Docs turn baby girls into boys - Hindustan Times

Docs turn baby girls into boys - Hindustan Times

I often cringe when I read articles on medical topics in the newspaper. It seems that reporters are out to grab eyeballs by creating sensational headlines - often at the expense of distorting the truth.

An excellent example is the recent series of front page articles run by the Hindustan Times, which talk about how surgeons in Indore are "turning girls into boys" . The reporter has not bothered to check the facts. A simple google search would have helped the reporter to understand what was happening. Sadly, rather than do this, the reporter has published a series of unverified statements, which have now been reproduced all over the web, adding to the confusion.

Admittedly, this is a very complex topic, which most doctors do not understand well themselves, because of all the nuances involved. Some babies are born with what are called ambiguous genitalia, which means their external genitalia are not clearly male or female. In these cases, ( which pediatricians treat as a medical emergency ) it is essential that prompt diagnosis and gender assignment be made, so the child can lead a healthy life in the future. There are entire medical textbooks written on this complex disorder; and a team of doctors ( including pediatricians, geneticists, endocrinologists and pediatric surgeons) are needed to tackle these rare disorders.

If you want to learn more, you can read factually correct information about this at
http://surgery.med.umich.edu/pediatric/clinical/physician_content/a-m/ambiguous_genitalia.shtml
and
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Birth_defects_ambiguous_genitalia.

Because these conditions are so rare and complex, most doctors will rarely see such babies. These disorders are also called Intersex disorders. The modern term for this now is disorders of sex development (DSDs).

These children are very unfortunate, as are their parents, because it's very difficult for the doctor to decide whether the child is a boy or a girl. Not only is this very distressing, it's often a matter of shame and guilt for the parents ( who often blame themselves whenever a child has a birth defect, because they assume they must have done something wrong to cause their child to be born with such a problem). In some cases, the right diagnosis is only made when the child reaches puberty, because the secondary sexual characters ( which are produced by the reproductive hormonal surge at this time) do not match the sex assigned to the child at birth.

Fortunately, thanks to modern technology, it's possible to do detailed testing, including genetic testing and imaging studies, which allow us to find out the child's genetic gender; and image the internal organs. It is then possible to decide whether the child should be reared as a boy or a girl; and if surgery is needed, what surgery should be performed; and when . ( Ironically, it's far commoner to perform surgery to " convert " a boy into a girl, because this is much easier to do technically ! )

What's even more upsetting about the entire episode is that no medical society or association in India has bothered to provide the medical facts objectively, so as to clear the confusion . A controversy has been raised in the name of protecting the girl child; and doctors are preferring to keep quiet, so they do not get involved in the controversy. This is a very unhealthy trend - for these unfortunate children; their parents; doctors; and society at large !

Another happy patient from Malpani Infertility Clinic !

We had been married for 10 years. We had our careers, home, and friends everything going for us. Just one thing made us feel incomplete, especially me, not having a child of our own. Initially we felt it will happen after 6 months, a year. Then we took treatment. We had hopes. But all the hopes kept dying year after year. What was worst was when elders and relatives kept asking us about when we were planning to have a baby. That pressure was unbearable. But after 10 years I was coming to terms with the fact that I would be childless.

We kept reading about the latest developments of science in this field in newspapers and kept tabs of the most successful doctors in the field. But we were afraid of the costs involved and that kept us from approaching them. But then we read some articles about Dr. Malpani and some new techniques which he had been treating patients with successfully. We decided to give us one final chance. When we first visited Dr. Malpani we were ready for the worse (what with just 30 – 40% chances of success), but I also had hopes that the ICSI procedure that he suggested might just work for us.

The egg collection procedure was a little painful but the embryo transfer procedure is just ok. But what makes it easier are the helpful nature and smiling faces of the nurses and attendant’s at the clinic. The first attempt was not successful. But it was a good decision of my husband to agree to freeze the embryos. So after a few months we decided to try again.

This time it worked. Those first 14 days were testing my patience. Then the anxiety over the result of the first Beta HCG test. The value was much higher than the 10mIU/ ml mentioned for a positive result. That was it. I was sure I was pregnant and carrying more than one baby. A visit to Malpani’s proved I was right. I was carrying twins. I was ecstatic. God had blessed me “chappad phad ke”, meaning abundantly. But the initial month was full of anxiety. I would get nervous over even a little bleeding. But Dr. Malpani was very supportive whenever I queried him over phone or email. The best thing is that before you know it he answers your email.
Now we are proud parents of twin girls. I must admit every time I see their cute smiles I can’t thank the Malpani’s enough.

How to treat paients with RESPECT - a guide for doctors !

This is a clever acronym !

" Steps of RESPECT

Respect – A respectful approach helps reduce defensiveness.
“I appreciate how hard this has been for you…”
Explanatory Model – Seeking patients’ explanations of their symptoms conveys an interest; presents
a starting point for discussions (not dismissals); and can promote patients’ forthrightness.
“What do you think is causing your symptoms? Why?”
Social Context – ‘Chit chat’ can promote comfort and provide insights into patients’ well-being.
“How are you doing today?” “How’s work?” “How is the family?”
Power – Resisting the impulse to take over and finding ways to share power can encourage patients to
think of themselves as partners in care, not consumers guided by the motto: Buyer Beware!
“What would you like to do? Why?
Empathy – Responding to feelings heard ‘between the lines’ and not judging those feelings, shows
that you’re not only listening, but that you ‘get it.’
“That sounds so difficult (frustrating, frightening, etc.).”
Concerns – Eliciting concerns can help patients start to process information and reach decisions.
“You seem reluctant to…” “Why?”
Trust – Acknowledging patients’ sharing of info can encourage them to continue doing so.
“I really appreciate your sharing that with me.”

Health IT Entrepreneurs: Now Is Your Time

“This is the best time to be a health and wellness entrepreneur,” gushed Steve Krein, CEO of Organized Wisdom, a four-year-old health site.

