I was just talking to a patient whose wife had failed an IVF cycle

I was just talking to a patient whose wife had failed an IVF cycle . She had had a poor ovarian response and he wanted to know whether it was worth trying another cycle again on not.
His question was simple . Is it worth subjecting her to the pain of an IVF cycle ? Do we have a chance of success ? Or is it futile ? Are we just breaking our head against a brick wall . He wanted my opinion, based on what we’d learned from the first IVF cycle. He loved his wife a lot , and was very protective of her. He didn't want her to go through the pain of another IVF failure , and while he understood that there were no guarantees, he still needed advise as to whether it was sensible to try again.

The major problem with an IVF cycle is not the physical pain of course - it's the emotional pain of failure, because there's so much riding on the outcome of an IVF cycle.

It's always hard to answer these questions because they involve so many intangibles . There are some decisions which doctors can't make for patients , so I tried my best to counsel him and put things in perspective.

Every IVF cycle involves a certain downside - but , there is an upside to it as well ! While it was true that his chances of success in terms of having a baby were not very good , often the one thing an IVF cycle provides is peace of mind that you've done your best , so that you have no regrets afterwards
It is true that there's a lot of emotional pain when the IVF cycle fails . This is acute pain , which can be very hard to manage both for the wife and for the husband – and often you feel that the world has ended and it can be hard to cope with this.

However, it’s also true that the infertile woman goes through emotional pain every time she has a menstrual cycle and she fails to conceive each month. Of course, the difference is that this is a chronic low low-grade long-term pain as compared to the acute pain of IVF failure, which is of a much greater degree.

What’s true is that how each person copes with the pain of an IVF failure varies remarkably ! Some patients are very resilient and find it easy to move on with their lives , whereas others go to pieces completely . Not only does this depend on their emotional reserves and personality , it also depends on how many external pressures they are subject to , and whether they doing the IVF treatment to keep themselves happy or to keep their mother-in-law happy !

I told him that this was a decision both of them would have to make , but in our experience doing a second IVF cycle is much easier because patients know exactly what they are going in for ; and because they've experienced failure the first time , their ability to deal with this the second time is a little bit easier, because they have more realistic expectations !

How to do a consultation systematically in 3 steps

I was giving an infertile couple a tour of our IVF lab. The husband was a cardiologist and he was marveling over how complex IVF is . He knows I am a big believer in Information Therapy, and he started wondering aloud how I could explain something so intricate, involved and complex as IVF in a 15 min consultation.

I explained that I have a standard three-stage format for doing a consultation. In step number one , I explain normal fertility - how babies are made when everything is working properly. I review normal anatomy and physiology ; the role of the cervical mucus and the fallopian tubes; the concept of the fertile time; when ovulation occurs and how to track this; and the importance of frequent intercourse to maximize normal fertility. This is a review of the basics , just to make sure that patients understand the fundamentals. Sometimes , people think they understand , while they really don't , but they are too embarrassed to ask questions to clarify their doubts. I feel it’s always worthwhile doing this , no matter how sophisticated the patient seems to be !

In step number two , I explain to the patient what is wrong with them , based on her diagnosis – for example, if her tubes are blocked or if she is not producing eggs . If we don't have a diagnosis then step number two consists of explaining what tests are needed to establish the diagnosis.

In step number three , I explain to the patient what we can do to solve the problem . For example, if the tubes are blocked, we can use IVF to bypass the block; or if eggs are not being produced, we can use medicines to induce ovulation.

This is a simple and systematic approach , which ensures I do not forget anything and have covered all the possibilities . The good thing about this model is that it can be applied to any medical problem – whether it's heartburn or backache !

Step 1 : review the basics of how things work normally – the normal anatomy and physiology , when all is well
Step 2: explain to the patient what’s wrong with him ( or what tests you need to do to find out what the problem is)
Step 3: explain how we can fix the problem

This is a helpful model, because it obeys the basic learning principle that we need to move from the known to the unknown when teaching a new concept to patients .

Putting an end to "Didn't Ask Didn't Tell" Syndrome in Patients

This is a guest post from a clever medical student , Muthukar Ramanathan. If there are more like him, the future of medical practise holds a lot of promise !

