Friday, August 31, 2012

The importance of seeing photos of your IVF embryos !

I often see patients who have failed IVF cycles elsewhere. These patients are confused , depressed and despondent because they are not sure what to do next. They come to me for a second opinion , looking for expert guidance.

The first question I ask them is - Can you please show me photographs of your embryos ?


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Thursday, August 30, 2012

Are IVF doctors overusing surrogacy treatment ?

India has the dubious distinction of scoring a number of medical firsts – for example, that  of being the diabetes capital of the world. We also seem to have become the surrogacy capital of the world, and patients from all over the world come to India for surrogacy treatment. This is a welcome sign , which suggests that Indian medical treatment has become world class,  and is great for infertile couples who actually do need surrogacy treatment. However, all this limelight is also causing some unforeseen problems – especially for infertile Indian couples doing IVF treatment.

We are now seeing many patients who are being advised surrogacy by their IVF doctors, because they have failed 2-3 IVF cycles. When the IVF cycles fail, the diagnosis the doctor glibly trots out is “ failed implantation” – and then promptly advises surrogacy. The implication is that if the embryos fail to implant, the “fault” must be with the patient’s uterus;  that her body is faulty and is rejecting the embryos which the doctor has so carefully created in the lab; which is why her best solution would be to use a surrogate !
Actually, this is completely flawed thinking, which benefits only one person – the IVF doctor. For one thing, it gets her off the hook for the IVF failure. After all, if the patient’s body is rejecting the embryos, what can the poor doctor do about this ?

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Wednesday, August 29, 2012

Providing a second opinion when an IVF cycle fails

As a senior IVF specialist , I'm often asked to give a second opinion on the IVF treatment which patients have taken another IVF clinic. This is a useful exercise for me , because it teaches me a lot. I can study the treatment protocols which other doctors use; and how they modify these , depending  upon the patient's response. I also probe to find out how much the patient has understood about their treatment, because this tells me a lot about good their doctor was. Good doctors take the time and trouble to educate their patients; and if the patient is well-informed, this is a sign that their doctor is a good physician. ,

Sometimes I'm forced to be critical of the treatment which was provided by the clinic . Providing a second opinion can be a difficult task , because you often have to second-guess what the other doctor did. It’s easy to point out flaws , errors and shortcomings with hindsight wisdom . It’s easy to be cleverer than the treating doctor because I am looking through a retrospectoscope ! However, I do not like criticizing professional colleagues,  and try to be respectful, because I always remind myself that I wasn’t there when the actual treatment was being performed, which is why I may not have insight into why the doctor chose to make certain decisions.


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Tuesday, August 28, 2012

Overtreating patients with low AMH levels

AMH is a relatively new blood test which is very useful in checking the ovarian reserve of women. It allows us to estimate the quantity and quality of eggs left in your ovaries, so can get a better idea of how you will respond to superovulation.  Basically, it allows us to check how young your ovaries are – and is much better than the older blood test of checking the FSH level, which was all what was available to us a few years ago.
However, like any other test, it has a lot of limitations. It provides useful information, but as with all biological systems, none of this is in black or white – these are all shades of grey. Like all tests, it needs to be interpreted by a skilled doctor, who uses his judgment to make sense of test result in the right clinical context.

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Monday, August 27, 2012

Will Clear Passage Therapy take up my challenge ?

Clear Passage uses a wide variety of clever techniques in order to lure patients. They claim to be able to treat lots of conditions , ranging from chronic pelvic pain to adhesions to blocked tubes. ( This is smart, because the more the number of conditions you claim to be able treat, the greater the number of patients will come to you.)

Patients who go to Clear Passage are self-pay , well-heeled patients who are self-referred. These are internet positive patients, who will scour the web to find alternative treatment options, because they are not happy with what their present doctor is offering. Clear Passage does a great job of targeting these patients !

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Saturday, August 25, 2012

Pregnancy after a failed IVF cycle

Linea nigra dark midline streak on a 22 weeks ...

All of us know of patients who have failed an IVF cycle and then got pregnant in their own bedroom ! This sometimes raises a lot of questions – how did they get pregnant when they failed the IVF cycle ? Was the IVF doctor good enough ? Or did he do a bad job with the IVF treatment ? Doesn’t this suggest that IVF doctors are greedy and tend to over-treat patients, by advising expensive treatments like IVF, even when they that the patient could get pregnant in their own bedroom ?


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Friday, August 24, 2012

Free IVF comic book - become an expert patient !

Are you thinking about doing IVF treatment ? 
Confused about what is happening during your IVF cycle ?
If your IVF cycle has failed, what should you do next ?

You can read and download a free 100 page comic book which can help you learn more about IVF ! 
 This comic book actually makes learning about IVF fun !  You'll be able to impress your doctor by how much you know !