The Indian healthcare system has become sick. Doctors are illness experts – and not healthcare experts. IT can help to heal it ! Information Therapy - the right information at the right time for the right person - can be powerful medicine !

Is the success rate higher with fresh or frozen embryos ?

In the past, everyone agreed that the success rate was much higher with fresh embryos. This was primarily because the embryo freezing technology was not very good. We used a technique called slow freezing, and unfortunately, as a result of the freezing and thawing, upto 50% of embryos ( or the cells in the embryo) would die. This is because embryo cells ( called blastomeres) contain a lot of water; and the freezing process would lead to ice crystal formation within these cells. When these embryos were thawed, these crystals would cause cell death. Obviously, embryos will dead cells have a much poorer chance of implanting, and most labs were resigned to this fact that the process of freezing and thawing would cause damage to some embryos. However, it was still well worth freezing, because the success rate for the embryos which survived the insult of the slow freezing and thawing had excellent implantation rates !

The good news is that the slow freezing technology has now been replaced by ultra-rapid freezing. This is called vitrification, and is the only freezing process we use routinely in our lab today. We have stopped slow freezing for the last 2 years, because the success rates with vitrification are so much better.

In fact, when vitrification is done by an expert, the survival rate is nearly 100% - which means practically all the cells in the embryo survive the freezing and thawing intact.

This is a huge advance, because we can now freeze supernumerary embryos routinely, and we are confident that they will survive the thaw !

Vitrification is a tricky process and does have a steep learning curve, which means that not all labs will have a good success rate with it. This is why some labs still use the older slow freezing technique, because they have more experience with it, and are skilled at doing this. It's sometimes hard to teach an old dog new tricks !

Since the survival rate of embryos after vitrification is so good, we have found that our success rate after transferring these frozen embryos is often better than with fresh embryos transfer. This may seem quite counter-intuitive ! After all, if we are transferring the top embryos in the fresh cycle, and freezing only the supernumerary embryos ( which are presumably not of as good quality), how could this be possible ?

There are 2 reasons for this.

1. The number of fresh embryos we transfer has now been cut down to 2-3 ( or even one, when we are transferring blastocysts

2. The uterine lining is far more receptive in a non-IVF cycle. During IVF, the meds we use for superovulation can cause the uterine lining to be out of synch with the embryo. In a frozen cycle, we can prepare the uterine lining, till it's maximally receptive for implantation !

This means that it's possible that IVF clinics will soon start moving towards doing more frozen embryo transfer cycles than fresh cycles ! ( In fact, the Kato clinic in Japan which does about 10000 cycles per year) does not transfer any embryos at all in the fresh cycle ! They electively vitrify all the blastocysts and transfer in the subsequent cycle - and they have an extremely high pregnancy rate.

What does all this mean for you ?

1. Before you start your IVF cycle, confirm that your clinic uses vitrification for freezing embryos; and they are good at this
2. Don't ask your doctor to transfer more than 1-2 embryos
3. Be proactive about freezing your spare embryos
4. Even if you do not get pregnant in your fresh cycle, do not lose heart. The chances of success with vitrified embryos is still excellent !

What is a luteal phase defect ?

Luteal phase defect ( LPD) used to be a very popular diagnosis many years ago. While most doctors today do not believe that this entity even exists, unfortunately, it’s still “diagnosed” commonly – and causes a lot of overtesting and overtreatment ! Let’s see why.

The luteal phase is the second half of the menstrual cycle during which the corpus luteum produces progesterone to maintain the endometrial lining of the uterus so that an embryo can implant in it . At the time of ovulation, the mature follicle releases the egg . It then gets converted into a yellow body called the corpus luteum, under the influence of the luteinizing hormone ( LH) produced by the pituitary. ( Remember that it's this LH surge which is responsible for the ovulation !) If the embryo implants successfully, the corpus luteum continues to be supported by the HCG produced by the embryo because the biological activity of HCG and LH is very similar. It now becomes a corpus luteum of pregnancy, which continues producing progesterone , the hormone which supports the pregnancy.

However, if no embryo implants, then the corpus luteum starts to disintegrate because the LH levels start to decline. The corpus luteum has a life span of about 14 days, and when it starts to die, the progesterone levels start to decline as well. Because the uterine lining now no longer gets the progesterone support it needs, it starts to shed, and the period begins.

In most fertile women, the luteal phase is usually 14 days. This means that the time between ovulation and the next period is fairly constant for most women.

Progesterone is the hormone ( a chemical messenger) produced by the ovaries that is necessary to support pregnancy. Progesterone is produced by the corpus luteum of the ovary after ovulation; and is essential for ripening the uterine lining so that the embryo can implant in it. Progesterone rises in the blood following ovulation, peaks on Day 20, and then declines .

The level of progesterone can be measured by doing a simple blood test. Normally, the progesterone level should be more than 15 ng/ml about 7 days after ovulation. This suggests that the corpus luteum is functioning normally. A very low Day 21 progesterone levels suggests the cycles was anovulatory ( no egg was produced).

In some women, even though ovulation does occur normally, the corpus luteum is of poor quality, as a result of which it does not produce enough progesterone. Doctors used to believe that low progesterone levels during the luteal phase could cause “ unexplained infertility “ and miscarriages. This was quite an attractive hypothesis and was popular for many years. After all, embryo implantation depends upon a ripe secretory uterine lining, which in turn depend upon adequate progesterone production by the corpus luteum. It was very easy to conclude that a poor quality corpus luteum could cause infertility – and since BBT charting used to be so popular , doctors would carefully scrutinise the BBT charts, to look for the duration of the luteal phase; and the duration and extent of the rise in the BBT after ovulation. If the luteal phase was shortened; or if the rise in the BBT after ovulation was sub-optimal, they would make a diagnosis of LPD.

