction is not a very efficient process, and that most embryos will not implant because they have genetic abnormalities we still cannot test for. This is the limitation of IVF technology today, and we need to come to terms with it.

The problem is that patients are unhappy when the doctor tells them the truth, because they want the comfort of certainty. Sadly, this is a mirage, but in order to keep patients happy and placate them, doctors will spin all kinds of tales to explain away the failure. Usually this involves "blaming" the patient , and this victim-blaming comes in all kinds of flavours
- you did not rest enough
-  you were too stressed out
- you did not take your medicines on time
your egg quality was poor
- your husband's sperm were bad

Doctors cook up all kinds of fanciful pretexts, but this false pretense just causes more harm. They end up subjecting the poor patient to all kinds of useless tests and treatments, which just waste money, but don't improve success rates !

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, May 17, 2018

What do we need to change for our next IVF cycle

After her IVF cycle failed, a patient sent me this email

In retrospect what do you think could have gone wrong? Is there anything I need to improve or change ? 

It's important to learn from each IVF cycle by analysing what went, and what didn't. The right time to do this is at the time of embryo transfer, because it is only until this point that we have any control. We can only three tangible variables -
embryo quality
endometrial ( receptivity) thickness and texture
the ease of the transfer

Once the embryos have been transferred into the uterus, we have no ability to check what happens inside the uterus. All we know is that human reproduction is not a very efficient process, and that most embryos will not implant because they have genetic abnormalities we still cannot test for. This is the limitation of IVF technology today, and we need to come to terms with it.

This was my answer to her.

No, there's no need to change anything, since it was a perfect cycle ( top quality blastocyst, excellent endometrium, easy transfer)

The problem is that human reproduction is not perfect !

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, May 16, 2018

IVF failure - incompetence ? or bad luck ?

IVF failure can be the result of bad luck , or sometimes the result of the IVF doctor's incompetence . The key question the patient wants an answer to is - How do I differentiate between the two ? 

Did my cycle fail in spite of the fact that the doctor did everything right " Or did it fail because the doctor wasn't able to make good embryos in the lab ?

The only way to answer this question is by getting photos of your embryos , and doing enough homework so you are able to interpret the images of your embryos . The good news is that this is easy to do - and if you need help, please feel free to email me !

You can see what embryos should look like at www.drmalpani.com/knowledge-center/ivf/embryos

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, May 15, 2018

How to prevent errors in IVF - what every patient needs to know !