----------------

How many times have you felt that you forgot to mention something important after leaving your doctor’s clinic ? Unable to ask an embarrassing question or to did not remember to discuss your recent allergy? This familiar problem of "Didn't Ask Didn't Tell" among patients is due to multiple reasons - chiefly lack of recollection, stress or even laziness. But this inability to communicate well with physicians ultimately hurts patients due to incorrect diagnosis or treatment.

As a medical student sitting as an observer in physician's office, I noticed that many times patients could not accurately provide much needed information about their symptom of chest pain . In the stressful & time challenged setting of the physician office, patients rarely had the presence of mind to ask their questions ; clarify their doubts; or confirm their diagnosis and treatment plan. These observations drove me to think there must be an easier way to help patients organize information and communicate with physicians. If patients have a more systematic approach towards recalling important information, it would allow patients to contribute to a strong physician-patient relationship and help the doctor to make the right diagnosis and offer the correct treatment.

Hence, I looked into creating a simple, logical sequence of questions that can be applied to the common medical problems most patients face. I realized that smartphones offer a perfect platform to capture information from patients through text, images and voice and smartphones are almost always easily available in the pockets. Hence, whenever a patient has a problem, he can immediately note down more details about his symptom – for example, the type of pain, its location ; what makes it better and what makes it worse; and so on, thus creating a more accurate picture of his medical problem ; and tracking its progression by comparing notes over a period of time. This is a free app called Mediari which is currently available free at iTunes store.
Download it at: http://itunes.apple.com/us/app/mediari/id455565341?ls=1&mt=8

Plans in the Future

After talking to many physicians and patients, I have come to realize that Mediari can serve a critical role in improving the ability of patient to track his problems as well as to describe them better to his physician. However, some patients might prefer a short note with a brief description and questions for the doctor. This truncated short note is a feature that I am trying to incorporate in the next update.

Another idea that I am considering is from Dr. Malpani who suggested linking Mediari to web based Personal health records. This is a very interesting idea that I am exploring as well when updating my app.

At the same time, I am working on a trial with patients in a pediatric setting (Mediari allows users to track up to 5 patients and parents can track their children’s medical problems ). I am also working on improving the user interface, so it’s easier and more intuitive for patients to use this app.

I am very encouraged by the inputs and insights that I have gathered from many physicians and early adopters. I hope that Mediari can help patients to take better notes about their health, to help them get better medical care

How do I decide which treatment is right for me ?

Many infertile couples are confused as to which treatment to select. There seem to be so many choices – and even worse, so many different opinions from different doctors ! It’s hard for them to figure out if IUI is better for them ( as recommended by their gynecologist) or whether they should move on to IVF ( as suggested by their RE) ! This is why it's very important to create a comprehensive treatment plan right from the beginning .

For example, I recently saw a young patient with polycystic ovarian disease . I sat with her and explained her options to her. Step number one would be ovulation induction with metformin , and if that didn't work, then we’d use ovulation induction drugs such as letrozole or clomiphene. If that failed, then one option would be laparoscopic ovarian drilling ; and if that didn't work , then her choices would include artificial insemination ( IUI) with injectibles; and if that also did not work ,then we would consider doing IVF. I created a flowchart to help walk her through her options.

But isn’t it the doctors job to decide what’s best for the patient ? Isn’t the patient likely to get confused when there are so many choices ? How can she decide for herself ?

I feel it’s helpful when you explain things systematically in a stepped care format, because patients learn that we have a lot of tricks up our sleeves and that there is loads of stuff we can do to help them to have a baby. The fact that it’s possible to become more aggressive if simpler treatments fail provides a safety net of reassurance. . However, some patients get upset when we discuss options , because they think this means that the doctor is confused and does not know what to advise !

The reason we use this approach is that all patients carry a certain degree of emotional baggage . Some patients are in a hurry and want to use IVF to have a baby quickly , because of social pressures . Others don’t want to take metformin because they dislike the idea of having to take medicines daily, because it reinforces the fact that they have a medical problem and can't get pregnant in their bedroom on their own. Others are petrified of having surgery ! It’s impossible for me to read a patient's mind , which is why I list all the options and then allow patients to select which one they would prefer . If they ask me for advise, I explain that I am very conservative, and prefer starting with simpler options ; and then gradually escalating over time if these fail,

All options offer different trade-offs between success rates; discomfort ; convenience ; and cost . However, these are decisions which are best left to a patient rather than to the doctor. Of course, if they ask me for advise, I am always happy to provide it . For example , for older patients, I am more likely to be aggressive , but I always make sure that patients have all the information regarding all their choices , so that they are empowered to make the right decision for themselves.

