Friday, June 30, 2006

The importance of writing it down !

Studies have shown that patients forget upto 50% of what a doctor tells them ( either because of the stress of having to go to a doctor; or because doctors speak too fast; or use too much medicalese).
If doctor-patient verbal communication has such a poor track record, this is a poor use of the doctor's time - and a dis-service to the patient as well ! We all know that human memory is fallible, so why can't we develop a better way of telling the patient what he needs to know ?
Lewis Carroll gently reminded us: “The horror of that moment,” the King went on, “I shall never, never forget!” “You will, though,” the Queen said, “if you don’t make a memorandum of it.”
In my practise, I summarise the consultation at the end in writing , and give a copy to the patient for his records. If this is too time consuming, then I feel all doctors should offer their patients a pen and paper and invite them to make notes during the consultation. This is such a simple and easy thing to do - why don't we do it routinely ? It will also allow the doctor to confirm that the meesage he wanted to communicate has not been garbled !

Who does varicocele surgery help?

As an IVF specialist, I see a lot of couples who have male factor infertility because of a low sperm count. The technical name for this conditon is a tongue-twister, and is labelled oligoasthenospermia - quite a mouthful for the infertile man to have to swallow. Once he recovers from the blow that he is "shooting blanks", the next question every man wants to know is how to improve his sperm count. Lots will try home remedies such as a high-protein diet; or wearing boxer shorts to cool off their testes, but none of these work. They then attempt medical therapy or alternative medicine, both of which have a dismal track record. They then end up being referred to their friendly urologist, who usually diagnoses that they have a varicoele.

A varicocele is a swollen varicose vein in the scrotum - usually on the left side . The condition occurs because blood pools in the varicose testicular veins (pampiniform plexus) since the valves in the veins are leaky and do not close properly. The reason for infertility associated with a varicocele are unclear. Perhaps the accumulation of blood causes the testes to be hotter and so damage sperm production; or the pooled blood brims over with abnormal hormones which may change the way the testes make sperm. The effect of the varicocele on an individual's sperm count is variable - and this may range from no effect whatsoever, to causing a decreased sperm count. Varicoceles may also have a progressively damaging effect on sperm production, so that the sperm count may decline with time.

How is a varicocele diagnosed? The doctor examines the patient in the erect position and feels the spermatic cord - the cord like structure from which the testis hangs. The patient is also asked to cough at this time. A varicocele feels like a "bunch of worms" and on coughing, this gets transiently engorged. Confirmation of this diagnosis is best done by a Doppler test at the same time. The Doppler is a small pen like probe which is applied to the cord. It bounces sound waves off the blood vessels and measures blood flow by magnifying the sound of blood flowing through the veins. This can be recorded. Patients with a varicocele have a reflux of blood during coughing which shows up as a large spike on the tracing. Other tests which are done to confirm the diagnosis of a varicocele include a Doppler ultrasound, which confirms the "diagnosis" in colour !

Most doctors are still not sure whether a varicocele causes a low sperm count or not ! It is possible that the varicocele may be an unrelated finding in infertile men - a "red herring" so to speak. Strangely enough, only a quarter of men with varicoceles have a fertility problem. Thus, many men with large varicoceles have excellent sperm counts which is why correlating cause (varicocele) and effect (low sperm count) is difficult.

This means that surgical correction of the varicocele may be of no use in improving the sperm count - after all, if the varicocele is not the cause of the problem, then how will treating it help? In fact, controlled trials comparing varicocele surgery with no therapy in men who have varicoceles and a low sperm count have shown that the pregnancy rate is the same – so that it does not seem to make a difference whether or not the varicocele is treated or not!

Because surgery for varicocele repair is simple and straightforward , many doctors still repair any varicoceles they find in infertile men, following the dictum that it’s better to do something, rather than do nothing ! However, keep in mind that varicocele surgery will result in an improvement in sperm count and motility in only about 30% of patients - and it is still not possible for the doctor to predict which patient will be helped. Of course, just improving the sperm count is not enough - and pregnancy rates after varicocele repair alone are in the range of 15%. However, one danger of doing a varicocele repair is that when it doesn’t help, patients get frustrated, and refuse to pursue more effective options, such as the assisted reproductive techniques.

The only group of men varicocele surgery consistently seems to help are the surgeons who perform it !

Thursday, June 29, 2006

If a picture is worth a thousand words, how much is a video ?

I have always wanted to add video to my blog. I think videos are a great educational tool. My friend, Veer, at showed me how to do this.
Here's a video we produced to help teach infertile couples the basics of babymaking. I'll be uploading more here soon - stay tuned !

Wednesday, June 28, 2006

The End of Medicine : How Silicon Valley (and Naked Mice) Will Reboot Your Doctor

The End of Medicine : How Silicon Valley (and Naked Mice) Will Reboot Your Doctor: "The discussion covered a lot of topics in The End of Medicine : How Silicon Valley (and Naked Mice) Will Reboot Your Doctor, and you can get a pretty good flavor of what the book is about. Helen had a 'freakish' heart attack at age 37, misdiagnosed as panic disorder, and now has an implanted defibrillator. The idea of early detection of heart disease or cancer seemed to hit home with her.
'Do you ever wonder if your doctor is really doing a thorough job when you go in for your yearly physical? I do. You go in and he/she hits your knee with a rubber hammer, runs a few blood tests and asks about any symptoms--all the time, checking their watch to make sure they can get to the next patient. What if a tumor is growing inside you or your arteries are clogging up faster than last night's dinner in the drain of your kitchen sink? Wouldn't you want to know in advance so that treatment could be started immediately before your life is threatened? Well, soon you might.'"
Sounds interesting ! I have pre-ordered the book from However, advanced medical technology is not likely to spell doom for doctors. For one thing, there are too many real-life problems with false positive tests . This will result in unnecessary overtreatment - and happy doctors , who will have much more busy-work to do ! Also, doctors aren't just technicians . They provide real-life emotional support - and as any patient will vouch for, a sympathetic shoulder to cry on can be invaluable. Silicon chips can't do this - yet !

Promoting medical tourism - Indian government style

There is now a lot of hype about how India is going to become the next medical destination, because of its ability to provide high quality medical care inexpensively. It is true that India is blessed with a large number of very competent medical professionals; and we do treat lots of infertile patients from all over the world in our IVF clinic.
One would expect that the Indian government would whole-heartedly support doctors who were trying to promote Indian medical tourism. However, the ground reality is very different ! For one thing, the Indian government treats doctors and hospitals unfairly. Though they earn foreign exchange for the country by "exporting medical services" , the government does not provide them any incentives for doing so. They get very step-motherly treatment ( as contrasted to five-star hotels and IT companies, which are pampered and coddled with tax-breaks and rebates). What happened to the "level playing-field" ?
To add insult to injury, rather than encourage tourism by providing medical visas expeditiously, Indian embassies give patients who want to come to India a very hard time ! I just got a call from a UK citizen who is now in Turkey and wants to come to India for her IVF treatment. The Turkey consular officer tells her it will take him 5 days to verify her application before he can issue her a visa. I called him up, requesting him to expedite the process; and he told me that after 9/11, Indian embassies have to be "extra-careful" about whom they issue visas too !
Here's another example of the government killing the goose which lays golden eggs !