In order to confirm this, additional tests were ordered. These included a blood test to check the progesterone level; and a painful endometrial biopsy, to take out a strip of the uterine lining and send it for histological examination.

An endometrial biopsy was the gold standard in diagnosing LPD. The endometrial biopsy is normally performed a few days before the next menstrual cycle is expected . The procedure consists of sampling a small amount of uterine lining and sending it to a pathologist for evaluation. Because the evaluation is done at a cellular level, the knowledge gained from it is at its most detailed and precise. The pathologist categorizes the lining as being typical of a particular cycle day. If this categorization is consistent with the actual cycle day that the sample was taken, the result is considered normal, and the uterine lining is in phase. If there is a discrepancy of more than two days, the lining will usually be considered out of phase and a diagnosis of LPD made.

The reason this diagnosis has now fallen out of favour is that we have realized that many normal fertile women also have LPD ! This is why few doctors bother to make this diagnosis, because it not affect the clinical outcome at all.

Why were my embryos of such poor quality ?

While a good IVF clinic is good at making good embryos, sometimes we will encounter patients whose embryos are all of poor quality.

What's a poor quality embryo ? This is one which divides slowly ( for example, one which has only 4 cells on Day 3) ; or one which has a lot of fragments. ( This is why you must ask your clinic for photos of your embryos, so you have documentation of the quality of your embryos ! )

Why does this happen - and what can you do about it if it happens to you ?

Remember that there are only 3 variables which influence embryo quality - eggs; sperm and the lab. This means that poor quality embryos could only be because of the 3 following reasons:

poor quality eggs;
poor quality sperm; or
a poor quality lab

Surprisingly, experience has shown us that the sperm are not important at all as regards the quality of the embryo. Thanks to ICSI, where we need only one sperm to fertilise one egg, we routinely get great quality embryos even from extremely poor quality sperm !

It seems that once the sperm has been injected into the egg and fertilisation achieved, the sperm does not play an important role in further embryo development. This is quite surprising and very counterintuitive - after all, sperm do contribute 50% of the embryos DNA ! This is an oversimplification, and there may be some exceptions, but it's true for the vast majority of patients ! If you stop to think about it, given the fact that the cytoskelton and mitochondrial energy needed to drive cell division ( for embryo cleavage ) comes from the egg, this is actually quite understandable

This means that the majority of the time, if you have poor quality embryos after ICSI, you can rule out a problem with the sperm - no matter how high your sperm DNA fragmentation levels are and how poor the sperm morphology !

This leaves us with only 2 possible suspects - poor eggs and poor lab conditions.

Since it's the egg which provides the machinery for embryo division, it's hardly surprising that poor quality eggs are the commonest cause for poor quality embryos .

Older women ; women with low AMH ( and high FSH levels); and poor ovarian responders are likely to have poor quality embryos, and this is to be expected.

However, sometimes the reason for the poor quality eggs may be because of a clinical problem, because the patient was not superovulated properly. This could happen because of many reasons:

Poor quality drugs used for superovulation
Using the wrong protocol for superovulation
Not using the right dose of meds for stimulation
Not timing the HCG properly ( giving it too early, or too late).

The last is a particularly common problem with PCO patients. Many doctors are so scared of
OHSS, that they end up mistiming the HCG injection or use prolonged coasting ( during which the estradiol levels drop and the eggs undergo atresia because of the absence of hormonal support) , as a result of which they get few poor quality eggs and therefore poor quality embryos.

A major role in creating poor quality embryos is a poor quality IVF lab. However, this is a reason which is often not openly discussed. For one thing, patients do not understand much about what goes on behind the closed doors of the IVF lab. Doctors also do not bother to explain too much, as a result of which there is little transparency and very poor documentation.

While it's true that having poor quality embryos because of a poor quality lab causes major heartburn, the good news is that this can be corrected the next time around !

If you have poor quality embryos, it's very important that you ask for documentation.

What were the meds which were used for superovulation ? What was the dose used ? How many follicles did you grow on ultrasound scanning ? What were their sizes ? What was the endometrial thickness and texture ? What was the E2 ( estradiol) level in the blood ? How many eggs were collected ? How many embryos were transferred ? What was the embryo quality ? Please ask for photos of your embryos !

Ask for a printed treatment summary from your IVF clinic - this is very useful when you need to get a second opinion ! I am happy to provide a free second opinion as well !

I need more information.

Could you please send me your medical details by filling in the form at
www.drmalpani.com/malpaniform.htm so I can guide you better ?

If you have poor quality embryos, you need to make some changes for your next attempt.

Your choices include:

Stick to the same clinic , but use a different protocol
Change to a different clinic
Use donor eggs, if you are willing to consider this option

These are all difficult choices, but going through them systematically will help you get the best possible medical care !

Pew Internet Report on “Peer-to-peer Healthcare” | Journal of Participatory Medicine

Pew Internet Report on “Peer-to-peer Healthcare” | Journal of Participatory Medicine

This week, the Pew Internet Project posted the findings of a study, “Peer-to-peer Healthcare,” conducted in collaboration with the California HealthCare Foundation. As the title suggests, the highlight of the study is the fact that 18% of internet users have gone online to find peers with similar health concerns. For those living with chronic or rare diseases, the number jumps to 23%. However, the results also show that, when attempting to arrive at a diagnosis, most people turn to health professionals.

The report, which can be viewed or downloaded at http://www.pewinternet.org/Reports/2011/P2PHealthcare.aspx, was written by Susannah Fox, Pew Internet’s Associate Director.

How to improve the vitrification of blastocysts

This is a guest post by our embryologist, Sai Gundeti.

Vitrification is the newer alternative to the traditional ‘slow freezing’ technique of cryopreservation of embryos for storage and future use. It is far more efficient and effective than the older technique, which is why we now use only vitrification in our clinic for cryopreservation of eggs and embryos.
It is the duty of the embryology team to learn this new technique, so they can offer the best possible care to their patients.