How clever and corrupt politicians will make a mockery of the LokPal bill

Everyone is very excited that Anna Hazare and his team have been able to catalyse the government into passing the LokPal bill. However I think the sense of euphoria is premature. While it's great that everyone seems to want to fight corruption , I wonder how well it will get implemented in real life.

What worries me is the fact that lower-level officers have also been included with the ambit of the LokPal bill. If I were a corrupt politician , the best way of protecting myself against the LokPal would be to make sure that a large number of cases were filed against lower-level Babus. The LokPal machinery would then get so swamped with fighting low level corruption that they would then have no ability to go after high-ranking officials or politicians !

In a few years, the LokPal would then become a mirror image of the present judiciary - lots of good intentions and plenty of power on paper , but very little ability to implement and execute.
Isn't this exactly what happened with the Consumer Dispute Redressal Forum ? It was supposed to provide the consumer with easy access to justice , without involving expensive lawyers or long wait times - but it's become completely clogged up and ineffective !

Bromocriptine is used for treating high prolactin levels in infertile women

Bromocriptine is a drug which is used specifically to treat women with hyperprolactinemia - a condition in women fail to ovulate because the pituitary is producing too much of the hormone called prolactin. Hyperprolactinemia is the cause of menstrual disturbance in about 10% of anovulatory women. Bromocriptine lowers prolactin levels to normal (the normal range in most laboratories being less than 20 ng/ml) and allows the ovary to get back to normal.

Read more at http://www.drmalpani.com/bromocriptine.htm

Misusing danazol to treat endometriosis in infertile women

Danazol is a synthetic hormone, and used to be commonly prescribed as one type of treatment for endometriosis. The brand name includes Danogen and Ladogal. It acts by suppressing the brain's production of follicle stimulating hormones and hence suppresses ovarian function. This is similar to an artificial menopause and results in the shrinking of not only the endometrium in the uterus (and hence no periods); but also hopefully the misplaced patches of endometrium outside the uterus found in patients with endometriosis, causing them to disappear.

Side Effects: Hot flushes, weight gain, acne, hirsutism (hairiness). These side effects are quite troublesome, and some women have to discontinue the drug because of these. Usually, while taking the danazol, your periods will stop completely - pseudomenopause.

Dose: The standard dose used to be 800 mg daily (4 tablets of 200 mg each). However, the side-effects at this dose are considerable, and many doctors have reported good results with doses as low as 200 mg daily. The usual course of treatment is 6-9 months and the extent of the improvement in endometriosis is then reviewed.

While danazol is useful for suppressing the lesions of endometriosis, it is not useful for treating endometriosis in infertile women. While taking the danazol , ovulation is suppressed, and because all it achieves is temporary suppression of the lesions, once you stop the danazol , the endometriosis recurs. This is why it is usually not advised for treating infertile women with endometriosis anymore, because it has not been shown to be helpful in improving pregnancy rates.

How lupron and GnRH analogs are used for treating infertile women

Lupron is a GnRH Analogue. There are many other kinds of GnRH analogues available ,such as Lupride, Buserelin, Triptorelin ( Decapeptyl) and these all act the same way. As the name suggests, they mimic the action of GnRH.

GnRH stands for Gonadotropin Releasing Hormone, which is a peptide ( a molecule which consists of a chain of amino acids) released by the hypothalamus. GnRH causes the pituitary gland to release the gonadotropin hormones, FSH ( follicle stimulating hormone) and LH ( luteinising hormone) .


Read more at http://www.drmalpani.com/lupron.htm

How Antagon and other GnRH anatgonists are used for treating infertility

In the past, most in-vitro fertilization (IVF) centres used pituitary down-regulation with gonadotrophin-releasing hormone (GnRH) agonists to prevent a premature LH surge and premature ovulation and luteinization. However, this required at least 7–14 days of GnRH agonist pretreatment.

This is why researchers developed molecules which would cause an immediate blockage of the GnRH receptors on the pituitary gland, to stop the pituitary from producing gonadotropins instantly . This was felt to be a more rational approach , as these would induce instant downregulation , and prevent a spontaneous LH surge more effectively .

