Saturday, December 31, 2011

Why iPills are more important than iPads in healthcare

Ipads are the cool new toys for doctors and patients to play with ! They are flashy and fun to use, easy to carry, make a fashion statement - and all the clever medical apps on ipads make them useful too.

However, ipads are costly - and not easily available either.

Far more important - and much less expensive than iPads for fixing healthcare are iPills - prescriptions for information therapy ! These are easy to prescribe - and easy to dispense as well !

Not only should doctors routinely prescribe iPills at the end of each consultation, patients should insist that their doctors give them iPills as well !
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Friday, December 30, 2011

Take an iPill and call me in the morning

As all good family physician's wives know, most complaints are self-limited and most patients will get better in the morning on their own. This is why " Take 2 aspirin and call me in the morning" is still extremely good medical advise

Tincture of time is often the best healer; and if things aren't better by morning , then the doctor can start a more detailed evaluation.

Today, instead of advising patients to take 2 aspirins, I advise them to take an iPill. An iPill is an information therapy prescription and has an equally useful role to play ! It helps to reassure patients that their symptoms are unlikely to be serious; and helps them to make better decisions.

At the end of each consultation, along with giving them pills, doctors need to give iPills as well - personalised information therapy prescriptions !

There are many ways of prescribing this - and digital tools are often the best way of delivering these.

Thursday, December 29, 2011

Review of the book, Using Information Therapy to Put Patients First

My teacher, Dr Bhandarkar, kindly reviewed my book, and had some very nice things to say about it !


It was a privilege to be asked to review Dr. Aniruddha Malpani’s book ‘ Using Information Therapy to Put Patients First ’. Dr. Malpani was my student at KEM Hospital and is now a practicing gynecologist and an ‘ IVF doctor’. But, his mastery over modern Information Technology is amazing. He has ably married his knowledge of both his specialties and produced this book. It is written in simple language and uses jargon only when absolutely necessary. This has made it a highly readable book. I enjoyed reading the book and learned a lot from it. While reading it, I was continually reminded of one the finest books of the same size as the present book that I have read 25 years ago viz. ‘ Statistics In Small Doses ’ by Winifred Castle. The similarity between the two books is uncanny: both have many small chapters, each dealing with one facet of the subject of the book, and are structured superbly with progressive increase in details of information. The chapters are independent of each other, and yet linked by the common theme, Information Therapy, for the empowerment of patients .

Dr. Malpani defines Information Therapy as the “ prescription of the right information, to the right person, at the right time to help him to make the right decisions ”. In this book he has discussed how not only patients but also doctors, hospitals, pharmaceutical companies insurance companies benefit from Information Therapy, medically and financially, the latter without the vulgarity of greed. It is a ‘ win-win situation ’ for every one in the health care world. For the doctors, whenever a patient asks questions about his ailment and its treatment, it should not be looked upon as a burden but as an opportunity to learn. In fact, in life ‘ No questions, No learning ’. Proactive Information Therapy does even better; for, teaching is the best method of learning.

The first eleven chapters describe in detail what the individual doctor can do for his patients and how he can do it. This part of the book resembles ‘ Good Medical Practice ’, a publication of the General Medical Council of Great Britain, in its philosophy. He rightly advocates ‘ ONLINE ’ technology for this purpose, and defends it with the skill of an advocate. He strongly favours each doctor having his own website to make it possible for the patient to learn about his ailment and its treatment at his home and at his own time. The book is full of URLs for a patient to use for learning more about what is prescribed, especially the drugs and their side effects, and to get answers to their questions on 24/7 basis. With the spread of computer literacy in India, and the availability of affordable computers this should be possible, at least for upper middle class and affluent patients. However, this method is time- and funds- intensive and is only possible for doctors who are willing to learn online technology, and are willing to spend the time and money needed, particularly in the initially stages. The online method of patient education also makes it possible for the patient to interact with the doctor via email, without having to visit him at his clinic, and even without using the telephone. Finally, the doctor can learn about the patient’s perception of the treatment which helps the doctor to fine-tune the treatment to suit the patient’s preferences It also facilitates the formation of online patient support groups.

This is followed by chapters on how it makes sense for hospitals, pharma companies and the health insurance companies to participate in generating and transmitting material for Information Therapy. Such an effort on their part gives them more visibility, more credibility, more goodwill and happiness on the part of the users of these services. It lowers their cost of doing business , making them more profitable.

The ready to use and easily accessible Information Therapy material on the internet; and that generated by the doctors for their own patients are the back bone of this effort by various health service providers. If the data generated by this effort is used to build centralized data banks, they will facilitate trans-physician, instant access to patients’ medical records, and therefore continuity and improvement in patient care. Such service has been made possible by the availability of smart-phones and tablets with increasingly powerful processing and transmitting facilities in them.