Tuesday, June 27, 2006

The problem with professionals

Everyone knows the Indian legal system is sick. The judicial system is clogged, and it can take decades to get justice. Well-meaning judges have tried to address this problem by introducing the option of ADR - alternative dispute resolution, so that citizens can resolve their problems quickly and get justice without enduring the inerminable wait which is the hallmark of the Indian judiciary today.
While one would expect that most people would jump at this opportunity to expedite matters and stay out of the court, a lawyer told me that the reason ADRs will never become popular in India is because of lawyers themselves ! There is so much more money to be made ( for the lawyers) by slugging it out in the court, that very few lawyers are honest and upright enough to offer the ADR option to their clients ( even though they know it would be far better for their clients !)
I guess it's pretty similar to the healthcare system. It's really an illness-care system; with doctors being so focussed on fixing problems after the patient falls sick, that they do not even think about preventing them ! What a waste of time, money and energy, which could have been fruitfully employed in improving the quality of life for everyone !

Placing The Patient At The Center Of Healthcare

Placing The Patient At The Center Of Healthcare: "The fundamental issue is not technology at all, or even errant business processes. In fact, without some changes in the 'culture' of healthcare, new technology will accomplish little. Why? Because the relentless advance of technology by itself doesn't fix things. It never has. Technology is never more than an enabler of good business decisions. Absent a complete understanding of the business problem, any 'solution' will be flawed. The challenge facing healthcare today is, first and foremost, properly identifying the problems.

So what's the missing part of the equation? The 'voice of the customer.' Call it an appreciation of how the needs and expectations of today's consumer have changed, or an understanding of just how disappointed patients have become with the current healthcare process. Ultimately, it means caring about what's important to patients, first and foremost."

Patricia Seybold expressed these principals well in The Customer Revolution – How to Thrive When Customers are in Control. The key "customer-centered" principles she identifies have been adapted and paraphrased below for healthcare and patients specifically:

1. Create a compelling "brand personality."
2. Deliver a seamless experience to patients across channels and touch points
3. Care about patients and their goals
4. Measure what matters most – to patients
5. Value patients’ time
6. Place patient “DNA” [information] at the core of the system
7. Refine operational excellence
8. Design any new system or process with the expectation that it will need to evolve
9. Provide self-service access to services if possible, when and where the patient wishes.

CRM to PRM- Bringing Consumers Into The Healthcare Fold

CRM to PRM - The Natural Evolution Of Bringing Consumers Into The Healthcare Fold: "The lesson to the healthcare marketer is this: Own the minds of the consumers. Manage their perceptions of your healthcare services so that when the need arises, they think of you first. Build relationships with your potential customers, and remember that when you successfully convert them from consumers to patients, there exists a need for well executed Patient Relationship Management."
Call it what you will - the key is providing good service for the end-user !

Power to the Patient with e-healthcare

Power to the Patient with e-healthcare" Patient self-service and secure communication will not be beneficial to patients unless there is adoption from physicians. In order to gain adoption the physician must be sold on the value proposition associated with providing these types of services. As an example, from a benefits perspective research from Healthcast 2010 indicates that an estimated 20% of the 830 million annual office visits per year could be eliminated by online communications between clinicians and patients. With each visit averaging about $63, about $7 billion could be saved each year in clinical messaging. Furthermore, patient self-service transactions and online communication can increase practice efficiency and productivity through fewer telephone calls, decreased administrative costs, and growth through attraction of new patients. One result of increased practice efficiency would be that more office visits could be reserved for, as well as physicians dedicating more of their time to those patients truly requiring face-to-face care."
E-healthcare is a win-win situation - if we can get doctors to buy in to the idea ! The ones who do ( the early adopters) will do much better than the laggards !

Monday, June 26, 2006

Yellow Book - Health Information for International Travel

Yellow Book- Health Information for International Travel: " The Yellow Book is published every two years by CDC as a reference for those who advise international travelers of health risks. The Yellow Book is written primarily for health care providers, although others might find it useful."
Filled with information - it's like having your personal online travel medicine specialists ( if you have the patience and energy to decipher the medicalese !)

Medical Humanities

Medical Humanities: "This site, established in 1994 at New York University School of Medicine, is dedicated to providing a resource for scholars, educators, students, patients, and others who are interested in the work of medical humanities. We define the term 'medical humanities' broadly to include an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theater, film, and visual arts) and their application to medical education and practice. The humanities and arts provide insight into the human condition, suffering, personhood, our responsibility to each other, and offer a historical perspective on medical practice. Attention to literature and the arts helps to develop and nurture skills of observation, analysis, empathy, and self-reflection -- skills that are essential for humane medical care. The social sciences help us to understand how bioscience and medicine take place within cultural and social contexts and how culture interacts with the individual experience of illness and the way medicine is practiced."
Doctors can and do have multiple interests - and not all of them are one-dimensional !

Priorities in Health

Priorities in Health: " Delivering efficacious and inexpensive health interventions leads to dramatic reductions in mortality and disability at modest cost. Globalization has been diffusing the knowledge about what these interventions are and how to deliver them. The pace of this diffusion into a country—more than its level of income—determines the tempo of health improvement in that country. Priorities in Health aims to speed the diffusion of life-saving knowledge."
This free online book reads like a typical scholarly tome. What upsets me is that there is no mention made at all of patient education ! Educating patients could be one of the most cost-effective use of scarce resources, since patients are the largest untapped healthcare resource ! Why leave them out of the solution ?

A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan

A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan: "Anyone enrolled in a health plan should be familiar with their plan’s internal review process and any external review program in their state in case problems later arise. This guide will help you navigate your employer or private health plan’s internal grievance procedure, as well as any external review program your state may have. "

Medicine and Madison Avenue

Medicine and Madison Avenue : "This website explores the complex relationships between modern medicine and modern advertising, or 'Madison Avenue,' as the latter is colloquially termed. The Medicine and Madison Avenue Project presents images and database information for approximately 600 health-related advertisements printed in newspapers and magazines. These ads illustrate the variety and evolution of marketing images from the 1910s through the 1950s. The collection represents a wide range of products such as cough and cold remedies, laxatives and indigestion aids, and vitamins and tonics, among others. In addition to the advertisements themselves, the MMA website includes historical material -- non-graphical text-only documents -- that put health-related advertising into a broader perspective. "
It's great fun to browse through this collection of ads from the past. The major tragedy is that modern advertisers ( DTC, direct-to-consumer) have become much smarter; and are able to fool consumers into arm-twisting their doctors to prescribe the "latest and newest" drugs for them !