Brand names of the GnRH antagonists include Antagon and Cetroride. Thus , treatment with the antagonist can be limited to only those 4-6 days when high oestradiol levels may induce a premature LH surge. This means they are usually started after the HMG superovulation has been given for 3-4 days - usually Day 7 or 8 of the cycle.

However, clinical experience with GnRH antagonists in IVF treatment thus far has shown mixed results, with no evidence that they are any better than the traditional GnRH analogues. They seem to be as good; but are more expensive; and do offer an additional option which may be useful in selected patients.

How can we get patients to take a more active role in their medical care ?

It's extremely easy to criticize doctors for the sad state of health care today. Most patients are very articulate about the fact that their doctor spends very little time with them ; that he makes them wait unnecessarily for long hours ; and that he provides them with precious little information about their illness. This causes a lot of heartburn and frustration ; and many people believe that doctors are now behaving more like businessman rather than professionals.

While there may be some truth in this criticism , it is also equally true that doctors are soft and easy targets. In fact , the press has played a major role in bashing doctors , and while it's true that stories about unethical doctors who indulge in corrupt acts help them to sell more newspapers , sadly all these stories also end up hurting the doctor patient relationship. Patients no longer respect doctors or look upto them . And in response to this , doctors feel frustrated and unappreciated and start practicing defensive medicine. Often , the relationship has become adversarial , so that it sometimes seems to be doctor versus patient !

There's very little to be gained by blaming anyone because this does not really help to solve the problem. This just sets up a negative vicious cycle which seems to take matters from bad to worse . Rather than blame doctors and bemoan the declining standard of medical ethics and the passage of the revered family doctor of the past, we need to understand that patients are as much to blame for this present sad state of affairs !

Most patients are quite happy to be passive and do whatever the doctor tells them . Unfortunately , this does not help them to get good medical care. It’s been proven that well informed assertive patients get better care from their doctors . The question we need to be asking ourselves is - how can we mobilize patients to start becoming more actively involved in their health care ! Just like war is too important to leave up to the generals, health care is too important to leave up to the doctors !

It often breaks my heart when I see patients who have done an IVF cycle elsewhere, and don’t have a clue as to how many eggs were retrieved; or how many cells their embryos were. While this means that their doctor was not transparent , it also reflects poorly on the patient that she was poorly informed and did not do her homework properly. While it’s true that patients cannot change their doctor’s behavior , they can definitely improve their own!

Patients cannot afford to be passive and docile. If they take an active role in their health care , they will find that the same doctor is much better positioned to be able to help them get better sooner !
Patients make lots of excuses for not being actively engaged . These include:
• I'm not the expert - the doctor is ! I do not understand biology or any of these medical terms !
• If I ask too many questions , my doctor gets upset - and in any case , he's not willing to listen to
me , so why should I bother ?
• Isn't a little knowledge dangerous ? Is it a good idea to become a “half-baked doctor” ? After all, the doctor has spent 10 years learning medicine, which makes him the expert. Isn't it better to just allow him to make all the decisions ?

While it is true doctors are medical experts , we also need to remember that doctors are experts on diseases , while patients are experts on their own bodies . These two types of expertise are complementary ! We need an active mix of both medical expertise and the patient's expertise to make sure that each patient gets the care which is best for them !

If you are a patient, please get off your butt and start making sure you are well informed. You need Information Therapy , because this is powerful medicine – and you can ask your doctor t prescribe this for you – and you can find it yourself. A good starting point is the free Healthwise Knowledgebase !

Patients can help their doctor – and themselves – if they start demanding Information therapy !

Was that an embryo which fell out after my failed IVF cycle ?

The mind plays games after the embryo transfer. Every little cramp or discharge can excite hope - or lead to despair ! This is especially true when the IVF cycle fails and patients get their menstrual period. They often imagine that they can see a little clot of tissue or a little ball of cells in the menstrual flow, and they feel that they have miscarried the embryo.

This actually reinforces their feelings of low self esteem. Not only can’t they get pregnant in their own bedroom, their body could not even hold on to the beautiful embryos which the doctor grew in the lab and transferred to the uterus !

