Saturday, September 29, 2012

Why aren’t patients better informed ?

Most people want to live long and healthy lives. Thus , when they fall ill, they are thirsty for information and want to find out all they can about their illness and their treatment options , so that they can get the best medical care . It seems to be common sense that every patient would want to know as much as possible about their illness. However the fact  remains that patients are still very poorly informed about their medical problems .

The question that arises is - Why is this so ? Is it that some people are so dumb that they just can't figure out what's happening to them and their bodies ? Or is it that some people are so passive that couldn't care less and are simply not willing to invest the time and effort needed to educate themselves ? Or is it that some patients have so much trust and confidence in doctors that they don't feel the need to find out anything
more ?  I don’t think it’s any of these !

I think the most important reason is that doctors have not done a good job of educating and informing patients - we have failed our patients  ! I think patients need to know and want to know , but for multiple reasons , doctors haven't done a very good job at communicating this information to them.

Part of the reason may be historical , when doctors felt that patients were too immature to understand all the medical intricacies and details ; and that if they had a serious problem it was better to hide this information from them , so they wouldn't get unnecessarily worried. While this kind of paternalistic approach may have been appropriate in the past , it's clearly not acceptable today ; but this attitude still persists, and some doctors patronizingly tell patients - Don't worry your head about this – there is no need for you to waste time doing a Google search - I will sort out all your problems for you !

It's not just doctors who have let patients down - the health insurance industry ; pharma companies; medical device manufacturers; and the government have failed as well. They all have a duty to educate and inform patients. I think some “experts” still assume that patients are not capable of understanding complex medical terms. The reality is we have not spent the time and energy to develop the tools in order to educate and inform patients in terms in which they can understand ! Everyone has different learning styles , and we need to tailor our messages so that the information we provide to patients is patient friendly ; available to them in a format which they understand ; and at the time and place at which they need it .

Given the ubiquity of the internet, providing online information is a great opportunity to fix the problem, and it would be a shame if we frittered it away ! This is a chance to change the entire way the health care system works.  The goal would be to create a platform where patients can educate other patients,  because patients are far better at doing this than doctors and other healthcare experts. 

The expert patient understands a lot not only about his own body and the disease, but about the illness;  how it affects individual’s hearts and minds; and can provide invaluable information about how to deal with the healthcare system ( something which most doctors are clueless about because they are part of the system and don’t understand how dysfunctional it is from the patient’s perspective !)

If this platform were created , then doctors and hospitals would not even need to create resources for patient education , because patients would do it for themselves. This would be copy right free; and available in many different languages and formats. Even better , this would create a positive virtuous cycle where patients can consume and create  as they learn more about their illness !

Friday, September 28, 2012

IVF as an option

Even though I am an IVF specialist, and know that most patients who come to me do so for IVF treatment, whenever I see a new patient, I always emphasize to them that IVF is just one of the options which is available to them for building their family.

I explain that no matter what their medical problem is, they always have four options to choose from – 2 nonmedical options and 2 medical options . The 2 nonmedical options are : child free living ( when they choose to decide not to have a baby ); and adoption ; and the medical options include IVF ; or third-party reproductive options ( such as donor eggs or surrogacy). ( Actually, there are 3 more non-medical options I should include for the sake of completeness. These are: continue trying in the bedroom; get remarried; and seek divine intervention , something which  I am sure lots of infertile couples do !)


Thursday, September 27, 2012

The X factor in IVF

It’s very frustrating when an IVF cycle fails. The sad truth is that no matter how good the IVF doctor is , the success rate in a perfect IVF cycle is still not hundred percent. Not only does IVF failure cause a lot of distress to doctors , it causes a lot of anxiety to patients as well ! When the IVF cycle fails, they wonder – Why did it fail ?  Was it because the doctor wasn't competent ? Or is there some other factor at play ? Should we consider changing clinics ?  Patients who have had failed IVF cycles even though apparently perfect embryos were transferred, are understandably upset, frustrated and distressed. They are looking for answers as to why they are not getting pregnant, and are emotionally very vulnerable.

Let’s try looking at this logically. There are basically just two variables which determine if a pregnancy will occur or not after an embryo transfer :
1.    The embryo , which the doctor creates in the IVF lab ; and
2.    The uterus .

If nature were perfect, then logically every time the doctor transferred a top quality embryo into a receptive endometrium, it would become a baby , and the IVF success rate would be hundred percent
( and my life would become much simpler !)  However, most top quality embryos do not implant , even when transferred into a receptive uterus.  This obviously means that along with the embryo and the uterus, there is an additional factor at play. Let’s call this the Factor X in IVF treatment.

Now whether this factor X is the clinical skill of the physician ; or the maternal environment; or the immune system in the endometrium; or just plain luck ( for lack of a more scientific term !) ,  can be extremely hard to determine.  That is the reason I'm labeling it as Factor X - because we don't really know what this is !
Now there will be some doctors who believe that if top quality embryos do not implant , this means there is a problem with the woman's immune system . Their belief is that these women have a defective immunological system ( for example, problems with their NK cells ), which causes them to “reject” these embryos. They will then try treating this with all kinds of immune therapy options , such as intravenous intralipids , lymphocyte immunization therapy and intravenous immunoglobulins .

Other patients believe that the reason their embryos  do not implant is because someone has put a curse on them – and they believe that the Factor X is a curse , which is why they will ask a witch doctor to help them exorcise this. ( Many IVF doctors believe that the quality of evidence which supports a curse as being the cause of IVF failure is at least as good as the evidence which supports a flawed immune system as being the culprit !)

Other patients believe that it’s excessive stress which prevents their embryos from implanting; and they trust that using Mind-Body Techniques to manage their stress will help overcome Factor X.
The reason it’s such a long list is that we don't have any clear way of defining the problem ; and because we can't identify it , we are not very good at solving it . Of course, as time goes by and our knowledge about embryo implantation improves , our ability to be able to decode what factor X is all about will progressively increase , and we will then be able to improve pregnancy rates in IVF cycles.

Meanwhile, we should all just agree to disagree !  The fact that it’s Factor X means none of us know what the right answer is – and it’s okay to follow your gut.

Wednesday, September 26, 2012

Men - the silent sufferers of infertility ?

This is a guest post from our expert patient, Manju.

