Monday, April 30, 2012

A tip to help infertile patients make better decisions

When you are infertile, it can sometimes be very hard to make decisions as to what your next course of action should be , especially when your IVF cycle fails. There are always many options , but because this is such an emotionally charged issue, it becomes very difficult to think through this logically. Should you just repeat the IVF cycle again ? or should you change your doctor ? or consider using donor eggs ? or surrogacy ? Or should we just forget about all this , and adopt a baby instead ? Having so many choices often leads to paralysis by analysis. The problem becomes even more acute when the husband and wife don't see eye to eye , and would rather adopt different solutions , because they have differing worldviews.

When you're stuck and don't know what to do next, it can be helpful to find a counselor who can walk you through your options and help you come to the right decision for yourself. A good counselor will never tell you what to do – she will help you find the answer within your own heart.

However, finding skilled counselors can be extremely hard - and another way of addressing this problem is to treat it as a business problem. You need to step out of your own body and pretend that this is a problem which is affecting someone else - perhaps a friend , who is confused , and needs to know what to do next, and has come to you for advise. You can then stop using your heart and start using your head. You need to approach this dispassionately and objectively , as a business problem , for which you can create a decision matrix and order your choices so as to maximize your gains.

While it may seem extremely heartless to take this approach, this is actually a far more efficient way ; and will help you to make the right decision much faster.

Here's another tip which will help you listen to what your heart is telling you - try tossing a coin ! Now I'm not suggesting that you let the result of the coin toss determine your future course of action ! No – this is far too important a matter to be left up to such a random event. My point is that while the coin is in the air, you will find yourself hoping that it comes up heads , rather than tails – or vice versa ! If you find yourself clearly preferring one side to another, this clearly means that your heart knows what’s right for you. It is telling you what to do next – and this simple trick is a useful way of being able to listen to your gut feel !

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Sunday, April 29, 2012

Our Surrogacy Gift - from Western Australia

We decided to start a family several years ago.  Being a same sex couple from Perth, Western Australia we had no choice but to look overseas to have a family.  I travelled to India in 2010 to visit a few clinics but came home disappointed.  We couldn’t give up on our dream of a family so we started to research again.   This is when we found the Malpani Clinic.   Speaking to Dr Malpani was very reassuring, he didn’t have any problem helping a same sex couple become parents.   WOW, our journey is beginning. 

I travelled to India in March 2011 for my initial visit and to provide him with my sample.   Dr Malpani then arranged everything for us.  Helped us plan our trip providing maps, list of accommodation near the Clinic and transport information.   Dr Malpani organised the surrogate, egg donor and legal contracts.  It seemed as though he took a personal interest in our wellbeing as well as helping us have our family.    Dr Malpani is very open and honest advising us upfront of all the costs involved which have remained as quoted throughout the entire process.

We had 3 tries with our first surrogates which were all unsuccessful.  The disappointment needed to be put into context as all pregnancies happen immediately as so much is involved.   Dr Malpani was always positive and encouraging.

Yay, success.  We are so excited and totally over the moon.  It hasn’t been overnight being 12 months since we first contacted Dr Malpani and 11 months since our first transfer attempt.   Dr Malpani  sent an email on a Sunday to let us know that we were pregnant.     When I received the email from Dr Malpani I knew it was the pregnancy test results. I couldn’t look so I threw the phone at my partner asking him to read it first.  Let’s just say that it was an emotional moment for us.  We have never experienced so much happiness at any news.  The word happiness just doesn’t seem to cover the emotions felt.

We are now 6 weeks pregnant.   The first ultrasound has shown a healthy embryo.  Dr Malpani is not financially motivated and is only interested in creating families.  I cannot recommend Dr Malpani and his clinic enough.

Brian & Adrian

[email protected]

Saturday, April 28, 2012

Information Therapy - Dial D for Doctor !

"You're a Doctor? How much do you make?"

I read this on another website..

Somebody asked: "You're a Doctor? How much do you make?"

I replied: "HOW MUCH DO I MAKE?" ...
I can make holding your hand seem like the most important thing in the world when you're scared...
I can make your child breathe when they stop...
I can help your father survive a heart attack...
I can make myself get up at 4AM to make sure your mother has the medicine she needs to live...and I will work straight
through until 4am to keep her alive and start the day all over again!
I work all day to save the lives of strangers...
I will drop everything and run a code blue for hours trying to keep you alive!!!
I make my family wait for dinner until I know your family member is taken care of...
I make myself skip lunch so that I can make sure that everything I did for your wife today was correct...
I work weekends and holidays and all through the night because people don't just get sick Monday though Saturday and during normal working hours.
Today, I might save your life.
How much do I make?
All I know is, I make a difference.

And that's why I love what I do !

Why do women who miscarry blame their uterus ?

