Promoting Patient-Centered Healthcare in India - Dr Shalini Ratan

This is Dr Shalini Ratan's talk at the Putting Patients First conference held in Mumbai, India recently

ChangeMakers Patient / Choices/ Empowerment Competition

HELP has entered the ChangeMakers Patient / Choices/ Empowerment Competition !

Health information services in India are quite pathetic. We currently run HELP (Health Education Library for People) in downtown Mumbai successfully.The idea is to create at least four such centers in Mumbai this year.Patient education has been shown to improve the doctor-patient relationship by providing Information Therapy.

Please vote for us !

Egg freezing - empowering women with more choices

Indian doctors and UK doctors - what can we learn from each other ?

This is Dr Abeezar Sarela's talk at the Putting Patients First Conference held in Mumbai, India recently.

Promoting Patient Safety in India - a talk by Dr Nikhil Datar

This is Dr Nikhil Datar's talk at the Putting Patients First Conference held in Mumbai, India recently.

What the US can learn from Indian doctors

One major problem which Obama faces is the collapsing US health care system. Everyone agrees it's broken - but no one seems to know how to fix it !

At the recent Putting Patients First Conference in Mumbai, we discussed what the US and India can learn from each other about providing quality healthcare.

One thing the US can teach India is about quality . The great thing about the US healthcare system is that every hospital and doctor ( no matter where they are located) will provide at least a basic minimum standard of healthcare quality. Unfortunately, this is sorely lacking in India - which means that while certain Indian hospitals are world class, most Indians are stuck with poor quality medical care.

What can India teach the US ? The reason the US healthcare system is broken is because costs have gone through the roof. Indians are very frugal and we can teach US doctors how to provide cost effective medical care . This is why so many patients come from the US to India for IVF treatment. Instead of "exporting patients", why can't US IVF clinics learn from Indian doctors as to how to provide their patients value for money ?

The one area where both are lagging is cCommunication between doctor and patient. In the US, they have an information overload; while in India, patients suffer because of a lack of information. We can learn to adopt a blended approach, so we can provide patients all over the world with the best of both worlds !

Indian doctors usually have an open mind and are willing to learn ! Unfortunately, US doctors feel they are the best at everything, and have a very closed mind. It'll be interesting to see which approach works best in the long run !

How do we decide how many embryos to transfer ?

Saiprasad Gundeti, Senior Embryologist, Malpani Infertility Clinic

There are multiple variables which need to be considered while deciding how many embryos to transfer.
When we decide about the number of embryos to transfer , our aim is to :

1. Select Top Quality Embryo(s) for transfer
2. Maximise the chances of pregnancy.
3. Minimise the risk of failure.
4. Minimise the risk of multiple pregnancy.

Each country has its own policies depending upon their patient population, their healthcare system and their laws.
In Scandinavian countries , not more than one embryo is allowed to be transferred.
In such countries, doing a Day 5 transfer is ideal.

Top Quality Day 5 Embryo

That’s not the case in India where we can transfer multiple embryos. However, we need to individualise this decision for each patient ! More is not always better – and transferring too many embryos increases the risk of a high order multiple pregnancy.

We need to be flexible !

For example, when doing a Day 3 Embryo Transfer for a young patient who is doing her first IVF cycle, we need to consider transferring only 2 embryos, as there are high chances of a pregnancy even with 2 embryos.

2 Top Quality Day 3 Embryos

At Malpani Infertility Clinic, we use the following guidelines. These are rules of thumb – the patient needs to make the final decision ! While the present fashion seems to be to push for a SET ( single embryo transfer) for all patients, this is a complex decision – especially when patients are paying large amounts of money for their IVF treatment. And for many IVF patients, twins are a welcome bonus as they represent their chance to create an instant family !

While it’s quite easy to make decisions when we have good quality embryos, it’s much harder to do so when the embryos are of poor quality. While it’s not necessarily true that transferring more embryos increases the chances of success when the embryos are of poor quality, patients are understandably reluctant to throw away their embryos ! This is especially true when patients have failed multiple IVF cycles in the past . Their logic is – even if the embryo has a poor chance of becoming a baby after transfer, at least it’s better than the zero chance if I do not transfer it. This can be a difficult call to
make !

DAY	Criteria	Age <>	Age > 38	Previous Failures
Day 2	Good Embryo Quality For e.g. 4 x 4-Cell Grade A	3 Embryos	4 Embryos	4 Embryos + 1 Embryo
	Slow Growing embryos. For e.g. 2 Cell Grade A 3 Cell Grade A	4 Embryos	5 Embryos	5 Embryos + 1 Embryo
	Poor Embryo Grade For e.g. 4-Cell Grade C	5 Embryos	6 Embryos	5 Embryos + 1 Embryo
Day 3	Good Embryo Quality For e.g. 8-Cell Grade A 6-Cell Grade A	3 Embryos 3x 8-Cell Grade A	4 Embryos	4 Embryos + 1 Embryo
	Slow Growing embryos. For e.g. 4 Cell Grade A 3 Cell Grade A	4 Embryos	5 Embryos	5 Embryos + 1 Embryo
	Poor Embryo Grade For e.g. 8-Cell Grade C	4 Embryos	5 Embryos	5 Embryos + 1 Embryo
Day 5/6	Good Embryo Quality For e.g. Grade A Blastocyst	2 Embryos	3 Embryos	3 Embryos + 1 Embryo
	Slow Growing embryos. For e.g. Morulae	2-3 Embryos	4 Embryos	3 Embryos + 1 Embryo
	Poor Embryo Grade For e.g. Grade C Blastocyst	3-4 Embryos	4 Embryos	3 Embryos + 1 Embryo

Note : The number of embryos to transfer :
1) may be increased if the endometrial thickness is poor
2) may be reduced if the patient is young

Putting Patients First - Conference in Mumbai , India by HELP

This is my talk on - How to make sure every patient is treated as a VIP. You can see more videos about the conference on the website, www.patientpower.in.

Why doctors will need to change

Sometimes I wonder what it will take for doctors to change their age-old habits - many of which are quite bad ! For example Indian doctors still do not bother to document their clinical encounters. They just advise a list of tests and a prescription, without even bothering to record their clinical findings - or even a provisional clinical diagnosis.

No amount of cajoling or bullying seems to make a difference. I think the only way of getting doctors to change will be pressure applied by their patients. As their patients change, doctors will need to evolve too !

Many patients are now online, looking for information about their medical problems; as well as the name of a doctor or hospital who can solve their problem. If patients go online, how can doctors afford to be left behind ?

Progressive doctors already have their own websites - and it's just a matter of time till digital clinics become the norm. Doctors will need to meet their patient's expectations - or they will lose them to savvy competitors, who will take the cream of their patients away from them.

Patients who e-mail with doctors see health improvements

Patients with diabetes or hypertension or both who communicated with their doctors via e-mail got better care and better health outcomes, new California research contends.

Email makes for happy patients - and happier doctors !

Hospitals without hospitality

Hospitals are meant to serve patients - but they can be extremely patient-unfriendly ! In fact, many of them can be dangerous . Hospital acquired infections and medical errors during a hospital stay are becoming an increasingly important cause of death in some parts of the world.