We women talk a lot about infertility, express our emotions associated with it, cry a lot and as a result get better emotional protection too! I have seen women complaining about their DH (dear husband)’s attitude to their infertility in many bulletin boards. They get lots of comforting words and support from fellow women. But I have never seen any men venting about their infertility struggles, their view of it or how they cope with it. Even my DH never expresses what is in his mind. I want to hear from him how it feels not to have a baby when everyone around him seems to be fathering a child. What does he think when he hears someone in his friend’s group announce their pregnancy? How does he feel when he sees couples with a cute little child? How does he manage when some of his friends just drop in and ask ‘is there any good news?’ These are all grey areas for me. Sometimes when one our friends say that they are pregnant, I tell my DH ‘does it hurt? Do not worry our turn will come too’, he smiles and replies very naughtily ‘when I am not responsible for that pregnancy why should I worry’ :) Although, he tries to make light of the issue for my sake, I understand that it is of course painful for him too!

The intense desire to have children is not just a women thing. Most men like most women love to have children. When a man is with the company of a young child you can experience the tender side of him. We went to India both the times when my little sister had her baby. I was a bit tensed how my husband will handle the situation. I was worried about his emotional safety. How would he react to the presence of a new-born child especially when we are going through infertility? Will he feel uncomfortable? To my surprise, I was amazed by his fatherly skills. He handled the new born with so much care and affection. Sometimes when the little one cries uncontrollably my sister will give the baby to him. He used to hold the baby in a comfortable position and shake him gently; the little one stops crying and goes to sleep within the warmth of his embrace. At those times, I could see his face soften with a motherly affection. Everyone in my home are proud of him but the only soul which is left weeping on seeing all this is me. I know he loves children. Whenever he sees a naughty, young child his face becomes bright with a smile. His eyes would follow the child as long as the little one is within the viewable distance. When he is eagerly looking at the child my eyes will be concentrating on his face trying to read his mind.  I will be caught in a swirl of emotions. My inability to give him a much desired baby strikes me so hard; my eyes will fill with tears unable to bear those emotions. So if someone says that the longing for a baby is a womanly thing and men are unaffected by infertility I can never ever agree with them.

I would like to share one of my experiences with an infertile couple who lives in my husband’s village. They are very young. They do not have children and I happened to hear from that woman (her name is Manju too!) why they are not able to have a child. She said at the age of 23 or so her uterus was removed because of a tumour! I was shocked! I guessed it may have been a fibroid and might be because of an over-enthusiastic or money-minded physician that this tragedy happened. She is not literate enough to explain her actual problem. Then I started to question her further and asked what she thinks about adopting a child. She said, ‘my health is not that great and we do not have good income too. In this situation, I do not want to take any additional responsibility’. She is not crying her eyes out and that is the best thing about village women. They are emotionally very strong and have enormous resiliency. Actually, city-dwelling, very modern, highly educated women are emotionally very fragile! Although the topic is uncomfortable for her she is able to share her opinion with me very matter-of-factly. I insisted that it will be wise to have a child at home as it would bring new hopes into their life and a sense of responsibility and happiness. She said, ‘my husband always wanted to adopt a child but I am adamant and I refused his wish’. This conversation was hard for me too. I started to think about myself and my infertility. I have seen her husband. He comes home very late after finishing his job. I have never seen him stand and talk to anyone. He seemed to be very silent. The next day Manju came to me. She said, ‘yesterday I told my husband what you suggested’.  I said to him that you wanted us to adopt a child. She told me, ‘you should see the glow in his face; he immediately started to talk about adopting a baby. For a long time afterwards, he talked about the adoption topic non-stop’. She continued, ‘he told me that, ‘see how Manju has understood our problem; what she said is very correct’! When we were returning back to Germany, while taking leave from everyone, Manju’s husband was standing at one corner. I will never forget the look in his eyes; the gratitude in them told me what he is going through!

Just because a man is not expressive doesn’t mean he is devoid of all the feelings women claim to possess. Many women tell me, ‘Manju we are women and our heart always yearns for a baby but my husband doesn’t feel like this!’ Can this be true? The problem with us is; the first thing we do when talking about infertility (or for that matter any sensitive topic!) is to cry. It is very uncomfortable for a man to see his wife cry and break down emotionally. A man thinks it is his responsibility to keep his wife happy and when he sees that his wife is not as happy as he would like her to be, he feels very frustrated and his ego gets hurt too. They really do not know how to react to such situations and their silence makes us think that they are cold, unfeeling and uncaring. From an evolutionary point of view, there is one more interesting reason why men can’t tolerate crying spells and high pitched voices. I happened to listen to a psychologist on TV and she was telling ‘if you want a man to listen to what you say, talk to him softly without becoming too emotional’. She also gave a beautiful explanation why it is so! When humans lived in caves, it was the man’s job is to hunt and gather food. Women took care of the children. When a man goes hunting, he has to be aware of all the danger signals around him. He used to listen keenly to the sounds made by wild animals so that he could avoid places which were perilous. He also has to be emotionally strong when he has to hunt animals. His sole intention should be to provide food for his wife and children and he should not get carried away by the pathetic sounds made by animals and their young ones when he kills them. A woman, on the other hand, has to be very sensitive to the cries of her children, so that she can feed them and take care of them well. These differences in their activities can explain why men’s brains and women’s brain respond to the same cues in such a different manner. A man is unable to tolerate high pitch voices as it is like a danger signal for him. The psychologist said, ‘please keep two things in mind if you want a man to listen to what you say-do not raise your voice, and talk slowly so that his brain can imbibe what you are saying. Never cry because it will make him uncomfortable and he will try to move away from that place’. I found that explanation to be very interesting.

When a couple deals with infertility, obviously a man gets hurt too. Fathering a child gives him gratification as it is considered as a proof of his manliness. When infertility strikes a couple and the man realises that he is not able to father a child, he starts to feel inferior. His emotional burden becomes worse if the problem is with his own fertility. He feels that he is less masculine, a total failure and his self-esteem goes down. When his wife does not understand what he is going through, and if she is always crying and complaining, then that just adds to his mental torture. I know women who break down in front of their infertile husband and cry thinking about a baby. Is it wise to do so? Have you ever imagined what kind of mental pressure you are subjecting your husband to? When your husband is the one who is having an infertility problem, as his wife, it is your greatest responsibility to make him feel comfortable. But many women fail to give the much needed intellectual and emotional support. When his wife is crying because she cannot have a baby and when a man senses that it is his inability which has caused such suffering to his wife, he naturally goes to pieces. Women have many ways to relieve their infertility related stresses. The best support a woman gets during infertile times is from her mother. She vents out whatever she is undergoing (physically and emotionally) with her mom. When I talk to my mom I have no inhibitions. I have no fear that I will be judged wrongly. All my mental stress clears quickly if I talk to her. But for a man it is impossible to get such emotional support. As a man grows older, he no longer feels comfortable sharing his emotions with his parents like a woman does. Since men are looked upon as being the stronger sex, crying or expressing emotions like a woman is considered to be a sign of his weakness. Hence he maintains his silence and suffers within himself. When a couple faces infertility, the man’s parents also tend to react differently to their daughter-in-law. As a result the connection between the man’s parent and his wife becomes strained. This makes a man’s condition even worse. He is caught in the emotional drama between his parents and wife. This makes him retract from his parents too. Infertility somehow pushes a man’s parents and siblings away from him. This is why coping with infertility can be so much more difficult for a man than for a woman! He is forced to bury himself in his work and pretend that all is well, even though he may be bleeding inside.