Becoming an expert patient will help you get better IVF treatment and improve your chances of getting pregnant !

Non-IVF specialists

We all know that IVF specialists are infertility specialists who offer IVF treatment . Lots of infertile patients flock to them , because they are seen to be the court of last resort . They can offer lots of clever technological solutions to problems which otherwise could not be solved . either by conventional medical therapy or surgery.

Interestingly there is another breed of infertility specialists, which I call the non-IVF specialist ! These are the infertility specialists who specialize in trying to make sure that the infertile patients who come to them do not need to go for IVF treatment.


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Thursday, August 23, 2012

Trying to have a baby ? Free 700 page comic book !

Trying to have a baby ? You can read and download a free 700 page comic book which can help you to get pregnant quickly. 

This comic book actually makes learning about infertility treatment and IVF fun ! 

Becoming an expert patient will help you get better medical care and improve your chances of getting pregnant !

Finding the best IVF expert for your treatment

Infertile patients spend a lot of time on finding the right IVF expert for their IVF treatment. Not only do they spend hours scouring the web for the right doctor, the pore over hundreds of bulletin board messages in order to find the doctor who's just right for them. All patients want the perfect doctor - one who is uptodate, runs a well-equipped clinic ; and is kind and empathetic. While a lot of these searches are done online , they will also talk to friends and family members who been through infertility treatment ; and request their family physician for a referral to the best IVF specialist.

While it's true that finding the right IVF doctor can make a world of a difference to your IVF treatment, I feel that sometimes patients waste too much time and energy on this expedition.

One problem is that when they think they found the right IVF doctor , they will stop doing their homework. They then tend to uncritically accept whatever suggestions the IVF doctor makes , even though some of these may not be scientifically very sound or sensible.

Even worse, the fact of the matter is that trying to find the right expert can often become such an obsessive exercise that it consumes a lot of energy, which can be better utilized in other pursuits. I feel rather than spend all the time and energy trying to find the right IVF expert, most infertile patients would be much better off if they spend the same amount of time and energy trying to become expert patients themselves.

Expert patients are able to identify the right IVF expert for themselves - they do not get swayed by brand names , press releases and five star ambience ! They're also able to critically analyze their doctor's advise, so they can craft a treatment plan in partnership with their doctor, which works for them, rather than just blindly doing what the doctor tells them to do

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Wednesday, August 22, 2012

Frugal medicine - what Indian doctors can teach the US healthcare system

America is the world leader in a number of fields - and this is true for medicine and healthcare as well. Doctors all over the world come to institutions such as the Mayo Clinic and Johns Hopkins , in order to learn about the recent advances in medicines. These institutes are considered to be the embodiments of medical perfection.

Most of the leading medical journals are published in the US ; and most of the authors of the authoritative medical textbooks work in US medical schools . If doctors need advanced training in a particular area, they usually travel to the US ; and lots of the newest medical equipment, tools, technology, and drugs come from companies located in the US. Most keynote speakers at international medical conferences come from the US ; and because medical journals are published in the US , a disproportionate amount of papers published in the medical literature originate from medical centers in the US.

This is why most doctors look up to US doctors ; and this is one of the reasons why the American medical system has such a disproportionate impact on the rest of the world.  I can vouch for this from my personal experience as well. When I was a medical student , the medical books we read were all authored by US physicians ; and when I needed to complete my training, I chose to go to the Johns Hopkins and Harvard because they were supposed to be the best medical centers in the world.

While I have a lot of respect and admiration for US doctors, I think the sad truth is that the US healthcare model is broken. While there are still pockets of excellent, the system itself is dysfunctional .

US healthcare is very technology dependent and there is a lot of mindless over testing in the US. There are many reasons for this. Americans have always prided themselves on their technological expertise,  and they put a disproportionate amount of their trust in tools and technology in all parts of their life. It’s therefore hardly surprising that they will do this in healthcare as well.

Since so many of these technological innovations originate in the academic medical centers in the US, medical professors and researchers aggressively promote the use of these devices by giving lectures all over the world. The one thing the US is still the undisputed world leader in is marketing and advertising – and they apply these skills to the healthcare field as well.

Since the “Made in the US “ label is considered to be a prestigious badge, and since these professors actively publish their findings and disseminate them in international conferences, doctors all over the world ate happy to imitate them.

The doctors who author textbooks are those who work in academic medical centers , and they tend to over emphasize uncommon problems, because these are what they find interesting.  When you consider medical journals ( which is what most doctors read in order to remain au courant, the situation is even worse,  because journals only publish case reports about rare and unusual problems. Medical journals are full of zebra – which most doctors will never see in their lifetime . However, doctors who read these journals then start looking for the zebras in their medical practice , because they want to have their paper published in the medical journal as well - this is considered to be a status symbol in the academic world.