I often see women who have had recurrent miscarriages , or who have failed many IVF cycles, who want me to do surrogacy treatment for them. From a purely rational point of view , this makes perfect logical sense . Their reasoning is simple – the fact that they are getting pregnant means that they are fertile; and the fact that the embryo is growing well within the uterine cavity for eight weeks and then not developing any further , clearly means that there is no problem with the embryo. Their unstated hypothesis is that their must be something wrong with either their uterus or the ability of their body to nourish the embryo after 8 weeks, as a result of which their embryo dies in utero and does not develop any further. It makes perfect sense for them to feel that their body is "rejecting" the embryo - perhaps because of some unexplained biological reason , which doctors still do not have the technology to be able to detect . If this hypothesis is true, then it makes sense to them to transfer their embryos into another woman's uterus , where they will not be rejected, so that they can grow and become a longed-for baby.


Friday, April 27, 2012

The bane of overtesting after a failed IVF cycle

I just saw a patient who had failed an IVF cycle. She was full of questions and was very confused because her doctor could not provide her with satisfactory answers. Her doctor had transferred two good quality blastocysts but these had failed to implant , and she wanted to know why. At the time of the transfer, the doctor was extremely optimistic and gung-ho – and had virtually promised her that she was going to get pregnant in this cycle, because everything was going so well ! When the cycle failed, the patient was distraught, and confronted her doctor, asking her for an explanation as to the failure.


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Tuesday, April 24, 2012

Lecture at the 8th Asia Conference on Healthcare and Health Insurance

I have been invited to give a talk at the 8th Asia Conference on Healthcare and Health Insurance. I will be speaking on - What health insurance companies need to do to put patients first.

Health insurance companies can help to catalyse a sea change in the healthcare system in India, if they decide to act as patient advocates. This is a huge opportunity - and I do hope they will make the most of it !

Article in the Times of India on dropping sperm counts

No fertile men in 50 years as sperm counts slide?

Monday, April 23, 2012

Internet report cards for doctors: threat or opportunity?

Internet report cards for doctors: threat or opportunity?
Aniruddha Malpani1
Daniel Strech. Ethical principles for physician rating sites. J Med Internet Res. 2011;13(4):e113). doi:10.2196/jmir.1899
For most doctors ,  the field of medical ethics remains an abstract subject which is of interest only to academics. However, ethics is applied to the resolution of conflicts in real life. This interesting paper uses the timeless principles of medical ethics to help to resolve a very modern conflict: how can we make sure that physician rating sites serve a useful purpose without causing harm?

Article on Information Therapy in the Times of India

"Searches for medical problems are the second commonest reason for going online, after pornography," says Dr Aniruddha Malpani, an IVF specialist from Mumbai, who believes in information therapy and runs the world's largest free patient education library, HELP.

He believes that the way forward for doctors is to encourage them to publish their own websites, and the way forward for hospitals is to provide information therapy.

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Friday, April 20, 2012

Some more pictures from the Vicky Donor premiere

The original sperm man at the Vicky Donor premier !

Vicky Donor and sperm donation in India

I attended the premiere of a new film yesterday. The movie is Vicky Donor , produced by John Abraham, which revolves around the topic of sperm donation. When we started India's first sperm bank over 20 years ago , sperm donation was a taboo topic. Very few people were willing to talk about it – and most people were quite aghast at the idea that Indian men would be willing to use donor sperm in order to have babies. We had to spend a lot of time educating people as to the important role donor sperm plays in infertility treatment - and why sperm banks were as important as blood banks. The media was very helpful in transmitting this message; and It's interesting to see how attitudes have evolved with the passage of time.

I don't see too many films and the reason I went for this premier was because we had been invited by the director,
Shoojit Sircar to provide medical inputs , to make sure that the film was medically accurate. I enjoyed talking to his assistant, Tushar, and was very impressed by how clever film makers are. Like any other film , the director has taken artistic licenses with medical facts to make sure that the story flows quickly , but this doesn't really detract from the message of the film.

I enjoyed the film ! It’s very well made ; and while the first half offers lots of laughs, the second becomes quite emotional. Not only does it talk about why sperm donation is needed, it describes the plight of the infertile couple very clearly. It's a touching tale , well told, and provides a much-needed perspective on how men and women look upon the problem so differently.
Both the hero and the heroine are newcomers to the screen ; as is the director , which makes the movie even more remarkable. I particularly enjoyed the way the doctor was played by veteran comedian, Annu Kapoor, who's done a masterly job. The supporting cast provided such excellent performances that for a moment you even forgot that they were acting. The story has been very well-crafted by Juhi Chaturvedi.

Do I have any criticisms ? These are minor and relate to a few medical inaccuracies which have crept in ( for example, placing the semen container into a thermos which contains liquid nitrogen to chill it – something which would kill the sperm in real life with a cold shock) . However , I feel the director is at liberty to take these , because they make the movie more interesting.