Here’s how we vitrify embryos in our lab.

It’s usually the supernumerary embryos which are vitrified, which is why embryo vitrification is generally carried out after the best ( top ) embryos have been transferred in the fresh IVF cycle . However, in some cases we may electively freeze all embryos , and not do an embryo transfer(ET) at all. These include: (i) when a patient is unable to have ET for medical reasons; (ii) when there is a high risk of Ovarian Hyperstimulation Syndrome (OHSS) or (iii) oocyte donation cycles, in which the recipient’s endometrial receptivity is not optimal for implantation.

At Malpani Infertility Clinic, discussions regarding embryo cryopreservation are made in consultation with the patient and are documented in the patient’s notes.
Survival rates after freezing and thawing are better than 95 %. However, sometimes survival could be partial i.e. an embryo may lose 1 or more cells , but it is still considered to be viable. An embryo is considered non-viable if it loses more than 50% of its cell mass.

We use SAGE/QUINNS vitrification medium to vitrify embryos. It contains Sucrose, DMSO and Ethylene glycol.

DMSO/Ethylene glycol are used as the permeating cryoprotectants, while sucrose as the non-permeating cryoprotectant. The optimal concentration of these cryoprotectants is selected to permeate cells and transform them to a solid state without formation of ice crystals. Protocols have evolved to minimize damage due to ice crystal formation, cryoprotectant toxicity and osmotic shock by using ultra-rapid freezing and thereby short exposure to toxic reagents.

Prior to Vitrification :
• Embryos are stored in Cryolocks with a coloured identification.
• Cryolocks are labeled as :
- Full name of the patient
- Patient unique freezing identification number
- Number of frozen per cryolock
- Date of freeze.
• All of this identifying information is recorded on a freeze event register that also includes details of embryos that have been vitrified and storage location.

Artificial shrinkage of Blastocysts before vitrifying them :
Increasing blastocoelic fluid in expanding blastocysts has been associated with poorer survival rates. This is why we routinely reduce the blastocoelic cavity prior to vitrification.

Artificial shrinkage is carried out by laser pulse using Saturn laser.
Ablation is done between the trophectoderm cells

Procedure :
• Blastocysts suitable for vitrification are identified. Those which have a large cavity ( expanded blastocysts) are selected.
• The dish is placed on the heated stage of workstation.
• The dish is positioned in order to give a clear view of the Blastocyst.
• 1.2 ms LASER duration for desired pulse length is selected and a single ablation opposite the Inner Cell Mass (ICM) and between the trophectoderm cells is done.
• This causes the blastocyst to start shrinking very quickly !
• The blastocysts are vitrified immediately to avoid re-expansion.

Vitrification procedure :
• “Equilibration Medium” and “Vitrification Medium” are equilibrated until they are at room temperature upto to 30 minutes prior to use.
• The Blastocyst is transferred to the Equilibration medium and allowed to equilibrate for 8-10 minutes. The blastocyst initially shrinks and then returns to its former shape.
• The blastocyst is now transferred to the Vitrification Medium and quickly loaded onto cryolock labeled with patient’s name.
• The cryolock is quickly plunged into liquid nitrogen vertically and gently stirred in liquid nitrogen for approximately 5 seconds so as to avoid formation of an isolating air bubble layer around the cryolock.
• The procedure is repeated for subsequent Blastocyst. We usually freeze only one blastocyst per cryolock, because the survival rates are so high !
• When all embryos have been vitrified they are stored in an allocated dewar location.
• Full records of all details concerning the vitrificaiton, as well as details of storage are documented.

Why wasn't the doctor able to collect any eggs ?

At the end of the egg collection, the first question every patient wants to know is - How many eggs did you collect, doctor ?

Egg retrieval is usually a very straightforward procedure, and we usually get at least one egg from each mature follicle ( more than 18 mm in size) . This is why we expect to collect at least as many eggs as there are mature follicles . However, sometimes, much to the doctor's chagrin and the patient's dismay, sometimes we do not get any eggs at all. This is not common, but let's examine why this happens , and what we can do about it.

Technically, if we do not collect any eggs at all , this condition is called " empty follicle syndrome
( EFS) ". Sadly, this term is abused and misused by many IVF doctors, who are happy to make this "diagnosis" and blame this condition when they are not able to collect any eggs from the patient.

In reality , empty follicle syndrome is a very specific condition, which refers to an iatrogenic complication, when we do not recover any eggs from the follicles because the patient has not been given her HCG injection ( the " trigger " shot) properly. This can happen because of many reasons ( some of which we can pinpoint only in hindsight !)

1. The HCG was not given properly
2. The patient did not take the HCG at the right time

Often the HCG is given late at night , and errors are commoner at this time. Thus, the nurse may forget to dissolve the active powder in the solvent, as a result of which the patient gets a shot of only sterile water ( and no HCG at all !). This kind of mistake happens far more commonly than you would assume - which is why it helps to be obsessive !

We insist that patients retain their HCG vials so they can show these to us before the egg collection ( allowing us to verify that the injection was given properly). In other cases, patients have confused am with pm, and taken the shot 12 hours ( and even 24 hours !) after they were supposed to !

Some clinics even routinely measure the blood HCG level prior to egg collection, to document that the HCG was administered properly.

How is EFS diagnosed and managed ? First, the doctor needs to think of it - and this diagnosis is usually thought of only after the egg collection has started ! If the embryologist has not been able to identify even one egg in the follicular fluid after Dr Anjali has flushed 3 mature follicles, we stop the procedure and re-assess. The first step is to do a urine pregnancy test ( which checks for the presence of HCG in the urine) - and we can do this on a urine sample obtained by catherisation of the bladder. If this is positive, this confirms that the HCG was given properly and empty follicle syndrome can then be confidently ruled out . We then reposition the patient, and continue with the procedure, and will often get eggs with more aggressive flushing.