I love the fact that the Cleveland Clinic has a CEO - a Chief Experience Officer,whose job is to ensure that the experience which a patient has during their hospital stay is smooth and pleasant, so they take back happy memories of their hospital stay.

What a great idea - I wish more hospitals would implement this ! I am sure that looking at a hospital from a patient's perspective will be quite an eye-opener for some hospital CEOs !

Natasha Malpani is featured on the Oxford University website

Here's where I take off my doctor hat and put on my father's cap.

My daughter, Natasha Malpani, just completed her MSc in Immunology at the Oxford University as a Clarendon Fellow on a 100% scholarship. She's been featured on the Oxford University website !

Checklists for IVF patients

Atul Gawande's book, Checklist , highlighted how important it is for doctors to routinely start using simple checklists in order to prevent errors.

Checklists are equally important for patients !

How do you select a good doctor ? the right hospital ? the right treatment ? We all use checklists, but do this informally and intuitively most the time.

It's helpful to make this explicit, to ensure that you have covered all the important variables.

We have created an online checklist for IVF patients at http://www.drmalpani.com/IVFCycleModule/IVFCycle.php, to help empower infertile couples, so that they can make sure they get the best medical care and are treated as respected partners in their treatment.

This checklist helps doctors as well, because well- informed patients will take better care of themselves. It's important that you be your own advocate during your medical treatment - and if you know what to expect, you will be in control of your IVF treatment cycle !

Beating the biological clock with cryopreservation !

Unexplained infertility vs incompletely evaluated infertility

Many patients are diagnosed with having unexplained infertility. This means that all their fertility tests - semen analysis; hormonal blood tests ( FSH,LH,PRL,TSH and AMH) for egg quality; HSG ( hysterosalpingogram) for tubal patency; and ultrasound scanning for ovulation monitoring are normal.

This can be a very frustrating diagnosis for patients. " But doctor, if everything is normal, then why aren't I getting pregnant ? " Patients are never happy with doctors who honestly answer - We do not know ! Patients expect a scientific definitive answer from their doctor who is meant to be an expert - and if a doctor cannot provide this, then be mustn't be very competent at his job is the natural conclusion many of them jump to . The truth is that our technology for identifying problems is still very crude. Thus , while we can check if the fallopian tubes are open or closed , we still cannot determine if the tubes are functioning properly or not. Similarly, while we can count the number of sperm in the lab and grade their motility, we still cannot find out if they are capable of fertilising an egg !

In actual fact, patients should be relieved that the diagnosis is one of unexplained infertility. This means that all their test results are normal; and that their basic reproductive apparatus ( eggs, sperms, tubes and uterus) are working fine !

However, the major fear in their minds is that if the doctor cannot find a problem, how will he able to fix it ? Does this mean that I will never get pregnant ?

The truth is that while we are not very good at identifying problems, we are very good at bypassing them !

A better term for unexplained infertility would be undiagnosed infertility - and this says a lot more about the limitations of our diagnostic technology, rather than anything about the patient !

However, when patients are told their diagnosis is "unexplained infertility" they are so hell-bent on finding the explanation ( because how can a doctor provide treatment without first making a diagnosis ?) , that they pressurise doctors into running a further battery of tests. In their mind, unexplained infertility means incompletely evaluated infertility - that the doctor is not been meticulous in completing all the tests . Some doctors are happy to pander the patient's hankering for a diagnostic label ! They start doing all sorts of unnecessary tests ( such as laparoscopy or endometrial biopsy to test for TB). When they finally find a problem ( which is just a matter of time because it is a mathematical certainty that the more the tests you do, one of them will turn out to be abnormal), the doctor then triumphantly proclaims that he has found the elusive diagnosis - which the earlier ( presumably incompetent) doctor had missed because he was not diligent enough.

The danger with this approach is that a lot of these "abnormalities" are just incidental red-herrings, which do not affect the patient's fertility at all. However, now that a problem has been "found", it needs to be treated ! This wastes a lot of time and money while the doctor and patient are barking up the wrong tree. Patients finally end up getting fed up and frustrated - and then refuse to explore treatment options such as IVF which would have allowed us to bypass the problem and achieve success in a much more timely and cost effective fashion !

A baby for a couple from Hyderabad

We are a couple from Hyderabad, and I would like to share my success story @ Malpani Infertility Clinic Mumbai….. Some one rightly said " We have not lost faith in GOD but transformed it from GOD to Doctor” somehow I had a doubt in this statement but now I do not find any false in this statement, since this situation was true for us with Dr. Malpani and his team. Its is five years now we are married and for the first two years we planned not to have any children, and for the next 3 years we tried to have children and left no stone unturned and visited all doctors, experts, used all medicines with an hope that things will be fine, however our every hope was turning against hope and one day we heard about Dr. Malpani clinic, but we were not too sure about and thought it is another clinic who will advise to take some other medicine or wait for some more time. But somewhere in the heart we were of the hope of things turning in our favor, and decided to write a mail with all the details of reports and explaining the problem, my wife was all perfect , but there was some problem with my sperm count and it was almost NIL. Trust me we would have exchanged at least 50 mails before we left for Mumbai for treatment in month of August, and to our surprising he replied to all the mails even at midnight 1:00 A.M. and with all the information we traveled to Mumbai. Then we planned our trip to Mumbai and met Dr Anirudh Malpani. After meeting Dr Anirudh Malpani whatever little doubts we had with regards to treatment and expertise had disappeared. We found Dr Malpani and his team very friendlier, caring and above all the place is more than a home away from home and as you see in his entrance " Right place to have your baby” The treatment continued for about 20 days where from the day one my wife is given injections which continue for all the days and finally the day has come where doctors and his expert team make "sperm meet the egg”, to my surprising the reports says zero sperms but trust me Dr Malpani with his experts team were able to retrieve sperm from me and could fertilize the egg. On the 3rd day post egg retrieval, they could produce eight A grade embryos and four of them were implanted, from there a three days of rest and we flew back to Hyderabad, its was a fourteen day test match we were playing with all for luck and grace of Ganesha. Finally the day has come to face the result and to our surprising and GOD’s grace the test was positive and the gift was not one but two……. She is now in her third month pregnancy and every thing is fine and normal like natural pregnancy, even today I write to Dr. Malpani for assistance and he is the only person who replies so promptly without any hesitation and with all care and above all with great responsibility as a Doctor… Finally I would say this would have not been possible without Dr. Malpani and his entire team, they are the greatest gift for us in this modern world………. I pray GOD for their happiness and good health and all the luck in their life. Rgds Srinivas and Madhavi mailto:[email protected]

Making sense of your infertility treatment options

I just saw an infertile 42 year old woman who said - Doctor, my husband has a low sperm count. Can you please prescribe some medicines so we can improve it and have a baby. "

It always amazes me that even in this day and age so many infertile couples do so little to try to make sense of their treatment options.

Many find it very hard to decipher the medical terms their doctor uses. They do all the tests the doctor asks for - and are often completely lost when he then explains to them what the next action steps are.