One of the reasons I really enjoyed the film is because I have great regards for someone who can use entertainment to educate. Bollywood carries a lot of clout in Indian society , and using this to educate people about serious topics is a challenging task . Infertility is always been a taboo topic , and this movie has very courageously chosen to tackle this head on. They have chosen not to make it too serious , because very few people would watch a tear-jerker. They have very successfully blended the need to keep an eye on the box office , with the motive need to provide a socially meaningful message. Just like impact investing is challenging because it needs to meet two goals at one time – both providing investors with an attractive return on investment , along with helping entrepreneurs to provide socially useful services, this movie too tries to provide the combine the best of two worlds – entertaining viewers while educating them; and making money for the producers as well. While I'm not a movie buff , and cannot predict how well the movie will actually do it the box office , it's been produced inexpensively and it is my prediction that it will perform well. It will be great that along with providing a box office index to judge the impact of a movie, critics would start judging the social impact of films as well. Taare Zameen Par was a path breaker, because it did such a great job with spreading awareness about dyslexia in India.

Film-makers carry a lot of clout; and I do hope Eros films will use Vicky Donor as a catalyst to provide an ongoing platform around which infertile couples can continue discussions about infertility. The problem with any film is that it has a very short shelf life, and that once it's been seen , people forget about it. However, thanks to the internet it's possible to continue engaging infertile couples , so that the discussion does not die away. Eros films released trailers of the films on YouTube , in order to promote the film , and these have become extremely popular. We have been flooded with emails from prospective donors from all across the country in the last few days ! I do hope they will capitalize on this , so that they can show that not only do movie makers make money and entertain people, they can also help to mold social attitudes.

Ironically , with the recent advances in reproductive technology , the need for sperm donation has progressively reduced, because thanks to ICSI, it's now possible for even men with zero sperm counts to have babies , so that not many men need sperm donation anymore. However, the need for egg donation has progressively increased , as women choose to postpone childbearing , and hopefully we will see a movie about egg donation – Juhi Donor - in the next few years !

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Thursday, April 19, 2012

IVF Success story for a NRI from the USA

My name is Farzana and I am one of the blessed patients of Dr. Malpani‘s .My journey of trial and tribulation began when I got married 10yrs back .We both were very fond of kids and started trying right away . I never knew my irregular periods will be such a big problem as being young you tend to take things lightly. After two years of trying we finally went to a gynecologist to get ourselves checked .To my dismay I was diagnosed with polycystic ovary syndrome and straight away told to be on medication and diet control and that’s it. Nothing happened for another 3 years and after lot of sobbing and crying we decided to go to a reproductive specialist in California.

They were very straight forward about our infertility and told us as we have crossed our prime age it will be difficult for us to conceive .They put us on three cycles of clomid which failed and later on we were suggested to go for IUI’S( intra uterine insemination ), which we did and after 7 failed cycles of IUI’S finally I had enough of it , with all the medicines, doctor’s appointments , hopes and disappointments and not to forget the feeling of worthlessness which took a toll on my well-being . My positive personality and carefree attitude vanished , I had changed for the worse .By that time we had drained all our funds as the medical treatment of our infertility problem was not covered by insurance in US.
One day I decided to take matters in my own hand and searched for fertility related problems on the net and right away Dr. Malpani’s website came up. I wrote to him casually about my problem and to my surprise I got a prompt reply and Dr.Anirudh Malpani suggested me to stop my IUIs right away and go for IVF’S , which I am thankful to him for.

Dr.Malpani’s clinic came as a pleasant surprises . It didn’t look like a typical doctor’s office but rather had a comfortable cozy ambience with friendly front office staff and cordial nurses.
Dr. Anirudh Malpani talked to us in detail as a friend and discussed with us about our problems and frustrations, he suggested that we are not alone and he and his staff will always be there throughout the IVFprocess. The best thing about the doctors is they remember your name and Dr. Anjali Malpani is a fresh breath of air in the clinic, her friendly demeanor will put you at ease from the beginning and you will immediately come to know that you are in good hands.

The IVF procedure becomes easier when you get a good support from the doctor and nurses, you are explained everything in detail from the start to the beginning and even get the courtesy to see your embryos before the transfer.

Though I had 4 failed IVF’s but doctor Anirudh and Anjali Malpani tried there level best to provide me with all the best options to conceive. I have never seen any doctor so confident and positive, Dr. Anjali always told me that I will conceive .Now here I am 2 months pregnant with all the support and treatment of Dr.Malpani. By God’s grace I am constantly guided by Dr.Anirudh malpani regarding my medicines and treatment though in USA .The best line I ever heard “Farzana I will always be your doctor no matter where you are “.

[email protected]

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Wednesday, April 18, 2012

Why I admire women with vaginismus who come for infertility treatment

Vaginismus is an extremely distressing problem where the woman is medically completely normal , but because of an involuntary spasm of the vagina muscles , she cannot allow vagina intercourse. Women with vaginismus experience shame and guilt because they blame themselves. They feel that they are depriving their husband of sexual pleasure, by not being able to have intercourse with him. Even worse, when people start asking questions as to when you plan to have a baby, they cringe with shame and embarrassment, because they know they will not be able to get pregnant , because they can't have sex in the first place. Because this causes so much distress, it’d very hard to share this problem and discuss it with anyone else. They feel they are freaks. While some husbands get understandably upset, many can be quite understanding because they love their wives, but don't really know how to resolve the problem because they don't want to inflict pain on their wife ! This becomes the elephant in the room which no one does anything about.