The author then stresses the importance of medical librarians, who are professionals specially trained in searching information from books, CDs as well as on the internet, and make it availability to practicing doctors, their patients and to the research workers. To do this successfully, they must be respected and given their proper status in the complex hierarchy of the healthcare world.

The author then takes to task the half-baked, circulation-oriented and. therefore, hurried, inaccurate and misguiding medical reporting on the ‘ latest medical advances ’ in the newspapers. He makes a plea that medical reporting in newspapers must be entrusted to a team of full-time devoted news reporter doing exclusively medical reporting.

Information Therapy makes for a more transparent and therefore more trustworthy doctor-patient relationship. It must be recognized that the patients also have ‘ The Right to Information ( RT I ) ’ and this right must be respected by all concerned. It now has received the judicial seal, and it is in the doctors’ interest to embed this in their day to day medical practice.

While doing all this, we will do well to learn from the experience of other countries such as the U S which have such services in place in an advanced form; and then modulate them to suit the ethos in this country.

All in all, this is a comprehensive, easily readable and informative book, and it is worthwhile for every doctor to possess his own copy. Now that the new medical syllabus in India includes an exclusive, 2 ½ month term for a Foundation Course immediately on admission to a medical college, this book should be recommended reading for every new entrant to the medical college. That is the best time to read this book. For the citizens, it can be a Right to Health Information adviser.

It will be helpful if the future editions include a summary appendix , listing all the URLs mentioned in the book and the type of information offered in each of them.

Great going, Aniruddha !

Dr S. D. Bhandarkar, M.D., F.R.C.P. (Edin.), F.R.C.P. (Glasgow)
Retd Hon. Professor & Head, Dept. of Endocrinology & Associate in Clinical Pharmacology
Seth G S Medical College & K E M Hospital, Mumbai

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Wednesday, December 28, 2011

The first trimester of an IVF pregnancy

This is a guest post from our patient.


The first trimester can be the most exciting time in your life as well as the most nerve-racking. The initial news of your pregnancy comes with great joy!

For those that have gone through infertility treatments, getting through the first trimester may be a very trying time. The average fertile couple trying to conceive will typically get a positive pregnancy test shortly after a missed period and will be seen by an OB-GYN a few weeks later. For the infertile couple, the first pregnancy test will come just two weeks after conception; it will be followed by at least one more blood pregnancy test 48 hours later. If the numbers rise correctly, an ultrasound will be scheduled for the patient to determine the number of embryos implanted and if there is a fetal pole and yolk sac. As you can imagine, each step in this process creates great anticipation for the couple. Once the initial ultrasound confirms everything is developing correctly another ultrasound may be scheduled a few weeks later. On my first ultrasound I was very nervous , came to know that I am pregnant with singleton , it was very assuring I got to hear my baby’s heart beat on the second ultrasound which was scheduled just after 2 weeks , that was very exciting moment ! Most infertility patients do not return to their regular OB-GYN until at least 8 weeks in pregnancy. So did I consult with local OB-GYN after 8 weeks. As I was already on hormone regime and folic tablets, I was advised to continue the same by my local GYNE.

For us, the initial news of our pregnancy was surprising and exciting. It was hard to believe that I was actually carrying another life. In the very beginning, I didn’t experience too many early symptoms, which often made me question if I indeed was pregnant. When an ultrasound scan shows everything is fine , this is very reassuring, Since I was on a progesterone regime, I was required to insert a gel compound vaginally thrice a day for the first 12 weeks. I did have brown discharge couple of times which made us worried and increased my anxiety level, later I read articles and wrote to Dr. Malpani and came to know it might have been “old blood” from implantation bleeding. I remember searching endlessly on the Internet for early pregnancy symptoms wondering if I really was experiencing anything super early on, or possibly it was simply wishful thinking. I did not had morning sickness but I would feel very tired and had many exciting emotional roller coaster rides. Many times I used to feel like crying with no reason , I was too fragile . Mostly I was able to do my work day comfortably . However, I do suffer from a nasty nose blockage due to Pregnancy Rhinitis, which causes me to get up at the middle of the night and sometimes leaves me exhausted during the day. I resisted taking any medicine since when were doing IVF, and have treated this with saline water irrigation, steaming, and gargling regularly . Breathe Right strips are helping a lot for coping up with nose block. I was never “so sick” that I couldn’t do my chores at work and was able to take care of home too. I have had very dry skin problem, my skin is too sensitive and it is becoming so dry that I put Vaseline ointment thrice a day, do not know if it is related to pregnancy . I am hoping my skin begins to look better in the weeks to come.