Unfortunately, many doctors also "complexify" matters rather than simplifying them. They take a perverse pride in doing so, because it allows them to position themselves as experts in a difficult subject which the poor patient will never be able to understand !

I think they just make matters unnecessarily complex. Infertility is quite a simple topic, when broken down into its component parts.

Basically, you need just 4 things to make a baby - eggs; sperm; uterus and tubes.

If you are not getting pregnant, you need to identify what the bottlenecks are; and prioritise these, so you can focus on the important ones !

Thus, for this 42 year old woman, even if her husband has a low sperm count, her major problem is her advanced age, which is going to impede her ovarian reserve. Even if her husband had a normal sperm count, she would still need IVF, because time is now at a premium for her !

Using this simplified approach, we can quickly get to the heart of the problem - and then identify a solution which allows us to tackle the problem efficiently ! Every problem has a solution - and the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby . The quality of a doctor’s answers depend upon the quality of the patient’s questions - and if patients learn to ask the right questions , their chances of getting the right treatment will improve dramatically !

Public hospitals vs private hospitals

The general perception amongst patients is that private hospitals provide better care. They definitely look much more impressive ! They have the ambience of a 5 star hotel. Because they are clean, well maintained and posh, patients automatically feel that the medical care must be better as well. Private hospitals also help to propagate this image with clever marketing and public relations campaigns, where they tom-tom their newest 128 slice MRI scanner they have recently purchased .

My contrast, most public hospitals are run-down; poorly maintained; and over-crowded. This is why most patients who can afford to go to private hospital usually opt for these.

Actually, a lot of this spit and polish in corporate hospitals is just positioning and hype. The truth is that public hospitals often contain centers of excellence within them, which can be world class. While this is not true across all departments ( many of which are understaffed and
underfinanced ), in some departments the quality of care is much better than it would be in any private hospital.

One of the reasons for this paradox is that these public hospitals are teaching academic hospitals, which have young professors , some of whom are very smart; very talented; and very driven. They have world-class technical skills - and also have the administrative ability to be able to get funds from the government to create islands of excellence within these public hospitals. They oversee research projects ; train young doctors; offer cutting edge treatment options; and travel all over the world to hone their skills.

How do you identify these centers ? Unfortunately, this is a big challenge ! The only way you can do so is by having "insider information", so you know who is doing what and where !

A major benefit of going to these hospitals is that they are much less expensive - and they provide much better value for money ! Also, because they do not treat too many well-off patients , if you can even speak English well , you are likely to be treated like a VIP !

Ethical issues in IVF treatment

Open publication - Free publishing - More infertility

How much does IVF treatment cost ?

Open publication - Free publishing - More infertility

How we decide on which day to transfer your embryos

This is a guest post from Dr Saiprasad Gundeti, Senior Embryologist at Malpani Infertility Clinic.

Embryo transfer represents the final stage of the IVF treatment and is the climax of the IVF treatment cycle. How do we decide on which day to transfer your embryos ? Day 1 ? Day 2 ? 3 ? 5 ? Which is better ? and why ?

Unfortunately, human reproduction is not a very efficient enterprise. This is true in the bedroom as well as the clinic, and most embryos do not become babies. This is because many embryos have a genetic error ( which is often random) and will not implant, because Nature will prevent them from doing so. This is why the implantation rate even for top quality embryos is about 40%.

So how do we select the top quality embryo to maximize your chances of success ? And how do we decide which day to transfer it ? And how may do we transfer ? All complex questions, which IVF clinics need to deal with daily !

While some clinics are very rigid about which day they will do the embryo transfer, we are very flexible; and since we offer the entire range of options in our clinic, we try to select the option which will maximize your chances of success .

While there has been a lot of hype about blastocyst transfers, we now believe that if an embryo is going to become a baby, it will, whether we transfer on Day 3 or Day 5 ! Keeping the embryos in the lab for an additional 2 days will not increase their chances of implanting !

There are 2 type of embryo transfer. These are

* ZIFT (ZYGOTE INTRAFALLOPIAN TUBE TRANSFER)
* UTERINE EMBRYO TRANSFER

ZIFT (ZYGOTE INTRAFALLOPIAN TUBE TRANSFER)

* In this procedure, the Embryos are transferred into the fallopian tubes.
* The procedure is done by performing laparoscopy under General Anaesthesia.
* Maximum 4 embryos can be transferred.
* 2 embryos in each fallopian tube, if both the tubes are patent.
* The advantage of a ZIFT over a regular embryo transfer is that it has a higher success rate, because the fallopian tube provide a better in vivo environment for the early embryo than the IVF lab !

Limitations of ZIFT

* Only Day 1 and Day 2 embryos can be transferred by performing ZIFT. With day 3 or blastocyst stage embryos, the risk of an ectopic pregnancy is high.
* Clinics without a OR in which to do a Laparoscopy , cannot perform ZIFT.
* ZIFT requires the presence of an anesthesiologist, since it is done under general anesthesia.
* We cannot perform ZIFT, if the fallopian tubes are blocked.
* It is more expensive.
* Not all IVF experts have the expertise to perform a ZIFT because it requires a higher level of surgical skills.
* It is especially helpful in poor ovarian responders , with few embryos
* It is very useful in patients with cervical stenosis, where a uterine embryo transfer is technically difficult, because it allows us to transfer the embryos directly into the fallopian tubes, allowing us to bypass the cervix.
* You can learn more about ZIFT at www.drmalpani.com/zift.htm

UTERINE EMBRYO TRANSFER

* This is the standard procedure. In this procedure, the Embryos are directly transferred into the uterine cavity.
* The procedure usually does not need Anaesthesia.
* Number of embryos to transfer is decided considering the day on which the transfer is performed.

ON WHICH DAY POST ICSI/IVF, CAN WE PERFORM EMBRYO TRANSFER ?
Generally embryos are transferred on Day 2, Day 3 and Day 5 post ICSI / IVF. Remember that day of egg collection ( also known as DPO = day post ovulation) is Day 0.

HOW DO WE DECIDE ON WHICH DAY TO TRANSFER YOUR EMBRYOS BACK TO THE UTERUS?
There are multiple variables which we consider while deciding when to transfer your embryos back to your uterus.

PRE – EGG COLLECTION

* Number of Follicles developed during superovulation:

More than 10 Follicles –

* Can perform embryo transfer on Day 5
* Can easily transfer your embryos on Day 2 or Day 3
* Can do a sequential Embryo transfer i.e transfer some embryos on day 2 or day 3 and some on day 5.

Less than 10 Follicles –

* Cannot take a decision on transferring your embryos on Day 5
* Can perform your embryo transfer on Day 2 or Day 3
* Cannot take decision on doing a sequential embryo transfer

Less than 5 Follicles –

* Cannot perform your embryo transfer on day 5
* Can perform your embryos transfer on day 3 only if the eggs collected are mature
* Can perform your embryo transfer on day 2

POST – EGG COLLECTION

* Number of eggs retrieved after Vaginal Egg Collection

More than 10 Eggs –

* Can perform your Embryo transfer on Day 5 considering maturity of eggs.
* Can transfer your embryos on Day 2 or Day 3
* Can perform sequential embryo transfer
* Can freeze good quality supernumerary embryos after transferring best embryos on day 2, day 3 or day 5.