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Tuesday, April 17, 2012

Why patients need to complain

As a practicing doctor, I hear a lot of complaints about the bad experiences which patients have had at other clinics. For example I recently sent a patient to an x-ray clinic for her HSG. While the procedure was performed flawlessly from a technical point of view, she was extremely unhappy about the fact that she'd been made to wait for over three hours. She was complaining quite volubly to me when I asked her a simple question – Have you made a complaint to the clinic in writing?

She looked back quite puzzled as she had never thought about doing so. I explained to her that unless patients provide feedback , it's not really possible for doctors to improve their services. Doctors need constructive criticism in order to be able to improve.

Patients are often very unwilling to complain. They are quite scared to complain about the clinic at which they taking treatment currently , because they're worried that if they do so , the staff will get upset with them, and may not provide their patient with quality medical care . Patients are vulnerable and are scared that the medical staff may abuse their position of power if they take offense . This is why most patients keep quiet and put up with poor quality medical care, even if they are seething on the inside.

After the treatment is over, most patients forget about how unhappy they were ; and will not bother to take any action, since the problem lies in the past. Partly , this is because they feel they powerless and helpless , and assume that doctors don’t care about complaints from patients, because they are too high and mighty and too busy to bother over such trifles. If things are going to improve, then why bother to take the time and trouble to complain ? It's true that complaining takes a certain amount of energy , but I think this is actually a duty which patients owe to doctors ; to themselves ; as well as to future patients. If you've not been happy with a particular service, if you take the trouble to point out this deficiency to the hospital , it's possible that an enlightened hospital administration will take the complaint seriously and fix the problem , so that the other patients they treat in the future won't have to put up with the same inconvenience you did.

Sadly, patients are often too lazy to complain. Their commonest justification is selfish - Since my treatment is now over, how will complaining help me ? It’s easy for them to justify their passivity by saying that there’s no point in complaining, because doctors don’t care and will not listen ! However, if patients do not speak up, then to whom will doctors listen ?
It's obviously in the patient's best interest to make sure they get good quality treatment from doctors. It's also in the doctor's best interest to make sure that they provide good quality treatment. The best way to create a win-win situation is to provide an atmosphere where patients feel that their complaints will be treated as gifts !

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Monday, April 16, 2012

Why did my IVF cycle fail ? And what can I do differently the next time ?

When an IVF cycle fails , patients want to know what they need to do differently next time. Was there a problem with the eggs ? or with the sperm ? or with the uterus ? While it can be very hard to pinpoint the problem precisely , it's important to think through these questions intelligently .

In the vast majority of patients, if fertilization has been achieved, there is very little role which the sperm have to play. In one sense , sperm are just missiles which Ignore warning carry the husband's DNA ; and once they have fertilized the eggs, there is not much which they contribute to further embryonic development. This is why pregnancy rates even for men with extremely abnormal sperm are very good when we use techniques such as ICSI. If the sperm DNA fragmentation test is abnormal, this causes a lot of anxiety and many doctors will blame a high level of sperm DNA fragmentation for IVF failure , claiming that it's the fragmented sperm DNA which is causing genetic abnormalities in the embryos, as a result of which they fail to implant, but this is not a hypothesis I subscribe to, because there’s no evidence to support it.


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Saturday, April 14, 2012

Free Medical Translator

It can be hard for a doctor to take a medical history when he cannot understand what the patient is saying. Imagine how much worse the poor patient’s plight must be ! Being ill – and then not being able to explain to your doctor what’s wrong with you because your doctor cannot speak the local language can add immensely to your frustration. Unfortunately, translators are not easily available ; which is why we have developed this application, which allow doctors to take a medical history from patients, even when they do not speak the same language. This is a work in progress; and we plan to add more modules and languages in the next few months. We hope to create a universal platform, which doctors from all over the world will be able to use !

Check out the Free Medical Translator demo at

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Friday, April 13, 2012

Is your hysterectomy really necessary ?

A school friend came to me for advise yesterday. She is now 48 years old and was having heavy period which were also painful , for the last two years . She been advised to have a hysterectomy , and wanted to know whether it was better to do a vaginal hysterectomy or a laparoscopic hysterectomy.

While chatting to her, I pointed out that hysterectomies are often performed needlessly. Many studies have shown that lots of them are done even though they are not required; and that the most important determinant of the hysterectomy rate in a given town is the number of gynecologists who practice in that town ! There is no question that hysterectomies are one of the most overused surgical procedures; and that even though there are now many better many nonsurgical alternatives to treating heavy periods and pelvic pain, this remains one of the most commonly performed surgical procedures.