However, if the urine pregnancy test during the egg collection is negative, this suggests that we are dealing with EFS. We stop the procedure; draw a blood test for HCG ( to confirm the diagnosis); give the patient a shot of 10000 IU HCG IM ; and reschedule the egg collection after 36 hours.We will then get eggs from the follicles at this time, thus "treating " the EFS effectively !

However, there are other reasons for not getting eggs from follicles, and these are unfortunately all too common in small, poorly run IVF clinics.

1. The follicles may have ruptured prior to the start of the egg collection. This can be diagnosed by the ultrasound scan, which shows that the follicles are no longer intact and there is fluid in the pouch of Douglas behind the uterus . This is uncommon, but can happen when clinics "batch" patients and do lots of egg collections on one day, when they are running late.

2. Sometimes, the doctor may have a technical problem during the egg collection. This is true if the doctor is not experienced; or if the patient is very obese; or if the ovaries are adherent to the pelvic side wall because of adhesions; and if the doctor does not take the time and effort to flush the follicles . This is more of a problem when the egg collection is not done under general anesthesia. In these cases, the procedure may cause so much pain to the patient that the doctor may be forced to abandon the egg collection, giving the excuse that " the ovaries were not accessible".

3. In older women with very few follicles ( and low estradiol levels), we may not get any eggs from the follicles , simply because even though the follicles look good on the ultrasound scan , they may not contain any eggs at all. This is seen in women with low AMH levels and poor antral follicle counts.

The best way to prevent these problems is to ensure you select an experienced IVF clinic ( which does at least 300 IVF cycle per surgeon every year). In patients with few follicles, it's best to do the procedure under general anesthesia, with double-lumen egg collection needles which can be used to flush the follicles ( to ensure that the doctor can retrieve even small immature eggs which are tightly stuck to the wall of the follicle).

It's important to remember that when the doctor does not collect as many eggs as is expected, it's not usually because of a biological problem with the woman, but rather a technical problem during the egg collection.

Unfortunately, doctors are not very forthcoming and forthright when this happens, and it's often hard for patients to find out what went wrong. However, armed with the right information, they are better equipped to decide what to do differently the next time !

Options include: better monitoring of the superovulation, with more aggressive superovulation and checking the estradiol level before timing the HCG; changing the IVF clinic; and using donor eggs ( this is useful only for women with poor ovarian reserve). Most other women with empty follicle syndrome have a good chance of getting pregnant with their own eggs , if the IVF treatment is monitored properly the next time around.

Is my IVF doctor's treatment correct ? Is he doing the right thing ?

As an IVF specialist, one of the commonest questions patients ask me is - Is my IVF clinic offering me the right treatment ? Are they using the right protocol ? Are they monitoring me properly ? Was the treatment which was offered to me correct ?

This often puts me in a spot ! It's hard to know what another doctor did, without having complete and accurate documentation. This is why I do not like second guessing other doctors or commenting on their treatment, as every doctor does things differently !

Sometimes I do cringe when I see how poorly the IVF treatment cycle was done . This is especially true when the treatment was done at a small clinic, which does less than 100 IVF cycles per year; or in a clinic which batches patients, and depends upon an IVF specialist who flies down once a month to do the actual IVF treatment.

However, while hindsight is 20/20, it's very hard to judge what a doctor did and why, unless you are actually there.

This is why I tell patients - do your homework before selecting an IVF clinic - and then find a good doctor whom you can trust !

Using MDConsult for CME for Indian doctors

While the internet is a great way of delivering medical information to doctors at the "point of care", the trouble with the web is that it can be very hard for doctors to find the content they need. How can they trust the information ? how reliable is it ? has it been updated ?

A far better option is MDConsult ! MDConsult allows doctors 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 the doctor will never need to buy another medical book in his life ! Even better, he can be reassured that the information he is referring to is reliable and trustworthy !

MDConsult provides high quality CME, convenience and peace of mind at the doctor's desktop - for only Rs 9995 per year !

We have been providing MDConsult subscriptions to Indian doctors for many years now, including leading doctors such as Dr Udwadia and Dr Bhandarkar ! Every doctor
has renewed their subscription year after year - and this is a testimonial to the high quality of content with MDConsult provides !

MDConsult is the world’s largest online medical library. You can take a free tour at http://info.mdconsult.com/tour/

And try out a free 30-day demo ( provide your credit card details but cancel before 30 days so they do not charge you !)

For doctors who enjoy learning, MDConsult is addictive ! Not only can you use it to optimise your care of patients with complex problems, it's also very useful in keeping you uptodate, because you can browse through the latest issues of medical journals ! You can even access it on your mobile, so you have easy access to the information you need - when you need it, no matter where you are !

You can share what you learn with your patient, because MDConsult has an extensive library of patient educational materials. You can also print out the relevant articles and provide them to the referring doctor, so your colleagues are impressed by how well-informed you are !

Why patients need to take the initiative

I am always amazed by how smart some of my patients are ! While I am an IVF expert and know a lot about the technical minutiae of IVF, I do not know much about how to solve the additional challenges patients face when they need to travel to India for their IVF treatment. I am happily impressed by how well organised some of my patients are ! Travelling to India from the US for IVF treatment is quite a challenging exercise - but something they do with ease !

What I like about these patients is that they take the initiative, thus making it easier for me to help them.

For example, they will design their own IVF calendar ( using Excel or Word ), so it's easy for me to review and approve. This helps them to arrange their logistics efficiently - and makes it easier for me to OK their travel plans.

I wish more patients would do this, so they can get better care from their doctors. The really smart ones will create tools which they can share with other patients, thus allowing others to benefit from their experience and expertise !