Less than 10 Eggs –

* Cannot take decision on transferring your embryos on day 5 before knowing maturity status of eggs.
* Can transfer your embryos on day 2 or day 3
* Cannot perform sequential embryo transfer
* Cannot decide about freezing supernumerary embryos.

Less than 5 Eggs –

* Cannot transfer your embryos on day 5
* Can transfer your embryos on day 2.
* Cannot transfer your embryos on day 3, unless all your eggs are mature
* Cannot freeze supernumerary embryos.

POST – ICSI

* Total number of Mature Eggs (MII) injected

Less than 5 Mature Eggs

* Cannot transfer your embryos on Day 5
* Can transfer your embryos on day 2
* Can perform your transfer on day3, but need to wait to see how many eggs fertilise.
* Cannot freeze supernumerary embryos.

5 – 10 Mature Eggs

* Can transfer your embryos on Day 2 and Day 3.
* Need to wait till Day 2, to take decision on transferring your embryos on Day 5.
* Can freeze good quality supernumerary embryos after transferring the best embryos to your uterus.

More than 10 Mature Eggs

* Can easily transfer your embryos on Day 2 and Day 3
* Can transfer your embryos on Day 5
* Can do a Sequential Embryo transfer.
* Can freeze good quality supernumerary embryos after transferring the best embryos to your uterus.

ON DAY 1 (POST FERTILISATION ASSESMENT)

* Number of Eggs fertilized (i.e. Eggs with 2 pronuclei in them)

1 – 4 2PN –

* Strictly need to transfer your embryos on day 2.
* Cannot transfer your embryos on Day 3 or Day 5.

5 – 10 2PN –

* Can easily transfer on Day 2 and Day 3
* We need to wait till day 2, to take a decision on whether we can transfer your embryos on Day 5. Decision depends upon the quality of the embryos once they start cleaving on Day 2
* Can freeze supernumerary embryos, but need to assess their quality.

More than 10 2PN –

* Can transfer your embryos on Day 2 and Day 3
* Can usually offer the option to transfer your embryos on Day 5
* Can freeze supernumerary embryos.

Embryo Transfer on Day 2 and Day 3


Top quality Day 2 Embryo Top quality Day 3 Embryo

* Day 2 transfer can be considered for all patients.
* Need to have at least 6 embryos on Day 1 to consider transferring embryos on Day 3

Pros

* High number of Supernumerary Embryos can be frozen after transferring the best embryos into your uterus.

Cons

* The chances of success with a Single Embryo Transfer are reduced
* Need to transfer 3 Grade A embryos on Day 2 and at least 2 Grade A Embryos on Day 3, which may lead to multiple pregnancy.

Embryo Transfer on Day 5

Top Quality Day 5 Embryo

* The basic requirement to do a Day 5 Embryo Transfer is that we should get lots of Eggs, as only 40 % of fertilized Eggs make it to Blastocyst stage in vitro
* Embryos which are Top grade on Day 2 have a better chance of forming blastocysts when cultured till Day 5

Pros

* Can consider Single Embryo Transfer effectively.
* Top quality Embryo can be selected to transfer, which will a have high probability of implanting in your uterus.
* Can transfer 1 or maximum 2 Top Quality embryos, thereby reducing the chances of multiple pregnancy.

Cons

* Only 40 % Embryos make it to Day 5. This means patients with few eggs and those with a low fertilization rate cannot be considered for Day 5 Embryo Transfer.
* Low Freezing rate for supernumerary embryos as all Embryos don’t turn out to be top quality on Day 5.

The infertile patient's guide to the internet

Open publication - Free publishing - More infertility

Experimental versus Unproven treatments in infertility

There are many areas in reproductive medicine in which our ignorance is still phenomenal. While we are very good at fertilising eggs in the lab, we still do not know what causes a low sperm count; and we do not have much to offer the patient with poor ovarian reserve.

When these patients come to IVF specialists, they often end up getting very disheartened. Honest experts will explain to them what the limits of our technology are , to help them make a well-informed decision. While many are willing to accept these limits , others are quite unhappy and will want to explore alternative options.

While many IVF specialists will pooh-pooh these options, I encourage patients to explore them. After all, the options I am offering will continue to be available - and if they feel they'd be better off trying something else, then they should do so. This way they have peace of mind they did their best - and I am always by their side to hand hold them, if they need this.

I explain to them that these are uncharted territories; and we do not have much evidence whether these alternative options are of any use or not. They can be considered to be unproven - or experimental - depending upon what your worldview is. It's fine to try these out, using yourself as a guinea pig ( you can think of this as being a self-funded personal clinical trial ). I will be happy to help you check if the treatment is helping or not. If it does , that's great - we've all learnt something and I can then recommend this option to other patients as well ( even though one swallow does not make a summer, anecdotal evidence is still helpful ). If it does not, then we can move on to Plan B !

The point is that doctors and patients are all on the same side - irrespective of which "system of medicine" we use to achieve our goal . Let's treat them all with equal respect - and let the proof of the pudding be in the eating !

Making sense of IVF stories in the news

Open publication - Free publishing - More infertility

Why do doctors advise bed rest after an IVF pregnancy ?

When an infertile patient gets pregnant after IVF , they are on top of the world. All that hard work and effort has finally paid off - and you can now look forward to cradling your baby in your arms soon !

However, there are still 8 months to go before your baby is born - and the pregnancy can be packed with anxiety and suspense. Will everything go well ? Will the baby be normal ? Every ache and twinge causes worry because you are scared you may miscarry. This is a "precious pregnancy" - and you do your best to take things easy and be as careful as you can, so you can nurture your baby.

This is one of the reasons why many doctors advise bed rest during an IVF pregnancy. In fact, some patients will voluntarily place themselves under house arrest, because they do not want to take the slightest risk !

The truth is that there is no sensible biological basis for providing this advise. In fact, bed rest can be demoralising and is very unhelpful, because your mind starts playing games when you sleep in bed all day long !

However, it's often patients ( and their relatives) who force the doctor to provide this kind of advise.

When I tell my patients they do not need bed rest, many of them look at me in disbelief, as if I am an idiot and do not know what I am talking about !

Isn't it "common sense" that pregnant women need bed rest to prevent a miscarriage - after all, this is what doctors ( and midwives) have been advising for generations, so it must be true ! Won't walking around cause the baby to fall out ? Isn't this an "artificial" pregnancy which needs to be treated with much more caution and attention ?

If a doctor agrees with this advise , then patients are happy, and feel he is a good doctor because he is providing advise which is sensible by their preconceived notions

However, if he does not agree, then they start wondering if they can trust anything he says ! If he does not even understand the medical importance of bed rest, then his medical competence is suspect !

Most doctors are too busy to argue with patients. It's also good for them to advise bed rest. They can charge extra for home visits ! And if something goes wrong, then the doctor cannot be faulted, because he provided the right advise !

However, if he does not advise bed rest, and the patient miscarries, then no one will ever forgive this doctor. They will actually blame him for the miscarriage ! ( Didn't he know how precious this pregnancy was ? How could he be so callous and careless ? I wish we had gone to a better doctor !" ) His entire reputation will be tattered and torn to bits - and in a few years, he will be left with no patients !

