Why it's easier to treat unexplained infertility rather than to diagnose it. Video on Unexplained Infertility by Dr Malpani

 

The paradox of unexplained infertility - treatment is easier than diagnosis !

Whenever infertile couples go to the doctor, they expect him to make a diagnosis , so he can tell them what the reason for their infertility is. They know that once that's been established, the doctor can treat this and they can have a baby.

The reality is that we can't always find the cause for infertility in some couples. This is true in about 1 in 10 couples, and they are diagnosed as having unexplained infertility . This is really a non-diagnosis, and this frustrates patients. They feel the doctor is useless because he can't even find out what their problem is. Their biggest worry is that we can't find out what the problem is , how will we able to treat it ?

The reality is that the diagnosis of unexplained infertility just means that our technology is not good enough to pinpoint where the problem is. The good news is that our technology is good enough to bypass any problem !  At the end of the day , we shouldn't care about problems – we should only care about solutions ! 

Unexplained infertility simply means that all the basic tests have been done , and everything has been found to be is fine. In fact, you should be happy that everything is normal, so don’t get upset please ! 

Even though we have not been able to find out exactly what the problem is, but we can still increase the chances of your egg and sperm meeting, so we can give you a baby. Treatment options include IUI and IVF , and there's no need to get distressed or upset if you are young, as the success rates for treating unexplained infertility are very high.

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 !

Queries about using the Malpani Baby Kit for Self Insemination

Patients often have many questions about how to use the Malpani Baby Kit for Self Insemination.

Here are the answers.

" We are planning for baby due to painful sex. We are trying home insemination. Through Youtube , we tried with a syringe last time . What we observed is almost all the liquid injected into vagina was coming out along with the syringe when it is pulled out. While surfing we came across your video and we are planning to buy your DIY kit. Have a few queries could you please provide your inputs.

1. With your kit ,when we insert the speculum ,won't it cause burning or pain inside vagina ? In that case can we use lubricant provided in your kit to apply on speculum or please suggest how to loosen vagina. I don't get lubrication properly.

You don't need to use the speculum if you don't want to. It's easy to insert the soft plastic pasteur pipette deep into your vagina . This will automatically deposit the semen near the cervix.

2. Through the pipette should we drop semen near the cervical opening or should insert pippet slightly to cervix opening.

Near the cervix is fine. Sperm can swim and will find their way to the cervical mucus, so please don't worry about this

3. With my previous experience injecting through a syringe I noticed almost all liquid came out of vagina, what should we do to make semen stay inside vagina.

Lie down with a pillow under your hips for a few minutes after the insemination

Leakage is normal . This happens after sexual intercourse as well, because the vagina is a closed blind tunnel/sheath

4.After sperm ejaculation how long the sperm should be kept outside, I mean should we wait before inserting into vagina after semen collection.

15 min is enough for it to liquefy

5. Is it necessary to get naturally lubricated inside vagina and get orgasm during this process ?

No, there is no relationship between sexual arousal, orgasm and fertility

5. Can the kit be delivered to my hometown which is small taluk in Karnataka.

Yes

You can buy the  Malpani Baby Kit for Self Insemination. online !

The endometrium and infertility - what every infertile couple needs to know about the uterine lining

For an infertile couple, it can be quite scary to go to a doctor , because doctors use a lot of medical jargon .

Many of these are difficult long words, which are hard to pronounce, and which they have never heard before. The problem is compounded by the fact that most doctors never bother to take the time and trouble to explain the meaning of these terms.

One of these foreign words is the endometrium . Yes, this is quite a mouthful, but it’s just the scientific word for the inner lining of the uterus . Endo means inside , and metrium means uterus , so don't get confused .

If you are willing to be patient and do your research for yourself, it's very easy for you to get up to speed , because understanding the problem of infertility and its treatment is not very complicated.

After all, you only need four things to have a baby – normal eggs, uterus , sperm and fallopian tubes.