Many infertile women behave in ways which can make the life of their husbands a living hell. The first mistake women make is to submerge themselves within their sorrow. They tend to obsess about a baby all the time and they forget all their day to day duties and happiness. It’s very hard for a man to deal with his wife’s crying spells – especially if he loves her. While he can handle his personal pain stoically, seeing his wife suffer leaves vulnerable and heart-broken. Infertility also kills the sex life of couples. It turns a pleasurable act into a ritual which is done only for the sake of a baby. For a woman, the best sex stimulation centre is her brain. When her brain is too occupied with infertility and making babies, the act of making sex becomes very difficult. Women have high libido, but they desire sex only when all the conditions are just right! For a man on the other hand, sex can be like soothing medicine for all his troubles and frustration. This difference in the mental make-up between men and women also adds to the problem. When physical intimacy is denied, a man feels that the emotional bonding with his wife is lost. This further adds to the problem. His only solace during infertility, his wife, seems to move away from him both physically and emotionally. He stops sharing his pain with his wife because he is scared she may break down emotionally. After all, isn’t he meant to provide her a shoulder to cry on? If he starts crying as well, how will she cope?  This makes the situation much more complicated. The other mistake most women tend to do is to talk about her husband’s infertility to her parents. I have seen this happen in many families. The woman’s parents are very happy to tell everyone that their daughter is super fertile and the lack of a baby is due to the problem with their son-in-law (it is actually the fear of social stigma that makes them behave this way!) Sometimes I wonder how ignorant and self-centred people are! How could they even talk about such things without any guilt? Isn’t it the duty of the wife to safeguard her husband’s self-esteem? If a couple faces infertility, is it necessary to reveal whose problem it is? Is it really anyone else’s business? As a couple, doesn’t infertility affect both of them equally? Playing the blame game is emotionally destructive!

Men and women have different coping styles in response to stressors. This may add to what is an already stressful time. Even though men desire to have children , they are usually not afflicted by the “babylust ” which strikes women. They tend to analyse the situation rationally and might have a clearer dispassionate view of the problem .  On the other hand, a woman’s intuition is stronger. Instead of being adamant about your own viewpoint, it is much wiser to work as a team. A baby is not the only solution to the problem of infertility ! You might one day find yourself in a situation where you have to decide when to give up all the draining infertility treatments, stop trying to conceive , and get on with your life. This kind of end to your infertility journey can be very hard for both of you , especially if you do not have alternate plans. So it is always wise to keep other options like child-free living and adoption open. When your husband talks about these topics , try to listen to him patiently and give your views about it. Do not react to such talks with an emotional outburst. If you do so then that will be the end of a rational discussion and this will in turn leave your husband in ambiguity and uncertainty. He will be totally confused how to deal with your emotions. Achieving an emotional closure and moving on with your life is very necessary if the infertility treatment does not work. As his wife it is your duty to provide him the opportunity and space to do so. Chronic grieving can lead to significant psychological damage to you and your partner. Your relationship will get adversely affected as a result of this. If you want your marriage to withstand the tests of time you should learn to weather the storm of storm by climbing the peaks and valleys together. I have seen many infertile couples do this successfully. Caring enough to bring out the best in each other, and wanting his happiness even above yours seems to be the key! Many men when faced with infertility tend to divert their attention to their career and try to excel in it. Support your man during such times and see his self-esteem grow. This will also give you immense happiness. Many infertile women tend to think that their happiness is solely dependent on a baby and as a result tend to suffer and make their man suffer too. Remember “The foolish man seeks happiness in the distance, the wise grows it under his feet”.

When you are tackling infertility, provide emotional support for your husband. Having a rational discussion about your infertility will provide your husband with confidence and strength because he is reassured that you have a mature sensible outlook; can cope well; and have realistic expectations. Crying might give you relief, but, when you make it a habit to cry and get depressed every time the topic of infertility springs up, you will end up making your husband miserable as well. It is not wise to complain about his parents all the time. Just like you need your parents when you are in distress, he needs his parents too (whether they are good to you or not doesn’t matter!). Even though he doesn’t express himself to his parents as you do, he will feel emotionally comfortable if you maintain a good relationship with your in-laws. Taking care of his physical needs will make him feel more secure and cared for. Sex helps to provide emotional catharsis and improves bonding. This helps you as well. Remember that a man’s ego is fragile and it is in your best interests to make him feel strong and comfortable! If your husband is suffering from infertility never discuss it with anyone else - especially not with your parents (if they will go around spreading the news to everyone!). Remember, just like you are his better half, he is your better half as well, and hence infertility cannot be an individual’s problem! Tackle the situation wisely so that your relationship becomes stronger during the crisis of infertility!

You can email Manju at [email protected]
Her blog is at

Tuesday, September 25, 2012

Should we be doing PGD for everyone ?

When we make embryos in the IVF lab , our goal is to transfer a single good-quality ( top quality) embryo inside a receptive uterus , so that the embryo implants and becomes a baby . Part of the problem is that we still not very good at identifying which embryo will become a baby. Today, we judge the quality of the embryos based on what they look like under the microscope. We grade them , depending upon their morphological appearance – for example , whether the embryo has any fragments ; whether they cells are equal; and how quickly the cells are dividing. We then select the best looking embryo, and transfer this into the uterus. Unfortunately , even a top quality perfect looking embryo may be genetically abnormal,  and it's not possible to judge its chromosomal normality just by looking at its appearance.