The problem with all this testing is that it's very easy to tick off boxes asking for panels of tests , but it's not very easy to think about which tests are required , and when. Because doctors love rare cases , they often order many tests , in order to pick up the unusual patient with the rare abnormality , so that they can brag to their colleagues about the diagnostic acumen. However , they fail to think about how much of the testing is completely inappropriate and uncalled for.  A patient of mine who has had recurrent pregnancy losses, and now lives in the US , wrote about how a nurse automatically collected over 22 test tubes of blood for testing , saying this is part of our routine workup for recurrent pregnancy loss. While this may seem very impressive , and patients can be very impressed by how thorough their doctor is and how painstakingly they hunt for problems, the fact is that most of her test results will come back as normal , and therefore not add any value at all to her medical care . This is the elephant in the room, which no one talks about – the sheer waste in routine US healthcare. To make a bad situation worse, not only are many of these new tests much more expensive , they also much harder to interpret , because they've not been standardized, and no one really knows what abnormal results mean , because we don't have enough experience with them.

Not only do doctors love ordering all these fancy new tests , they get very excited when one of the results come back as abnormal . They pat themselves on the back , because they finally identified the problem and picked up an abnormality which the earlier doctor had missed. Patients are also quite happy , because they feel that their new clever doctor has pinpointed the problem , and therefore will be able to provide an effective solution. However, it is a mathematical certainty that the more the tests your doctor orders, the more the abnormalities he will find – but a lot of these abnormal findings are red herrings , which have no clinical value at all , because they do not affect the clinical care of the patient.

American medicine, like a lot of other areas in America , has become wasteful because it has been supersized. We need to realize that this is not the best way of practicing medicine , and we need to start learning what I call frugal medicine.

Frugal medicine requires a thoughtful talk to intelligent, caring able to listen to the patient is selective about what tests the authors. These are not easy skills to acquire and there are not many role models to follow. Unfortunately, the commercial demands of modern medicine and the aggressive marketing by large multinational, multibillion dollar diagnostic testing industries and device manufacturers will mean that patients will have to do a lot of hard work if you want to find doctors who willing to practice cost-effective sensible medicine

Bigger is better is a broken model. Small is beautiful !

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Tuesday, August 21, 2012


Cryptospermia or cryptozoospermia is not a very common condition, which is one of the reasons this diagnosis is often missed. The word crypto means hidden , and as the word suggests , patients with cryptospermia have occasional sperm in the semen , but because their numbers are so few , they are very difficult to find, and easy to miss. This is quite a common problem when the semen analysis is done in a general medical laboratory, where the laboratory technicians are not experienced , and don't know how to do the semen analysis properly.  A lot of technicians will do the microscopic analysis of the semen sample quite casually – and will report it is as having a zero sperm count or azoospermia , if they cannot see sperm in the first quick glance.


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Monday, August 20, 2012

Why are girls being abandoned and battered ?

It's heartbreaking to read newspaper stories of girl children who have been battered to death by their parents or abandoned to die.

Thanks to the PNDT Act, everyone is aware about the skewed sex ratio in our country and the need to ban female feticide. However, even the word feticide itself is so highly emotionally charged that we sometimes forget that it has been used to frame the debate in such a way that it prevents us from clearly thinking about the issues involved objectively.

When we refer to sex selective abortions, we talk about female feticide. Then why don't we refer to all abortions as feticides ? All abortions involve killing the fetus , and not just the sex selective ones ! However, when the woman finds herself with an unwanted pregnancy, we give her the right to terminate this pregnancy because we respect her right to choose for herself. We believe that she has the freedom to choose what is right for herself, and our laws protect this freedom.  However, the word feticide is so highly emotionally charged , that we refuse to use this when we talk about medical abortions for unwanted pregnancies. This is why we all implicitly conspire to use double standards and refer to these pregnancy terminations using the much more neutral term , MTP or medical termination of pregnancy.  This is not something which is localized to India , and you see the same kind of debate in the US as well. Here , both the camps are equally strong , and while the antiabortion camp will talk about pro-life , the pro-abortion camp does not call themselves anti-life - they call themselves pro-choice !

It's all very well to talk about why society and the government need to lay down policies in order to protect the female fetus.  However, a truly enlightened policy would simply ensure that every child is a wanted child. If we can do this , then parents will naturally love and nurture their children because parental  love is one of the strongest biological urges humans have .

While we are tom-tomming our efforts to protect the female fetus in utero, what kind of protection are we offering these baby girls after birth ? Will we end up improving the sex ratio at birth – and then make the problem of neglected girls from 0 - 6 even worse ? The irony is that when Amartya Sen wrote his landmark paper about missing women 20 years ago, he was referring to the premature death of girls and women because of their neglect by their family and society – not to female feticide !