Please remember that an embryo is just a small microscopic ball of cells , which is not visible with the naked eye. If the embryo fails to implant , it gets silently reabsorbed about 2 or 3 days after the embryo transfer. This means that the period which comes after a failed IVF cycle just consists of menstrual blood and the shed uterine lining.

There is no way anyone can see an embryo in the menstrual flow after the IVF cycle has failed . Please don’t let your mind play games with you if your embryo doesn’t implant ! This usually just means that there’s an intrinsic genetic defect within the embryo, which is why nature did not allow implantation to occur . It does not mean that your body rejected the embryo or that you did something wrong. And just because one cycle has failed doesn’t reduce your chances of getting pregnant in the next cycle !

How do we mobilise the world's largest untapped healthcare resource ?

Patients are the world's world's largest untapped healthcare resource ! If you want to know why, then please watch e-Patient Dave's TED Talk here !




HELP will be organizing its 2nd Annual Conference on Putting Patients First. The theme this time is : Using Information Therapy to Put Patients First in India.

This will be held at Nehru Centre on Sunday, 9th October’11 . Mr.Ken Long , Vice President, International Operations at Healthwise, U.S.A, will be the keynote speaker and he will be talking on “What Healthwise is doing in the US to Promote Information Therapy – what we’ve learned so far”.

On this occasion, we will be releasing a book titled, Using Information Therapy to Put Patients First.

Using Letrozole for ovulation induction for treating infertility

The standard medicine used for making women grow eggs ( a treatment called ovulation induction) for many years used to be clomid ( clomiphene citrate). A recent alternative to clomid is the new drug called letrozole( Femara). Letrozole, is an aromatase inhibitor, and is now being increasingly used as an alternative to clomid for inducing ovulation.

The problem with clomid is that because of its antiestrogenic activity, it would cause the cervical mucus to dry up; or make the uterine lining thin. This effect would reduce fertility, so that even though ovulation induction was achieved, women would not get pregnant. Letrozole does not have the anti-estrogenic activity which clomid does, so that the uterine lining and cervical mucus with letrozole is often better than it is with clomid.

The dose is 2.5 mg daily for 5 days, starting from Day 3. Aromatase is an enzyme which converts androstendione ( an androgen) to estradiol, and because this action is blocked by letrozole , the estradiol level in the blood drops. The resulting lower estradiol will in turn stimulate the release of increased amounts of pituitary FSH and LH, and thus stimulate ovulation.

Letrozole was first developed as a medicine to treat certain women with breast cancer. It is because letrozole is an antiestrogen and reduces the estradiol level that it is effective in treating patients with estrogen receptor positive breast cancer .

However, the fact that letrozole is used for treating breast cancer causes women a lot of needless worry ! This fact is conspicuously printed in the patient information leaflet with the drug – and women then start worrying that letrozole will cause them to develop breast cancer. They are also very confused as to why the doctor is giving them a drug to treat breast cancer, when what they have is infertility !

Please remember that letrozole is safe and effective. A drug which is used for treating breast cancer will not cause it ! And do remember that one medicine can be used for many different purposes. The use of letrozole for ovulation induction is an off-label use, as it is not officially approved for this purpose, because pharmaceutical companies do not want to spend the money which is needed to get this approval.

Hesperian needs help !

Hesperian is known for producing easy-to-understand and highly reliable materials for community-based health care in print. Over the years we have worked hard to make new material available for download as PDFs, and we recently offered our books in an online reader.

In October 2011, Hesperian will launch a brand new set of digital tools!

These new online tools - developed with the help of our network of partners around the world -- will expand the reach of the powerful messages in our books while helping health workers and others to customize materials for the needs of the communities they work with. We've included a few facts to introduce this new Digital Resource Center and will keep you up to date as the launch approaches!

Some basic facts
- A powerful adaptation tool will allow users to easily customize Hesperian health guides to create training materials, fliers, posters and brochures that will move people from knowledge to action.
- Our materials will be available on line in a lightweight MediaWiki format in 10 languages, with more added over time.
- A searchable image library will make available over 10,000 Hesperian illustrations - simple line drawings that help explain complex health information -- for local use and adaptation.
- Hesperian is developing mobile phone applications that health providers anywhere can use to obtain basic health information and create their own materials. The app we are currently building provides information about pregnancy and birth -- check out our video
http://startsomegood.com/Venture/mobile_apps_to_save_lives_where_there_is_no_doctor/Campaigns/Show/Mobile%20Apps%20to%20Save%20Lives%20Where%20There%20Is%20No%20Doctor
to see the section on maternal health emergencies).