Points to Consider on the Subject of Surrogacy

Points to Consider on the Subject of Surrogacy: "Many people do not understand the fairly intricate legal procedures (translate: substantial time and cost) which are required pre-birth in order to make sure that the biological parents are named as parents on the child's birth certificate. I have had numerous calls and letters from people who were sure that I was trying to fleece them when I explained this. They truly believed that they could just give the hospital a written statement from the IVF doctor, or the surrogate, or themselves, and that would take care of things. Please do not be fooled into thinking that you can avoid the standard legal procedures, whatever they may be for your jurisdiction. In California, these procedures vary depending on whether the surrogate conceived via artificial insemination (AI), or by in vitro fertilization (IVF). During an IVF pregnancy, the Intended Parents file a legal proceeding which the surrogate (and her husband, if married) join in agreement. The court then issues a Judgment which states that the Intended Parents are the legal parents; that neither the surrogate nor her husband have any legal rights or responsibilities; that the hospital personnel must name the Intended Parents on the birth certificate; and that the Intended Parents are allowed to name the child. Since the hospital personnel only have ten days post-birth to prepare the birth certificate, it is wise to start the legal proceeding during the sixth month of pregnancy, to allow sufficient time for the court to process the paperwork."
At least this can be done legally in California. None of this is legally possible in India, which means all surrogacy treatment in India at present is technically illegal. The law does not recognise genetic parentage; and only recognises the birth mother as being the parent.

Sunday, June 25, 2006

Obesity and infertility

Obesity is one of the prices some of us pay for modern society’s prosperity . Not only is food easily available ; it’s also inexpensive; and because of modern conveniences, there is little need to walk or be physically active.
Being overweight affects everything. You can take lists of diseases from every specialty and find some obesity-related ones in each. Hypertension, coronary artery disease, pulmonary problems, diabetes, skin health...the lists are endless. One of them is being infertile.
How does obesity interfere with fertility? What is the connection between obesity and PCOD ? obesity and hypothyroidism ? obesity and insulin resistance? How do you judge whether you are obese or not ? And how does one lose weight ? Lots of complex questions – and no easy answers ! Let’s look at them one by one.
While most women are happy to blame their obesity on hormonal problems ( what used to be called “ glandular deficiency “ in unkinder times ) , usually the underlying reason for obesity is simple – the caloric intake is more than caloric expenditure. However, sometimes hypothyroidism can cause both obesity and infertility, so you should start by doing a simple blood test for TSH levels to check for this. Thyroid problems are easy to diagnose and usually easy to fix. However, what if you are amongst the vast majority of overweight women who are infertile, and have normal thyroid function ?
We first need to understand how obesity causes biochemistry to gang up on normal ovulation . There are three sources of estrogen in the body: the ovary (directly) ; as well as the adrenal glands; and fat cells (indirectly). The ovary makes estrogen in quantities which depend upon the phase of the menstrual cycle. The adrenal glands make androgens (male hormones such as androstenedione. Since all of these sex-hormones ( including testosterone and progesterone) are derived from cholesterol, these hormones are converted back and forth in the cells . In the case of the adrenal androstenedione, fat cells can convert it into an estrogen called estrone. If you're significantly overweight, a steady oversupply of estrogen ( from the “peripheral” conversion of androstenedione to estrogen in the fat cells ) will blunt the peaks and valleys of the ovary's function, which ultimately interferes with ovulation and can cause infertility.
Many obese women also have polycystic ovarian disease
( PCOD) . Patients suffering from PCOD have multiple small cysts in their ovaries ( the word poly means many). These cysts occur when the regular changes of a normal menstrual cycle are disrupted. The ovary is enlarged; and produces excessive amounts of androgen and estrogenic hormones. These prevent ovulation, which causes infertility. This diagnosis can be confirmed by vaginal ultrasound, which shows that both the ovaries are enlarged; the bright central stroma is increased ; and there are multiple small cysts in the ovaries. These cysts are usually arranged in the form of a necklace along the periphery of the ovary. Blood tests are also very useful for making the diagnosis. Typically, blood levels of hormones reveal a high LH ( luteinising hormone) level; and a normal FSH ( follicle stimulating hormone) level ( this is called a reversal of the LH : FSH ratio, which is normally 1:1); and elevated levels of androgens ( a high dehydroepiandrosterone sulphate ( DHEA-S) level, which is called hyperandrogenemia.
And that’s not all ! To make a bad situation worse, obesity aggravates insulin resistance. Insulin is a hormone secreted by the pancreas which helps the body’s cells to utilize blood glucose (sugar) by binding with receptors on cells ( like a key would fit into a lock), so that the glucose can pass from the blood into the cell, where it is used either to supply energy. In insulin resistance, the body's cells have a diminished ability to respond to the action of the insulin hormone. In order to compensate for this, the pancreas needs to secrete additional insulin. This results in high levels of insulin in the blood ( hyperinsulinemia); and a diagnosis of hyperinsulinemia can be made if fasting insulin levels are over 15 uU/ml. In about one third of people with insulin resistance, when the body cells resist even these high levels of insulin, the glucose builds up in the blood , resulting in type 2 diabetes. High levels of insulin also cause hyperstimulation of ovarian steroid production , thus worsening the vicious cycle because of increased production of estrogens and androgens.
Obesity has also been associated with an increased risk of early pregnancy loss after IVF, decreased pregnancy rates, decreased fertilization, higher gonadotropins requirements, as well as an impaired response to gonadotropins. The cause of a poorer IVF treatment outcome in obese women may be due to poor oocyte quality with subsequent lower fertilization and/or implantation defects caused by a qualitatively poor endometrial milieu. Obesity is also associated with increased problems during pregnancy, such as an increased risk of hypertension; and gestational diabetes.
How can you judge if you are overweight or obese ? In order to do so, you need to measure your BMI, or Body Mass Index . This is an index of your relative "skinniness or fatness", because it factors in your weight as well as your height. Body mass index is calculated with the formula: weight (in kilos) divided by height (in meters) squared. A high BMI indicates obesity.
A standard medical definition of "normal" body weight is a BMI of about 18.5 - 24.9
· A BMI under 18.5 indicates that the person is "underweight"
· A BMI of 25.0 - 29.9 indicates that the individual is "overweight", but not obese
· A BMI over 30 indicates obesity
· A BMI over 40 indicates extreme obesity
If you are overweight, you can enhance your fertility and your chances of having a healthy baby by losing weight . This is why weight reduction should be the first line treatment for obese, infertile women. This needs a multidisciplinary approach to weight management that fosters lifestyle change through proper diet, exercise, behavior modification and stress reduction .
The tragedy, of course, is that this is easy advise to dispense – but very hard to do in real life. No one wants to be obese and losing weight can be really hard to accomplish. Some IVF clinics refuse to treat obese patients; and turn them away unless they can reduce their BMI. I feel this is adding insult to injury. Obese women who are infertile don’t choose to be obese, just as they do not choose to be infertile; and if , after they have tried to lose weight but failed, it’s unfair to withhold infertility treatment from them. Forcing them to wait until they lose weight just causes them to lose even more precious time, and makes a bad situation worse.
If an infertile obese women understands the importance of losing weight; and sincerely tries to do so; but fails to do so even after 6 months of trying, I feel the least we can do is at least help her to have a baby. Improving her fertility may help to improve her self-esteem !