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Saturday, August 18, 2012

Why do you want a baby ? Genes , Pregnancy and Parenting


Fertile couples find it easy to make a baby in their bedrooms. Most of us take our reproductive ability for granted , and expect to be able to have babies when we are ready to grow our families.  The urge to procreate is extremely strong and as Sir Osler said, there are two primal desires for humans - to get and to beget !

Why do most of us want to have babies in the first place ?  Very few of us bother to analyze our motives, because babies are often the happy results of our pleasurable bedroom pursuits.  Many couples are just following their basic biological urges , as commanded by their selfish genes. For others , babies are a welcome byproduct of their sexual activity , and they are quite pleased to grow their families. Many others will blindly obey the social pressure to have children , simply because this is what is expected of them.
What about the minority who actually thinks about why they want have a baby ? There could be multiple reasons.


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Friday, August 17, 2012

When less is more – or is it ? The pros and cons of mini IVF

Patients with poor ovarian reserve can be extremely challenging. Because we know that not every egg becomes an embryo and not every embryo becomes a baby , doctors will do their best to get IVF patients to grow lots of eggs to maximize their chances of getting pregnant.

However, it can be very hard to super ovulate patients with diminished ovarian reserve. It seems that no matter what we try, these ovaries just do not respond well to our medications. This can be very frustrating both for doctor and patient , which is why doctors have come up with lots of strategies to deal with these patients.

The standard approach is to be more aggressive with super ovulation and use a higher dose of gonadotropin injections to help coax the ovaries to grow more eggs. Doctors have also tried to tweak the super ovulation protocol by using a mix-and-match of various drugs, which is supposed to help the ovaries to perform better during the IVF cycle. These include androgens such as DHEA; injections of growth hormone which can be extremely expensive; and supplements such as Royal jelly and wheat germ. Many clinics will also combine the super ovulation with acupuncture and yoga.

However, the results with a lot of these protocols have been mixed and while some patients do well, the vast majority still end up growing only a few eggs no matter what we do.

This is why some clinics will use the mini IVF or a gentle IVF protocols for these patients. The logis is simple - since we cannot get them to grow lots of eggs , then why not just make the best possible use of the few eggs which do grow , without making them spend a fortune on expensive drugs which don't seem to do much good.

This is a perfectly reasonable alternative treatment option, provided patients have realistic expectations of what this approach can achieve . Unfortunately, the proponents of mini IVF tend to over promise too much in order to convince patients and doctors that this is a better approach. They highlight the successes without explaining the limitations and the downsides.

The fact remains that with the mini IVF approach , the cancellation rates of IVF cycles is extremely high and patients need to be prepared for this. The mini IVF approach is a sensible approach, provided the patient is well informed and who has realistic expectations. As the patient your best option is to find the clinic, which is flexible enough to use all the possible options and alternatives so that you can maximize your chances of having a baby and achieve peace of mind that you gave it your best. However, this may involve doing repeated cycles , in order to find out what works best for you.

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Thursday, August 16, 2012

Masturbation, sperm counts and fertility

Misconceptions are very prevalent about sensitive , personal and private topics such as sexuality. Masturbation is still an area about which myths abound. This is especially true in conservative societies, which will consider this to be a taboo subject, as a result of which young men are completely clueless as to what the impact of masturbation is on their health and fertility.

A number of men with a low sperm count ( and a zero sperm count ) believe that the result for this is the fact that they used to masturbate as teenagers. They believe that masturbation has drained all the sperm from their body , as a result of which they are now sexually weak , and cannot produce good quality sperm any more. A lot of these men do not understand the difference between sperm and semen ; and are often misled as a result of advertisements and billboards put up by quacks. A lot of these quacks are now online as well , where they prey on the ignorance of these young men.

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Wednesday, August 15, 2012

Empty Follicle Syndrome ( EFS) - a guide for IVF doctors

English: Digital camera shot though a microsco...

A vaginal egg collection is a very routine procedure in an IVF clinic. The procedure is over in about 20 minutes , and good doctors will usually get one egg from each mature follicle.

However, one of the dreaded complications which can mar a vaginal egg collection is called the empty follicle syndrome. The doctor starts puncturing the follicles , and is dismayed when the embryologist does not getting any eggs whatsoever in the follicles. The procedure  in the OR seems to be technically straightforward. The follicles collapse well when aspirated and thee is free flow of follicular fluid into the test tubes. However, when the embryologist scans the follicular fluid under his microscope, he does not find any eggs as all !


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Tuesday, August 14, 2012

Before you start your IVF cycle - Advise from an expert patient !

Starting IVF treatment can be quite scary. There are so many myths and misconceptions, and it's hard to separate fact from fiction. Will the hormones make you fat ? Are the injections painful ? Will they increase your risk of breast cancer ? Is your IVF doctor the best ?

While your doctor will provide you with guidance, it's much better to get advise from the horse's mouth - someone who's " been there and done that" ! This is a guest post from our expert patient, Manju !

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