There are many reasons for this. The most common is the fact that gynecologists are trained to be surgeons ! They like operating , and are quite happy to propose a surgical solution for a woman who has a problem , even though it could be treated by less aggressive measures.
A lot of this boils down to their worldview; and it’s interesting that exactly the same problem of heavy painful periods in a 48-year-old woman would be handled completely differently by a homeopath , for example , who would treat her with medical therapy.

It's not that there is a conspiracy against patients; or that gynecologists are out to do unnecessary surgery. Most doctors want what's best for our patients , and will not deliberately set out to harm them. However, if you have a hammer in your hand , you do tend to see nails all the time !

I was talking to her about alternative nonsurgical methods for dealing with her problem, because I told her that she was quite likely to become menopausal very soon , at which time her problems would naturally disappear . However, she became agitated and upset. She had pretty much made up her mind she wanted a hysterectomy and she didn't really want to hear about nonsurgical alternatives - she just wanted to know which route was the best option for her ! However, as a friend , I didn't think it was fair on my part not to explain the downsides of doing unnecessary surgery to her.

Part of the reason she was so confused was she said she had already been to over four different gynecologists ( one of whom was an uncle) ; and all of them had uniformly told her that she needed a hysterectomy. Why I was I being a contrarian ? When I asked her whether any of them had advised medical therapy, she said - I tried this for two months , and this helped, but when I stopped , the bleeding and the pain came back , so I decided to go in for a surgical solution. She had obviously not being given an adequate therapeutic trial with medical therapy, which is why she felt that surgery was her best solution - something which was a result of a flawed perception on her part.

She had had a MRI scan done and requested me to see it. “ My MRI scan shows I have a 3 cm chocolate cyst; and a 4 cm fibroid. After seeing these images , all the gynecologists agreed that I needed to have my uterus removed. “ It's become an increasing problem that doctors no longer seem to treat patients anymore. Rather than talk to the patient, they are more interested in treating the images which the radiologists and sonographers produce for them. Now these are gorgeous images , which give us great insight into the disease and the distortions which they create in the anatomy , but there's very little correlation between what the MRI or ultrasound scan picks up , and what the patient perceives. Thus it's well known that a patient could have a very large endometriotic cysts , which may not cause any symptoms at all. She may remain blissfully unaware she has such a large cyst, because she has enough sense not to go to a doctor !

The bottom line is that it's very unlikely that an asymptomatic patient will be benefited from a surgical intervention . If there are nonsurgical alternatives, it’s best to pursue these aggressively , before considering a surgical option. I told her that her surgery was an elective procedure ; and it would be best if she tried aggressive medical therapy , before making a final decision.
Unfortunately she wasn't very happy , because she had mentally geared herself up for going through the surgical procedure . After hearing me , she was completely confused. However, it’s better for patients to be confused , because they know they have alternative options, rather than end up doing surgery which was never required in the first place , and then regretting this later on.

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Thursday, April 12, 2012

Why it's not a good idea to have laparoscopic surgery before doing IVF

Many infertile women have fibroids and endometriosis. These are extremely common findings in all women in the reproductive age group ; and we'll see them in fertile women as well, so it's not very surprising that we find see them in infertile. Now , when a gynecologist sees fibroids and endometriosis in an infertile woman, even if plans to refer this patient for IVF , he will often advise endoscopic surgery to remove the fibroid; as well as treat the endometriosis. The logic behind this is that removing the endometriosis will help to "cleanup the pelvis" and therefore increase the chances of embryo implantation. Many gynecologists explain to patients that fibroids can grow during pregnancy, and can cause a miscarriage; which is why it's good idea to remove them before actually starting the IVF cycle.


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Wednesday, April 11, 2012

Are books better than doctors ?

I have a back ache and am thinking of joining a gym , so I can exercise my back muscles to prevent the problem from getting worse. My wife insisted that I go see an orthopedic surgeon and get his advice as to what exercises I should do and which I shouldn't , because she's worried that exercising may strain my back and make the problem even worse.

I was very reluctant to go to an orthopedic surgeon because while they know a lot about things like arthroscopy and hip replacements , they actually know very little about mundane things like back pain, because this is a garden-variety bread-and-butter problem which doesn’t excite or interest doctors . Doctors don't understand much about exercise ; and if there's a problem , they usually refer the patient to a physiotherapist , and that's that. I was wondering what the advantage of seeing a doctor would be.

I also told her that I've read enough books on back ache , which describe what exercises can help and which will not, so I am quite well informed. I'm not sure what value going to an orthopedic surgeon would add to my life. She was quite insistent that orthopedic surgeons are experts and know a lot about all this stuff . Her point was that a book is all about theory , while a surgeon would provide practically useful advise.

I feel that a book is actually a much better source of information , because it is written by an expert who has a special interest in the problem , and is willing to take the time and trouble to share his expertise with others. This is why I would rather learn about what exercises to do and how to do them from a book , rather than going to a doctor.