If there is a problem with the uterus lining or the endometrium, then this is easy to diagnose, using vaginal ultrasound scans.

The endometrium gets shed during the menstrual period as the menstrual flow, and at this time, the lining is thin. The uterine lining grows in response to the estrogen produced by the follicle during the follicular phase. Prior to ovulation, the  endometrium is about 8 mm in size, and trilaminar in texture. This is reassuring, and suggests normal endometrial function.

In case the lining is thin, or distorted on the scans, this suggests there may be a problem with the endometrium , and the doctor can do a hysteroscopy to confirm this. Many of these problems - for example, an endometrial polyp, are easy to fix , provided you don’t allow the doctor to bulldoze you by using a lot of fancy medical terms which are designed to confuse you, rather than enhance your understanding.

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 !

Tubal (ectopic) pregnancy - so near and yet so far !

Being infertile is bad enough, but one of the biggest tragedies is when you get pregnant, but the pregnancy is not in the uterus , and is lodged in the fallopian tubes. This is called an ectopic or tubal pregnancy. Implantation just a few centimetres from the right place can make such a big difference !

The risk of an ectopic pregnancy is higher in infertile women , because often their tubes are partially damaged ( even though they are open, they may not be functioning properly). Sadly, we can't prevent this.

You can have an ectopic pregnancy even after doing IVF , because even though we're transferring the embryo directly in the uterus, it can travel backwards into the fallopian tubes and get stuck there.

The problem with an ectopic pregnancy is that the fallopian tube is not designed to allow a baby to grow , and if the diagnosis is delayed, the tube can actually rupture, and this can be a life-threatening complication .

This is why it's so important to monitor the early stages of pregnancy in infertile women. You should test for pregnancy as  soon as possible . The doctor will monitor you by checking your blood HCG levels and doing ultrasound scans , so that we can make a diagnosis as early as possible.

The good news is that if this is done in a timely fashion, we can kill the ectopic pregnancy with a simple methotrexate injection, so you don't need a laparoscopy , forget about open surgery. The bottom line is that an ectopic pregnancy is a problem which is easy to treat , if diagnosed in time.

The tragedy occurs when the doctor fails to consider this possibility, which is why patients need to be well-informed, and ask the doctor to rule out an ectopic. This can be tricky, because the symptoms of both an intrauterine pregnancy and an ectopic pregnancy are exactly the same, which is why you need to be proactive, and ask for the blood tests and scans.

Read more at http://www.drmalpani.com/knowledge-center/articles/ectopic

Busting the myths and misconceptions about IVF

How to compare different IVF Clinics and make the right choice ?

IVF clinic in Mumbai - Malpani Infertility Clinic

About genetic testing during pregnancy | Relation of genetics and Infertility

Points to know about birth defects | Do sperm defects cause birth defects?

How to increase your Sperm Count? | Correlation between sperm count and infertility

Frustration of a Failed IVF Cycle | How to manage stress of Failed IVF?

How to be a good IVF patient ?

Sexual dysfunction can cause childlessness | Erectile dysfunction

Day 3 or Day 5 Embryo transfer?

Everything about follicular tracking ultrasound scan | Ovulation tracking

Symptoms after an Embryo Transfer Cycle | Early IVF pregnancy signs and symptoms

Overview of Asthenospermia | Semen Analysis | Male Infertility

What are Pus Cells in Semen Sample ? | Semen analysis | Male infertility

Teratozoospermia - Meaning, Diagnosis and Treatment options | Male infertility

How can you find a trusted IVF Doctor ? | How to select the best IVF clinic ?

One important question to ask your IVF clinic

Assisted Reproductive Technology (ART) Regulation Bill explained by an IVF specialist

Why did my IVF treatment fail ? How can you make it right next time?

Why choose IVF Treatment ? | What are the advantages of IVF Treatment ?

Which is the better option: Artificial Insemination (IUI) or Self Insemination at home ??

