Wednesday, January 31, 2018

Mind games during the 2ww

A patient sent me this query
This is our first icsi cycle and am on 5th day of embryo transfer. Initially had cramps and it raised a bit more but since yesterday night I see no symptom and I am worried. Plus sometime bloating, my breasts has been so hard and am feeling I have been bit more aggressive than usual , am not on complete bed rest but tend to roam in home only . Medicines include progynova, ecoflora , folic acid and vitamin tablets , progesterone injection- aquagest alternative days and some progesterone vaginally daily two times. My skin is so so dry . I heard people saying tat u should get lower back pain or leg cramps but have cramps only on left side since the time of transfer plus yesterday I had bit abdomen pain also I sleep only three to 4 hours at night later I'll be half awake with the rush of thoughts being positive or negative. Am such a strong girl but now this is making me crazy. How to manage this. Sometimes I have extremely cold feet and since the day of transfer I have mild cough though am following the exact doctors advice.is it ok to experience all this. What is this symptoms leads to ? Should I be hopeful ?

Most patients find themselves going crazy during the 2ww, because they are a " little pregnant" ! They know they have an embryo inside their uterus, but are not sure whether this will become a baby or not, which is why they are full of doubts and worries .

Bulletin boards and forums are full of conflicting advice, which makes things even worse, and they don't know whom to trust !

Is having cramps a good sign ? or is not having cramps a good sign ? They find it hard to deal with this uncertainty, and will often end up browsing the web for hours on end, to try to make sense of what's happening inside them. They often drive their partner crazy as well, because he does not know how to reassure them !

The reality is that every woman's experience is different, and you can't jump to any conclusions, based on any of these symptoms. You just need to be patient, and wait for your beta HCG test result.

The good news is that your embryos are safe in your uterus, like a pearl in an oyster - nothing you do can harm them !

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



Tuesday, January 30, 2018

I am glad patients are learning to say No !

A patient send me this email
Sir, I m having a chocolate cyst in my left ovary of 3.6*2.8 CM and a normal right ovary . My first doctor advice me for immediate laparoscopy. I am trying for around 10 months. I changed my doc as I was scared of surgery. Can you help ?

I am glad patients are speaking up and refusing to subject themselves to unnecessary surgery !

With today's technology, infertile patients do not need a laparoscopy, but doctors continue to do this for them, without any good reason. Read more at http://www.drmalpani.com/knowledge-center/infertility-testing/laparoscopy-and-infertility

Such a tiny chocolate cyst will not affect her fertility, and unnecessary surgery would actually reduces her fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing her ovarian reserve.

Patients need to learn to speak up !

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, January 29, 2018

How not to get ripped off by IVF doctors

This is a great article, at http://www.conceptionadvice.com/how-not-to-be-ripped-off-by-fertility-clinics/

Please do read it  - a lot of these malpractices are rampant in Indian IVF clinics as well.

I especially love the following paragraph !

Blinded by Pseudo Science

If a stranger down the pub told you the best way to get pregnant was to get a cheap bit of plastic and waggle it around inside your womb, would you believe them? Probably not. But if that advice came from a doctor and was given a fancy scientific sounding name, would you believe them?
Some fertility clinics offer add-on services as a supplement to the core treatment (i.e. in addition to a treatment like IVF). While these add-ons sound scientific, they have no evidence to prove that they improve your chances of getting pregnant. They won’t just harm your bank balance; some may even harm your chances of getting pregnant.
At the time of writing this, the following add-on services have no conclusive evidence that they improve your chances of getting pregnant:
  • Endometrial scratching
  • Embryo glue
  • Ultra-high magnification sperm selection (also known as Intracytoplasmic Morphological Sperm Injection or IMSI)
  • Multiple Ejaculation Resuspension and Centrifugation (MERC)
  • Fertility immunotherapy
  • Embryo time lapse imaging
  • Assisted hatching
  • Preimplantation Genetic Screening (PGS) – Not to be confused with Preimplantation Genetic Diagnosis (PGD), which is a legitimate treatment
This list is not exhaustive and new add-on services are being developed all the time. So, how do you stop yourself being taken in by one or more of these?

Should I use donor eggs ? or do surrogacy ?

A PCOD patient asked me for a second opinion after failing an IVF cycle at another clinic.