Why the web is a much better way of delivering CME for doctors

Most doctors learn best around their patients, because this information is " sticky" . For most patients with "routine" clinical problems, doctors do not need to refer to their text books . They use their experience to deal with bread and butter problems. However, when they are presented with a patient who has an unusual clinical problem , they do need to refer to medical text books and journals - and the most useful medical information is the information which they can access easily at the " point of care ". Once they encounter a patient with a particular illness , and learn about the management of this issue at that time, this is information which remains with them for the rest of their life, so they can easily access it again whenever they encounter another patient with a similar problem. This is why clinical experience is so highly valued - and why patients are so relieved when their doctor says - I have seen a patient like you before !" .

The best way of providing this kind of "patient-specific" information to doctors is through the internet. The web has now become practically ubiquitous all over India - and most doctors have a PC and/or smartphone with an internet connection.

The good news is also that there are lots of online resources about diseases available free. However, most of these resources are for patients - and while they can be very useful, not only is their quality is patchy , they are often of limited use to doctors, because they are not technical or detailed enough ; and may not be regularly updated.

These free resources - for example, open source medical textbooks and journals are very useful for a quick review - and while some are of high quality, they are still not always reliable or authoritative.

The gold standard is still published medical journals and textbooks. All publishers recognise this fact, which is why all medical journals are now available online. However, doctors need to pay a subscription fee to access these journals - and these fees can add up very quickly !

Ideally, what Indian doctors need is a single web site, which provides them access to the full text of updated reliable published medical books and journals , which they can refer to when they are stumped by a patient; or need to brush up their knowledgebase. It should be available 24/7; be affordable; cover all specialties; be updated and authoritative; and without advertising.

The good news is that MDConsult meets all these needs - and my next article will discuss how Indian doctors are using MDConsult.

Indian doctors , learning, and CME

In reality, all learning is self-learning. We talk about teaching doctors to help them keep uptodate, but in reality, no one can teach anyone else - it's only the student who can learn ! A good teacher will provide as many avenues and opportunities as possible, so that students can learn for themselves.

Adult learners are a different breed - and this is especially true for doctors, who are highly qualified and very busy professionals, with major time constraints.

Not only is it hard for them to take time out of their busy schedules to learn, it's even more important for us to ensure that whatever techniques we use to teach doctors, these are proven to be effective in helping doctors to improve their knowledgebase.

Unfortunately, lectures and presentations at medical conferences are very ineffective ways of transmitting information. Most doctors will forget over 80% of what is presented during a conference - and this poor transmission of information has many reasons.

1. The material is poorly prepared
2. The lecturer is boring
3. The listener cannot ask questions or clarify his doubts
4. The material is not relevant to the listener

The only effective way of ensuring that doctors remember and learn effectively is by making sure that what is taught to them is relevant to their needs - they should be able to use the information , because it is directly related to the problems which the patients they treat they have.

The trick is to provide content which is tailored to their patient's needs - and this is something which is very difficult to do in real life in a conference.

A far better way of teaching doctors efficiently is to help CME become an integral part of their patient care. The best way of doing this is by providing them with high quality medical content ( from books and journals ) which is tailored to the kind of patients they are seeing at that time.

Fortunately, most patients present with routine problems and doctors can treat this without having to refer to a book or journal. They have enough experience and expertise to be able to handle common medical problems with ease. However, when they do see a complex or difficult patient, they may be stumped. Sadly, rather than use this as a learning opportunity, most doctors will just muddle their way through, using whatever (outdated) knowledge they have - or asking a consultant for help. Good doctors do feel helpless and inadequate at this point - but few will have the maturity or the time to go to a medical library to do more research about their patient's problem.

While a consultant maybe able to help their patient, and they can learn from what the consultant did, this is actually not the best way of learning. Ideally, they should have a trusted reference source which they can tap - right at the point of care, so they can refer to this, and refresh their knowledge; or find out what the latest clinical guidelines are. This is where evidence-based medicine ( EBM) can help in dramatically improving medical care - but we need to make sure it is easily available to the doctor on his personal computer/ smartphone, so he does not have to waste time and energy in hunting for this information.

It's very encouraging to see many initiatives ( such as BioMedCentral) which are using open source medical publishing models to ensure that doctors do have access to this kind of information. However, these efforts and still patchy and uneven - and difficult to sustain, because of the lack of funding.

Medical textbooks and journals which are published by commercial publishers are still the most reliable source of authentic, reliable and updated information - and everyone understands the importance of being able to provide this kind of content to doctors . However, medical journals are expensive to subscribe to, so that this is still not a very effective solution in real life for Indian doctors.

The good news is that the world's largest online medical library,MDConsult, with over 80 full-text medical text books and medical journals , from the world's largest medical publisher, Elsevier, is now available to Indian doctors at a highly subsidised price ! I will talk more about this in my next post.

Why doesn't Flipkart do a better job of selling ?

I buy a lot of books from Flipkart and am a fan - I love their prompt and reliable service !

I recently bought a new Samsung Galaxy 2 phone from Flipkart. I hate commuting and shopping, so the fact that I could buy this online at one click was great. Flipkart delivered the phone promptly in 2 days, and I am very pleased with the phone and their excellent service !

However, I was disappointed with the fact that the Flipkart shopping cart was not intelligent enough to sell me accessories for my new mobile phone. For example, I would have been happy to buy a screen protector film for my phone - but they did not offer me this choice.

Flipkart could easily do a better job with tracking customer behaviour - they just lost a chance to sell more products.

Happy patient from Kolkata

Hi, We are from Kolkata and this is our story that we would like to share.
First of all, would like to extend our warm gratitude to Dr.Aniruddha & Dr.Anjali Malpani, and their staff making our IVF treatment a SUCCESS !!!

I am on the ninth week of pregnancy now and hoping and always pray it will be a SUCCESS until the baby is born.

We tried 4 times IVF in Kolkata but every time we were disappointed, then from the website of Drmalpani we come to know about Dr Malpani.