Together, these tools will help community health workers around the world to read, download, adapt and share information with a global audience. We have already received valuable feedback from communities in Honduras, Malawi, Lebanon, Pakistan, India, the Philippines and Nepal where our partners have field tested prototypes of these technologies.

Help support our work

Hesperian invites you to get involved in the Digital Resource Center - as a partner, a volunteer or a donor. Our current campaign seeks to raise funds for the development of our first mobile app described above: a module about pregnancy and birth that will help women stay healthy and safe during pregnancy and childbirth. We have only $800 to go to reach our goal before August 22! To make a donation, please click here:
http://startsomegood.com/Venture/mobile_apps_to_save_lives_where_there_is_no_doctor/Campaigns/Show/Mobile%20Apps%20to%20Save%20Lives%20Where%20There%20Is%20No%20Doctor

For more information, contact us at [email protected]

Indian surrogacy is successful, but new parents feel duped

" It should have been Myleen and Jan Sjodin's greatest happiness. Their newborn was healthy, they were in exotic India and, following Myleen's uterine cancer, their surrogacy was successful.

Instead, the Toronto couple claim, it all turned into a nightmare as the doctor hiked her fees just before the baby was born, hitting them at their psychologically weakest point. She also didn't pay outside hospital bills and tried to use India's infamous bureaucracy to delay their homecoming, the couple say."

Read more at http://articles.latimes.com/2011/apr/18/world/la-fg-india-surrogacy-20110418

Let the buyer beware is still sensible advise !

Wanted: IVF specialist for Malpani Infertility Clinic

We are growing and are looking for an IVF specialist to join our team.

You need to be experienced and have done at least 100 egg collections and embryo transfers.

We provide great working conditions and a very competitive salary.

Please contact: Dr Aniruddha Malpani

A success story for a couple from Ranchi ( Jharkhand)

We would like to share our success story and our entire experience and feelings with all those who are involved or will be involved with this clinic and I am confident that it will help them to take a correct and positive decision which will change their life forever.

We are very thankful from the bottom of our heart to Dr Malpani and his team for helping us in fulfilling our dream of having a baby and giving us peace of mind and freedom to think without stress like we had in last one years.

We were married for two and a half years and were trying to have a baby for the past one year. We are 38 years old. We under went several medical tests and came to know that there is some hormonal imbalance in my husband’s report. The word infertile came as a shock to us and it was very sickening and painful visiting Dr’s and hospitals for the guidance and treatment. We started taking treatment by Urologists & Andrologist at Delhi. After taking medicine for three months, we found that FSH level is very high. Then we stopped medicine and did the test after four months, we were astonished to find the report of FSH level was nearest normal. Then we stopped treatment.

One day when we were browsing through the net I came across Dr. Malpani clinic and Dr. RS at Mumbai. We mailed our medical reports to Dr. Malpani and Dr. RS for guidance. We did not get any positive reply from Dr. RS but we were very very surprised by the very quick & informative response from Dr. Aniruddha Malpani. Then we followed it up by asking a lot of doubts & queries we had & once again we got a quick and to the point response. In the mean time we read several articles about infertility from his book “ How to have a baby ” on net. We really appreciate his response to each and every mail of ours promptly, inspite of his heavy busy schedules.

Then we decided to go to Mumbai for treatment. We both were working and so we found it difficult to get one month leave from office. So we both left our jobs and decided to go to Mumbai for treatment.

On our first visit we were a bit nervous but after meeting the Doctor we were relaxed and felt very comfortable. Dr. Aniruddha is very cheerful and a positive attitude personality. We were impressed by his pleasing manners, attitude and confidence. He explained everything clearly to us and made us feel very comfortable. We learnt that running away from the problem or avoiding it is not at all worth it. He answered all our queries and did suggest ICSI being the best option under the circumstance. He encouraged us to be positive and optimistic.