All members in the family are taking very good care of me, specially my husband . The poor guy has to cope with my mood swing all the time . I read a lot on the internet and found Dr. Malpani’s site and very good. I never hesitated to write to Dr. Malpani about my worries and sincerely thank him for writing me back in very assuring manner.

I surely feel that the concerns and worries of the naturally pregnant women and women who get pregnant with medical help are very different. My friend is also pregnant at the same time. She is blessed with a natural pregnancy, and as compared to her, I get worried about trifles and my anxiety level is very high .There are many things that she does not even bother about or does not even know ! I worry about every little thing!

I am trying to go easy and not to push myself for anything and she does not hesitate to go for parties and for out station trips too.

I am trying to eat healthy , taking milk regularly , and whenever we go to eat out , I try to make sure I eat fresh food. I am restricting myself with road trips , sometimes my husband says - take it easy .

After first trimester, we had an ultrasound, in which I took my husband with me, and now he feels more connected with the baby .

All in all, my first trimester has been great. Of course there were the evenings and days of worries and anxiety, but I know it could be worse. I’d gladly take all of the terrible symptoms in order to be pregnant; I’d go through anything! My first trimester is nearly over and I am feeling better and better each day. I am really looking forward to the renewed energy that I keep hearing about in the second trimester and hoping that a little “baby-bump” pops out soon.

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Saturday, December 24, 2011

Embryo transfer vs implantation

Lots of IVF patients are not very clear about the medical details of their IVF cycle. This sometimes causes them to use medical terms inappropriately. Many are confused about the difference between embryo transfer and embryo implantation and will sometimes use these terms inter-changeably.

There's actually a world of a difference between the two !

Embryo transfer is a simple clinical procedure where the doctor transfers your embryos into your uterus, using a plastic tube called an embryo transfer catheter. This is a mechanical step, which involves transferring the uterus from the petri dish in the incubator to your uterus.

Implantation , on the other hand, is a complex biological process which occurs within the uterus.

How are the two connected ?

When the doctor transfers your embryos on Day 3, they are about 8-cells. They continue to divide in utero , if all goes well , until they form blastocysts. This hatches, and the cells of the embryo embed themselves into the wall of the uterus . This is usually on Day 6 or Day 7 after the egg collection.

Implantation is a silent process over which we have no control. It involves 3 phases - apposition; adhesion ; and invasion, based on an interchange of a beautifully synchronised exchange of molecular signals between the endometrium and the embryo. All the steps are equally important, and need to occur sequentially. There is no special day or time which is more important than another ! We are not able to track or monitor implantation ; and we cannot influence it either. We do give you estrogen and progesterone to prepare your uterine lining for the implantation, but whether or not your embryos will implant; and how many will implant , is not something we can influence or predict.

This is hardly surprising. After all, the embryo is just a microscopic ball of cells - how can we track what it's doing after we have transferred it into your uterus ?

So why don't all transferred embryos implant ? This is simply because human reproduction is notoriously inefficient - after all, not every fertile couple gets pregnant every time they have unprotected sex during their fertile period ! The commonest reason for failed implantation is a genetic abnormality in the embryos , and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for.

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Friday, December 23, 2011

Menstrual cycles and infertility

There is lots of variation in menstrual periods even in normal fertile women. Sometimes the period maybe heavy; sometimes it maybe light; sometimes there may be clots or spotting ; and sometimes there maybe more cramping than usual. These are common variants, and most fertile women don't even notice them.

Infertile women, on the other hand, obsess over every minor variation. Was the period too heavy ? Was there clotting ? Could that have been an early pregnancy which miscarried early because I lifted a heavy bucket ?

If my period has become very light , does this mean my uterine lining is too thin ? Does this mean that the embryo will not be able to implant ?

My periods are due in 2- 3days, but my breast fullness and tenderness is much more this time. Is it just PMS ? or does it suggest an early pregnancy ?

Is the spotting I get before my flow mean that I have endometriosis ?

The mind plays all kinds of games in infertile women , and since you cannot see the eggs and the sperm and the uterine lining, you worry about the only thing which you can see - your menstrual flow. You try to correlate every variation in your periods to your inability to get pregnant.

The truth is that there is little correlation between your menstrual cycle and your fertility , as long as your cycles are regular.

In any case, rather than worrying needlessly about this, the best option is to get a basic medical evaluation, to reassure yourself that all is well !

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Thursday, December 22, 2011

IVF or IUI - should I let the patient decide ?

I just saw a 28 year old woman with unexplained infertility. I am a conservative doctor and suggested that the logical treatment option for her would be intrauterine insemination ( IUI).

However, she was quite adamant that she wanted to do IVF. She had done her homework and knew that IVF had a much better success rate than IUI. Since it did not involve surgery or have any medical risks, she was sure IVF would be better for her, because she did not want to waste time.