For most doctors, it's much easier to toe the line and tell patients what they want to hear, rather than to spend time educating them and correcting these old wives' tales. This is why all these myths and misconceptions continue to flourish !

The abuse and misuse of surrogacy

Surrogacy in India gets a lot of press - and often for all the wrong reasons.

There's a lot of talk about how rich Westerners are coming to India for surrogacy and exploiting poor women by using their uterus to have a baby.

Actually, it is true that there is a lot of exploitation occurring - but it's not just the poor women who are being exploited.

In my opinion, a lot of the exploitation is by the IVF clinics - but not of the poor women, but of the rich infertile couples who come to them for treatment !

Many infertile couples are quite desperate to have a baby and are willing to clutch at straws. They've read a lot about how India has become the surrogacy capital of the world - and how it is much less expensive to do surrogacy in India than in other parts of the world. Because so many of them have failed many IVF cycles, they naively believe that surrogacy is the solution to all their problems. After all, the fact that they are infertile means that their bodies are defective. If they use a healthy young woman to have a baby, how can this possibly fail ?

They therefore scour the internet, looking for surrogacy treatment - and there are lots of doctors who are happy to oblige them, because surrogacy treatment spells big bucks for the clinic. Unfortunately, many doctors do not bother to educate the patient , which means a lot of them end up wasting a lot of their money pursuing the wrong treatment.

For example, for many older women, surrogacy is not a good treatment option. This is because their infertility is a result of their old eggs - there's nothing wrong with their uterus, which means that using another woman's uterus will not help to improve their chances of getting pregnant. It will just add to their costs, that's all !

However, in their desperation, they do not bother to do their homework or explore their options intelligently. Surrogacy seems to be the solution to their problems in their eyes and they are happy to pay the money, sign a contract and start treatment. Doctors are happy to pander to their whims - after all, which doctor in their right mind will turn away so much income when it's falling into his lap ? And what's wrong with doing the treatment - isn't this what the patient wants ? After all, if the patient wants it and is willing to pay for it, isn't it the doctor's job to provide the treatment ?

Doctors do not bother to explain to patients that the success rate with surrogacy is limited - especially when it is done with an older woman's eggs. When the surrogacy cycle fails, the infertile patient just blames herself - and signs up for another cycle !

Even worse, many doctors actively cheat their patients. They tell the patient the surrogate is pregnant by claiming that her HCG test is positive. The patients ( who are in the USA) have no way of verifying this - and are on top of the moon. They start celebrating - and then after 8 weeks, they get a phone call, saying - Sorry, your surrogate miscarried ! The patients just blame their fate - and are happy to try again . At least we achieved a pregnancy - maybe we'll be luckier the next time. The doctor has already collected his full fees for the first treatment cycle - and then very kindly offers the patient a discount for their second treatment cycle ! Patients are hooked - and some have done 4-5 surrogacy cycles, without ever getting a baby !

Sadly, there is no way of checking what is happening, as a result of which unscrupulous doctors merrily continue taking hapless patients for a ride. Many doctors really do not care what happens, as long as they get their payment - and there's always another sucker waiting in line !

It's just a matter of time till these malpractises are exposed - at which time , the shi*te will hit the fan and all IVF doctors, both good and bad will pay the price !

My suggestion to patients is simple - do your homework ! Your best protection against exploitation is information therapy !

How MDConsult helps me to become a better doctor

A book which I have found very useful in helping me to grow my practise is Dr Marshall Zaslove's text book, The Successful Physician - A Productivity Handbook for Practitioners.

Dr Zaslove emphasises that there are 3 tools you need to master if you want to become a successful doctor.

1. Time management, to improve your efficiency. Remember that you are a daily-wages earner - and the more productive you are, the better your clinic will run ! Doctors are often a major bottleneck in a clinic's efficiency ( but are often not smart enough to realise this , or too clueless to fix the problem. )
2. Relationship management ( which includes dealing with patients, staff and colleagues)
3. Knowledge management

In this post, I'd like to focus on knowledge management. The reason patients come to doctors is because doctors have expertise in a specific domain - medicine. However, the half-life of medical knowledge is very short in this day and age, when technology makes rapid advances every week. Doctors cannot afford to become outdated if they want to maintain their cutting edge.

Sadly, the truth is that most doctors in India, once they start practise, very rarely invest any time or energy in ensuring they are uptodate. While they will attend medical conferences for continuing medical education, most conferences are primarily social networking events which allows doctors to take a break and catch up with friends, rather than a means of learning more.

The USP for a doctor is his medical knowledgebase - and woe betide a doctor who does not read the latest medical journals and books. This is something which doctors in the US take for granted - but which most Indian doctors ignore, because they do not treat themselves as professionals who need to constantly hone their expertise and domain knowledge. ( Most Indian doctors have not bought a medical text book after they graduate; and many have never read a medical journal in their life after completing their MD). Most doctors depend upon their friendly medical representative to educate them - and we all know that the quality of the information which pharma companies provide is highly suspect !

There are many excuses for this sad state of affairs.

I am too busy.
I already know all this.
Medical journals are too expensive !
All these medical books are written by US doctors, so they do not apply to my practise
Who needs all this theory anyways ? Medicine is a practical science - and I am a master at this ! None of my friends bother to read, so why should I ?


However, if you become outdated, you will end up losing your patients to well-equipped specialists in corporate hospitals. This can also be embarrassing , when patients with internet printouts know more about their disease than you do ! Also, this failure to update yourself with the latest medical knowledge can result is lawsuits for medical negligence – the doctor’s biggest nightmare.

While you may try to use the internet to keep updated, the sad truth is there is very little high quality medical information available on the net !

The good news is that now for less than Rs 30 per day, Indian doctors can subscribe to the world's largest online medical library, MDConsult . This allows you to remain uptodate by providing online instant access to the FULL-TEXT of over 40 respected medical books and 50 prestigious medical journals which are constantly updated. This means you will never need to buy another medical book in your life ! MDConsult provides convenience and peace of mind – at your desktop - for only Rs 9995 per year ! This is a highly discounted price for Indian doctors only . You can take a free tour at http://info.mdconsult.com/tour/

In order to subscribe to the MDConsult Core Collection ( www.mdconsult.com), please mail a Demand Draft, for Rs 9995 only, payable to Health Education Library for People. For a little more than Rs 20 per day, you now have your own personal medical library, which is constantly updated, so you never need to buy another medical text book again in your life !

I know that using MDConsult has made a world of a difference to my practise. For example, while I know a lot about infertility, many patients with genetic diseases come to me for PGD treatment. Thanks to MDConsult, I now have instant access to reliable information on all genetic diseases - no matter how rare they are. I can share this with my patients, and my expertise dazzles them. Also, this knowledgebase allows me to impress my colleagues ; and helps me to prepare papers and presentations for medical conferences. It's also very useful when I need to talk to reporters and journalists.

Why don't Indian doctors use EMRs ?

Why do Indian doctors continue practising in exactly the same way their seniors did 40 years ago ?