We were extremely happy by his instant response of all our queries by email . We reached Mumabi and went through the blood test where we found that my AMH level is low and we totally lost our hope. But Dr. advised us to go and take a chance with IVF and we followed his advise.

And in my first attempt with him I got pregnant.The really good part in Dr Malpani's clinic is that everything is very transparent. He showed us the embryos before transfer which was not shown to us before in Kolkata. Taking injection for ovulation was also very easy, as it is provided from the clinic and we can take it at our place. In our earlier case we even not aware what injection I was taking and what was the dose.

I really appreciate his sincerity and genuinity. May god bless him so that he continues his good job successfully in future.

I really recommend all infertile couples to take a visit once in Dr Malpani's clinic and you will not regret

[email protected]

Why infertile couples from all over the world come to Malpani Infertility Clinic for their IVF treatment !

A very pregnant patient from the US !

After three years of trying to conceive our first child (with efforts that included three rounds of Clomid with IUI, plus one un-medicated IUI) with some of the top infertility specialists in California, my husband and I were feeling sad, discouraged and borderline broke (our insurance didn't cover any infertility treatment), with still no baby in sight. We realized that IVF was the appropriate next step for us, but were daunted by the incredibly high costs in the US (our fertility center's rates start at $15K per cycle and can go up to $25K when taking on ICSI and other add-ons, but they couldn't tell you exactly how much it would cost until you were already committed to a cycle). We knew that giving up on our dream of having a family was not an option, but that paying upwards of $20K for only one cycle with a 20-30% chances of success wasn't an option either.

And then we found Dr. Malpani. I'm still not exactly sure how I came across his name during one of my many late-night Google searches. But as soon as I found his website and started reading, everything started to click. There it was, in plain English, everything we'd wanted to know and hear on one page: exhaustive educational materials, comprehensive FAQs, and the exact rate of what one IVF cycle would cost at his Mumbai office. Best of all, Dr. Malpani had incredible success rates. Here was the transparency, affordability and competence we'd been searching for. It just happened to be in India. Within three months, we were en route to Mumbai.

Our experience at Dr. Malpani's office during our weeks of treatment in his Mumbai office was always professional, caring and personalized. From our first consultation and exam when a treatment protocol was prescribed through to the transfer of the embryos, I always felt that I was receiving top-notch care based on his extensive experience in the field. When my initial drug treatment wasn't creating as many eggs as we'd hoped for, Dr. Malpani quickly re-assessed the situation and upped my dosages (all the while keeping me closely monitored).

In spite of the fact that an initial baseline fertility test I took in their office suggested I may only produce 5-7 viable follicles, on the day of my retrieval they were able to get 13 eggs ! Of these 13, 8 were fertilized and on their way to becoming embryos. On the third day after my retrieval, 3 Grade A embryos were transferred, while 2 more embryos made it to blastocyst stage (we're freezing them in Mumbai for next time!).

After three days of bed rest in our Mumbai hotel, I was cleared to travel and we spent the next 10 days exploring Kerala and Tamil Nadu (Dr. Malpani is very relaxed about letting you get on with your life post-transfer and always put my mind at ease about riding in bumpy Mumbai taxis and Kerala tuk-tuks and drinking the occasional glass of wine or second cup of tea).

Two weeks after the transfer, we were back home in California and I discovered I was pregnant! It freaking worked! At first we couldn't believe it (three years of negative pregnancy tests can really test a girl's faith...). Subsequent blood tests confirmed that my pregnancy was progressing (with only one baby). Per normal IVF protocol, Dr. Malpani prescribed me Estradiol and Progresterone supplements to support the first 9 weeks of my pregnancy.

And now, here I am, nearly 36 weeks pregnant, with a lovely nursery ready to receive our little boy or girl in a few weeks' time. There are times when I just stop in the middle of my day amazed about the wonderful journey that brought us to parenthood: the years of disappointment in trying to conceive and the leap of faith that took us to India and Dr. Malpani. All the depression and sadness my husband and I felt before is now replaced with incredible excitement and anticipation for the little life we created thousands of miles away. A true modern miracle (and a great story to tell!).

I cannot express my gratitude to Dr. Malpani, his wife, Dr. Anjali Malpani, and his entire staff for guiding us through this entire process with grace, knowledge and that certain Indian frankness that always grounded our fantasies in reality, while remaining optimistic and hopeful.

If you are considering IVF in India with Dr. Malpani, please don't hesitate to contact me for more information (on everything from the medical stuff, to where to stay in Mumbai, to where to sight see in the days between appointments.

Namaste!
Katie and Andrew Curry


Katie Curry [[email protected]]

India Today selects Dr Malpani as one of Mumbai's top IVF specialists

New Patients Putting Physicians Under the Microscope

" Physicians are now the ones under close examination by a new generation of patients

By Shelly K. Schwartz | May 18, 2011

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Patients these days are a demanding lot. They insist on the latest procedures, they expect more bang for their buck, and they'll gladly jump ship for a practice that can better accommodate their busy lifestyles. Indeed, as the healthcare industry evolves from a patriarchal system in which doctors did the talking to one that gives patients an equal voice, so too has the population it serves. Technological innovation, new models of delivery, and higher out-of-pocket medical costs have transformed the passive patients of old into consumers as never before."

Actually, patients have always carefully scrutinised their doctor - after all, so much depends on finding the right doctors, that patients have always been willing to invest time, energy and money in finding the right doctor.

However, in the past they had to depend on referrals from their family physician; the doctor's reputation - or "word of mouth" - methods which usually did work well, but were not always reliable.

Today, thanks to Web 2.0, patients find it much easier to research their doctor - and thanks to globalisation, their choices have also improved considerably, so they are not restricted by geographical limitations anymore !