This is why PGD ( preimplantation genetic diagnosis) in which we biopsy the embryo to remove one or more cells from it to check their chromosome copy number (using CCS ( comprehensive chromosome screening))  , offers  great promise . PGD will allow us to select genetically normal embryos, which have a much better chance of implanting, as compared to genetically abnormal embryos.

Not only would this theoretically help to improve IVF pregnancy rates , it would also reduce the rates of miscarriage ( which often occur due to chromosomal errors in the fetus) ; as well as babies with birth defects  such as Down syndrome). So, if PGD is such a great idea , why don't we routinely offer it across the board to every IVF patient ?

The fact is that even though PGD technology appears very seductive on a theoretical basis, when we actually try applying this in practice , things often don't work very well . This is partly because we are still on a learning curve as regards PGD . Not only does PGD require a lot of experience and expertise on the part of the embryologist, removing cells from the embryo may end up damaging the embryo and thus reducing pregnancy rates . There are also real life practical issues. For example , when we analyze a single cell , we may not get accurate information, because our technology is still imperfect. Remember that a normal CCS report does not guarantee that the embryo has no genetic defects whatsoever – after all, it’s still not possible to do a comprehensive screen to rule out all possible genetic defects ! After all, how many questions can you ask a single cell ? Also, because biology is so messy, issues such as mosaicism ( the fact that not all the cells of an embryo are exactly the same), means that this technology will never give 100% accurate answers. Also, such sensitive tests are also likely to be plagued by problems of false positive and false negative results , as a result of which interpreting them can be quite challenging.

The problem is that there are a lot of clinics who create a lot of hue and cry about how useful PGD technology can be. They publish lots of articles on the techniques – and because this is  new technology, they grab a lot of media attention, because reporters are only interested in what is new ( whether it’s useful or not is often a secondary issue, unfortunately !) When na├»ve patients read these optimistic articles ( which are full of positive spin), they want to use all the newest and latest technology for their own IVF cycle, as they feel this will help them improve their chances of getting pregnant.

This puts a lot of pressure on IVF doctors to do PGD for them – they are scared that if they do not, their patient will go off to someone who does.  IVF can be a very competitive field, in which doctors are always trying to play the game of one-upmanship ! Most conservative clinics will still take a “wait and watch approach “ – let’s see how this new technology evolves. Part of the reason is that if the embryo gets damaged as a result of the PGD , the doctor will feel much more guilty about this , as compared to an IVF cycle failing because of inherent biological problems with the patient. Fortunately most doctors prefer not to intervene when there is scope for doing harm. After all, the first rule in medicine is – Primum non nocere – First, do no harm !

Monday, September 24, 2012

The best treatment option for patients with recurrent implantation failure

One of the most frustrating group of patients for IVF specialists are those with recurrent implantation failure. These are patients for whom we've done multiple IVF cycles , but who still do not get pregnant. These patients as labeled as having repeated IVF failure ; or recurrent implantation failure , which is actually just a waste paper basket diagnosis which means we really do not know why the embryos we transfer do not implant for these women.

On an intellectual level , we understand that there are broadly only two groups of reasons for failure of implantation. One could be that the embryos are not of good quality; while the other is that there is a problem with endometrial receptivity .

Unfortunately, because it is still very difficult for us to pinpoint what the problem is in an individual patient, there is a lot of hocus-pocus and mystery surrounding the treatment options for these patients . They are emotionally very vulnerable and very desperate . They will often keep on changing doctors , and each new doctor will offer his own particular flavor of some magic potion in order to solve the problem. This could range from using intravenous Intralipids; to doing PGD for comprehensive chromosomal screening; to using immunotherapy for treating NK ( natural killer ) cells .

A lot of this is extremely speculative stuff ; and I feel a better treatment option would be one which is based on sound science. This would be to grow all the embryos to blastocyst stage; freeze all of them; and then transfer them in the next cycle. While this may seem to be a lot of hard work, there is a sound scientific basis to this approach.

Growing embryos to blastocyst stage ( rather than transferring them on Day 2 or 3) is the best way we have today of ensuring that the embryos are competent. While it's true that not all blastocysts are genetically normal , which is why not all of them will implant , given the state of the technology available today, this is the best approach we have for making sure that the embryos are viable. If the embryos do not grow upto the blastocyst stage in the incubator in vitro (assuming that the IVF lab is experienced and competent ), this means that means the problem for recurrent implantation failure is quite likely to be an embryo problem. This is especially true when patients with recurrent implantation failure have had multiple failed IVF cycles with only Day 2 or Day 3 transfers ; and the earlier IVF clinic has not tried to grow their embryos to the blastocyst stage.

While the fact that their embryos have arrested in vitro; and have failed to develop to blastocysts ( which means they will not have any embryos to transfer at all) can break their heart , at least this way they know where the problem lies , so they can then approach their next treatment cycle armed with more intelligence . This approach provides valuable information, rather than leave patients groping in the dark.

Why not transfer the fresh blastocysts ? This is because endometrial receptivity may be suboptimal in a super ovulation cycle , because of all the hormones which have been injected. Because the thrust of superovulation is to focus on growing good-quality eggs , sometimes we may not be able to optimize endometrial receptivity at the time at which the eggs are ready for retrieval. Once we have frozen all the blastocysts, we can then focus all our energies in the next cycle on improving endometrial receptivity. This approach allows us maximize the chances of implantation, because we are transferring good-quality blastocysts into an optimally prepared endometrium.

This approach allows us to use sound scientific principles , without resorting to a lot of expensive hocus-pocus , to maximize chances of success in this group of heartsink patients . Only very skilled IVF labs can offer this kind of service, because it needs a lot of expertise and experience to do this successfully.

Sunday, September 23, 2012

Why doctors and patients have a hard time understanding each other !

Curse of Knowledge– The curse of knowledge, otherwise known as the paradox of expertise, represents the difficulty of experts ( doctors)  to use commonplace jargon to communicate their ideas to those that are not experts. Because experts tend to surround themselves with other experts, it can be very difficult for an expert not to use technical jargon when communicating with people who not experts.

ASK Problem – the ASK Problem stands for the Anomalous State of Knowledge. This is a problem that arises when the decision maker ( the patient) does not have the knowledge that it takes to ask questions, since asking questions often relies on having intimate knowledge of the subject at hand.

This is a very thoughtful article; and you can read more about this at

A clever mnemonic to help doctors respond to a patient's emotions

While most doctors are great medical technicians, they often are not good communicators. NURSE is a very helpful tool, which can help doctors to show empathy to their patients.