Free Second Opinion for all infertile patients | Malpani infertility clinic

Step by step instruction of DIY insemination kit in Hindi

Step by step instruction of DIY self insemination kit | Malpani baby kit

Why I love answering IVF patient's questions

 

One of the commonest complaints which patients have about doctors is that they aren't willing to answer their questions.

For me, it's exactly the opposite , so if you want a doctor who is happy to clear your doubts, please talk to me. I love answering patient’s questions because these keep me on my toes. 

Having to explain to patients means I need to simplify complex medical topics and strip them of jargon, so patients understand what I am saying.
More importantly , these questions help me to empathize with my patient , because I'm not a mind reader , and I don't know what their worries and anxieties are. If they ask questions, I can resolve these, and patients appreciate this reassurance. 

Patients want openness and transparency, and if I can clarify matters for them, they don’t have to spend sleepless nights about a doubt which I could clear up if they'd asked me the question directly. 

Finally, your questions also help me to generate content for my website , because if one patient has a query, it’s quite likely that others will have this too, and if I can answer these online, I can help many of them. 

Remember that the word doctor is derived from the word, “docere”, which means to teach ! And I love prescribing Information Therapy – it’s free, and has no side effects !

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

Why I think aloud when talking to my IVF patients

I often think aloud when formulating the IVF treatment plan in front of my patients. 

Now this might sound surprising, because most patients expect their doctors to be expert oracles who tell them what to do.

I do this deliberately,  because then they can see my thought processes , and on what basis I have made my decisions. 

Medicine is a complex science, and the outcomes of IVF are always unpredictable, 

When they can follow my logic, they know on what basis I have chosen a particular option for them. Making my reasoning open and transparent is helpful, because it allows patients to share in the decision-making process.

They can ask me why I prefer a particular treatment plan, as compared to its alternative. It also encourages them to offer me additional options to consider, so they can provide their own inputs.

Because I'm thinking aloud, I have to be clear and cogent in my logic, because I need to explain this to my patient. This sharpens my thinking, and makes the patient much more involved and engaged in what's happening to them.

It also shows I respect them, and expect them to participate as partners in their treatment.

This strategy helps me to demystify IVF for them, and they can see I am being thoughtful and analytical when formulating a personalized treatment plan for them. 

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 !

Pus cells in the semen - and how to make sense of the report

 

One of the common findings in a semen analysis report is the presence of a few pus cells per high power field ( pus cells/ hpf). The technical word for this is called pyospermia or leucocytospermia.
Pus cells are WBCs - white blood cells, and less than 5 pus cells / hpf is considered to be normal, but this finding is often highlighted in red as being abnormal, and this often causes both the doctor as well as the patient to worry.
The WHO Manual states that less than 1 million WBC per ml is normal, but the majority of labs never bother to measure the actual concentration of the WBCs - the technician simply eyeballs the sample and estimate this in terms of rounds cells seen in each visual field when scanning the samples through the microscope.
Patients are worried that these pus cells suggest they are suffering from an occult infection - perhaps a sexually transmitted disease ( STD) which they knew they had acquired in the past, and they are worried that they can transmit this to their wife.
They are also worried that this hidden infection can kill their sperm, or reduce their ability to fertilise the eggs.
Doctors are also happy to "treat" this abnormality by putting the man on antibiotics, because these are so easy to prescribe, and because this seems to be a logical thing to do. They hope these antibiotics will kill the bugs causing the infection, and this will boost the man's fertility.
The reason this is flawed logic is because the "pus cells" seen on a semen analysis report when checked through the microscope are simply round cells, which are misinterpreted as being pus cells .
When examining the semen under the microscope, it's very easy to identify sperm because they have a tail and are moving rapidly. However, seminal fluid also contains many other cells, including the epithelial cells which line the male reproductive tract, as well as sperm precursor cells.
Most laboratory technicians will report every round cell they see as a pus cell or a WBC , but most of these are actually immature sperm precursors, called spermatocytes or spermatogonia , which look exactly the same. However, most labs don't have the special stains needed to identify whether this round cell is a WBC or not , which is why they will report all the round cells as pus cells !
The doctor then promptly prescribes antibiotics, but this is a complete waste, because there was no infection in the first place, and antibiotics will not cause the sperm precursor cells to go away !
Patients end up wasting a lot of time and money on taking antibiotics . Some doctors will also send the semen sample to the microbiology lab to try to culture the microbe causing the purported infection. However, it's surprisingly difficult to culture the semen sample properly, because it's often contaminated with the commensals on the skin of the penis, such as E.coli , which causes further confusion !
The bottom line is if your semen report does show a few pus cells, please don't panic ! Please repeat it again, and ask the lab to do the special stains needed to check if these are actually WBCs.
Otherwise, your wife will keep on getting older and losing her fertility, while you waste time because of a poor quality laboratory, or a poorly informed gynecologist .