IVF treatment is cost effective and should be funded by the government

IVF treatment is cost effective and should be funded by the government : "IVF costs cannot be considered in isolation. Every baby born after NHS IVF treatment carries a price-tag of 13,000 pounds, but its economic influence does not end there. Even after its education, child benefit and healthcare are paid for, it will contribute, on average, a net 147,138 pounds to the Exchequer throughout its lifetime. It pays for itself by the age of 31 in tax alone: the model does not include the wealth it creates in the private sector. The “break-even” point is just two years older than for naturally conceived children, who contribute a net 160,069 pounds . This suggests that failing to fund IVF is a classic false economy. The investment might cost a little now, but it will be paid back many times over in the future."
This study proves that IVF is cost effective. In fact, IVF babies usually make excellent citizens, because infertile couples usually make excellent parents ! They usually invest much more time and energy on their children than most other parents do !

Saturday, June 24, 2006

Embryos and the New Reproductive Technologies:

Embryos and the New Reproductive Technologies:: "The need in the field of reproductive medicine is not only ethics and morality, but laws. Certainly morality and ethics cannot be legislated. However, this area of medicine and high tech fertility procedures has outpaced the laws, which reflect only traditional ways of 'making babies'. It’s time that the legislature move into the twenty-first century and define what we as a society have accepted as a usual course in the treatment of infertility. This would mean re-defining 'mother' and 'father' to include the variety of options available to patients at fertility clinics. Patients who do go through these procedures should take care to protect themselves by hiring an attorney who is an expert in the field of reproductive medicine. By providing for contingencies, and transferring parental rights through such legal counsel, couples will avoid many of the heartaches later. Unfortunately, nothing can prevent the heartache of leaning that your embryos, which were to be in safe keeping, were sold off to the highest bidder."
I find this suggestion truly frightening ! Why would patients trust a lawyer more than they trust their own doctor ? I wonder how many IVF clinics would want to treat a couple who wanted to transfer their parental rights ? And how can you transfer your parental rights ?

Doctors need to become politically active

For most doctors, politics remains a dirty word, and a popular joke says politics is derived from poly, meaning many, and from ticks, signifying blood-sucking parasites. While many of us enjoy complaining about the poor quality of our leaders , and talking about how corrupt and inefficient they are is a popular topic of party conversation in India today, we cannot afford to take such an ostrich in the sand attitude anymore.
The government is now passing new rules and laws which curtail medical autonomy and this bodes ill for the future of our profession. We have no choice but to become politically active, if we want to regain control over our professional independence.

An excellent example of the increasingly intrusive government policies in healthcare is the recent amendment to the PNDT ( Prenatal Diagnosis and Treatment) Act . This amendment is a major slap in the face of all medical professionals, because it treats all doctors as potential criminals, who need to be constantly policed. Thus, the Act mandates that all clinics which perform ultrasound scans should prominently display a sign saying, “ Fetal sex determination not performed here”. This is highly demeaning and is an insult to all doctors ! Why should doctors have to put up a sign which says they do not perform an illegal act ? Using the same analogy, all police stations should also have a sign
saying , “Bribes not taken here “ ! To compound the insult, the Act has created an avalanche of non-productive paperwork, because all ultrasound scans performed during pregnancy need to be reported. Even worse, this Act demands that we compromise our patient’s confidentiality, because the name and address of every pregnant woman undergoing an ultrasound scan ( which today has become a routine procedure) should be reported to the government !

The fact that such a poor piece of legislation was passed in the first place makes for an interesting story, and underlines how powerless doctors have become in the face of vested interests. After the Census 2001 figures were released, an NGO moved a public interest litigation in the Supreme Court, claiming that the decline in the sex ratio was a result of fetal gender determination, because the government was not implementing the PNDT Act properly. In response to the Supreme Court directive, the Health Dept secretaries were hauled up, and they promptly bent over backwards to comply. Unfortunately, bureaucrats only understand paperwork, and the Act was passed uncritically, because it appears to be designed to protect the girl child. In reality, this amendment encroaches on our patient’s reproductive rights, because it prevents them from using technology to plan their family. Unfortunately, no one has spoken out against it, and sadly, future generations will pay the price ! What is to stop the government from further restricting reproductive freedom by implementing an even more coercive population policy which enforces a one-child or two-child norm, as suggested by former Union Health and Family Welfare secretary, A.R. Nanda ?
Doctors are obliged to protect their patients’ best interests and we need to stand up for our patients. We do not function in a vacuum, and we need to take a leadership role in shaping medical policies which affect public health and private medical care for the sake of our patients – and for our sakes as well ! This is an opportunity we need to seize, and while individually there is little we can do, together we can command respect and clout. An excellent example of our collective power is the fact that a surgeon kidnapped recently in Bihar by goons was released only after the members of the Indian Medical Association of Bihar jointly threatened to strike.

We need to learn from doctors in the U.S. . Predatory insurance contracts, HMO cost pressures, burdensome government regulations, and the threat of unjust malpractice suits have galvanized them into organized political action. They can no longer afford apathy since their survival is now at stake, which is why they are playing an increasingly active role politically. They have realized that if they wish to continue to practice quality medicine , they have to get legislators to pass doctor-friendly and patient-considerate reforms. Doctors have started to lobby for their rights, and many medical societies are active and alert in this area. There are none so blind as those who will not see, and if Indian doctors continue to turn a blind eye, we will soon find ourselves in the dire predicament the medical profession in the U.S. does today. American doctors are so buried in paperwork today in order to meet legal guidelines that many are choosing to retire at the age of 40, because they cannot put up with the irksome burden any more. The malpractise crisis has taken the joy of medicine away, and if we don’t watch out, the three devils of modern medicine in the U.S. today – stifling insurance contracts; HMO cost squeezing techniques; and an avalanche of governmental regulations and paperwork are all likely to become a reality in India in the next few years in response to market pressures which shape the Indian economy as we become part of the global economy.

Healthcare has become an important issue in India today. The government is finally seeking to play an active role in ensuring our population is healthy, because it realizes that our people are our most important resource, but because of poor health care, they cannot reach their potential. Unfortunately, though this is such a vital area in which doctors have so much expertise, they have provided precious little input, and this is sad. We need to take a leadership role, and by becoming politically active, we can influence issues beyond medical practice, such as prescription-drug costs and universal medical coverage. We must be involved in the process that governs the way we practice. Isn't it better to be a player than a victim? We need to play an active role in ensuring that we take only the good from the West, and leave out the bad, so we can capitalize on our strengths. Government policies that threaten the quality of health care are often developed by officials who aren't knowledgeable about medicine. Doctors who hold public office can defend our profession and protect the patient-doctor relationship.