This was developed by OncoTalk at

N = NAMING. Begin by naming the patient's emotion
U = UNDERSTANDING. Appreciate the patient’s predicament or feelings
R = RESPECTING. Acknowledging a patient’s emotions is an important step in showing empathy.
S = SUPPORTING. You can express concern, and acknowledge the patient’s efforts to cope.
E = EXPLORING. Link the “I” of the doctor to the “you” of the patient.

If you are a doctor, please read this - it's a great guide on how to have a conversation which may be emotionally charged, when you need to break bad news to a patient.

If you are a patient, please share this with your doctor - it will help him to become a better healer !

Saturday, September 22, 2012

Day 2 versus Day 5 transfers

When blastocyst transfers were first introduced in the IVF clinic, there was a lot of hope and hype and excitement . We felt ( or were led to believe) that if we could grow embryos up to Day 5 in the incubator and then transfer them into the uterus, the implantation rates would increase . It was logical to assume that blastocyst transfers would improve IVF success rates .Remember that a Day 2 or Day 3 embryo does not belong in either the uterus or the test tube – it should actually be in the fallopian tube ! It was only because we were not able to grow embryos satisfactorily upto Day 5 in the IVF lab that we were forced to do Day  2 and Day 3 transfers in the early days of IVF. However, as time progressed , we have learned a lot about how to keep embryos happy in the IVF lab , thanks to improvements in incubator technology ; in the formulation of IVF culture medium ; as well as the embryologist’s expertise. This is why it is now possible for most good IVF labs to happily grow embryos in vitro to blastocysts.

In spite of this , there are still many labs which still transfer on day two or three. Why do they do so ?
Paradoxically, I do not believe that a blastocyst transfer will necessarily increase pregnancy rates . Let me explain why. While it is true that a blastocyst transfer allows us to select the best embryos ( because we can allow the Day 2 and Day 3 embryos to compete amongst themselves in the incubator and then select the ones which grow the best in vitro at Day 5) , rather than play eenie- meenie-mina-moh when trying to select the top quality embryo on Day 2 or 3. This is because sometimes all the 8 embryos on Day 2 may look perfect , with four equal cells and no fragments. It then become very difficult to predict which of these has the best chances of implantation. Obviously , not all of them will continue to divide to form blastocysts . Instead of selecting embryos at random , and not doing a very good job with embryo selection , doing a blastocyst transfer allows us to preferentially select those embryos, which are more likely to implant and become a baby. This means that the major benefit of blastocyst transfer is that it allows us to improve our ability to select the top quality embryo . If an embryo is going to arrest on Day 3 or Day 4, there’s no point in transferring this into the uterus on Day 2, even if it does look perfect ! Having said this , do remember that if an embryo is going to become a baby , then it will do so , whether we transfer on Day 2 or Day 5. After all, culturing the embryo for three additional days in the incubator will not increase the chances of its implanting !

So does this leave you more confused than ever as to whether Day 5 is better than Day 2 ? It actually should not ! Any good IVF clinic should be able to grow embryos up to blastocysts routinely, so that they can then pick and choose what is best for the individual patient . This decision needs to be based on multiple factors: for example , how many IVF cycles has the patient failed earlier ; whether there are enough eggs ; whether the embryo quality is good enough , and so on. However , if your IVF lab is not good enough , and cannot grow embryos up to blastocysts , and therefore transfers all embryos routinely for all patients only on day 2 or day 3, this is very worrisome . It's important for doctors to be able to offer individualized treatment , so they can select what's best for each patient , but doing this requires a lot of experience and expertise .Being able to grow embryos up to blastocysts allows doctors much more flexibility , so they can pick and choose the right treatment option for each patient. Thus, if your clinic wants to transfer five Grade A Day 2 embryos , then you should worry , because any clinic which wants to transfer so many embryos at one time is most probably not very confident about their embryo implantation rate. This is why they may resort to transferring too many embryos , in order to increase their pregnancy rates  ! However, the risk of transferring too many embryos is that you end up increasing the risk of a multiple pregnancy.

One of the questions many patients ask is – If I only have 2 embryos , then isn't it really risky to grow them to blastocyst ? Suppose we culture them in vitro , and they fail to grow ? If they arrest , and I do not have any blastocysts at all, then my chances of getting pregnant are zero. Isn’t it better to transfer something, rather than nothing ? After all, isn’t it possible that the embryo may develop in my uterus, but may not develop in the incubator ? Can I afford to take this risk ? This is true, which is why many IVF labs will transfer embryos on Day 2 or 3 , and refuse to do a blastocyst transfer , if you grow few eggs. This is because the end point of an IVF cycle for the clinic is an embryo; and if they have made embryos for you, they are satisfied, because they have successfully accomplished their task. Patients are happy with IVF clinics when they can make good embryos for them !

However , for the patient , the end point is not an embryo, but a baby ! A good clinic and a smart patient will have the courage to grow the embryos to blastocyst in the incubator, even if you grow few eggs . This is because if you do transfer your embryos into your uterus on Day 2, and you do not get pregnant, you will never know if the reason for the failed implantation was because your embryos were not capable of growing and developing further; or if because your endometrium was not receptive . If you had tried to grow them to blastocyst in the incubator, and they had arrested in vitro, this means they would have arrested in your uterus as well, and would never have implanted in any case ! By not allowing them to grow to the blastocyst stage, you have just subjected yourself needlessly to the dreaded 2ww of anticipation and fear . Even worse, you are no wiser for your next cycle, because you still do not know if your embryos are capable of forming blastocysts or not !

For patients with recurrent implantation failure , growing embryos up to the blastocyst stage provides a lot of useful information . If your embryos do develop to blastocysts in the lab , you know that your embryo quality is reasonably okay . However , if all your embryos arrest on Day 4 and none of them form blastocysts , this means the problem is with your embryos and not with your uterus ; and that you would be far better off using donor eggs to get better quality embryos, rather than considering  surrogacy ! On the other hand , if you transfer them all on Day 2 or Day 3, you may have the satisfaction that you reached the stage of embryo transfer, but this is likely to be a very short-lived satisfaction ! The downside is that if your cycle fails, you will still never be sure what to do for the next cycle , because you're not sure whether the reason for the failed implantation was a problem with the uterus , or a problem with your embryos.