Why a Root Cause Analysis is often useless in patients with IVF failure

Many patients who fail an IVF cycle, want the doctor to tell them exactly why the cycle failed. They want the doctor to get at the root cause , and this is completely logical. After all, once the root cause has been identified, the doctor will be able to fix the problem, and the next IVF cycle will succeed.

Sadly, life doesn't work this way, because biological systems are complex, and it's not possible to get a simple answer to what seems to be a very simple question. This is because there are multiple interlocking parts , and it's not possible to tease them out individually to find out why a particular cycle failed.

The reality is we can't even find out why a particular IVF cycle succeeded, but obviously when it succeeds everyone takes that for granted , and no one asks us why the cycle succeeded. But just like we can't answer why a particular embryo implanted successfully, we can't answer why a particular embryo didn’t implant.

Now it's very tempting to do lots of tests to find out what the “ underlying reason “ for the failure is . There are lots of complex expensive tests available, and doctors love doing these ! They include operations such as a hysteroscopy to check the uterine cavity, and an embryo biopsy to do a genetic analysis of the embryo. And these tests seem to make a lot of logical sense as well. After all , if you transfer an embryo into the uterus and it doesn’t implant, clearly this means there’s either a problem with the embryo or with the endometrium , and we just need to run tests to find out what the problem is, so that we can fix it and prevent a failure, the next time around.

Now, just because it sounds logical doesn't mean that it's feasible. The sad truth is that while it's easy to do the tests, interpreting them is extremely hard , simply because there's so much overlap between the results in fertile patients and infertile patients – and even in the same patient from one cycle to another . Most of these tests are unreliable and give inconsistent information, which actually ends up misleading both the doctor and the patient . They then go around chasing red herrings , which don’t help.

A classical example for this is a positive TB PCR test for the endometrium. Now this is positive in lots of fertile women as well , but fortunately they have enough sense not to do the test ! Now , when this test comes back as positive in a patient with a failed IVF cycle the doctor is delighted and says - See, this was the reason the cycle failed ! We have pinpointed the cause of the failure, and once we treat this, your next cycle will succeed. The patient is also pleased that the doctor has been so thorough and careful in identifying the problem and treating it.

 However, the ugly truth is that this abnormality wasn't the reason for the failure at all. It’s just an incidental finding, which doesn't actually affect embryo implantation at all. However, it’s hard to explain the concept of false positives and base rates to patients, because this is a complex and difficult topic, and most doctors don’t understand this themselves.

This is why most doctors will just mindlessly do the tests. They are happy to do these, partly because that's what their patients expect – and partly because it helps them to make even more money, even though they know in their heart of hearts that these tests are quite useless.

Now , every once in a while, the doctor will “ treat “ the abnormal test result and then do an IVF cycle and the patient will get pregnant. And in the doctor's mind - and the patient’s as well - the patient got pregnant because the doctor did the test , made the right diagnosis and corrected the abnormality.

However, this can be extremely misleading, because it's easy to confuse correlation with causation . The truth is that it's quite likely that even if the “ abnormality “ hadn't been treated , the patient would have got pregnant in the next cycle because IVF success is often a matter of randomness . Just being perseverant and patient is often all that it needed – there’s no need to change the treatment protocol if the cycle went well.