The biggest nightmare for any IVF patient is that the lab may mix up their eggs and sperms with another patients. This has happened in many clinics, and IVF is as prone to errors as any other treatment because it is provided by a host of people working together – doctors, nurses, receptionist, ultrasonographers, lab technicians and embryologists. It requires lots of coordination, and there are few treatment processes for which a team approach is more important than for assisted reproduction. Close, continuous communication is required at many levels to ensure everything goes as planned.
Communication matters
All of these can produce an environment of controlled chaos that must be managed. Important to the issues of patient safety and the integrity of an ART program are the ways in which a program handles the difficult issue of medical errors. Total freedom from error is only possible in theory. Response to errors, when they occur, reveals the integrity of the program and should be based on established processes.
The errors
* One, in which the eggs or sperm are mistakenly used with the gametes of another person; or the wrong embryo is transferred to a patient
* The second, which leads to the loss of sperm, eggs, or embryos (for example, because of a power failure as a result of which the incubator malfunctions).
IVF mix-ups are every patient’s and doctor’s nightmare, and lots of high profile cases have been described where this has happened. The trouble is that eggs, sperms, and embryos look exactly the same under the microscope ! Errors can be avoided by:
* Obsessive labeling
* Double witnessing, where a second person double checks the identity of all the dishes in the lab can help reduce this risk
* Electronic witnessing, using coding and RFID (radio frequency identification) technology has also been introduced to prevent gamete mix-ups.
If a mix-up does occur and is noticed, this must be brought to the doctor’s attention immediately. Even if the embryo has not been transferred, the patient should be informed, so they can decide on a course of action they are comfortable with.
The second type of error may or may not lead to a reduced chance of reproduction. A loss of part of a sperm specimen or improper handling of immature oocytes may not result in a dramatic change in the outcome of the cycle for the patient. Although there can be a difference of opinion about whether this should be disclosed, the ASRM Ethics committee states that it’s best to disclose even minor mistakes that have potentially adverse effects for patients. “If, on the other hand, there is clearly no adverse effect and if disclosure may unnecessarily compound the stress of patients, disclosure may not be obligatory.” However, the perception of dishonesty resulting from attempts to cover errors is often worse than the actual medical error.
Maintaining transparency is important
Process mapping
In addition to reducing effort, which in turn can decrease the sources of error, the process map gives all the staff members an overview of the complete treatment cycle, so that the right hand finally knows what the left hand is doing. This improves coordination and communication, and allows each staff member to put patients first. Because they can see the big picture, the staff is now no longer just focused on doing their individual job, but understands that their goal is to help the patient along her IVF journey.
Flow process diagrams allow us to assess the risk of error at each step in a clinical process. For example, what would happen if the lab did not report the estradiol value in a timely fashion to the doctor when he is timing the HCG trigger shot? The systematic evaluation of risk points can lead to an action plan that results in minimal errors in the future.
Establishing metrics and tracking provides a means for following the success of error reduction over time. Parameters can be as simple as checking to see what percentage of patients are phoned the day after egg collection to make sure they are comfortable and are not developing OHSS. Such simple proactive measures can help to make IVF safer for patients.
We use an EMR (electronic medical record) to document that we have provided treatment correctly and safely. This allows team members to communicate with each other, and with the patient as well.
The laboratory is the last stop in the complex process of IVF treatment and laboratory personnel must confirm that all consents are current and complete for the intended treatments. In the absence of these documents (whether paper or electronic), the embryology laboratory should not perform the procedures.
Improving safety is not the responsibility of only the clinic staff. Thus, drug manufacturers have started to provide the medications which patients need to self-inject daily in pre-filled syringes, so that their chances of making a mistake in taking the injections is reduced. The patient is the final line of defense against errors. Making sure the patient knows what is supposed to happen next is the best way of reducing errors. This is why we have created the free My Fertility Diary app (www.myfertilitydiary.com); it allows patients to track and monitor the progress of their IVF cycle. If they know what’s going on, they are empowered to speak up when the cycle does not progress as planned.

Regular interaction is required to assure that infertile couples are adequately prepared, and that scans, blood tests, egg collections and embryo transfers are performed seamlessly. IVF offers a wide variety of mix-and-match treatment options, because there can be multiple sources of eggs, sperms, and uteri; and lots of different physicians are involved, including reproductive endocrinologists, urologists, anesthetists and counselors.

IVF programs can be madhouses of activity, and the possibility of an error creeping in is every IVF clinic’s nightmare. There are two primary types of errors in IVF:

Good IVF clinics have policies and procedures in place that deal specifically with medical error. These should include definitions; statements about who should be informed, when, and how; and mechanisms for determining the cause of the error and preventing its repetition. Policies should encourage a culture of openness, address the ill effects of trying to cover up errors, and very importantly, include corrective actions to minimize future errors. They should be based on the understanding that errors can and will occur, and that a better assessment of errors will improve the mechanisms for preventing and correcting them. This has a positive effect on staff morale, which further enhances safety. A mechanism for reporting both within the clinic and the laboratory allows for analysis of near misses. Incidents that do not result in harm should also be reported to allow process optimization that can prevent serious errors.

IVF care is a complex clinical process, and the clinical activity needs to be categorized into compartments. This allows us to depict them as flow diagrams that allow study of sources of error or risk. This promotes the ability to streamline the interaction of multiple complex tasks performed by different clinical and administrative units such as nursing, laboratory, and billing departments.