Doctors are well-educated, and because they are in constant touch with their patients, they are aware of ground reality. They are highly respected members of society, and are likely to become much better leaders than the present tribe of politicians, many of whom are corrupt and semi-literate. But can doctors become good politicians ? Isn’t this role better left to others ? Interestingly, there is a strong tradition of doctors entering politics. Our past history provides many role models of doctors who have become excellent leaders, and a shining example is Dr Jivraj Mehta, the Dean of Seth G S Medical College, who later became the Health Minister of Bombay state.

It’s also worth recollecting that the very first article in the very first issue of the largest selling medical journal in the USA, Medical Economics ( dated October 1923) was titled The Place of the Physician in Politics." The author was Dr Royal S. Copeland of New York, one of two physicians in the US Senate. Copeland argued that doctors, thanks to their experiences in caring for patients in the cities and countrysides of America, had the broad vision required of a public servant. Copeland acknowledged that a doctor would be reluctant to leave his profession for a different calling. However , "when he does venture into this field, his education, his experiences, his human contacts, his broadened sympathies and intimate knowledge of the endless needs of the human family must make him a useful and active agent for the good of the nation. He knows the heart of humanity."

Organizing doctors, the saying goes, is like herding cats, and because of their fiercely independent spirit, Indian doctors have failed to play an active role in healthcare policies, because they are not organized or united. The tragedy is that we often waste our time and energy fighting each other. While many doctors are politically active , they are usually active only in medical politics , where they squabble over promotions, medical society chairmanships, and grants. What a waste !

Many doctors are now sitting for the IAS examination to become IAS officers, because they want to take a more active role in running the country. Doctors often top these examinations, and they do become good bureaucrats, because they are trained to think scientifically, search for the truth; and to fight for their patients and to serve them. As an aside, it’s interesting to note that politicians want to stop doctors and other professionals from applying for IAS jobs, because they are worried that it will be difficult for them to coerce educated public servants into doing their bidding !

The best way is to start small – apply for a corporator’s seat, for example. Unfortunately, many doctors have huge egos , and expect to get elected just because they are doctors. Ground reality can be unflattering and you’ll have to learn humility - don’t expect to become health minister just because you are a doctor. Fortunately, you may not have to indulge in corrupt practices to get elected, because good doctors have lots of good will in the community . If nothing else, trying to get elected will teach you the art of negotiation and compromise ! Don’t expect other doctors to be supportive – and even your family members may feel you are crazy to leave the security and comfort of your medical work. While it is true that becoming politically active may cut down your medical practice , you may find that your patients may be your most loyal supporters.

We all need to evolve with the passage of time , as Shakespeare so eloquently described when talking about the seven stages of man, and joining politics allows a doctor to do so. Your sphere of influence grows, so that your “stage “ is then no longer your clinic or your hospital, but the city or the state – and your patients are then no longer just the ones who come to your clinic, but rather the entire population. You start to think on a much larger scale , so that your potential for doing good also becomes much larger. In India, poverty remains the leading cause of ill-health, and as Rudolf Virchow , the father of pathology
( and a member of the German parliament ) wisely said many years ago, “ Medicine is a social science and politics is nothing else but medicine on a large scale. If medicine is to fulfill her great task, then she must enter the political and social life. Since disease so often results from poverty, the physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”

Doctors will make far better leaders than the corrupt politicians we have today. Because they are educated, financially well off and able to think scientifically, they will be able to make decisions which are in the best interests of society, rather than only looking out after their personal selfish interests. Unfortunately, most able doctors are so devoted to their profession , that they hesitate to take on the larger work of helping to heal the ills of our nation. However, we owe this to our colleagues, to future doctors and to our patients !

NB. I wrote this article for my column in HouseCalls magazine where it was published a few years ago. It's still valid today !

Friday, June 23, 2006

Is google getting smarter ?

I just did a google search for vaginismus ( a condition in which a woman finds sex painful because of an involuntary spasm of the muscles surrounding the vagina).
I was very impressed when google offered me the following additional search options to fine-tune my search :
" Refine results for vaginismus:
Treatment Tests/diagnosis For patients From medical authorities Symptoms Causes/risk factors For health professionals Alternative medicine"

I guess google figured out that I was looking for information on a medical topic; and was offering customised results, based on my needs.

However, when I tried a search on
in vitro fertilisation, these additional options for "refine results" did not come up. Does anyone know what's happening ?

You've got a great doctor - what's next ?

It's not enough to just find a great doctor and then let him do what he wants. You need to become a smart patient as well - and the better you are as a patient, the better your doctor will be ! It's a dance - and your role is as important as the doctor's !

Finding the best doctor

I am an IVF specialist, and when my patients get pregnant, I refer them to an obstetrician. One of the commonest questions my patients ask me is - Please refer me to the best doctor !
I don't refer patients to a specific doctor. I believe that most doctors are technically competent - and in any case, it's the mother who is having the baby, not the doctor. This means that obstetricians mostly just need to provide reassurance that all is well.
I suggest to patients that they short-list 3 doctors - and interview them, so they can find the doctor who appeals the most to them. Chemistry is a key component in the doctor-patient relationship - and only a personal interaction will allow you to judge which doctor is "right" for you !

Thursday, June 22, 2006

The Fight to Cover Infertility; Suit Says Employer's Refusal to Pay Is Form of Bias - New York Times

The Fight to Cover Infertility; Suit Says Employer's Refusal to Pay Is Form of Bias - New York Times: "The Fight to Cover Infertility; Suit Says Employer's Refusal to Pay Is Form of Bias, By JANE GROSS. Published: December 7, 1998.
On Thursday morning, after a fitful night's sleep, Rochelle Saks had her last artificial insemination. Her medical plan does not cover infertility treatments, she owes her doctor almost $10,000 and she can afford to pay only a few hundred dollars a month to retire the debt. Thus, he has refused to continue treating her.''I've been up since 2:30 in the morning, thinking this is our last try,'' Ms. Saks said before that final visit to the doctor. ''We cannot afford to go any further on our own.''

But a bold decision to sue her employer could turn the tide for Ms. Saks and others like her. She is among a small but growing band of plaintiffs who have filed class action complaints with the Federal Equal Employment Opportunity Commission, charging that denying medical coverage for infertility treatments is unlawful discrimination."

Here's an excellent example of patient activism, where patients take things in their own hands, to help themselves. I wonder why more patients don't do this ?

Consumer's Medical Resource: Turning Patients Into Informed Consumers

Consumer's Medical Resource: Turning Patients Into Informed Consumers:Escalating costs. Varying degrees of quality. Increasing dissatisfaction. The U.S. health care system has fallen into severe decline over the last decade, dramatically bringing into question the future of a trillion-dollar industry. Is a revolution around the corner? Consumer's Medical Resource (CMR) sees an inflection point in the current health care delivery system in which the process is becoming consumer, not provider, driven.

The three key forces accelerating this transformation to a consumer-driven health care market are:

* Health care costs are escalating - again.
* Perceived lack of quality, dissatisfaction with the managed care system.
* The impact of Internet connectivity.

In response to these market place realities, CMR believes a consumer-driven approach is the best way to ensure that high quality, satisfactory, cost-efficient health care is delivered in the United States.