Here is the summary in response to your questions,
1. I donot have pics of embroyos.
18 oocytes were retrived; MII oocytes 16+2
ICSI DONE
16 EMBRYOS DAY 2
DAY OF CRYOPERSERVATION Day 3
Cell grade 8X8A,3X6A;2X5B
3grade C embryos dizcarded
FIRST fet 1early stage and 2 compaction grade
Result negative
Second fet 1blastocystand 2 early stage embroys tranfered result negative
Uterus is arcurate and both tubes patent
Query
Are the embryos okay..? or donor eggs suggested since AMH is very high ie 24
Or
Is it that uterus is arcuate and implantation not possible?
Is surrogacy suggested?


The poor patient is very confused - and her doctor is adding to her confusion, by not sharing information with her.

This was my advice.

Any clinic which does not provide embryo photos is a poor quality clinic.
PCOD patients have lots of eggs, so there's no need to use donor eggs.
An arcuate uterus is a normal anatomical variant, of no clinical importance.
Rather than think about changing your uterus or your eggs, you would be much better off changing your IVF doctor ! 

Sunday, January 28, 2018

How doctors add stress to the poor IVF patient's life


Being infertile is bad enough, and an IVF cycle is stressful because you are never sure whether it's going to work or not. Not only is the uncertainty difficult to handle, the fact that it's so expensive just adds to your anxiety. While we can't reduce the uncertainty which plagues IVF , the tragedy is that IVF doctors often add insult to injury , by making the treatment unnecessarily stressful .

For one thing, they subject patients to lots of useless tests, which are completely unnecessary , because they don't change the treatment options we can offer to patients. They justify these by doing it under the garb of being " complete and thorough" . Not only do these tests consume a lot of time, they also waste a lot of money .

Also, if the results are abnormal ( as they often will be), then the poor patient is subjected to months of completely unnecessary treatment for "correcting " the red herring which was discovered. Doctors end up treating the abnormal test result, and not the patient ! A classic example of this is the diagnosis of tuberculosis , based on pointless tests such as TB-PCR or PAMP. These tests are plagued with false positives , so that patients are unnecessarily exposed to toxic anti TB treatment.

Even the IVF treatment cycle itself is made unnecessary complicated . Patients are made to come for scans and blood tests every single day. This is completely pointless , because we know that follicles are going to grow only at 1 - 2 mm per day, so that doing more frequent scans doesn't change the treatment protocol ! Of course, this strategy makes the doctor's clinic look very full , and this impresses patients, because they can see the doctor is extremely busy ! Many patients like this , because it is social proof that they've chosen the right doctor ! Their logic is - if there are so many patients waiting to see the doctor, isn't this a sign that the doctor is a good one ? This reassures them that they're at the right place, and their doctor is the best doctor !

 Many of them are also very impressed at how meticulous and thorough the doctor - after all, isn't more always better ? However, this just provides a false sense of security , because all this over testing doesn't change anything which the doctor can do for the patient in tangible terms, as regards improving the chances of success. Also, many doctors insist that the injections be taken at the clinic itself, so they are given expertly by the clinic nurse ! Again, this is completely unnecessary , and the poor patient is forced to waste time and money traveling to the clinic on a daily basis just to take the shots - something which she can easily do for herself at home ! Many doctors continue to prescribe painful IM progesterone injections , even though vaginal progesterone is more effective and much kinder ! This leaves the poor patient's butts so sore , that they can't move. The newest torture is adding the painful low-dose heparin ( Lovenox) injections on an empiric basis, the theory being that this helps to improve the chances of implantation by improving uterine blood flow, though this is completely speculative !

Finally, patients are subjected to all kinds of unnecessary restrictions such as bed rest after a transfer. This just makes the poor patient's life miserable, without improving their chances of success. I wish IVF doctors would learn to be kinder to their patients !

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, January 27, 2018

Why do patients allow IVF clinics to get away poor medical care ?

IVF treatment is expensive, and since it is a planned treatment, patients have the luxury of being able to choose the best clinic, to maximise their chances of getting pregnant.

A patient sent me an email after she had failed 2 IVF cycles at the "best IVF clinic" in Chennai, and when I asked her for more details about her treatment, this was her answer.

I apologize as I would not be able send the printed treatment summary as this clinic does not share any treatment summary with the patients nor the picture of the embryos.