A major lacuna is the poor quality of medical records which most doctors keep. The medical record is the heart of clinical care - and yet it's extremely poorly maintained in Indian clinics today. The majority of doctors do not even bother to store and keep their patient's medical records - they just write down their opinion on their letterhead and hand it over to the patient. Usually, this is just a laundry list of tests the patients needs to do and a hand written illegible scrawled prescription - without even a mention made of the clinical findings or what the diagnostic impression is ! While it's good that the patient owns his own records, what happens if the patient forgets to get his records for the next visit ? This creates a lot of frustration for the doctor, who berates the patient for his carelessness - but the damage is done ! Wouldn't it make much more sense to keep a copy - and give one to the patient if he wants it ? Is this a lot of hard work ? Not anymore ! In the old days, one would have to make carbon paper copies or provide xeroxes, but using electronic medical records, this is now very easy to do !

Clinical care protocols are very similar in the US and in India. This is hardly surprising - after all, patients are the same the world over , and most will need the same kind of treatment. However, while most Indian doctors will provide exactly the same standard of medical care a doctor in the US does, why is there such a big difference in the way they keep medical records ?

In the US, every medical encounter is carefully documented ! Perhaps this was originally done for protecting against lawsuits for medical negligence; but today, the US government is making it compulsory for all US doctors to use EMRs - not just to improve the quality of care, but also to reduce costs ! Why don't Indian doctors use exactly the same approach to documenting their clinical care ? Are they too busy to do so ? too lazy ? or do they feel it's not important enough ?

Why do most doctors in India not bother to document their clinical encounters well ? Why is medical record keeping still shoddy and badly done in most practises ?

If Indian doctors understand the clinical importance of keeping good quality medical records, then why are they so reluctant to use EMRs ( electronic medical records ) ? In the past, it was true that PCs were very expensive; and that few doctors would afford them. Also, many older doctors were not very computer -literate; and the software programs which were available for medical record keeping were very doctor-unfriendly ! A combination of computer-unfriendly doctors and doctor-unfriendly software meant that most doctors were quite disillusioned with EMRs and were not willing to use them.

The good news is that things have changed dramatically ! Technology has improved; computers have improved; and Indian medical software companies such as Plus91 ( in which I am an angel investor) are realising the importance of mapping the doctor's clinical processes and respecting his work-flow so they are now making EMRs which are doctor-friendly and which enhance his productivity !

So why aren't Indian doctors rushing out to buy these , given the fact that they are inexpensive and can help them to improve the care they provide to their patients ?

Partly, this is because of the unhappy experiences doctors have had with Indian medical software in the past. It was the computer-savvy early adopters who were the first to lump on the IT bandwagon 10 years ago, to try to use computers to improve clinical care. Unfortunately, they burnt their fingers, which is why they are reluctant to try again.

As a consequence, most doctors do not know any one else who is using EMRs; and because they have little exposure to practise management skills during their training, they still do not understand the value an EMR can provide to their life.

Another major problem is that Indian doctors are not willing to pay for this. This is because they have been completely spoilt by the pharma companies . Because they are so used to getting everything free from pharmas, they are not willing to pay for anything at all ! This means EMR companies find it hard to sell their products - but if they do not generate revenue, how will they be able to produce good software ?

Please remember that your patients form the heart of your practise - and your patient's medical records are worth their weight in gold. If you keep them carefully; update them religiously; and share them with him, you can show your patient that you have all his medical details on your fingertips. This will help to inspire confidence in your clinical skills . Patients will rave about how well-organised you are - and this word of mouth marketing will help you get more patients, as it differentiates you from other doctors.

Also, by keeping your patient's records, you are creating a lot of patient loyalty and "stickiness" . If your patient is confident you know all about him because you have all his medical details, he is going to be very reluctant to switch doctors - after all, who wants all the hassle of explaining his medical history all over again to a new doctor ?

However , if you do not keep your patient's records; and the patient has to start explaining everything which has happened to him every time he sees you, be is likely to lose confidence in you very quickly ! ( That doctor does not even remember my name - forget about my medical problems !)

Hospitals in India have started documenting medical care electronically; and boutique medical clinics and chains have also started doing so. This is very heartening progress - and doctors who do not start doing so soon are going to find they will start losing their patients to computer-savvy doctors ! You need to move with the times - or you will get left behind !

Taking infertile patients for a ride !

I got an email from a patient whose fallopian tubes were blocked at the fimbrial end. I explained to her that her best option would be IVF.

She was very concerned about how expensive IVF was; and wanted to explore alternative options. She sent me a link to this website - Blocked Fallopian Tube Kit (USA & Canada)
http://biotanicalhealth.com/products/blocked-fallopian-tube-kit-usa-canada and asked me my opinion as to whether this would be useful.

Visiting this site made my blood boil - and also taught me a lot about how people will prey on an infertile patient's desperation and ignorance and take them for a ride. It's also a great example of clever marketing ! The manufacturer has cleverly packaged a few herbs, tampons, books and DVDs ( costing about US $ 50) - and is selling them as a Kit ( for over US $ 500 ) to help women with blocked tubes get pregnant ! It's a great selling job because the site has testimonials and long-winded explanations as to why this kit works ( all of which are just hot air ) If this actually worked, I'd be happy to close my IVF clinic and send all my patients to this person ! The reality is that this is all marketing hype, which is being used to exploit infertile couples.

The only way couples can protect themselves from such quacks is by arming themselves with Information Therapy !

How to be a happy doctor

The answer is simple - make sure you have happy patients !

( It may be simple, but this does not mean it's easy !) However, having a single-minded focus on keeping your patients happy will help enormously in increasing your happiness !

Why do Indian doctors provide such a poor experience for their patients ?

Indian doctors have an excellent reputation for their clinical skills and patients all over the world look upto them . Because of their exposure to a large number of patients during their training in medical college, they have a lot of clinical experience; excellent diagnostic acumen; and are technically proficient. They are quite conscientious and are willing to work long hours for the sake of their patients.

However, most doctors in India still do not use technology intelligently. The majority do not bother to store and keep their patient's medical records ; or if they do, it's done in an extremely disorganised fashion. Most prescriptions are hand written illegible scrawls - and most doctors still manage their clinics very poorly . The doctor is often rushing from clinic to clinic , while his patients are made to wait for ever and ever. Phone calls are poorly handled, because doctors do not realise the importance of running their practise as a small business.

The major problem is that while doctors in India are taught to be good clinicians during their training, they are never taught how to run their practise. They have poor practise management skills, and are so focussed on the clinical care they provide , that they lose sight of the overall big picture as regards the services they provide to their patients.

Remember that when a patient comes to your clinic, the amount of time he spends with you is only a few minutes. Most of it is spent waiting; filling up forms; paying money; or talking to your staff. While many doctors feel that all these activities are administrative paraphernalia which are below their dignity, the fact remains that all these do contribute significantly to the experience your patient has in your clinic ! However, if you do not spend time and energy in training your clinic staff; or if you treat your front office staff badly, they are likely to treat your patients badly as well - causing a lot of unhappiness and grief for everyone !