Consumer's Medical Resource (CMR) provides Medical Decision Support (MDS™) services to employees of FORTUNE 500, and other large organizations, who face serious, complicated, and chronic illness. MDS™ is a decision support service that offers patients in-depth, objective, personalized, and latest-breaking information on their diagnosis and available treatment options. The information is assembled and distributed by a physician-led team. These physicians are affiliated with 'America's Top 5' medical schools."

Advice Is the Newest Prescription for Health Costs - New York Times

Advice Is the Newest Prescription for Health Costs - New York Times: "After a 15-minute office visit in February 1999, a cardiologist told the parents of Dominic Fernandez, 3, that he needed open heart surgery and a possible heart transplant -- ''right now, or he will not survive through the summer.''''We were just overwhelmed,'' said Beverly Fernandez, a warehouse manager for Honeywell. Her son was still recovering from surgery nine months earlier for congenital heart problems. ''I wanted to know more about transplants'' and the alternatives, she said.She called Consumer's Medical Resource Inc. in Duxbury, Mass., a medical information service available through her employer. A physician and a researcher listened to her account for an hour. Within the week, she received packets of medical journal articles and books on heart transplants, including failure rates.Relieved because she felt better informed, she got a second opinion from another cardiologist who recommended monitoring Dominic for six months. After additional repair surgery -- no transplant -- eight weeks ago, her son, now 4, is ''doing wonderfully,'' she said."
Information is still the best presciption - and smart companies are making money providing this !

Top Ten Monthly Fertility Mistakes Women Make

Top Ten Monthly Mistakes Women Make ( adapted from the book, A Few Good Eggs : Two Chicks Dish on Overcoming the Insanity of Infertility by Julie Vargo and Maureen Regan.)

1. Women go on the Pill to regulate their cycles without first
determining why they are irregular.
2. They disregard heavy periods.
3. They worry too much about the colour and texture of their periods.
4. They worry about their physiological vaginal discharge
5. They have productive baby-making sex at the wrong times of their monthly cycles.
6. They think that every women has a twenty-eight-day cycle and every
women ovulates on day fourteen.
7. They are not sure how to track their menstrual cycle.
8. They try to maximise their fertility by " storing up " sperm by scheduling sex only on their fertile days in an effort to get pregnant.
9. They try to time sex by charting their temperature ( BBT charts)
10.They don't use OPKs
It's true that most women have very little understanding of how their reproductive system works - and for many of them, their menstrual cycle is a complete mystery !

Here are my comments on this list.

1. Women go on the Pill to regulate their cycles without first determining why they are irregular.
Irregular cycles mean that you do not ovulate. This is called anovulation; and women who don't ovulate will have irregular cycles; and will also be infertile. The infertility is a result of the anovulation. While taking the Pill will regulate the irregular cycle so that it starts coming like clockwork, it will not treat the underlying anovulation problem. This means that when you stop the Pill when you want to have a baby, your periods will go back to becoming irregular again - and you will need ovulation induction treatment to correct your infertility.

2. They disregard heavy periods.
While heavy periods are not always a sinister sign, if your periods have started becoming progressively heavier, then you need to seek medical attention. This could be because of a uterine polyp, for example; and this polyp could also cause infertility.

3. They worry too much about the colour and texture of their periods.
You only need 4 things to make a baby - eggs, sperms, uterus and tubes. Now since women cannot see their eggs, and all they can assess is their menstrual flow, many infertile women obsess over even minor normal variations in their menstrual flow. If it's too dark, they feel that there are toxins in their body which are not being washed out; or that the "bad blood" is getting accumulated in their bodies, causing them to become infertile. This is why a D&C ( dilatation and curettage) used to be such a popular procedure in the past; women felt that the doctor was cleaning out the dirt in their uterus !

4. They worry about their physiological vaginal discharge
For many women, their private parts are a "no-man's" land
( pun intended) . They don't have a clue as to how their insides work; and these worries are magnified a hundred-fold in the mind of an infertile woman, who thinks that her infertility is a result of her body is defective. A mid-cycle vaginal discharge is normal, and is a result of the production of cervical mucus prior to ovulation. However, many women think this discharge represents an infection; and demand treatment for this !

5. They have baby-making sex at the wrong times of their monthly cycles.
Many women are uncertain as to how to calculate their "fertile" period. They know it has a relationship to their ovulation cycle, but often don't know what this is, as a result of which they don't time baby making sex properly. You can calculate your fertile days by using our free fertility calculator !

6. They think that every women has a twenty-eight-day cycle and every women ovulates on day fourteen.
This is true only in textbooks - and many women's bodies have not read the text book. Completely normal women have cycles which range from 21 days - 45 days - and this is very normal, as long as the cycles are regular. Ovulation occurs 14 days before the next period is due - which means it can occur normally from a range of Day 7 ( for women with a 21-day cycle) to Day 31 ( for women with a 45-day cycle).

7. They are not sure how to track their menstrual cycle.
For example, women are often unsure of the significance of spotting. They think that the spotting signals the start of their period, and count the spotting as Day 1. Actually, the spotting is pre-menstrual spotting, and should be ignored. Only the start of a proper flow is considered to be Day 1. If they miscalculate, they end up mis-charting their entire cycle, and get frustrated and confused. To make a bad situation worse, they are reluctant to ask their doctor about this, because they feel that this is basic knowledge,which every women should know, and they don't want to ask "stupid " questions.

8. They try to maximise their fertility by " storing up " sperm by scheduling sex only on their fertile days in an effort to get pregnant.
This can actually be counterproductive. For one thing, husbands get very frustrated, when their wives "allow" them to have sex only on the fertile days. They feel they are being treated as "studs" whose only job is to "perform" and impregnate their wife. Not only does this take all the fun out of sex; it can actually cause infertility, if the timing is done incorrectly.

9. They try to time sex by charting their temperature ( BBT charts)
The BBT chart is a hangover from the hoary days of gynecology, when doctors did not have a clue as to how the reproductive system worked; and keeping BBT charts gave women something "useful" to do. It also allowed doctors to pore over them - but the analysis was as flawed as the analysis of traditional soothsayer, who would analyse tea leaves or the entrails of a sacrificed animal, to try to fortell the future. While BBT charts are useful for pinpointing when ovulation occurs
( on a retrospective analysis), they are useless for helping women to time sex during their fertile time. This is because the temperature rise occurs only after ovulation - by which time the woman is already infertile !

10.They don't use OPKs
Because OPKs are not available in India, most women in India have no idea as to how they can use OPKs to track their ovulation and their fertility. This is a shame, because OPKs can be very useful tools to help couples plan baby making sex. Unfortunately, even most gynecologists do not advise their patients to use these, because they are not easily available at the chemist; and because they prefer doing ultrasound scans to monitor ovulation ( even though the scans are much more intrusive, and waste a lot more of the woman's time and energy). The good news is that Indian women can now buy OPKs from our clinic; and from our online store.