" Why should I do a treatment which has a success rate of only 10% when I can go in for a treatment which has a success rate of 46 % ? I am paying for this myself, and my time is at a premium. I have only one life, and want to enjoy being a mom when I am young and have lots of energy. Both IUI and IVF involve coming to the clinic 6-7 times each month, and I'd rather select an option which would have a higher yield. I am the kind of person who flies first class - and IVF would actually be more cost effective for me !"

This was a woman who knew her own mind, and it was hard to argue with her logic. Money was not an issue for her; and she was well-read and well-informed.

This is a good example of IVF being done for patient reasons, and not medical reasons. I believe we should respect patient autonomy , and allow the patient to decide.

Will this lead to overtreatment ? Yes, but there are lots of advantages to this approach.

It saves the patient valuable time , because she'd rather focus on bring up her baby and moving on with her life, rather than making multiple trips to the infertility clinic !

This approach is quite ethical, because it put patients in charge of their treatment ( respects their autonomy) ; provides them the benefit of a higher success rate ( beneficence) ; and also has no risks or downsides ( non-maleficence) .

Is it ethical for me to refuse her request ?
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Wednesday, December 21, 2011

What is Information Therapy?

Every doctor is supposed to educate and inform his patients; do we really need a buzzword for such a basic concept? The tragedy is that this fairly simple and obvious notion is not implemented routinely in today’s world.

Information Therapy can be defined as the prescription of the right information, to the right person, at the right time to help make a better health decision. But this is not free-floating generic information by simply Googling it. In fact, the problem is that there is too much information available online today –of which a major chunk is unreliable and misleading. In fact, easy access to so much information at the click of a button has made both doctors and patients skeptical of using this information in the real world. An overload of information has resulted an in information smog , which often leads to further confusion and uncertainty.

Information Therapy refers to prescription-strength information, tailored to your needs. Ideally, this information is best dispensed by your own physician – the one person whom you trust, and who knows you and your medical problems intimately. Equally importantly, Information Therapy must result in a tangible good – it should help you make better decisions. The key question is- what is the ‘right’ information? Who decides what is right and what is wrong?

The right information needs to be accurate because it is evidence-based; approved by experts; up to date; easy to read and understand; available in many different formats ( local languages and audiovisual formats); and referenced. Producing such high-quality information is not easy and we underestimate the cost and complexity involved in doing so. This is one of the reasons why there’s such little quality information available in Indian regional languages – no one has invested the time and the trouble to create this as yet, since they still do not see the value in doing so.

The right person means that this information needs to be delivered to you (and your caregivers), so you can make (or help in making) the decision (or behavior change). The right time means it should be provided when you need it – “ just in time “ to help you make a better medical decision .
There are many ways of delivering this powerful tool. Information Therapy can be clinician-prescribed, system-prescribed, or consumer-prescribed. At present, most patients get information through their own research. However, they are often not knowledgeable enough to conduct searches that provide valuable results. Ideally, the information should be prescribed by doctors – but this is likely to happen regularly only when they get paid for this! The good news is that hospitals and health insurance companies that systematically implement information therapy applications will be in a better position to gain market share, profitability, and prestige over those that do not. They will hopefully start doing so routinely because it makes business sense for them!

Healthcare is rapidly evolving globally. It may take some time for India to catch up, but the current US scenario should serve as both a warning and learning tool. We have empowered consumers (who demand time, information, control, and service) and embattled doctors (who are more respectful of the patient, but are burnt out and resentful because they are starved of time and poorly compensated). We have a new focus on quality (which promotes safer medical care and a move towards pay for performance); and a new way of validating what works and what does not in medicine (the science of evidence-based medicine). We are also equipped with new technology to reach out to consumers – thanks to the internet, which connects anyone, anywhere to top-quality information 24x7. These drivers create a compelling case for information therapy — a new approach to healthcare that revolves around an expanded patient role.

As healthcare evolves :
• Every clinic visit, medical test and surgery will be preceded or followed by Information Therapy prescriptions.
• Information prescriptions sent between in-person visits will extend the continuity of care.
• Patients will play an active role in shaping how they want the information to be delivered to them

Information Therapy is a very cost-effective solution that allows your doctor to put you at the heart of the care he provides you. As Kahlil Gibran said, ‘Progress lies not in enhancing what is, but in advancing toward what will be.’ Information Therapy is the future – and in India, using our medical and IT expertise, we can outdo the rest of the world and become leaders in this space. You can start by requesting your doctor to prescribe information every time you see him.