Unfortunately, because doctors ignore and neglect these aspects of their practise, they do a bad job with delivering services to their patients. Many do not learn to use assistants efficiently to leverage their time; while others would rather do everything themselves, because they have never learnt to delegate well.

Even worse, though that have a lot of clinical experience and expertise, they do not share this efficiently, because they do not publish medical papers or articles. The only reason US doctors are more prolific in their writing skills is because they use the time and expertise of secretaries and editors to hone their publishing skills. India has so much untapped non-clinical talent which doctors can easily use to provide better services to their patients - and a higher profile for themselves !

Sadly, most doctors are not entrepreneurial enough and have poor practise management skills because they do not learn how to handle staff; and to delegate non-core non-clinical activities to others. Unless Indian doctors learn to maximise their productivity and efficiency using technology and other people's time, they will never be able to grow to their maximum potential !

The good news is that there are now many clever young entrepreneurs ( who are not doctors) , who are entering the Indian market. They realise that the way doctors provide medical care leaves a lot to be desired - and have come up with clever new solutions to address patients' pain points. They understand that healthcare is a service business - and while the doctor has an important role to play, there are lots of ancillary services which need to be provided around the doctor, both to improve his productivity; and to make the patient experience more pleasant.

As these businesses grow and flourish, hopefully all doctors will realise the importance of paying attention to how critically important it is to focus on the complete patient experience in their clinic - not just on the clinical care they provide ! The good news is that it's easy to fix these problems - we just need to pay attention to them !

Why I Love My Doctor

This is a guest post from a thoughtful patient !

Just like with any romantic couple, a successful doctor-patient relationship heavily revolves around trust and effective communication. Without these two vital components, a doctor-patient relationship is most likely to end up in flames. While most people switch physicians because they are unsatisfied with their doctor's performance, some—like myself—love our doctors. And here are the top reasons why.

My Physician…

Doesn't make me feel inferior. I've heard tons of horror stories where patients said they felt too intimated to ask their doctor's questions because their doctor made them feel dumb when they did. This is totally unacceptable. My doctor has never once belittled me nor may be feel incompetent in any way. I've always felt free to ask my doctor questions regarding my health, medicine or medical procedures without any sort of fear that he would make me feel dumb and neither should yours. Some physicians do have a tendency to talk in medical jargon and his or her patient might not understand. But it's the physician's job to clarify and break the information down to ensure that the patient is aware of their health condition. I love my doctor because even if I might be hesitant to ask questions during examination (I don't want to interrupt him), he always makes sure to ask me if I have any questions.

Doesn't rush me. Some physicians are known to treat their patients like cattle. Rather than taking their time to address their patients' health concerns, some doctors tend to overbook visits and are more focused on getting as many patients in-and-out of their offices as they can. This again, is unacceptable. My doctor has never made me feel rushed or like an object being passed through the assembly line. He gives me ample time to ask questions so that I do not leave confused and gives me time to update and discuss with him in full detail any changes that may have occurred since my last visit, including any new over the counter medications I may be taking.

Is respectful and sensitive. Since the beginning, my doctor has made me feel comfortable around him by continuously being respectful and sensitive to my needs. No health concern is ever too minor to get looked at and he doesn't make me feel foolish if I convince myself it was more serious than it actually is. He has never made any disrespectful comments regarding my body and has always maintained a professional level by using the anatomically correct words for body parts (believe it or not, my friend's doctor used to refer to her breasts as boobs).

Knows my medical history. Some doctors have so many patients that unless they see a particular patient on a regular basis, they tend to forget who everyone is. While it's understandable that doctors deal with tons of new people everyday and might forget a few faces, if they treat their patients as just a number rather than on a more personable level, then patient's lose trust and don't feel comfortable confiding in their doctor. Because my doctor knows my medical history without having to look at it inside of a manila folder, it makes me feel as if he really cares about my well-being. In-turn I also feel confident that he is the most qualified person who will be able to meet my healthcare needs.

One tip for doctors. One easy way of making sure you always know your patient's medical history is by using EMRs ( electronic medical records) !

By-line:
This guest post is contributed by Kitty Holman, who writes on the topics of nursing schools. She welcomes your comments at her email Id: [email protected].

Why I prefer email as compared to a phone conversation with patients

We treat patients from all over the world and many of them want to do a phone consultation with me before coming to our clinic for an IVF treatment.

I can understand why they want to do so - after all, going half way across the world to get treated by a doctor you've never seen or met is a major leap of faith - and talking to the doctor can help to reduce some of this anxiety !

While it's true that the human touch is very important in providing good medical care, the truth is that it's not humanly possible for me to do so. This is true for many reasons.

For one, because of time zone differences, it's quite difficult to find a time slot which suits both the patient and me. We often end up playing phone tag - causing even more frustration ! Also, phone connections in certain countries ( such as Africa) are not of good quality, so that it's hard to hear each other. Also, sometimes patients forget some of their questions ( not all of them are well organised enough to prepare a list of their questions) , which means they often need to call twice or thrice ! Also, sometimes they do not understand what I am saying , because I may use a medical term they are not familiar with and it can be hard to explain everything in detail on a phone call . Another problem is that the husband calls me ; and after I finish answering his queries , his wife calls in another 5 minutes for additional clarifications, because he could not explain to her what I told him ! And when I am busy seeing patients in the clinic , it's hard for me to spend time on the phone . This means that my phone conversations are often short , which gives patients the wrong idea that I am curt or rude !

However, my major argument against a phone consultation is that it is not a very efficient means of communication ! There is no documentation , and too much scope for confusion and errors. This is why I prefer email, where everything is written down. I can answer as many questions as the patient has - and the patient can share this information with friends or family members who are doctors or nurses , to make sure I am providing sensible advise. They can also cc their spouse, to make sure everyone is on the same page. Because we can store and refer later on to this email conversation trail, there is no scope for ambiguity; and no confusion about medications or their dosages .

It's also much easier for me to answer more complex questions in case more clarity is needed, because the patient can ask for more details in his reply, in case he does not understand something I have said. Moreover, the advise I can provide by email is far more sophisticated and reliable as compared to a phone call, because I can think carefully before sending the email ! Email also allows the patient to send me all their medical records, so I have all the medical details I need to provide intelligent answers , customised to the patient's medical history !

A major benefit with email is that I can provide links to the relevant pages on our website, so they can get even more detailed information about their specific problem. While some patients email is much more impersonal than a phone call, I believe email is much more efficient, when used intelligently !

This is why I request patients who want to talk to me to send me their medical details by filling in the free second opinion form instead, so I can guide them properly. Some get upset with me because I refuse to talk to them on the phone - while others understand that I am doing so in

Are IVF injections painful ?

One of the major reasons patients do not want to do IVF is their fear of injections. They know that during IVF they need to take injections for many days - and many patients are understandably reluctant to take these shots because they have been told that these injections are painful !

While it's no fun to take injections , the good news is that the injections used for IVF treatment are not painful !

Lupron and Anatgon ( which are used for downregulation) and given subcutaneously, just like a diabetic takes insulin injections. these are easy to self-administer and are not painful.