The ICSI treatment started on 24^th Aug’ 2010 under the able guidance of Dr. Aniruddha Malpani & Dr. Anjali Malpani. All the staff of the clinic were very helpful and friendly, especially sister Sheetal. She helped us a lot. Each passing day increased our confidence and made us feel that I am in safe and competent hands. The treatment took approximately 20 days and ICSI was done on 10^th September’2010. Just before ICSI I almost cried with joy when I was shown on the monitor by my Doctor my six developed embryos of which two were 4 cell Grade A, One 2 cell Grade A & One 2 cell Grade B embryos. It was a speechless moment and truly remarkable and we have to see it and believe it. After transfer of 4 embryos I took rest for four days and returned to Ranchi ( Jharkhand ) by flight on 15.09.2010. We kept ourselves in touch with Dr. Malpani regularly to cool our nerves . After 14 days on 24^th September’2010 I had Beta HCG test. The positive result of the blood test made me and my husband feel on top of the sky. It was such a beautiful and joyous moment. We can’t believe that it truly happened. We immediately mailed the report to Dr. Malpani to inform the good news. He was so happy and congratulated us. After that I enjoyed my pregnancy and the entire days of pregnancy was a new learning experience every day.

Finally on 12^th May’2011 at 10:10 a.m. we were blessed with the most beautiful baby boy one could ever wish for. We have named him ANIMESH (name of Lord Shiva & Vishnu) and nick name Soumya. I had all along heard that a doctor is next to God, now I firmly believe it is true. Thank you very much Dr. Malpani. May God continue bringing success and happiness to both of you and to your patients.

We would request such similar skeptical couples not to waste time by searching for alternatives. Dr. Malpani’s clinic is the right place to make their dreams come true.

Mrs Sabita Rani [[email protected]]

How your doctor decides the dose of your IVF meds

When you do your IVF treatment, a very important decision the doctor needs to make is - What should your starting dose of HMG / FSH ( brand names for these key IVF meds include Repronex; Gonal-F; Follistim) be for optimal super ovulation? This is a key decision because this determines how many follicles you’re likely to grow. If he selects a dose which is too low , you may not have enough eggs or embryos. And if he selects a dose which is too high, you may grow too many follicles and end up with OHSS.

We do have rules of thumb for this, but as with any biological system , it’s very hard to predict how a patient will respond finally, and we need to acknowledge that some of this is trial & error.

As a general rule for most young patients, the starting dose is 3 amp of Menogon , which is 225 IU. This will then be tweaked, based on various factors for example, for very young patients who are less than 25 we would start with 2 amps; for patients who have polycystic ovarian disease we’d start with 2 amps; for patients who are more than 35 , we’d start with 4; and for those who are more than 38 , we’d start with 6.

The starting dose needs to be modified based on various fahttp://www.blogger.com/img/blank.gifctors, and the variables which need to be considered are:http://www.blogger.com/img/blank.gif

your age;
your BMI;
your Day 3 FSH and E2 levels;
your AMH level;
your antral follicle count ; and
your ovarian response in the past

If you’ve done an IVF cycle earlier , this provides us with a useful base line, based on which we can then decide what the starting dose for this cycle will be.

Other factors , such as past history of endometriosis or ovarian surgery would cause us to increase the starting dose. Similarly patients with a history of ovarian hyperstimulation ( OHSS) in the past would cause us to reduce the dose.

No matter what the starting dose is , the fact remains that after 6 days of super ovulation , when we do an ultrasound scan , this is a key moment of truth which will tell us whether we have selected the right dose or not. Based on the scan result ( and sometimes doctors will do a blood estradiol level as well to check your ovarian response) , we may then need to either continue the same dose ; or reduce it ; or increase it , depending on your ovarian response.

Scam targeted surrogates as well as couples

" Surrogates went to Ukraine to be impregnated with no prospective parents lined up, believing the arrangement was legitimate. The scheme unraveled when one pregnant woman grew increasingly nervous.

http://www.latimes.com/news/local/la-me-baby-ring-20110814,0,3021399.story?track=rss

I wonder how many such scams unfold in India ? This is why it's so important to find a reputable IVF clinic is you want to do surrogacy !

You can read more about how to protect yourself if you need surrogacy treatment !

What's common between leeches and angioplasty ?

I hope this catches your eye ! Please, please read the post !

Medical care today encourages overtesting and overtreatment. As this post suggests, however, that's nothing new !

How to get more patients by remaining uptodate !