It's high time patients learned to be more assertive, and to demand photos of their embryos from IVF doctors.

Every good IVF clinic provides embryo photos routinely, to document they have provided high quality care to their patients.

I can understand why IVF clinics may not want to share information - after all, if they are not able to create good quality embryos, they are naturally reluctant to let the patient know this, so they can blame "poor endometrial receptivity"  for the "failed implantation".

What I cannot understand is why educated patients allow doctors to get away with this ! After all, patients have a legal right to their medical records ?

Why would they want to waste their hard-earned money going to poor quality clinics ?

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 !




Friday, January 26, 2018

Misusing PRP ( Platelet Rich Plasma) treatment for "treating" infertility

Infertile couples are desperate, and many IVF doctors are happy to take undue advantage of this, in order to maximise their income.

The latest racket is the use of PRP, or platelet rich plasma. This is supposed to contain stem cells, which have " miraculous " properties, which can treat anything and everything ! After all, stems cells are magical - they can transform themselves into any kind of cell in the body, because they are the original progenitor    cells !

This is why andrologists now inject PRP into the testes of hapless infertile men with testicular failure, to " help them" to produce sperm; and gynecologists inject PRP into the ovaries of infertile women with premature ovarian failure, to help them to produce eggs ! To add insult to injury, they charge an arm and a leg for this "treatment" !

The major problem is that PRP is extremely easy to do - hair transplant surgeons use it routinely all the time, and IVF specialists now want to get on the bandwagon ! It's tragic that " PRP treatment " has become such a farce today  !

How to waste money on your IVF treatment

Infertile patients can be quite desperate, and sadly many IVF doctors exploit their ignorance.

They make them do lots of useless tests - and subject them to unproven and expensive treatments, which are of no clinical value !

The only way patients can protect themselves is by investing in Information Therapy - ignorance can be expensive !

You can read about this at http://www.drmalpani.com/knowledge-center/infertility-testing/wasteful-infertility-tests

Sunday, January 21, 2018

Are you fed up of going to disorganised IVF clinics ?

Because you are so desperate to have a baby, you will move heaven and earth to achieve your goal. You know that IVF is your best option, but you are completely confused as to which IVF clinic to select, because they all seem to be the same when you read their ads or visit their websites.

You start checking them out, and this is when you get disillusioned.

Most clinics are highly disorganised, and refuse to share any information . You are made to wait unnecessarily for hours on end; and finally only get to talk to a junior doctor, who seems to be completely clueless. You are offered a generic plan, and they refuse your answer your genuine questions, so you end up being disappointed and disheartened. Many will want you to sign up as soon as possible, because they seem to be more interested in extracting money from you, rather than on helping you to have a baby !

Sounds familiar ?

We are happy to provide you with a free treatment plan, customised to your needs, so that you know what the right action steps are. This will help you maximise your chances of having a baby - and will also help you to ensure that your doctor is offering you the right treatment, and being upfront and honest with you.

If you don't want to be taken for a ride, 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 are couples so poorly informed about fertility ?

I just got this email .

I recently got married 2 months back on 26th November 2017 and we had intercourse and was eagerly waiting for a happy news as I’m 30 yrs and my wife is 25yrs old. Unfortunately she got her periods on time on 17th Jan and we consulted gynecologist on 18th. Doctor suggested to do semen analysis without having contact for 3 days.

It's disappointing that even well educated people have such a poor understanding how inefficient human reproduction can be. It takes time to make a baby, and it's sad to see them panicking needlessly when they don't get pregnant in a few months

What's even worse is that instead of educating them about the facts of life, their doctor is taking them for a ride by asking them to test their fertility !

Unnecessary tests lead to unnecessary expenses and useless "treatment" !

Saturday, January 20, 2018

Thursday, January 18, 2018

Using WhatsApp to improve Doctor patient communication.