This dichotomy between theory and practice is completely artificial ! All sound theory is based on practical experience – and a book is written by an expert who has a lot of real-world expertise.
We have medicalized life so much , that we seem to feel that we need permission from a medical expert before we can do any thing - even doing something as simple as exercising ! ( It’s ironic that most exercise books will also start off with a disclaimer – please take your doctor’s advise before starting a fitness regime !) I think this is a broken model and not one I'm willing to subscribe to. While doctors are great and can provide a lot of value, we need to use our commonsense so we know when to use their services - and when not to.

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Tuesday, April 10, 2012

When patients know more than their doctors do

Life used to be much easier in the past for both patients and doctors, when doctors were acknowledged to be the medical knowledge experts . They knew all there was to know about treatment options for all kinds of diseases . They spent many years in medical college , learning from their medical textbooks and their professors ; and since medicine is a professional guild , they transmitted information to each other and shared experiences by reading medical journals and attending medical conferences . They know what to do when the patient had a problem, which is why patients went to them when they fell ill . They were able to provide solutions which the patient would accept , because he knew that the doctor knew much more about how to solve their problems , than they possibly could.

However times have changed, Firstly, with the explosion of medical knowledge, there’s really no way a doctor can keep up to date with all the changes which occur in medicine . Most doctors have become specialists, who know a lot about their own particular field , but understand very little about what's happening in other areas . Unfortunately , patients don't come with neatly packaged problems with well defined diagnostic labels. Most have more than one disease and will often have multiple problems. So while a gynecologist may know a lot about treating heavy menstrual periods , she may not know anything at all about the glaucoma which the patient also happens to have . Secondly, it’s become much easier for patients to become well informed about their medical problems . There is a wealth of reliable information available online - a lot of which is written for patients , and a lot of which is was written by patients. This helps patients to become experts on their problem , and armed with information therapy, they often know much more about their own diseases that the doctor will . Finally , it’s patients who are the experts on their own bodies. They have their own worldview, and know exactly how they want be treated as human beings - not something which a doctor can figure out within a 15 minute consultation !

Some doctors respect the fact that there are intelligent patients who are experts on their disease ; and are willing to listen to their opinion . They respect their patients and encourage them to provide inputs , so they can tailor the right treatment protocol for each individual patient. However , many doctors feel threatened by well informed patients . They will use pejorative statements , such as – Who’s the doctor here – you or me ? If you don't like my advice , go find another doctor !” This is a very paternalistic approach which is a hangover from the past, and is not something which works well today .

However, there are patients who feel intimidated and threatened , and because they are scared of their doctor, they will passively listen to whatever the doctor dishes out. The truth is that there are often areas in which you are likely to know much more about your problem than your doctor; and you need to be respectful and share this information with your doctor , so you can work together as partners in your medical care.

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Saturday, April 07, 2012

The trouble with trying to be conservative

I'm a conservative doctor and try to avoid surgical interventions as far as possible. I also try to treat all my patients as intelligent patients , who can make well-informed decisions for themselves when I explain their option to them. I think this is a sound philosophy , but I recently nearly burnt my fingers following this.

I saw a patient for whom I made a diagnosis of an unruptured ectopic pregnancy. She was one of those unlucky three percent who had an ectopic after embryo transfer . Because we were monitoring her hCG levels closely, we made the diagnosis quite early – when she was 5.4 weeks pregnant, and her hCG level was 1450 . The diagnosis was made based on the fact her HCG levels were rising slowly; and we couldn't see a in the uterine cavity on the vaginal ultrasound . I explained to her that this was an ectopic pregnancy, which needed to be treated promptly with methotrexate. I shared a website with her, which explained what an ectopic was; why it was potentially a time bomb ; and why it needed prompt intervention before it became a life-threatening condition. She was an intelligent patient , who understood what I said and agreed to follow instructions.

However, she then disappeared for six days and then came back again with a third ultrasound report from another doctor . Her hCG level had risen to 3600 by this time ; and the repeat ultrasound was reported as showing no evidence of an ectopic !

I had to sit and describe the concept of the HCG discriminatory zone to her , in order to explain why her sonographer had missed the diagnosis. A sonographer will only interpret the black and white shadow he sees on his ultrasound screen . He is not a clinician – and the eye only see what the mind knows. Ultrasound works by bouncing high frequency sound waves off the body’s tissues. In an early pregnancy, the only thing we can see is the gestational sac, which is a fluid filled structure and appears dark on a scan. It’s easy to see this when the sac is in the uterus, because the uterine wall consists of muscles. This is solid, which is why it has a different acoustic texture from a sac . This acoustic contrast makes it easy for us to pick up a very early pregnancy when it’s located inside the uterus . However, when the sac is outside the uterus in the fallopian tube , the acoustic contrast is not as pronounced; which means we have to wait till the sac becomes much larger , before we can see it. The danger is that if we wait too long , the sac may burst, leading to internal blood loss and possible death.