Friday, September 21, 2012

How freezing all your embryos improves IVF pregnancy rates

Traditionally , we have always transferred fresh embryos in the IVF cycle. Basically, we would select the best quality embryo(s), and transfer this, with the hope that this would implant . If there were spare( supernumerary ) embryos of good-quality , we would then freeze these; and then transfer them in a later cycle, in case the fresh cycle failed. The transfer of frozen embryos allowed us to maximise the  chances of success.

 Interestingly , lots of clinics are now observing that the pregnancy in frozen cycles seems to be better than with the fresh cycles ! While this may seem counter intuitive, there are multiple reasons for why this is so. For one, our technology for freezing embryos has become much better, because we are using vitrification . As a result of this, 100% of embryos survive after the thaw, if the embryologist is experience and has the required expertise. Even more interestingly , these embryos have a better implantation rate, because the endometrium ( uterine lining) receptivity is much better in frozen cycles as compared to fresh cycles. In a fresh superovulated cycle, our focus is on growing many eggs.


Thursday, September 20, 2012

IVF and unrealistic expectations

Every patient who starts an IVF cycle does do with the hope that it will be their first and last cycle. IVF represents their last hope ; and they understand that this is the one technology, which maximizes their chances of getting pregnant – it is often the court of last resort, on which they bet all their dreams ( and often their last rupee) . However, not only is IVF expensive, it also causes a lot of emotional distress, which is why everyone wants their IVF cycle to be successful .

This is a perfectly rational and reasonable hope, but this sometimes sets up unrealistic expectations , which can cause a lot of grief , not just for the patient , but for the doctor as well. If patients have unrealistic expectations , and the cycle fails , they are often not able to deal with this failure if they have not been adequately counseled which is why they will often vent their anger on their doctor. Many patients who fail IVF will blame the doctor and end up believing that the doctor was incompetent; or did not do a good job .


Should you ask your IVF doctor to do PGD for you ?

While the academic debate about the true utility of PGD may rage on , the question which patients want an answer to is simple – Doctor, should I do PGD or not ? The answer to this is exactly  like the answer for lots of other vexed issues in medicine – it depends !

It depends upon:

what your worldview is and how aggressive you want to be in your treatment
how fed up you are
how many IVF cycles you have failed
what your medical problem is
which clinic you go to

PGD should still be considered to be a research tool , and is best used in an experimental setting , so that we can collect and analyse data in a controlled clinical trial, to evaluate whether doing routine PGD for all patients actually ends up improving pregnancy rates. While common sense suggests that PGD should improve pregnancy rates, we all know that in reality biology doesn't always follow logical rules - and only controlled clinical trials ; and time and experience will tell us what the truth is . Because it's such a complex questions , there are likely to be lots of different answers , depending on whom you speak to . This is why it's important that patients have realistic expectations and be well informed , so that you know exactly what you are going in for .

Part of the problem is that clinics which aggressively promote the use of PGD engage in marketing hype. They are invited to give lectures at a lot of medical conferences , because PGD is considered to be cutting edge technology ; and doctors want to learn “what’s new” ! They present PGD as being the state-of-the-art technology; and are quite dismissive of “old-fashioned” clinics which do not offer this. Many IVF clinics suffer from an inferiority complex if they do not PGD; and many suffer from “PGD envy” . Many doctors still naively believe that more is better – and will look upto experts who use technology which they do not have access to.

To add to the problem, thanks to the internet , patients  read a lot of success stories from women who have failed multiple IVF cycles , and then got pregnant after going to clinic X which did PGD for them. It’s very easy to fall into the classical logical fallacy of post hoc, ergo propter hoc; and when we read newspaper articles about these success stories, we automatically assume that it was doing the PGD which led to the ultimate success. In reality , whether it was the PGD which helped them to achieve their pregnancy ; or whether they would've got pregnant in any case on their nth attempt, even without doing PGD , is something which we will never really know ! While the patient is happy to give credit to the PGD; and the clinic is happy to take this credit, often this is not really deserved at all !

Let’s look at this a little more closely. CCRM is one of the world’s leading IVF clinics; and is a big proponent of PGD . One of my expert patients pointed out a very interesting fact to me. “ I just went through the papers CCRM has published on how PGD helps to improve pregnancy rates. In 2011 they published a paper on CCS ( comprehensive chromosome screening ) and they said they achieved an implantation rate of (a beating fetal heart beat per embryo transferred ) of 68.9% ; while in their control group of patients (without CCS) , their implantation rate was much less - only 44.8%. This would suggest that PGD and CCS is clearly superior !

If CCRM can achieve such high pregnancy rates, then why shouldn’t all other clinics be able to do so ? Does this mean that other clinics are not as good as CCRM ? That CCRM is technologically superior ? Is it that other doctors are not doing PGD because they're envious of the special skill sets which CRM
offers ? Does CCRM have a “magic sauce “ which other clinics cannot replicate ?

However, I then went through a CCRM paper on blastocyst transfer published in 2001 ( CCRM was the first clinic in the world to popularize blastocyst transfer) . At that time ( over 10 years ago !) they reported that transferring two good blastocysts lead to an implantation rate of 69.9% . This means they achieved the same ( very high) implantation rate in 2001 without doing CCS, as they did in 2011 after doing CCS ! This clearly shows that CCS does not help at all ! How could their implantation rate in 2011 in the control group ( without doing CCS ) be only 44.8% (in 2011) when in 2001 they said that with the transfer of two good blastocyst (without CCS) they achieved an implantation rate of 69.9%? “

If you dig deeper, like my expert patient did, it seems that the CCRM success rates 10 years ago ( when they first started doing blastocyst transfer without doing PGD ) were as good as they are today, 10 years later ! This causes you to wonder if CCS helps at all ! Or whether there is some other factor at play.
We need to accept the fact that research can be complicated; it’s not easy to find the truth ; and that we shouldn't rely on just one single study to come to conclusions.  This is why most doctors prefer remaining conservative , until we have better data from more centers.

Wednesday, September 19, 2012

The flipped classroom model for patient education

The world of education is being reinvented, thanks to the Khan Academy ! Flipped classrooms have become an extremely popular way of educating students , instead of the traditional method where students would be locked up in a classroom , and forced to listen to a teacher who would drone on and on using the chalk and talk method , in order to transmit facts which experts had decided were required to create educated adults. The teacher would then assign homework , to make sure that the students had learned these facts , so that they could regurgitate them at the time of the examination. This was the traditional model, which most of us were brought up on . It was not a very successful or a useful model,  because it never respected the learner. While some of us are good at cramming facts and passing exams, most of us probably forget everything we were taught the moment the exam was over , because a lot of the material taught in school was completely irrelevant to our daily lives .