WhatsApp is one of those apps which practically every doctor uses routinely in India. Most doctors use it for personal reasons , and many have also started utilising it to connect with their patients as well. Unfortunately, they do it in a disorganized and haphazard fashion, which means they are not making the best possible use of this very versatile platform !
Here's one way of making sure that WhatsApp can be used effectively to help improve medical care.
The doctor needs a dedicated mobile just for his clinic, which is used exclusively for this purpose , so he doesn't get troubled at all odd hours because of patients contacting him. The moment the patient contacts the clinic , the receptionist adds the patient's mobile as a new WhatsApp contact, and starts a conversation with that patient .  For example, this can be used to send a google map to the patient, so they can find the clinic easily !
When the patient comes for the first appointment, she adds a photo of the patient, as well as her demographic details as well . After the consultation, she ( or the doctor himself, or even the patient) can then take a picture of the consultation summary, as well as the prescription. Patients can continue adding the results of their lab reports and scans to this conversation, once they have done these, so the doctor can review them as needed. This way, he can interpret the results far more intelligently, because he has the clinical context he needs.
The beauty of WhatsApp is that all these documents are encrypted and secure, so you don't have to worry about confidentiality . You can thus create a  chain of conversations, which seamlessly provides a timeline of the patient's medical history, which both doctors and patients can refer to as needed. Because it's documented, there's no risk of miscommunication  ! Even better, patients don't need to keep on calling the clinic for every minor problem . The doctor can create lots of templates, which he can attach to the conversation as needed, to make sure the patient knows exactly what they need to do. If required, the doctor can even create WhatsApp groups of patients with similar problems ( for example, all patients with  diabetes). Not only can he educate them all at one time by sharing educational tips, they can also interact with each other, and thus help one another during their journey .
This is much better than a phone call, because the signal to noise ratio is far better . Doctors can now communicate with their patients in their own local language. Even if patients are illiterate, it's possible to leave messages for them using audio !
This will also empower patients. The WhatsApp trail will actually be far better than just the ordinary medical record, because it allows patients to provide their inputs and interpretation, rather than being only a medical document which doctors often refuse to share with patients ! Patients can also share their medical reports , and get a second opinion from another doctor anywhere in the world.
The beauty is that there is no incremental cost or friction for using WhatsApp for improving doctor-patient communication ! Doctors and patients use WhatsApp all the time, so there is no training needed - and it's free ! Patients are delighted , because this is not an additional communication channel they can use connecting with their doctor when they need to - no matter where in th world they are !   WhatsApp offers a direct and free backup of all communication including images and videos to the google drive, so you need not worry about what to do in case the phone crashes or goes dead (and they do).

While it's not great for an emergency, let's not forget that 90% of interaction with a doctor is for routine medical problems.  And the asynchronous nature of communication which WhatsApp allows means  that when the doctor is unable to pick up the phone, patients can use this channel to ask a query and/or send a photograph and get a response by a doctor when he gets free !
And if doctors want, they can always charge for these conversations, so that it's an additional source of revenue for them !

Also, once Whatsapp wants to start generating revenue, they will add lots of additional features which will help doctors to connect more effectively with their patients .  And there's no reason why they couldn't do this for other professionals as well - such as lawyers !

Tuesday, January 16, 2018

How do you differentiate between a good and bad IVF clinic ?

Why do IVF doctors lie to patients?

We often see IVF patients who are quite unhappy with the quality of information they've received from their doctors. The one thing which bothers them a lot is that doctors change what they tell them, and this is why they don't trust them anymore .

A common example is that at the time of the embryo transfer, the doctor is very optimistic and hopeful. He gushes about the high quality of the embryos he has created in the lab, and says things like, " Of course you will get pregnant ! You have a 90% chance, because your uterus is perfect, and your embryos are beautiful. These are  grade A embryos and because your transfer has gone off smoothly , you have a very high chance of success, so best of luck !"  He's trying to transmit a lot of hope and positivity and optimism to the patient, but unfortunately these are just empty words. He does not provide the patient with any documentation as to the embryo quality, and because he does not provide photos of the embryos, she's pretty much forced to believe everything the doctor says ! She's quite happy during the 2 ww, because the doctor is so positive and hopeful !

However, when the beta HCG comes back as negative and she goes for a followup visit to the doctor, he starts singing a completely different tune. He says things like, "Well, you didn't get pregnant because your embryo quality wasn't very good, and we will need to use donor eggs " . Or he may say - " Your uterus lining was not very good, and we will need to do additional tests to determine the reason for the failed implantation." The patient feels cheated and let down, because it now appears that the doctor wants to wash his hands off all responsibility for the failure !  She wonders - "Why did you tell me that my chances were very good at the time of the transfer ? Why are you now saying something so completely different?" She starts losing confidence, not only in that particular IVF doctor, but in all IVF doctors , because she thinks that all IVF doctors are pretty much the same.