A better way of making sure doctors learn and update themselves

If conferences are such a poor way of teaching doctors, then what can the profession do to ensure that doctors remain updated ? Is it possible to trust that all doctors are responsible professionals who will take the time and trouble to educate themselves on an ongoing continual basis ? Sadly, no. While most doctors are conscientious and will make a concerted effort to learn, not all will do so .

So what's a better option which will ensure that doctors learn reliable, updated, accurate evidence based medicine, without wasting time and money ?

The answer is surprisingly simple !

In medical college, doctors are used to memorising vast amounts of information from their medical textbooks, so that they can pass their examinations , qualify and start practise. Unfortunately, most of what they learn is very transitory and they forget most of it once they start practise. However, while doctors may forget book learning, they will always remember the lessons their patients teach them. The best way to learn medicine is to learn about the diseases your patients have ! Doctors learn best around their patients; and if you read about your patient's problem, you will remember what you read - and never forget this !

This is "sticky information" because you get a chance to apply it in real life - and once you have done so, it becomes a part of your personal knowledgebase !

Reading medical books and medical journal articles about the problem the patients you have is the best form of CME. Books and journals are authoritative; reliable; and peer reviewed. They are edited and quality controlled; and can be printed out and referred to when needed.

However, medical textbooks get outdated very quickly; medical journals are expensive ; and few doctors have the time to actually go to the medical library ! This is where technology can come to their rescue ! " Just in time " learning is the best way of learning anything - and the advent of the internet now allows doctors to learn about their patients at the "point of care".

I will look at reliable online resources in my next article, to show how doctors can use these to ensure their medical education is always updated !

Physician Professionalism: The Crucial Core Competency You Can't Teach

" As a former full-time faculty member, I regularly had to rate residents in six core competencies — six general categories of skills or assets needed for one to be considered a competent physician, one who could safely care for patients independently. I had often felt that the most crucial of them all, and the one that is the hardest, if not impossible, to teach is professionalism. Without it, all the others are moot.

One can learn the pathophysiology of a disease (medical knowledge), know the appropriate tests to order and the gold standard of therapy (patient care), learn it through actual patient interaction (practice-based learning), utilize the rest of the health team (systems-based practice), and be able to explain it to the patient and the rest of the health team (interpersonal and communication skills)."

Professionalism is closely tied to ethics; and either a doctor is ethical or not - something which is already a part of his core well before he joins medical college ! Sadly, it's not something which medical schools can teach.

Why medical conferences are a waste of time and money

I am very pleased that the Indian Medical Council has made continuing medical education ( CME) compulsory for doctors. The hope is that by making this mandatory, doctors will invest in educating themselves, so that they remain uptodate with the latest medical advances, helping them to provide state of the art medical care for their patients.

The only form of CME credits which the Indian Medical Council recognises is attendance at a medical conference. This medical conference has to be approved by the Council ( presumably based on the quality of the content provided for the participants) ; and doctors who attend approved conferences get a certain number of credits for their attendance. Doctors need to prove that they have accumulated a certain number of credits every year if they want to renew their registration.

However, while this is a great idea on paper , its implementation leaves a lot to be desired. The biggest problem is that in real life, medical conferences are terrible tools for teaching doctors ! Lectures are the most inefficient form of transferring information, but our schools and medical colleges still insist on using this outdated format to teach their students. Unfortunately, the authorities have been very short-sighted , and they seem to recognise only this kind of learning for providing CME credits.

Have you ever attended a medical conference ? Half the audience is outside in the hallways, chatting , collecting freebies at the stall, and eating. Most are fast asleep once the lights are dimmed; while others doctors go out shopping or sight-seeing once lunch is over . Few speakers have the eloquence and presentation skills to grip their audience because and most speakers are selected based on a quid pro quo basis - " If you invite me as a speaker for your conference , I'll invite you for mine :) . This is why most conferences have the same speakers talking on the same topics. Most presentations are boring and poorly prepared. They often contain outdated information, prepared at the last minute by a junior resident, who has copy and pasted stuff from the web. The speaker then reads out the text on the slides - and tries to show off his erudition . The only reason doctors can get away with this is because few doctors in the audience are listening - and most doctors know even less than what the speaker does ! This is why the "learning" which doctors get from conferences evaporates so quickly !

What about the "international faculty" who is often prominently featured in the brochures which are used to market these conferences ? While some of them are star speakers, most are quite mediocre - and come only because a pharma company has sponsored their trip !

How is this attendance going to help them to become better doctors ?

Conferences are a farce as far as their value in teaching doctors is concerned , but they will remain popular for many reasons. For one, they are a great way of ego-boosting for the conference organisers ! Presidents and Secretaries of Medical Associations love hearing themselves speak - and a conference gives them a great opportunity to do so. Associations have budgets to hold conferences - and they will continue to do so .

Pharmaceutical companies love sponsoring conferences ! It gives them a great chance to sell their wares to hundreds of doctors in one places - and getting a speaker to pitch their product is a great advertorial for them !

What about international conferences ? Many of these have now become circuses ! There are so many participants and so many sessions going on in parallel, that it's impossible for attendants to learn anything meaningful. However, it's a great pretext to take a holiday - hopefully to an exotic location for which a pharmaceutical company will pick up the tab !

Doctors love attending conferences. They feel good about attending them, because it's easy to justify doing so - see what a good doctor I am - I know all about the latest advances because I attend so many conferences ! In reality, the only thing most conferences are good for is for networking, schmoozing and meeting old friends ; socialising; and having a good time. These are important and valuable goals, so I am not badmouthing them . My only request is that it's high time we called a spade a spade - and acknowledged the fact that conferences are not good tools for teaching doctors !

The reality is that these conferences represent a waste of a lot of precious time and money ! Can we really afford to waste the doctor's precious time like this ?

And more importantly, if conferences are not an effective way of ensuring that doctors remain updated, then what's the option ?

This will be the subject of my next post.