I was very upset that in spite my spending so much time explaining her treatment options to
her , she had chosen to just disregard my advice and potentially risk her life. While is no doubt that conservative treatment is better for patients , it actually offers an increased risk for doctors , because if the patient does not follow the advise, there's no way in which a doctor can be sure that the patient was compliant.

I was quite upset . At one level , I could understand why she was reluctant to take the methotrexate. Since her pregnancy tests were positive, she was still hoping against hope that this was an intrauterine pregnancy ; and that she would finally have a baby after so many years of waiting. However, false hope doesn't serve any useful purpose ; and while it can be hard to come to terms with the truth , it's far better to acknowledge this quickly , rather than wait for complications to occur. Part of the problem was that she was feeling absolutely fine – and when she googled the symptoms of ectopic pregnancy (which include pain and vaginal bleeding) she was perplexed that she did not have any of them. If she had no symptoms, maybe my diagnosis was incorrect ? Moreover , when she went to a sonographer to repeat the scan in order to get a second opinion, he had told her that he could not see an ectopic ! This is why she was quite hopeful that perhaps she has a very early pregnancy , which I had misdiagnosed. This is why she was keen on waiting , in the hope that everything would work out to be fine.
However, this approach can prove to be an expensive mistake , because as the hCG levels rise and the ectopic pregnancy becomes larger , the failure rate of medical treatment with methotrexate also rises.

Also from a doctor's risk management perspective, this could potentially have been a complete disaster. When I first made the diagnosis of an ectopic pregnancy, I could've admitted her in hospital and done an emergency laparoscopic surgery to remove the ectopic . This would have been definitive treatment and would have been perfectly acceptable , because it would have treated the problem quickly, cleanly and efficiently. However, as a good doctor , I wanted to avoid surgical intervention , which is why I recommended a more conservative treatment to her. However, she just pretended to agree with me and then choose to ignore my advice. If she had failed to turn up for a follow-up , it's quite possible that this ectopic pregnancy would have grown and ruptured ; and then she could have sued me , because she could claim that I was negligent in not doing an immediate laparoscopy , when I had made the diagnosis the first time. The irony is that I was trying to avoid surgical intervention in her own best interests – and yet this could have come back to haunt me , for no fault of mine.

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Friday, April 06, 2012

Why I expect my patients to be able to interpret their own reports

Before doing an IVF cycle, I need to order multiple tests for patients , in order to make sure the quality of their eggs, uterus and sperm are fine. When patients come to me with their reports, the first question I ask them is - What's your opinion about your results ? Are they normal or
not ?

Some patients get very confused when I ask them this . After all, this is the question the patient is meant to ask the doctor! They can't figure out why a doctor would ask this question ! Does this mean that I don't know how to interpret the test reports and that I need their advice ?

No, of course not ! All it means is that I expect my patients to take an active intelligent interest in their treatment - and a good way of making sure that they're doing so is by asking them questions every time I see them . This is why quiz them , and not only is this helpful for my patients, it helps me as well. Let me explain.

I tell my patients that they have to do their homework if they want to take treatment at our clinic. This way , patients have a much better understanding of exactly what we're trying to accomplish for them in the IVF lab. This makes it much easier for them to cope with the ups and downs of the IVF cycle, so that no matter what the final outcome , at least they have peace of mind they have received good quality medical care.

This kind of approach is good for patients because it increases their self-confidence levels . They no longer think of themselves as being incompetent or unable to understand what's happening during their IVF cycle. Many doctors love using jargon and complexifying IVF treatment, to put patients in their place. This helps them to project themselves as being high-level experts, who know so much that the patient will never be able to understand their thought processes.

Our approach is exactly the opposite , because I think patients are intelligent – and if they cannot understand what I am doing, it’s because I am not doing a good job with my
explanations ! Being aware of what's happening to them helps me to make sure that no errors are inadvertently made either by me - or by my stuff. An actively engaged , well-informed patient is the best protection against medical errors - and Information Therapy helps to improve patient safety considerably, at no extra cost !

It's also good for me because it helps me to check that I have done a good job in explaining to my patients exactly what's happening to them. Patients are quite intimidated when they're talking to the doctor ; often , even when they don't understand what I tell them , they will continue to nod their head because they scared that if they say they don't understand , they will look like idiots . However, by asking patient's questions , I can make sure that they have a clear grasp on exactly what's happening.

It also helps my nursing staff to provide better care. They have to treat my patients with respect, because they know exactly what’s happening !

It's quite humbling to realize that even though I think I'm a good communicator , a lot of patients still don't understand the basics about IVF, no matter how hard I try. This is a valuable learning experience which keeps me on my toes , so that I keep on trying to develop new tools to be able to improve the signal-to-noise ratio in our doctor-patient communication.

Another fringe benefit is that sometimes patients will use a clever metaphor to illuminate a medical procedure . I can then incorporate this, when I'm explaining something to other patients. Asking my patient's questions allows me to learn from them !

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Looking for the right IVF clinic

I received this email from a patient today.