This is why it's so important that patients demand that their IVF doctor provide photos of their embryos routinely to them . This is good for the doctor as well, because it inspires trust in the patient. They can see that the doctor is  very confident , and knows he doing a good job, which is why he is willing to be open and transparent . This simple step will help to keep IVF doctors honest, and will also ensure that the patient has realistic expectations from their IVF treatment.

 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, January 11, 2018

How doctors add stress to the poor IVF patient's life


IVF treatment is stressful as it is , and many doctors make it even more stressful. Being infertile is bad enough, and an IVF cycle is stressful because you are never sure whether it's going to work or not. Not only is the uncertainty difficult to handle, the fact that it's so expensive just adds to your anxiety.
While we can't reduce the uncertainty which plagues IVF , the tragedy is that IVF doctors often add insult to injury , by making the treatment unnecessarily stressful .

For one thing, they subject patients to lots of useless tests, which are completely unnecessary , because they don't change the treatment options we can offer to patients. They justify these by doing it under the garb of being " complete and thorough" . Not only do these tests consume a lot of time, they also waste a lot of money . Also, if the results are abnormal ( as they often will be), then the poor patient is subjected to months of completely unnecessary treatment for "correcting " the red herring which was discovered. Doctors end up treating the abnormal test result, and not the patient !

A classic example of this is the diagnosis of tuberculosis , based on pointless tests such as TB-PCR or PAMP. These tests are plagued with false positives , so that patients are unnecessarily exposed to toxic anti TB treatment.

Even the IVF treatment cycle itself is made unnecessary complicated . Patients are made to come for scans and blood tests every single day.  This is completely pointless , because we know that follicles are going to grow only at 1 - 2 mm per day, so that doing more frequent scans doesn't change the treatment protocol !

Of course, this strategy makes the doctor's clinic look very full , and this impresses patients, because they can see the doctor is extremely busy ! Many patients like this , because it is social proof that they've chosen the right doctor !  Their logic is - if there are so many patients waiting to see the doctor, isn't this a sign that the doctor is a good one ? This reassures them that they're at the right place, and their doctor is the best doctor ! Many of them are also very impressed at how meticulous and thorough the doctor  - after all, isn't more always better ? However, this just provides a false sense of security , because all this over testing doesn't change anything which the doctor can do for the patient in tangible terms, as regards improving the chances of success.

Also, many doctors insist that the injections be taken at the clinic itself, so they are given expertly by the clinic nurse ! Again, this is completely unnecessary , and the poor patient is forced to waste time and money traveling to the clinic on a daily basis just to take the shots - something which she can easily do for herself at home ! Many doctors continue to prescribe painful IM progesterone injections , even though vaginal progesterone is more effective and much kinder ! This leaves the poor patient's butts so sore , that they can't move.

The newest torture is adding the painful low-dose heparin ( Lovenox) injections on an empiric basis, the theory being that this helps to improve the chances of implantation by improving uterine blood flow, though this is completely speculative !

Finally, patients are subjected to all kinds of unnecessary restrictions such as bed rest after a transfer. This just makes the poor patient's life miserable, without improving their chances of success.

I wish IVF doctors would learn to be kinder to their patients !

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, January 10, 2018

Why infertile couples need to make some tricky decisions for themselves !



I received this email from a patient.

 My husband and I have been trying to conceive for more than a year. I have low AMH which is 0.2 ng/ml and my FSH fluctuates from a value of 7 to 18 IU. I have been through one hysteroscopy for polyp removal. We did one IUI and now we are going through Natural cycle IVF. My question is related to a lesion in my uterus. My current doctor thinks it could be a fibroid or a polyp but more likely a fibroid. It is on the fundus of the uterus and on the left side. It is 5mm in to the cavity so it is not likely to affect implantation of an embryo. She thinks that if it is a fibroid and we try to remove it then it is most likely to form scar tissue in that area and prevent implantation. I have attached saline sonogram report and HSG report. We would like your opinion whether we should remove this fibroid or not before embryo transfer?

This is a tough call, because both options are equally good, and there is no evidence that removing such a small polyp will help to improve pregnancy rates. The truth is that many medical problems are not black or white - they are shades of grey, and patients need to decide for themselves.