Monday, May 14, 2018

IVF for treating recurrent miscarriages

Recurrent pregnancy loss ( repeated miscarriages or habitual abortions) is one of the most frustrating problems in medicine. It is hard for patients , because getting pregnant , and then losing the baby again and again is traumatic. It's bad for doctors, because patients have so many questions , and we don't have any answers ! The truth is that our tests are not very good, and there is little we can do to make n accurate a diagnosis. This is why, in about 80% of patients with recurrent pregnancy loss , inspite of extensive testing, we will not be able to find an underlying cause.
Based on experience over many years, the one thing we do know is that the commonest reason for a miscarriage is a genetic problem in the embryo.                What makes this so tricky is that these are random genetic errors which we cannot pinpoint; cannot test for; and cannot prevent. This is why pregnancy becomes such a hit and miss affair for these patients. It's literally a gamble, and there are patients who have had three and four miscarriages , who have then gone on to have a healthy baby with no intervention other than TLC - tender, loving care !
So what is the poor patient to do? She can, of course, keep on trying in her own bedroom but, obviously, every time she loses her baby, her heart breaks.
One option is to do IVF. Now, logically , this seems to make no sense at all !  Patients say, " Isn't IVF a treatment for infertile couples ? Since  I'm getting pregnant in my own bedroom, this means I am fertile, so why would IVF help me ?"
The reason is because it saves these patients precious time. In a fertile woman , off the eggs which she produces every month, in 11 of the 12 months this egg is healthy and genetically normal, so that if it forms an embryo and implants , she goes on to have a healthy pregnancy. However, even in these women, 10% of the time the egg will be genetically abnormal , and give rise to a genetically abnormal embryo, which will miscarry. This is why about  10% of all pregnancies miscarry , even in fertile women, and there is nothing much we can do about it.
Now, it's possible that for women with recurrent pregnancy loss the rate , at which they produce genetically abnormal eggs is higher than it is for normal women. Let's assume that 80% of the eggs which they ovulate are genetically abnormal, which means these will form genetically abnormal embryos, which then have a much higher chance of miscarrying.
There is nothing much we can do about this when she is trying in her bedroom, but if we did IVF , we would get lots of eggs in that one cycle. We could create lots of embryos, and allow these embryos to grow to day five ( blastocysts) , which means that a lot of the genetically abnormal embryos would not develop up to this stage. By transferring only top-quality blastocysts , we'd reduce the risk of a genetically abnormal embryo implanting, because the chances of the blastocyst coming from a genetically normal egg are that much higher.  So why not test the embryos by doing PGS before transferring them. Sadly, this  has not been shown to be helpful , because the PGS technology is still very immature, and only allows us to count the number of chromosomes in the embryos.  Yes, the holy grail is to improve the genetic technology to screen for all abnormalities, but  until we reach that point I think this is a perfectly acceptable option for trying to improve the odds of a woman with recurrent pregnancy loss having a healthy baby more quickly rather than allowing nature to take its own. Yes, she may still miscarry even after doing IVF, but the chances will be lesser, so this is an option she may want to pursue.
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, May 12, 2018

Second opinions for IVF patients

While second opinions can be quite helpful in reducing " avoidable medical care" , they come with their own set of challenges. . Patients are scared about seeking out a second opinion because they are worried that by doing so, the doctor who is treating them will get offended and may disengage himself from the treatment. Patients are scared of physicians and don't want to risk antagonizing them!

The two sides of the coin

1. Not all second opinions are correct. Sometimes, it's the "first opinion" which might have been the right decision for the patient, and only time is able to tell which doctor was right. It's naive to simply assume that the second opinion was better than the first! Let's not forget that doctors who give second opinion are also often biased to giving one which is different from the first opinion – after all, doctors love playing a game of one-upmanship to show they are better than their colleagues! Second opinion services are incentivized to "adding value" to patients by providing a different perspective. Not surprisingly, a third opinion could be completely different!

2. Second opinions can aggravate the situation. It might be convenient to take a second opinion online, but this may end up leaving the patient confused and paralyzed into inactivity when the opinions differ. Who does he believe? The online anonymous doctor who has been positioned as being an expert? Or his personal doctor, who knows him and whom he can talk to face-to-face? Conflicting opinions may also cause him to lose trust in the medical profession in general, and in his doctor in particular. This erosion of trust is harmful for the patient, because if one cannot trust his/her doctor, it's harder for healing to take place.

3. The true value of a second opinion is realized not when it differs from the first opinion but rather when it agrees with it. This reassures the patient that he is on the right track, and it reinforces his confidence in his doctor.

Empowering the patient
There are few black and white areas in medicine. Considering there are multiple options available to both doctors and patients, the whole activity of seeking a second opinion should not degenerate into a doctor vs doctor game, driven by individual egos.
It's important to emphasize the key role the patient needs to adopt in making the final decision. It's not enough to just take a second opinion, and then leave the final decision to a doctor. A mature patient acknowledges that it's his responsibility to make the final call! The mantra in medicine today is “shared decision making,” and patients need to become expert, empowered, and engaged so that their voice is heard.
That doesn’t mean patients need to become medical experts! However, they do need to learn to use information therapy, which aids patients in making the right decision . Information Therapy provides patients with evidence-based guidelines, so that they can ask for the right medical treatment they need – no more and no less.

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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