Wednesday, June 21, 2006

Top Ten Tips for Financing Infertility

One of the most amusing books I have read on infertility is: A Few Good Eggs : Two Chicks Dish on Overcoming the Insanity of Infertility by Julie Vargo and Maureen Regan.

The book is targetted towards infertile women living in the US, and is written in the currently fashionable "chick-lit" style. It's amusingly written; and is a breath of fresh air , if you are the sort of person who finds a sense of humour helps you cope better with infertility.

The book has lots of Top-10 lists, and here's their list of Ten Financial Facts You Need to Know.

1. Infertility is an expensive condition to battle.
2. Your insurance company probably will not cover all of your treatment.
3. Insurance companies often consider infertility treatments to be
investigational and therefore don't cover the.
4. While your insurance may not cover infertility, they may cover the
disease that causes it.
5. Some doctors will let insurance coverage dictate your treatment plan.
6. There are creative ways of financing infertility treatments.
7. Some clinics offer a reimbursement program if treatments like IVF
are not successful.n
8. You need a budget and a financial plan if you are undergoing
infertility treatment.
9. Infertility treatments are a financial gamble because money doesn't
guarantee success.
10.Nothing in life is free.

Here are my comments on this list.

Remember that most of these apply to couples in the US; and if you are lucky to be living in France or Israel ( where the government pays for IVF treatment), then you can skip this section !

1. Infertility is an expensive condition to battle.
Unfortunately, this is very true. We have lots of patients who can get pregnant with IVF treatment, but who just cannot afford it. This is such a shame !

2. Your insurance company probably will not cover all of your treatment.
In fact it most probably will not cover any of it if you live in India ! Infertility is excluded from most insurance policies . Actually, there is no good medical reason why insurance companies refuse to cover infertility treatment in India, except for the fact that all they care about it their bottom-line - and it's in their financial best interests to not pay for as many illnesses as possible ! The less they pay out, the more profit they make !

3. Insurance companies often consider infertility treatments to be investigational and therefore don't cover the treatment.
This is is one of the many tired excuses they use to refuse coverage. Even though IVF treatment has been around for over 25 years, and is standard medical practise, it's still considered to be "experimental" and is excluded ! Talk about adding insult to injury !

4. While your insurance may not cover infertility, they may cover the disease that causes it.
This is true. Thus, if you have endometriosis, the insurance companies will cover for an operative laparoscopy; or for medications given to suppress the endometriosis. The trick is to ensure that the paperwork you submit to your company for reimbursement is in order - and that the word infertility does not appear on it. If you claim reimbursement for a laparoscopy done for pelvic pain, they will pay up. If you claim for the exact same surgery for infertility, they will not ! Go figure !

5. Some doctors will let insurance coverage dictate your treatment plan.
Since doctors need to be paid, your treatment plan will often be molded by your insurance plan coverage , rather than your medical diagnosis ! Thus, a patient living in Chicago ( where the State law mandates that IVF be covered) is much more likely to be advised IVF treatment, as compared to one ( with exactly the same diagnosis) who lives in Los Angeles ( where there is no such law).

6. There are creative ways of financing infertility treatments.
You can cut down some of your costs by shopping around for drugs and medications from online pharmacies, for example. If you are young, you can halve your costs by donating your eggs to other infertile couples. This is called egg sharing.

7. Some clinics offer a reimbursement program if treatments like IVF are not successful.
Money-back options are a very useful option, which are well worth exploring. Not only do they give you peace of mind, they are often very cost-effective. They put a cap on your total expense, and also allow you to stick to your treatment plan.

8. You need a budget and a financial plan if you are undergoing infertility treatment.
Unless you are Croesus or Donald Trump, this is true. Not only can treatment be expensive, it can really eat into your resources because the outcome is always uncertain - there is no predicting when you will hit the jackpot.

9. Infertility treatments are a financial gamble because money doesn't guarantee success.
IVF treatment is like buying a lottery ticket. No one forces you to buy a lottery ticket either, but unless you buy a ticket, you are not going to win the lottery - and the more the tickets you buy, the better your chances !

10.Nothing in life is free.
You need to decide how much time, energy and money you are willing to invest in your quest for a baby. If you succeed, it's an excellent investment - after all, a baby is priceless ! Even if you don't, going through treatment will give you peace of mind you tried your best - and this can be invaluable too !

Monday, June 19, 2006

Indian Digital Drug Reference

Indian Digital Drug Reference: While there is a lot of indormation about drugs from the US and UK on the internet, unfortunately there is surprisingly precious little about Indian drugs. While the pharmacology remains the same, it's hard to find information on what consumers need to know - stuff like brand names and their prices. This website has some information - but this is a major lacuna, which needs to be filled !

HELP stars in India's leading newspaper - The Times of India

HELP stars in India's leading newspaper - The Times of India: "HELP provides people access to vast, up to date resources on every topic under the umbrella of ‘health’. It aims to empower people by providing them with the information they need to promote their health, and prevent and treat medical problems in their family in partnership with their doctor. And as an icing on the cake: entry as well as all these services are free of cost for everyone. "

Saturday, June 17, 2006

Helping sick children network

Helping sick children network : "PatchWorx is a fun and secure on-line community that breaks down the barriers of isolation, offering a warm and friendly environment for children facing illness and disability. We welcome the children (ages 5 to 21), their parents and siblings, to a place where they can share laughter and tears, stories, ideas, and learn from each other."
Children and computers go hand in hand - and PatchWorx can help children with illnesses and disabilities to connect with each other !

Computers for Kids in Hospitals

Computers for Kids in Hospitals : "GoFetch is the official name for the ongoing Computers for Children project at Vanderbilt Children's Hospital. The program offers computers for patients and families to use while in the hospital. The computers will keep hospitalized children and families connected to the outside world and to each other."
This is such a clever idea !

Friday, June 16, 2006

Why I don't want my daughter to become a doctor

My parents are doctors, and so am I. Since I have a successful practise, most of my friends assume that I would want my daughters to become doctors too. After all, they would have a ready-made practise they could walk into; and this would be a valuable asset we could provide them for their future. I am sure they would make good doctors too - when the dinner-table conversation is all about patients and medicine, doctor's children usually learn a lot about practising medicine by osmosis ! However, I am doing my best to discourage my daughter from taking up medicine because I don't feel it's a wise career decision for her . What's my rationale ?
While my personal medical practise has been very satisfying and gratifying, and I am very happy that I am a doctor, I am afraid that the circumstances under which doctors will practise medicine 10 years from now in India ( which is about how long it will take her to start practise ) will be very different.
I feel Indian medical practise will go downhill, the way it has in the US . Everything will be driven by HMOs and health plans. Doctors will have to spend half their lives on paperwork; or arguing with clerks about the "medical necessity" of the treatment their patients need. They will have little autonomy, as third party payers will tell them what they are allowed to do for their patients - and what they are not allowed to do. While the emotional income of doctors can be superb, I feel this too will take a beating, because patients will no longer regard the medical profession in the high regard which they do today. This is why so many doctors in the US are retiring in their 40s, because they are sick and tried of bureaucratic interference and the ever-present threat of medical malpractise.
I am also worried about the growing impact of the corporate hospital sector in the country. It will be difficult for doctors to establish an independent medical practise - and working for a corporate hospital is as bad as working for any other corporate which is concerned only with its bottomline.
The other worrying trend is the increasing encroachment of the government on medical practise. Governmental interference and regulation has increased manifold, and is set to increase even further. Unfortunately, doctors have not been able to unite against this political interference .
Finally, the progressive reservation of postgraduate seats in medical colleges means that the entire Indian medical educational system is sick. Products of this sick system are likely to be incompetent and poorly prepared.
So, if I don't want her to become a doctor, what do I want her to become ?
I'll discuss this in my next post.