A good doctor will explain the options, but will leave the final decision to the patient, when he feels both are equally good

Yes, it's a hard spot for a patient to be in, because most patients want an authoritative doctor who will tell them what to do ! They are confused when the doctor asks them to decide for themselves ! Isn't the doctor the expert ? Shouldn't he be telling them what to do ? If the doctor is confused, imagine the plight of the poor patient !

Yes, it can be hard to make a call, and a useful rule to follow is to " take the path of least regret".

Think of the following scenarios.

Suppose you choose not to remove the fibroid, and go ahead with the embryo transfer . If you don't get pregnant, how much will you kick yourself for not insisting on having the fibroid removed ?

On the other hand, suppose you do the hysteroscopy and find the cavity is normal, how much will you regret wasting the money on an unnecessary intervention ?

This is a very personal decision, which only patients can make for themselves, based on their individual philosophy . There are no generic right answers - just the answer which is right for you!

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 !






Sunday, January 07, 2018

How do I boost up my low sperm count ?

How do I boost up my low sperm count ? This is one of the commonest questions I am asked.

I first have to request the patient to send me their semen analysis report. Lots of labs do a very poor job of reporting a semen analysis - and many doctors still don't know that a count of more than 15 million per ml is considered to be quite normal !

They label a man whose sperm count is 30 million per ml as being infertile, and start "treating" him for his low sperm count ! No wonder so many of them get pregnant after the " treatment"  - they never needed this in the first place !

Many men do have a low sperm count, and then I need to educate them about what we can do to help them.

I tell them to read more about the problem of a low sperm count ( oligoasthenospermia)
at http://www.drmalpani.com/knowledge-center/the-infertile-man/oligospermia

However, I remind them not to jump to conclusions based on just one report.
I tell them to get it re-checked again - from a reliable lab !

If it is persistently low, I remind them that there is no reliable way of improving sperm count or motility with medicines or surgery. False hope can be cruel, but wasting time and money doesn't help !  If they want to try alternative therapy, such as Unani medicine or ayurvedic potions ,

However, if it is persistently low, then often their best option is ICSI ( www.drmalpani.com/our-services/icsi)

The good news is that we can always fertilise eggs in the IVF lab using ICSI, no matter how poor the sperm count is, because we need only 1 motile sperm to fertilise 1 egg when doing ICSI !

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, January 06, 2018

Why infertile couples need to make some tricky decisions for themselves !


I received this email from a patient

 My husband and I have been trying to conceive for more than a year. I have low AMH which is 0.2 ng/ml and my FSH fluctuates from a value of 7 to 18 IU. I have been through one hysteroscopy for polyp removal. We did one IUI and now we are going through Natural cycle IVF. My question is related to a lesion in my uterus. My current doctor thinks it could be a fibroid or a polyp but more likely a fibroid. It is on the fundus of the uterus and on the left side. It is 5mm in to the cavity so it is not likely to affect implantation of an embryo. She thinks that if it is a fibroid and we try to remove it then it is most likely to form scar tissue in that area and prevent implantation. I have attached saline sonogram report and HSG report. We would like your opinion whether we should remove this fibroid or not before embryo transfer?

This is a tough call, because both options are equally good, and there is no evidence that removing such a small polyp will help to improve pregnancy rates. The truth is that many medical problems are not black or white - they are shades of grey, and patients need to decide for themselves.

A good doctor will explain the options, but will leave the final decision to the patient, when he feels both are equally good.

Yes, it's a hard spot for a patient to be in, because most patients want an authoritative doctor who will tell them what to do ! They are confused when the doctor asks them to decide for themselves ! Isn't the doctor the expert ? Shouldn't he be telling them what to do ? If the doctor is confused, imagine the plight of the poor patient !

Yes, it can be hard to make a call, and a useful rule to follow is to " take the path of least regret".

Think of the following scenarios.


Suppose you choose not to remove the fibroid, and go ahead with the embryo transfer . If you don't get pregnant, how much will you kick yourself for not insisting on having the fibroid removed ?
On the other hand, suppose you do the hysteroscopy and find the cavity is normal, how much will you regret wasting the money on an unnecessary intervention ?
This is a very personal decision, which only patients can make for themselves, based on their individual philosophy . There are no generic right answers - just the answer which is right for you!

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 !