Patient education can learn a lot from this flipped classroom model as well. What happens today is that the patient comes to the doctor , and then within the 10- 15 minute consultation, not only does the doctor have to take a history, do an examination , make a diagnosis and order tests, he also has to educate the patient about his illness and his treatment options . Obviously this is an extremely tall order , which is why it is hardly surprising that it fails so miserably ! This is  why most doctors often do such a bad job at patient education.

Just like students are not blank slates , waiting to be written on by the teacher ( or empty vessels , waiting to be filled up with knowledge hoarded by the teacher), patients are no longer are ignorant illiterates who come to the doctor for his expert advice and knowledge . Most patients these days are well informed ; and capable of finding information for themselves. While this does create its own set of problems , because they often end up with erroneous information, which confuses them, the fact still remains that patients have preconceived notions and ideas about their illness . We need to take advantage of the fact that when patients come to a doctor , they have already done a certain amount of homework for themselves . Smart doctors can actually use this as an opportunity to make sure that patients are armed with the right information , before they come to the doctor .

While it’s not always possible to use this method ( for example, during an emergency ), this works very well for most patients – for example, those with  chronic diseases . When the patient calls the clinic for an appointment , the receptionist can guide the patient to the clinic website . Here, the clinic can use products such as the Healthwise Knowledgebase to deliver information therapy to the patient, which is tailored and targeted to the patient's needs ! With this approach, the patient comes prepared with appropriate information by the time he comes to the doctor’s clinic. Not only does he know quite a lot about his problem , possible diagnoses , and possible treatment options , he can engage the doctor in a much more highly evolved conversation , which is likely to be more professionally satisfying for the doctor as well ! The doctor does not need to repeat the basics , as the website has already provided this information to the patient. This way the patient has done a lot of his homework before coming to the doctor - and even after the consultation is over , the doctor can continue to refer the patient to the website,  so that he has ongoing access to information as his problem evolves and his needs change.

This is a much more sophisticated model , because the doctor no longer serves as a bottleneck , either because of a shortage of time or energy or inability or lack of inclination to teach patients. Rather , it is the patient who is made to do the homework , and the role of the doctor is to act as a facilitator and coach to guide the patient to the right sources of information ; and help them apply this information to their particular specific problem. This is the kind of win-win situation, which the flipped classroom model has already succeeded in doing in schools, and which we can use to improve patient education as well.

Some of these patients will end up becoming expert patients ; and the doctor can then tap into their skill sets and use their knowledge, ability and experience to engage and educate other patients as well, thus creating a positive virtuous cycle, in which the patients do most of the work !

Tuesday, September 18, 2012

Sympathy,empathy and compassion

All of us want a doctor  who will care about us – someone who is sympathetic ; who understands our pain;  who will provide us a shoulder to cry on ; and a hand to help us heal . Even better than a doctor who provides only  sympathy is one who is empathetic – one who can identify with the pain and suffering we’re going through , rather than just providing pity. Such a doctor serves as a friend, philosopher and guide in our time of need, and helps us to cope with our illness in our darkest moments because of the emotional synchrony between his heart and ours. Even better than the empathetic doctor is the doctor who is compassionate – and the only doctor who learns to fulfill his highest calling as a healer is when he learns compassion.

Compassion transcends both sympathy and empathy because it converts feelings into action. Compassion is something we expect from our religious and spiritual leaders , but it's something which we often find is sorely lacking with our doctors. The tragedy is that every doctor should aspire to be a healer - and the best way to do so is to inculcate an attitude of compassion . Providing compassionate care is not only the best way for helping the patient to get better, it’s also very helpful for the doctor to become a better human being as well.
Unfortunately, with the way medical education is organized today , there seems to be little chance of young doctors learning even sympathy, let alone compassion. The intense competition to get into medical college means that we are selecting nerds who are good at cramming and have a high IQ – but we do not check their EQ. During their medical college, students are subject to intense competitive academic pressure. They are forced to memorize and regurgitate the thousands of facts their medical syllabus prescribes, because they need to score high marks in their examinations in order to qualify as a doctor. Unfortunately, there are no marks awarded for being compassionate and caring !

Because of the pressure of time, medical residents are forced to look after a large number of poor patients during their training in public medical colleges. Instead of inculcating a caring attitude in our young doctors , we are actually ending up squeezing this out of them , so that by the time most medical students have graduated from medical college and become doctors , they've actually ended up becoming hardened  and apathetic – it seems as if all the humanity has been drained out of them. This is such a tragedy ! Some are fortunate and manage to escape this dehumanizing influence by finding a senior doctor who serves as a mentor and role models , from whom they can imbibe humanitarian qualities , so they can lead a more fulfilling and happy life for themselves.

Sadly , not only do most doctors seem to be completely uncaring and apathetic , they actually end up becoming antipathetic ! A lot of them are so fed up with the constant demands which are being made on their precious time and limited energy , by an uncaring government which does not pay any attention to the personal aspirations of doctors; insurance companies, which are more interested in paperwork, rather than patient care ; and patients who often fail to say a simple thank you when they get better , that the medical profession is under siege. This kind of attitude has become so pervasive that most doctors no longer enjoy being doctors – they no longer look forward to taking care of their patients. Things have come to such a sad pass that doctors sometimes actually start treating patients as their enemies , because they feel that their patients place unreasonable demands on their time and money. Many doctors no longer feel adequately compensated , either by money or by recognition for their services , as a result of which they become bitter . This shows , not only in their personal life , but in their professional life as well , when they are taking care of their patients. This just ends up creating a negative cycle , which causes harm both to doctors and patients as well.

Monday, September 17, 2012

Social egg freezing for young professional women !

This is the best time in the world to be a woman ! Not only do women have many more career and professional opportunities than they had in the past, they also have a number of inherent biological advantages as compared to men, which allow them to shine. Not only is their emotional quotient much better, they are also better at multitasking , as a result of which they will often do better than their male colleagues, if they are allowed to do so . Thanks to the new laws which promote gender equality ( for example , those against sexual harassment ), it is quite likely that women will continue to do increasingly well as time goes by.

However, while the opportunities for women to crack the glass ceiling is going to progressively improve,  the fact still remains that they pay a price for this . Just as they have certain biological advantages, they also have certain biological disadvantages – and one of them is their biological clock. While women would love to have their cake and eat it too – become the CEO and have babies as well, with the way modern society is set up , it has become extremely difficult for them to do so.