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Malpani Clinic in the DNA newspaper

Tuesday, December 20, 2011

IVF sucess story for couple from Sri Lanka

We, Thushara and Medha being Sri Lankans, living in Colombo, are pleased to make few words regarding our success story with many thanks to Dr. Aniruddha and Anjali Malpani and their staff at the Malpani Fertility Clinic at Colaba, Mumbai, India. We had to pass a long way to reach this destiny, it was more than 11 years, from the date of our marriage. During this period we visited to many doctors in Sri Lanka and abroad even followed western and eastern medical prescriptions, without any interval. We were really fed up with the matter and that feeling created more and more negative impact with regard to the possibility of having a baby. All the doctors said that we haven’t any serious problem rather that some hormone imbalances, but the result was so far from us until we met Dr. Malpani.

We came to know about the clinic of Dr. Malpani during our thoroughly search for a doctor in India, by that time I also had an opportunity to work in Mumbai for some times. It was a silver line in the dark cloud . We came to Mumbai and met Dr. Malpani. The first impression was very encouraging and it defeated all of our negative attitudes regarding another circle of treatment. He spoke to our broken heart and healed the wounds in our heart and the mined, that was a spiritual treatment we got for the first time. We met several best doctors with whom even we can’t talk properly or ask any question regarding the gray areas in the fertility process. Sometimes Dr.Malpani was a teacher to teach us the steps and the process in depth and resolved all the questioned we had regarding the treatment. This approach we haven’t experienced at any other places in Sri Lanka or abroad. He took his own time for the explanation and encouraging to keep our moral fitness and mental balance for the purpose. It was a psychological therapy before the treatment. We were surprised to see the a doctor spent such a time for the wellbeing of the patient. Kindness and the friendly relations of both Dr. Aniruddha and Anjali Malpani and the service of their dedicated staff was a blessing for our burning soul. The entire environment of the clinic was a very pleasant place for us.

When we came to know that Our first IVF was positive we enjoyed a lot. it was a spiritual happiness and it was like a shower after a long drought. But we were devastated from the message that the pregnancy had some defect due to its genetic problem. However , this time too, Dr. Malpani gave us full moral impetus to keep the balance to go for the next round of the IVF treatment. With his immense motivation and consultations we did the 2nd treatment. It was very successful, keeping us waiting for another 10 months for the result. We got a lovely and healthy baby girl!

Baby gave us a rebirth and a new life, even I am in 40 years and wife is in 38 years. We had more confidence on the success rate of IVF treatment of the Malpani clinic, we had an opportunity to share the information with other IVF patients who came to the clinic from across the world and they also had the success stories with more babies.

We extend our sincere thanks and gratitude to the divine hands of Dr. Anirudha and Anjali Malpani and their divine look at the patients which you can’t find anywhere in the world other than at the Malpani Clinic in Mumbai , India. As Buddhists we have a spiritual bond with India ,since it is the birth place of Lord Buddha. Now we have the second reason to further strengthen that bond with the Bharat, since it is the Birth place of our lovely daughter. The names of Aniruddha and Anjali have been embodied to us and will live with us forever.

We highly recommend to any couple who are searching a right place for their IVF treatment, don’t miss the Malpani clinic in Colaba, Mumbai, India. You will have a better understanding and the confidence once you visit the clinic. If someone wishes to know any specific information through our experience with Malpani , we are pleased to keep you updated, Don’t waste your time and money. Don’t delay your parenthood; don’t delay of writing your success story in this column.

You may contact us through – [email protected] at your convenience.

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Monday, December 19, 2011

Does your IVF clinic have a full time embryologist ?

There are many IVF centers sprouting up in India today. This is because there is a huge demand for treating infertile couples. This is hardly surprising, given the fact that over 10 million couples get married every year- and that 10% of these are going to be infertile.

It's also considered to be a highly lucrative field; and all gynecologists today want to start IVF clinics. They have the space and the money; and are happy to invest in starting an IVF lab because they think this will be highly profitable.

The trouble is that they forget that the IVF lab is only as good as the person who runs it. This scientist is called an embryologist - and the tragedy is that there just aren't enough embryologists in India right now. This is one of IVF's dirty little secrets - embryologists in India are in very short supply.

Since it takes 2-3 years of full time experience to become an expert embryologist, many IVF clinics today rely on traveling embryologists to treat their patients. These embryologists are very skilled; but they are also very busy, because they have to serve many clinics all over the country. This means that they can spend only 1-2 days at each clinic

This is why the doctors are forced to do " batch IVF". They group over 20-40 patients together, and treat them all in this 1-2 day window period

While this works well for young patients, the results are terrible for older women , because the doctor cannot tailor make or customise the treatment protocol for patients with poor ovarian reserve - they are forced to use a "one size fits all " approach.

The major benefit of this approach is that it's much more convenient and less expensive for the patients, because the do not need to travel out of town.