MDConsult training tutorial

View more presentations from Aniruddha Malpani.

MDConsult is the world's largest online medical library - and Indian doctors can now subscribe to this at a highly discounted price.

Check out http://www.thebestmedicalcare.com/mdconsult/
to make sure you are always uptodate and well-informed !

What happens when you use the internet to google your symptoms !

How to improve a poor uterine lining

One of the most frustrating problems in IVF today is the patient with a persistently poor ( thin) uterine lining.

Normally, the endometrium should grow and become thick ( more than 8 mm) and trilaminar as the follicles grow, so that it is receptive and ready to accept the embryos when they are transferred into the uterine cavity.

However, sometimes this does not happen.

We do know that the growth of the endometrium depends upon:
the estrogen level in the blood
blood flow to the uterus
and
the health of the endometrial tissue itself

A problem with any of these will cause the uterine lining to remain poor.

Thus, poor estrogen levels will cause the lining to remain thin. This is commonly seen in patients who have a poor ovarian response . It's easy to check this by testing the estradiol level in the blood. If this is low, this is easy to treat by giving estradiol valerate.




As with any other tissue, the uterine lining needs an adequate blood supply to develop optimally. Uterine blood flow can be measured by doing a colour Doppler. While it was originally hoped that this would provide useful information, sadly we still do not know what to do with this data. Doctors have tried improving uterine perfusion by treating these patients with vasodilators
( such as vaginal viagra and nitroglycerine patches), but the results have been mixed.

Sometimes, it's the endometrial tissue itself which has been damaged. This is often seen in patients who have had endomterial TB ( tuberculosis) in the past. Similarly, uterine surgery can also disrupt the uterine lining. We find this in women who have had a D&C ( dilatation and curettage) done after having had an anembryonic pregnancy ( missed abortion). Over-enthusiastic curettage can result in the removal of the basal layer of the uterine lining, called the basalis . Once this has been denuded, new endometrial tissue cannot grow and the lining remains persistently thin, resulting in a variant of Asherman syndrome which is very difficult to treat. ( This is why we tell patients who have had a missed abortion to terminate their pregnancy medically with mifegest and misoprostol, and to not do a D&C.)

The other common iatrogenic reason for a poor uterine lining is a hysteroscopic metroplasty which many aggressive doctors do for infertile women to "treat" a narrow uterine cavity ( which is a normal anatomic variant , and should be left well alone !)

If a patient has an unexpectedly poor lining during an IVF cycle, it's often best to freeze all the embryos rather than transfer them in the fresh cycle. We can then work on improving the uterine lining before transferring the frozen embryos back into the uterus.

If patients have a history of a poor lining, we use the following protocol to see if their lining responds to an increased dose of estrogen.

This is the protocol we use.

Tab Lynoral ( ethinyl estradiol) , 0.05 mg , 1 tab daily with dinner, from Day 1 – Day 25.
We do a vaginal ultrasound scan on Day 12 to check the endometrial thickness and texture.
If this is fine, we then include a period by giving Tab Deviry ( medroxyprogesterone acetate) , 10 mg, twice a day from Day 16-25.
We can then transfer the embryos in the next cycle.

However, if the uterine lining remains persistently thin, we try doubling the dose of Lynoral and repeating the scan .

If it still does not improve, this confirms this is an end-organ defect in the endometrial tissue.
This can be very difficult to treat.

For these patients, we do a hysteroscopy, to confirm there is no correctable anatomic problem ( for example, adhesions) which we can remove.

We can also do an endometrial biopsy on Day 2 or 3 of the IVF cycle. This deliberate endometrial injury is supposed to provoke increased uterine blood flow, and sometimes causes the lining to improve.

We have also tried alternative medicine, such as using bromelain , 200 mg daily , to try to improve the uterine lining, but results are mixed.

A recent interesting paper ( Successful treatment of unresponsive thin endometrium, Fertility Sterility, 2011) has described the use of an intrauterine perfusion of Granulocye Colony Stimulating Factor ( G-CSF) . It is believed that the local delivery of cytokines and growth factors can improve the uterine lining. We are currently evaluating this experimental technique in our clinic and the initial results have been very promising.

For patients whose lining remains refractory to all therapeutic intervention, surrogacy is the final treatment option which has a very high success rate.