The injections which are used for superovulation ( the urinary gonadotropins such as Menogon) used to be given intramuscularly. IM injections are more painful than subcutaneous injections, because a larger volume needs to be deposited in the muscle; and because the muscles have more nerve endings than the subcutaneous fat. However, these are water soluble , and the pain is usually easy to handle. Using simple tricks ( such as ice-cubes to numb the area; or EMLA patches ) can help in managing the pain.

The good news is that the newer injections used for superovulation - the recombinant gonadotropins such as Follistim and Gonal-F; as well as the highly purified urinary gonadotropins
can also be given subcutaneously. These are not painful at all ( but are more expensive than the IM shots).

So why do IVF patients have the notion that the injections used for IVF are painful ? The painful injections are the oily progesterone injections which used to be given deep intramuscularly for luteal phase support after the embryo transfer. These are the shots from hell which patients never forget - and which leave a major scar - both in the mind and in the butt. In fact, it's these injections which often put patients off IVF treatment for ever !

The good news is that we do not use these at all - and many IVF clinics have stopped using them altogether ! Instead of giving the progesterone intramuscularly, we give it vaginally, in the form of a suppository. While this is messier, it's completely pain -free - and our patients are much happier !

Why do doctors have such large egos ?

Doctors are usually quite smart. They are academically bright , as proven by the fact that they managed to get into medical college inspite of intense competition; and have successfully graduated from a demanding course. Also, while not all doctors are brain surgeons, most are intelligent and have a high opinion of their own intellectual abilities.

However, some of them are quite badly behaved. They are rude to their patients - and make them wait interminably in their waiting rooms, for no good reason. Since doctors are in the business of saving lives , some of them start behaving as if they were demiGods. It's quite easy for them to delude themselves into having a very high opinion of their worth. This is often bolstered by their patients, who look upto doctors and often worship them. ( As a pithy saying goes, the reason doctors are on pedestals is because patients are on their knees !)

There are many reasons which contribute to this inflated opinion doctors have of themselves. For one thing, many doctors interact primarily only with their patients . Because they have a very limited worldview, they view themselves as being masters of their ( little) world. Also, they are top guns in the hospital hierarchy, and are used to having nurses and assistants obey their every little whim - something which reinforces their view that they are the best !

Also, not only does a big ego seem to be an occupational hazard, it also seems to be a contagious disorder. Residents learn to acquire their "high and mighty" style from their bosses in the hospital during their rounds - and this is a trait which seems to run in certain departments ( for example, heart surgeons). It's also much commoner in doctors who work in hospitals ( as compared to those who own their own clinics).

However, I think the real reason some doctors have such an inflated ego is because they have low self esteem - and an inferiority complex, which they try to hide . Many of them earn much less than their peers - and it's well known that MD postgraduates earn a fraction of their MBA colleagues. This burns many doctors up - especially when they recollect that these same MBA grads did much worse than they did in school. This is why some doctors need to primp and preen to show their patients who is the boss !

Good doctors, who have high self-esteem, do not need to put on these false airs and waste their time in posturing !

But talking about doctors and egos does remind me of this old joke.

A man dies & goes to Heaven.

Upon arriving at the Pearly Gates he is told "Welcome to Heaven, everyone is equal here."

The man is then given a tour of Heaven and finds that it is indeed true.

The man decides he's just got to try the food & goes & stands in the cafeteria line.

While waiting ,a man in green scrubs goes rushing to the front of the line & gets his food ahead of all the others.

"Hey, I thought everyone is equal here. Why did he jump the line?"

"Oh, him?" says St Peter, "That's God, he is just playing at being a Doctor ."

Failed fertilisation after IVF

Most IVF clinics are very good at making embryos in vitro, which means that for most patients, each IVF cycle results in the formation of embryos which they can admire.
( Tip: If you are doing IVF treatment, insist that the clinic give you photos of your embryos. This is the best documentation that you have received good quality medical care. You have a legal right to your medical records - every hospital has to provide them by law ! Please make a request for this in writing ! Poor quality documentation without photos of your embryos suggests you have received poor quality medical care !)

However, sometimes there is complete failure of fertilisation, as a result of which no embryos are formed. This can be a rude shock to the patient, and causes major heartburn !

Why do the sperm fail to fertiise the eggs in vitro in these patients ?

There are 3 possible sources of this problem: the eggs; the sperm ; and the Lab. Let's look at these one by one.

The commonest reason could be an egg problem. Poor quality, "tired" eggs will often fail to fertilise. This is true in older women ; and in those who have entered the oopause. Even though the structure of the eggs looks fine ( which means that under the microscope, their morphology is normal), they simply do not have the competence to fertilise and form embryos. Remember that the energy for fertilisation and cleavage comes from the mitochondria ( the power houses of the cells); and in older women, sometimes the mitochondria are just not able to provide the energy which allows the formation of the cell spindle.

We also see this in younger women who have PCOD. Doctors are often so scared of OHSS, that they end up mistiming the HCG injection, as a result of which they get few eggs and poor quality embryos.

What about sperm problems ? There are men who have very good sperm counts and motility, but whose sperm are not functionally competent; and cannot fertilise the eggs in vitro. Unfortunately, there is no way of predicting this in advance - and total failed fertilisation provides important diagnostic information that the " unexplained infertility " in this case was because of an undiagnosed male factor. The good news is that it's easy to treat this problem ( but only in the next treatment cycle) by doing ICSI. While it is possible to attempt rescue ICSI with these unfertilised eggs in the same treatment cycle, but the success rates with this are poor.

The third group of reasons is a poor quality lab. Thus, fungal contamination or bacterial infection in the IVF culture medium can kill all the eggs. A poorly equipped lab ( for example, one with malfunctioning incubators) will also have poor fertilisation rates. This can occur because of various other technical problems as well - such as electricity failure ; or the use of expired IVF culture medium. Unfortunately, it's very hard for a patient to find out if the failed fertilisation is because of a lab problem, because it's hard to get this information from the doctor.

Usually, if it's a lab problem, it should affect all the embryos of all the patients on that day. An important question to ask is - What happened to the other patient's embryos ? ( though this information may not be readily available ! ) The good news is that if the failed fertilisation is because of poor lab conditions, it's easy to fix this problem by finding a better IVF clinic for your next cycle.

A close examination of the eggs and sperm can give the doctor valuable information, which can help him to diagnose the problem and find the right solution . Are the eggs in the dish all immature ? Are the sperm in the IVF petri dish still motile after 24 hours ? ( If the sperm are all immotile, this suggests a problem with the IVF lab conditions). You should ask for photos of the unfertilised eggs. If they are dark, this suggests they have degenerated, which could be because of an infection.

What are the possible solutions ? If IVF was done, it's possible to do a rescue ICSI on the same day , though the success rates with this are not always good. The important thing is to use this hard-earned information to help in making decisions about the next treatment cycle !

You options include:
1. change the treatment. Instead of doing IVF, ICSI may be a better option, if the failed fertilisation was because of dysfunctional sperm
2. change the eggs. You might want to use donor eggs, if you have few poor quality eggs
3. change the clinic. This is often your best choice, as a new IVF expert will be able to look at the problem dispassionately and hopefully do a better job !