However, these clinics typically have a lower success rate because the embryologist cannot spend enough time on the " difficult " patients. He may have to do over 10 ICSI cycles in one day - and injecting over 100 eggs in a few hours can be fatiguing and stressful. Also, it's not possible to do justice to difficult and complex procedures such as TESE for patients with non-obstructive azoospermia.

Also, since they have to leave in 2 days, they cannot freeze the spare embryos - these are often "donated" to other patients or discarded

The documentation in these clinics is also poor, because the embryologist doesn't have the time to take photos of the embryos

Finally, the quality control leaves a lot to be desired . The embryologist needs to depend upon a technician to maintain the incubators and the IVF lab equipment - and when these are used only an episodic basis, they are often not in optimal working condition.

Please ask ! If your clinic does not have a full time embryologist, you might be better of finding one which does !

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Saturday, December 17, 2011

When bad things happen in the IVF lab

Most patients are pretty clueless about what goes on in the IVF lab.

Sadly, many doctors are equally clueless too and they leave everything upto the embryologist. While this works very well when you have a full time experienced expert embryologist, the sad truth is that not all IVF labs and IVF embryologists are upto the mark. While many are extremely hard working , talented scientists, others are poorly trained

Thus, some will use shortcuts, such as using donor sperm because they do not know how to handle TESE sperm

Others are not very careful about quality control , and will not bother to check that their equipment is working well

Some are not very honest with the patient and do not give the patients photos of their embryos - they just tell the patient that their embryos are of "good quality" ( even when they are not), thus taking advantage of the patient's ignorance.

Other will use one patient's eggs for another without her consent. They justify this by calling it
egg sharing , but really this is egg stealing.

Documentation is often poor and records are poorly kept. If there are accidents or mixups in the the lab , these are covered up and not reported

Thus, when the incubator malfunctions and the embryos die, they are not forthright with the patient. They explain that the problem is because of poor egg quality, and tell them to use donor eggs for the next cycle !

Sadly, it's easy to exploit poorly informed patients. Smart patients make sure they have done their homework, so they can arm themselves with Information Therapy !

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Friday, December 16, 2011

Side effects of Information Therapy

I am a big believer in Information Therapy. I feel that the more patients know about their medical problems, the better for them - and the better for their doctor as well !

I recently had an interesting conversation with a senior doctor, who was quite skeptical about the value of empowering patients with information. He felt this was just a new fad, and would just create more problems.

He believed that medicine was a complex subject – after all , it takes 8 years of full time training to become a surgeon ! How can one expect patients to understand the nuances of their medical problems in a few minutes ? Isn't it far better for them to trust their doctor, who is the true expert, and who can help them heal quickly ?

He was very critical of patients who came with pages and pages of internet printouts about their medical illness. They were often very confused ; and ended wasting a lot of their time ( and his ! ) wanting to discuss options and alternatives which did not make any sense at all. He felt that all this second guessing the doctor just caused patients to doubt their doctor – and this loss of faith and trust in the doctor would end up harming patients - and doctors as well.

Hypochondriacs have a field day googling their symptoms. They end up with “medical student “ syndrome, convinced they have all possible medical diseases, ranging from asbestosis to
zoonoses !

He was quite dismissive about “well-informed patients” who felt they had become “half-doctors” by reading and researching their medical problem online. A little knowledge can be dangerous – and patients who thought they know a lot about their disease often created more problems they solved, by challenging their doctor’s decisions. Doctors are not used to having patients disagree with them – and often ended up getting upset and angry. This just damaged the doctor-patient relationship, making this confrontational, rather than cooperative.

Everything he said was true – but this does not mean that there’s anything wrong with the idea of Information Therapy. Like anything else, information can be used properly – or misused and abused. The key is that the information we need to provide patients needs to be reliable, updated ; evidence based – and tailored to the patient’s needs. Rather than force the patient to search for this information himself, if the doctor prescribed information himself, this would create a win-win situation. The patient would trust this information, since it was coming from his doctor and not have to waste his time wading through pages of rubbish. The doctor would also be more confident that the patient was well-informed and had realistic expectations from his medical treatment.

The word doctor is derived from the word, docere, which means “ to teach”. When doctors don’t do so, we are abdicating our responsibility and forsaking our patients. They feel lost and are then forced to fend for themselves – thus wasting their time , and their doctors’ time as well , because they need to clear up their patient’s confusion and doubts.

The solution is simple . Doctors need to guide their patients and prescribing information therapy is a simple way of doing so ! This needs to be curated, reliable information, which both doctors and patients can trust, thus ensuring they are on the same page, and are active partners in a healing relationship.

There is a difference between information, knowledge and wisdom ! If doctors prescribe information intelligently , they can trust their patients will become knowledgeable, and together they can create a wise path to help their patients navigate their illness.