Friday, January 05, 2018

Unnecessary D&C after a miscarriage can reduce your fertility


It's not uncommon for women who get pregnant after IVF to have a miscarriage. After all, the miscarriage rate is about 15% in all pregnancies, and IVF does not protect against a miscarriage. While this can cause a lot of heartache, doctors often add insult to injury by suggesting that patients  do a D&C ( dilatation and curettage) to surgically evacuate the pregnancy. They justify this by saying that the surgery is a quick and simply minor procedure; and that they can send the pregnancy tissue ( aka POC, or products of conception ) for genetic testing, so they can find out why the miscarriage occurred. However, not only is this testing expensive, it's quite pointless, because it doesn't really change treatment options for the next IVF cycle, since these genetic errors are random in the vast majority of cases. However, if the result is abnormal, the IVF doctors will use this opportunity to up-sell their services, by suggesting that the patient do PGS when doing IVF in the next cycle, to reduce the risk of recurrence of another abnormality in the next pregnancy !

However, PGS reduces pregnancy rates, and you can read more about why it does this at http://blog.drmalpani.com/2015/05/how-pgs-overpromises-and-underperforms.html

However, what's much worse is that  the uterine scraping which the doctor needs to do at the time of the D&C actually reduces your fertility, because the curettage causes scarring and intrauterine adhesions. This is why we tell patients to always have their pregnancy terminated with medical therapy, using anti-progestins and prostaglandins, because this is much safer, as it avoids any surgical interference. It's a natural process, so there is no risk of creating intrauterine scarring.  The success rates of successfully evacuating the uterus is better than 97 %, which means it's very effective. Yes, it's more painful , and takes a bit longer, but it's much safer , and the uterus heals and goes back to normal in two periods.

Patients need to do a vaginal ultrasound scan one  week after the miscarriage , to make sure that the uterus is empty, because there is a small chance ( less than 3%) that the drugs may not work as expected. Interestingly, this scan will always show there is something in the uterine cavity, because the thickened endometrium ( uterine lining) of the pregnancy is still present. However, radiologists and sonographers will report this finding as retained products of conception , and scare the patient that the evacuation is incomplete. When the gynecologist sees this report, they advice the patient that they need a D&C, because the medical termination has "failed" ! However, this surgical intervention is completely unnecessary because the lining will naturally shed by itself when you get your next period.

I wish doctors would learn to be a little kinder and more conservative !

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, January 02, 2018

Why embryo pooling improves IVF pregnancy rates


The most frustrating problem in IVF today is that of failed implantation. While we have become very good at creating top-quality embryos in the lab and transferring them into the uterus, we still cannot ensure they will implant. This is because implantation is a biological process over which we have not control. Because we can't track what happens in the uterine cavity after we transfer the embryos, we really don't have a very good answer for why embryos don't implant for a particular patient, which means we are groping in the dark.

One of the options which can help to improve the probability of success is called embryo- pooling. This means we generate many top quality blastocysts over 2-4 fresh cycles; freeze them; and then, transfer them one by one, over a period of time , either in a natural cycle , or one in which the endometrium is prepared using estrogen.

Now this might seem complicated and expensive, but it helps to increase pregnancy rates. The reason for this is that the implantation rate of a top-quality embryo in a fresh cycle is less than it would be in a natural cycle . This is because when we super-ovulate the patient with hormonal injections in order to grow many eggs for IVF, our focus is on producing lots of good-quality eggs. This means that the supraphysiological high levels of hormones which the endometrium is exposed to may  cause its receptivity to become suboptimal, so that even though it looks perfect on a vaginal ultrasound scan, the endometrial receptivity may not be optimal.

One way of bypassing this problem is not to transfer in the fresh cycle, but to freeze all the embryos. The beauty is that when we use vitrification in a good clinic, the survival rate is practically 100%, so we don't lose any embryos ! We can then transfer these blastocysts , one at a time , in a frozen thaw cycle , when the focus is purely on preparing the endometrium for optimal receptivity . This allows the patient to get the best of both worlds, so that the pregnancy rate becomes higher.

This means women can do multiple fresh cycles; freeze the embryos; and then come back later on for transferring these embryos , one at a time. This is specially useful for older women , because time is at a premium for them. It makes sense for them to generate lots of embryos and freeze all of them, so they can transfer them sequentially.

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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