After all, human reproduction is not efficient, and even a fertile couple doesn't have a 100% chance of getting pregnant in the bedroom in the first month when they try . This doesn't mean that they change partners or do anything differently in the second month !

Unfortunately, this is not something which patients understand , because they expect instant gratification and 100% success rate when doing IVF .

And sadly, doctors aren’t  willing to share the truth with them , because doctors want to provide answers – after all , this is what patients expect, and they want to be seen as omniscient experts !

So rather than spend a lot of time explaining why we can't find out what the root cause is , and why running more tests is a waste of time and money, doctors are happy to pander to the patient's demand to do the tests.

This just adds to the confusion – after all, the more the tests you do , the higher the probability that some will be abnormal ! This is why these mindless battery of tests are so harmful. They cause the patients to waste a lot of time, money and energy on treating completely irrelevant abnormalities, which are of no clinical importance whatsoever.

The good news is that you don't need to do a root cause analysis because we have so much experience in treating patients who failed IVF cycles in the past. Empirical therapy works extremely well, so that instead of wasting time asking unimportant irrelevant questions which the doctor can't explain, you need to focus on what is in the doctor's control .

Make sure the doctor transfers a top quality blastocyst, and gives you photos of your embryos – this is all what the doctor can control. But do remember that after the doctor has made the embryo and put it back in your uterus, he has no control over whether it's going to implant or not, because embryo implantation is still a blackbox.

Not everything is within our control , and that's something which both doctors and patients need to come to terms with . A little bit of humility and a little bit of patience are invaluable .

Please remember the Serenity Prayer

God grant me the serenity to accept the things I cannot change;
The courage to change the things I can;
And the wisdom to know the difference.

Good doctors don't waste time looking for problems - they look for solutions ! 

What infertile couples need to do to make the right decisions for themselves

One of the hardest things about infertility treatment is making the right decisions.

Indian patients expect their doctors to make medical decisions for them . After all , doctors are medical experts , and that’s what they charge their professional fees for – to give their opinion. Most patients aren't sure they know enough to be able to make the right decision for themselves, which is why they would much rather outsource it.

Many Indian doctors are happy to be paternalistic and to make these decisions for patients , because they think patients aren’t able to make such complex decisions for themselves.

However, mature doctors understand that human reproduction is a very personal and a private affair, and there is no one single right answer for every couple.

This is why they ask their patients for their inputs . However, patients are often not confident enough to speak up . And sometimes some of them wonder why the doctor is asking them their opinion - after all , isn't the doctor supposed to tell them what to do !

This creates even more tension in the room, leaving both patients and doctors unhappy and dis-satisfied.

 Now, making decisions depends on both finding out the right facts, as well as listening to your feelings. For learning more about infertility and your treatment options, please go to www.drmalpani.com. There’s a wealth of updated, reliable, authentic, trustworthy medical information created by IVF specialists, and written for patients. These facts will also allow you to ask your doctor more intelligent and pointed questions.

 However, as far as listening to your feelings goes, that's something which only you can do for yourself. Yes, this is complex, partly because you've never had to make such difficult decisions in the past, and partly because this is not a decision you can make in isolation . You also need to think about your spouse's opinion, and get buy in from the rest of the family , especially for decisions such as adoption, which you may not have the freedom to make by yourself.

 Having said all this, please remember you're not the first couple in the world who is being confronted with this problem. Other people have dealt with it successfully , and your chances of being able to do so are excellent as well.

Please don't get disheartened ! Finding an empathetic doctor ; talking to friends and family members ; and a therapist or counselor can help you sort out your options , so you make a decision which you're at peace with . Remember you're going to have to live with the consequences of this decision for the rest of your life, so please use your head, your heart, your soul and your guts when deciding.

 There is no wrong decision – you just need to find the one you are comfortable with !