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Thursday, December 15, 2011

Egg sharing - or egg stealing ?

In many IVF clinics in India , doctors will often use one patient's eggs for another without her consent. They call this egg sharing - but really this is egg stealing. They do not bother to inform the patient that her eggs are being used for someone else !

For example, when they retrieve 10 eggs, they use only 6 for the patient, and borrow 4 to give to someone else

This is why there are so many patients who have 12 mature follicles on the ultrasound scan, but the doctor gets only 6 eggs !

This kind of lack transparency will end up giving all IVF clinics in India a bad reputation !

As a patient, you need to be well-informed about your treatment, so take an active interest in what is happening . You can always ask the doctor to show you the ultrasound screen during the scans, so you can track your follicles; and ask for prints of the scans as well.

Ask questions and speak up !

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Poor quality treatment - patient ? doctor ?

When the IVF cycle fails, patients often blame their doctor for not doing a good job. However, this blame game does not help at all ! It just creates anger and resentment, as a result of which patients become bitter and lose confidence in all doctors.

When things don't go according to plan, I always tell the patient that you need to take a proactive role in your treatment, before your treatment starts, s you know exactly what to expect. This way, if things are not going as expected, you know this before the problems get worse.

This does not mean that you need to become a medical expert - but it does mean you need to become an expert patient !

For one thing, there's little point in blaming someone else for problems. Even if these do occur because the doctor goofed, obsessing over this just makes a bad situation worse, because you them end up playing the "woulda, coulda, shoulda" game.

In any case, you can never change someone else's behaviour - you can only change your own !

Many patients complain that doctors don't give them their medical records. While it's true that
good clinics will do this routinely, part of the problem is patients don't bother to ask for them either ! If you request the doctor to give you a copy of your records in writing, no one will refuse to do so. You do have a legal right to your records , but you need to assert this.

The important thing is not to treat yourself as a helpless victim. Take active responsibility for your medical care - and learn from your mistakes, so you don't repeat them again !

Be charitable - and never attribute to malice which is a result of stupidity - everyone is allowed to make mistakes once !

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Wednesday, December 14, 2011

Pelvic pain and infertility

Lots of infertile patients also have pelvic pain . Both pelvic pain and infertility are common complaints amongst women in the reproductive age group, which is why the coexistence of pain and infertility is extremely common. Sometimes the pain is just garden-variety dysmenorrhea ; and sometimes its pain because of endometriosis, which causes both pelvic pain as well as infertility. Sometimes it's pelvic congestion syndrome and often we don't have a very good answer for why there is pelvic pain.


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Tuesday, December 13, 2011

Treating shadows in infertile couples

Modern medicine involves a lot of testing. While some is useful, overtesting leads to unnecessary overtreatment for many infertile couples. Here's how you can protect yourself, to make sure your doctor does not waste time treating shadows !
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The one thing Malpani Infertility Clinic does not have

Most IVF clinics take pride in using "state of the art" technology and often tom-tom the fact that they use the latest equipment.

There's one thing which our clinic does not have - unlike all other IVF clinics - and we take pride in this.

We don't have any assistants !

This means that every time you come to Malpani Clinic, you get to see either Dr Anjali or me , because there are no assistants !

So if you want hands-on personalised care, with treatment protocols tailored to your clinical situation, please come to us !

However, if you are happy being another number in a large impersonalised clinic, when you are never sure if you will ever see the "main doctor" again, then we are not the right choice for you.
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Saturday, December 10, 2011

Aphorism for surgeons

A surgeon takes 10 years to learn how to operate - and another 10 years to learn when not to operate !

Friday, December 09, 2011

Is doing IVF for women with high FSH levels futile treatment ?

I recently saw a patient who begged me to do IVF for her. She had an extremely high FSH level of over 40 mIU/ml which clearly meant that she had ovarian failure. The chances of her being able to produce viable eggs which we would be able to use for IVF were extremely low. She was a thoughtful intelligent patient who had a clear understanding of her medical problem and also understood that her treatment options were extremely limited. She was very sure that she did not want to use donor eggs and was wondering if I would be willing to do an IVF cycle for her. She was quite hesitant about making this request because she had been refused by many IVF specialists in the past. She felt that I would also refuse her request, which is why she made this very tentatively.

I sat down and explained to her that as long she had realistic expectations from me and the treatment I could offer her , I would be happy to take her on as the patient. Read more to find out why.
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Thursday, December 08, 2011

Failed IVF - is is the uterus ? or the embryos ?

Most IVF cycles result in the formation of good looking embryos ; and most patients naturally expect these embryos to become babies after the transfer. Now that all the in vitro lab work has been completed, nature will take over and make sure the embryos will become babies. Sadly, most IVF cycles still fail, and when good looking embryos fail to implant, the natural tendency is to blame the uterus , but this is usually not true !