My name is AF and my husband and I reside in USA. We are looking into traveling abroad for IVF treatment. If you could please answer my questions about your clinic I would very much appreciate it. I am sure you receive many emails, but please understand that we want to research the best we can before we make the big, scary, commitment to travel abroad for IVF treatment, so your quick response will be most appreciated and will ultimately guide in my choice of a clinic.

1. Do you recommend any other infertility tests for us?
2. According to my circumstances can you please give me a cost estimate for one cycle of IVF (please indicate if cost includes all medications and procedures necessary to complete the cycle, if medication is not included in cost estimate can you please provide a cost estimate for medication)?
3. Do I have to use your pharmacy for medications?
4. What is the success rate for someone in my circumstances/age group at your clinic?
5. How are your lab conditions? Is there any certification for labs in your country and does your clinic’s lab meet these qualifications?
6. Is there any nationally recognized accreditation for fertility clinics in your country, and does your clinic/Doctor meet these qualifications?
7. Who is the Doctor/s that will be performing the procedure and lab work, how are they qualified, and do they speak English?
8. What is the process for payment, and do you accept Visa or Mastercard?
9. Is there someone there who can help us coordinate travel?
10. Do you have a recommended acupuncturist?
11. Is there any protection for us if there happens to be complications with the procedure?
12. Do you have any plans that allow you to pay a set amount for multiple IVF tries?
13. If I had a clinic here that was willing to work with me for initial preparation before my travel (I do), could I complete the procedure in less than 14 days?
14. Do you have experience with patients from the USA?
15. Is there anything else that sets your clinic apart from other clinics worldwide, or that you would like to share about your clinic?

I was very impressed. This is thoughtful patient, who is doing her homework !

Here are my answers to her queries.

1. Do you recommend any other infertility tests for us?
I need the results of ALL the following simple medical tests before starting
An IVF cycle.

1. semen analysis for your husband ( to check his sperm count and motility);
2. Blood tests for you for the following reproductive hormones – FSH ( follicle-stimulating hormone),LH ( luteinizing hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs). Do this from a reliable lab such as SRL (;
3. A HSG ( hysterosalpingogram, X-ray of the uterus and tubes) on Day 8 of your cycle ( to confirm
4. Your uterine cavity is normal). You can read about this at;
5. A vaginal ultrasound scan on Day 10 or 11 which should check for the following.
a. ovarian volume
b. b. antral follicle count
c. c. uterus morphology
d. d. endometrial thickness and texture
Please send me the ALL the detailed test results and medical reports . You can scan them in as a single Word file and email them to me.

If the tests have been done in the past one year, there is no need to repeat them.
If there is a problem, then we can treat it prior to starting IVF!

2. According to my circumstances can you please give me a cost estimate for one cycle of IVF (please indicate if cost includes all medications and procedures necessary to complete the cycle, if medication is not included in cost estimate can you please provide a cost estimate for medication)?

Our charges for an IVF/ICSI treatment cycle are $ 4000 only. This includes all
Medical treatments and procedures. Medicines would cost about US $ 1000 more. However, the cost of medications can vary, and
Depend upon how many injections you need for adequate superovulation.

3. Do I have to use your pharmacy for medications?

No – though the meds are much cheaper if you buy them in India

4. What is the success rate for someone in my circumstances/age group at your clinic?

Our pregnancy rate is 46% when we transfer 3 Grade A embryos in women less than 35

5. How are your lab conditions? Is there any certification for labs in your country and does your clinic’s lab meet these qualifications?

We are registered with the Govt of Maharashtra

6. Is there any nationally recognized accreditation for fertility clinics in your country, and does your clinic/Doctor meet these qualifications?

No, India does not have this accreditation process as yet

8. Who is the Doctor/s that will be performing the procedure and lab work, how are they qualified, and do they speak English?

Dr Anjali and I take care of all our patients . We speak English fluently

8. What is the process for payment, and do you accept Visa or Mastercard?


9. Is there someone there who can help us coordinate travel?

There is more information on coming to the clinic at

10. Do you have a recommended acupuncturist?


11. Is there any protection for us if there happens to be complications with the procedure?

We’ve never had a problem in the last 20 years

12. Do you have any plans that allow you to pay a set amount for multiple IVF tries?

Because we have such high success rates, we can also offer you a guaranteed pregnancy treatment option.
You can read more about this at
You pay for 4 cycles in advance.
If you get pregnant ( pregnancy = pregnancy after 18 weeks of gestation) in any of these 4 cycles, everyone is happy !
If you do not get pregnant in these 4 cycles, we refund your money back to you.
This option will help you reduce your emotional risk and your financial risk

If I had a clinic here that was willing to work with me for initial preparation before my travel (I do), could I complete the procedure in less than 14 days?

Yes. If your local doctor agrees to help, you would need to spend only 10 days in Bombay.

14. Do you have experience with patients from the USA?

Yes. You can talk to some of our patients by email at

15. Is there anything else that sets your clinic apart from other clinics worldwide, or that you would like to share about your clinic?

You can read about how we pamper our patients at

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