Tuesday, June 13, 2006

Thinking About Medicine - Your Inner Peace

Thinking About Medicine - Your Inner Peace: "MOTORS because the pursuit of happiness, in its altruistic sense, can be the motor of your life.
“MOTORS” stands for:
M eaning --> find a meaning in what you do for a living but don't forget to set limits around it
O utlook --> have a positive outlook on life. Be philosophical but also focused on success
T ime --> spend quality time with F&F (Family & Friends)
O ut of of yuppie values --> don't focus on chasing money or prestige
R eligious / spiritual practices
S elf care practices, like sports, meditation"
This is useful for both doctors - and their patients !

The Wellness Revolution

The Wellness Revolution: "One seventh, $1.5 trillion, of the U.S. economy today is devoted to the healthcare business, what Paul Zane Pilzer refers to as the 'Sickness Industry.' However, by the year 2010, an additional $1 trillion of the economy will be devoted to products and services that keep us healthy, make us look or feel better, slow down the effects of aging, and prevent diseases from developing altogether. The implications of the shift to proactive wellness are far reaching from health to beauty to food to medicine."
Here's an interesting opportunity for doctors who want to become entrepreneurs !

Friday, June 09, 2006

Career versus baby

Many IVF clinics in urban centers all over the world are increasingly seeing a larger number of a new type of patient – the older woman, who chose to postpone childbearing because she wanted to pursue a career ; and now finds, when she wants to start a family, that she cannot conceive because her eggs are too old. Ironically, this same woman would have had many babies in her own bedroom in an earlier generation, when women married young and their primary goal was to build a family. It is true that the modern young woman has many more options and much more freedom than she ever did in the past. However, one of the prices women pay today for this freedom is a higher risk of infertility, as a result of their postponing their childbearing. There is a price you pay for everything, and sometimes it’s hard to have your cake and eat it too !
For example, I just did an IVF cycle for a very nice 32 year old woman. She is happily married, confident, articulate; and has a very successful career. She now wants to start a family, and has found to her dismay that she can't conceive on her own. During her workup, she found to her shock that her egg quality was poor. She could not understand why her egg quality was an issue when she was only 32 years old.
I explained the biology of fertility to her. All women are born with a certain number of eggs - and they don't produce any new eggs during their lifetime ( unlike men, who produce millions of sperm daily). As women grow older, their eggs start getting depleted, until they run out of eggs and their periods stop for ever. This stage is called the menopause. However, for a period of about 10 years before they reach the menopause, their egg quality declines silently, so that it's enough for them to get regular periods, but not enough for them to conceive. This phase is called the oopause, and is "silent" - there are no signs or symptoms, as the biologial clock ticks on with a vengeance. This is why when a young woman with regular cycles finds out she is infertile because of poor quality eggs, the news comes as a rude shock.

This is the first time these young people are having to confront their own biological limitations - their own mortality. Most other things in life have fallen into place for them. They work hard, do well in their exams and jobs, earn more money, get a promotion, buy a new car, a new house - and this is the first time they are being forced to deal with a situation which is out of their control - no matter how hard they work at it, or how much money they spend on it. This can be a very uncomfortable feeling, and they find their life spins out of control.
The commonest complaint I hear is - I wish my doctor had told me that my fertility would drop so dramatically. I wouldn't have wasted so many years taking birth control pills ! Why didn't my doctor warn me ? This is why most women find themselves between a rock and a hard place when they try to balance childbearing and their career.
In all women, fertility declines after the age of 20 , but from 20- 30 the decline is so gradual , that it really does not matter much. After 30, it does become an issue, and after 35, the decline is precipitate.

However, the rate of decline varies from woman to woman, and while some 40 year old women can happily make babies in their own bedroom, many 35 year olds have a hard time conceiving, and need IVF treatment. For some unlucky ones, even this does not help, because poor eggs result in poor quality embryos which do not implant. Their only option is then either doing donor egg IVF; or adoption – neither of which are easy options to select.
The trouble is that calendar age is not always a good index of fertility. It’s not the chronologic age which is important – it’s the ovarian age. Unfortunately, lumping all women more than 30 in one group is not very helpful – it’s like lumping apples and oranges together. While the majority will have no problems getting pregnant, a significant minority will have a paid a heavy price for their decision to postpone childbearing.

So what can you do if you are 25 and want to postpone childbearing because you want to pursue your career ? The easiest way to monitor your ovarian reserve ( your fertility potential ) is by doing a simple inexpensive blood test which measures your FSH ( follicle stimulating hormone) level. This is best done on Day 3 of your cycle. As a woman grows older, the FSH level rises, and high FSH levels correlate well with poor egg quantity and poor egg quality. Unfortunately, most family physicians and gynecologists are clueless about the importance of this test. When a 28 year old asks them whether it's safe for her to postpone childbearing, most of them give her a reassuring pat on the head, and tell her not to worry !
While this advise may be fine for some women, it's a major disservice for others. I feel women need to take matters in their own hands, and ask their doctor to measure their FSH levels, so there is a sound scientific basis for their reassurance. If the FSH level is borderline high, which suggests poor ovarian reserve, further testing to check ovarian reserve is called for, including an ultrasound scan for antral follicle counts; and a blood test to measure inhibin levels.
As Robert Ringer explains, remember that there is a price you pay for every decision you take in your life. There is a price you pay for pursuing a career; and there’s a price you pay for having a baby. No matter what you do in life, do it with your eyes wide open to the tradeoffs involved. And then deal with those tradeoffs with a mature confidence ... and don’t complain. If you find that you are not willing to live with the price of a decision you’ve made, cut your losses short and try to reverse the error as quickly as possible.

Thursday, June 08, 2006

Consumers in Health Care: Creating Decision-Support Tools That Work -

Consumers in Health Care: Creating Decision-Support Tools That Work - "In response to the trend of increasing consumer involvement in health care decision making, Consumers in Health Care: Creating Decision-Support Tools That Work examines the various forms and functions of tools available to help consumers make more informed choices. It summarizes evidence regarding the effectiveness of these tools, and offers possible strategies for overcoming limitations to their widespread use."
In the past, patients would expect doctors to make these decisions for them. Times are changing, and since they are often being forced to make these decisions for themselves, decision-support tools are going to become increasingly important. Patients with similar problems can also play a key role , by forming online communities to help each other in this process.

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