Read more
to find out why.

Wednesday, December 07, 2011

Why do frozen embryos have a higher success rate than fresh embryos ?

A few years ago, everyone believed that fresh embryos were better than frozen embryos . We felt that they had a better chance of becoming a baby ( in scientific jargon, that they had a higher implantation rate.)

However, we are now starting to realise that this is no longer true; and that thanks to vitrification, the success rate with frozen embryos is better ! This may seem counterintutive - but here's why transferring frozen embryos has a higher success rate than transferring fresh embryos.

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Tuesday, December 06, 2011

IVF treatment - Chance, choice and destiny !

While the IVF treatment process itself is well-defined, the outcome of an individual cycle is always uncertain - something which seems to be true for most complex biological systems. While we are very good at making embryos in the IVF lab, after we transfer them into the uterus, we have no control over whether or not they will implant.

So what affects the outcome of the IVF cycle ? Is it chance ? choice ? or destiny ? And what intelligent choices can you make to improve your chances ?

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Monday, December 05, 2011

IVF Surrogacy and Aamir Khan

Now that Aamir Khan has publicly acknowledged that he has had a baby using IVF surrogacy, surrogacy has become a hot topic once again in the news . As with every story, this will have a mixed impact - some good, and some bad.

The good impact is that surrogacy will now become much more acceptable as a method of family building. Celebs play a big role in influencing societal attitudes and the fact that Aamir Khan has used surrogacy to have a baby and has issued a press release stating this publicly means that many other infertile couples will want to learn more about this option.

The bad impact is that surrogacy will now become much more acceptable as a method of family building. Most infertile couples are pretty clueless about when surrogacy is an acceptable treatment option - and the danger is that since Aamir Khan has endorsed this option, many other infertile couples will follow blindly in his footsteps. The truth is that surrogacy is often misused, overused and abused. Using it for treating women who have had repeated IVF failures or miscarriages , even when their uterus is completely normal, is not good medical practise, in my opinion. However, it's much more lucrative for doctors, and now that Aamir Khan has given the practise his stamp of approval by using it personally, the overuse will multiply manifold.
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Why do doctors charge so little ?

If this question causes you to raise your eyebrows, let me rephrase this.

Why do lawyers charge far more than doctors do ? Both medicine and law are learned professions which have been around for centuries. It takes years of education to qualify as a doctor or a lawyer; and both are service professions.

However, lawyers charge disproportionately more than doctors do. Many lawyers charge as much as Rs 1 lakhs just to appear in court, whether or not they actually argue the case . Moreover, they have a much cushier lifestyle, with very little risk. They work fixed hours and do not have to deal with emergencies. The only skills they need are to draft and to argue, unlike doctors who have to learn how to operate as well !

Even though doctors slog much harder, they still charge much less than lawyers do. Their training is far more grueling and takes much longer. They have to be available at all hours - and are at high risk for being sued , in case something goes wrong ( even if it's not in their control).
Even though they perform a far more useful function than lawyers ( just think - if you were stranded on a desert island, would you rather have a doctor as a companion, or a lawyer ?) , they get paid a pittance. To add insult to injury, patients are always unhappy when paying the doctor and they pay his fees very grudgingly. However, when they need to pay their lawyer, most clients may much larger amounts, without complaining !

Why is this so ? Do we expect doctors to be superhumans , who are meant to slave for their patients without expecting any tangible financial returns ?

I think the reasons are primarily because of the differences in the training doctors and lawyers receive. Lawyers start of by fighting cases at which millions of rupees are at stake. They are used to dealing with large sums of monies - and are quite happy to charge a sizable chunk of this as their fee. After all, if they will millions for their client, why should their client mind giving them a small percentage of this as their fee ? Also, clients who win cases don't mind paying their lawyers, since he has earned so much money for them.

Doctors, on the other hand, are never taught how to handle money or to collect their fees. They are used to working for free during their residency , and never learn to charge what the worth of their services really is ! After all, if doctor saves your life, how do you put a monetary value on the service he has provided ? If I give an infertile couple an IVF baby , whatever they pay me will always be a small fraction of the real worth of the service I have provided them with !

Sadly, many doctors still feel that their ethical standards demand that they should be able to rise "above" the filthy lucre of money. I think this is incorrect. People only value what they have to pay for - and the more they pay, the more they value the service ! Today, doctors take on all the risk of treating patients, without being adequately compensated for their time, expertise and effort.

This is not a sustainable system. People respond to economic incentives; and the next generation of smart students will no longer want to become doctors - they will all become lawyers ! Serves us right !

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