Saturday, September 15, 2012

Free e-learning course on IVF

Infertile couples are hungry for reliable information about infertility and their treatment options . While there is tons of information online, a lot of this is garbage , and patients don't know what they can trust. Even worse, so much of this is couched in medicalese, that patients get lost and confused.


Friday, September 14, 2012

How to put delegates to sleep at a medical conference - Coma By PowerPoint

I recently attended a medical conference. I met many colleagues and made lots of new friends but was very disappointed by how little medical conferences have evolved over the past few years. Most conferences still use the traditional format where an expert stands up and goes through a deck of slides,  while his audience sits and listens. This is the old-fashioned chalk and talk method of delivering information , and multiple studies have shown that it's an extremely ineffective way of communicating information. Most people in the audience are either dozing or chatting with each other. There is very little audience interaction ; and most participants seem to be far more animated during the tea break then during the actual conference itself.

Why are we still stuck in a rut ? Why do we continue to use this outdated format of giving lectures in order to teach doctors ? This seems to be a hangover from our days in school , when we were locked up in a classroom , and the teacher droned on and on while we were forced to sit and listen to her.
Doctors are adult learners and have very different needs. It's high time medical conference organizers learned to respect the needs of the conference delegates , and organized conferences in order to maximize the transmission of information to the participants.

A major problem seems to be that most conference organizers do not respect the delegates. A lot of conferences are organized by medical associations and societies , which do this as an annual function. While the purpose of these conferences is supposed to be continuing medical education, most of the time they just seem to be platforms which the society office bearers use in order to talk about their feats and scratch each other's backs.

A lot of time is wasted in introductions and inaugurations. Speakers are usually selected not because of their expertise or their ability to give a presentation , but simply because they are friends of the conference organizers. The rule seems to be - if I invite you to give a lecture at my conference , you will invite me to yours, as a result of which the merry-go-round with the same set of boring speakers carries on year after year.

While some experts are extremely articulate , the sad truth is that most professors are not very good at giving lectures. They do not take the time and trouble to prepare their lectures ; and will often use the same deck of slides which they carry around with them from conference to conference. They will dim the lights; and then start to read out the contents of the slides. Not only does this induce boredom, it’s very disrespectful of the needs of the participants., who soon end up in a coma after the post lunch session.

This is actually very insulting to delegates and wastes an inordinate amount of precious time. Sadly, most delegates put up with this partly because they have very low expectations ; and partly because they do not know any better . Since most conferences seem to follow the same stodgy format , they aren’t aware that there could be a better way of learning.

The biggest tragedy is that medical conference organizers refuse to learn from what other industries are doing as far as organizing conferences goes. Most medical conference organizers have not heard of the concept of unconferences; and since there seems to be very little pressure on them change or improve , I guess this sad state of affairs will continue for a long time.

This is a tragedy, and medical conference organizers could learn a lot from successful conferences such as Ted Talks. Rather than put the lecturer first , we need to put the needs of the delegates first , and I think if they established their priorities correctly, they would be able to do a much better job.

If I were organizing a medical conference, how would I do it ?

I’d start off by asking attendees what they wanted to learn. I'd ask them who they would want as speakers ; and what topics they would like covered. In this day and age of instant electronic communication, this would be easy to do online ; and it would be possible to catalyze the process by putting up a list of frequently asked questions, to which the delegates could add their own.

Interested doctors could be asked to register online on the conference website; and then send in their doubts and queries by email. This will allow speakers to provide fresh insights , rather than a hodge-podge and re-hash of the same old topics. The conference would be special because it would be tailored to the delegate’s needs !

I would then identify the experts in the field ; and tell them that the purpose of the talk would be to answer these questions. While experts may know a lot about the technical details of their area of specialisation, many do not know much about how to present this information . I would spend time and energy helping them to polish their presentation , so that they can actively engage their audience and do a better job. I’d provide them with a template for their presentation – and encourage them to use a Q and A format for their lecture. This means that rather than just display slide after slide, they ask the audience a series of topical pertinent questions; wait for the audience to provide an opinion ; and then answer this question  ( using published data ) in their subsequent slides.

Most experts are quite happy to engage in a dialogue , and while this does occur informally during the lunch sessions ( when delegates get a chance to interact informally with the experts ) it's possible to get the audience out of their coma and interact with the speaker using digital technology while the lecture is going on. Delegates could use their smart phones to send SMSes to a particular number in order to ask questions  and clarify their doubts. These messages could then be displayed on the screen , and the expert could actually tailor his presentation so that these questions are answered properly, while the talk was going on .

While conference organizers do provide time for a question-and-answer session after the presentation, most delegates are quite reluctant to stand up and ask questions , as a result of which many of them leave from the conference with many unanswered questions. Many burning issues are never addressed because these slots are often monopolized by loudmouths who want to show off how much they know.  Even worse , since lecturers often overshoot their allotted  time , they will cannibalize the time devoted to the question-and-answer session , and since all the questions are lumped together towards the end of the presentation , many delegates forget their questions.

It's high time medical conference organizers turn the traditional model on its head , and instead of putting speakers first , they learn to put their listeners first . This would actually be very good for speakers as well , because it would put keep them on their toes ! Experts are likely to learn a lot from intelligent questions asked by audience members , because they have a lot of collective experience and expertise, which organizers and speakers need to respect !

This is actually a win-win situation because every speaker knows that he can improve , and would be happy to use professional help in order to do so. More importantly , with this kind of format , the audience is likely to actively participate, as a result of which the conference is likely to be lively, so that not only do people learn a lot because they are actively engaged , they will be happy to come back for the next conference !

Thursday, September 13, 2012

How being philosophical will help you deal with your infertility

This is a guest post from our expert patient, Manju.

Being philosophical helps you to find positive meaning in life,  even when faced with difficult or traumatic events. When you start to analyze and interpret the happenings in your life rationally, you will start to view things differently. You will develop resilience when you start thinking better. Remember, it’s not what happens to you, but how you react to it that matters. The way you think determines how you react to a situation!  This IVF journey has helped me to understand certain philosophies of life which I wouldn’t have learned in such a short time period , and at such a young age!

I have learned that creating a life which is perfect in every way is not easy. I myself am a miracle and I should learn to appreciate and respect the life I was given and be grateful for my blessings!

I have learned that being good doesn’t guarantee a struggle free life but good people learn to handle their struggles in a better way without becoming bitter!

I have understood that even the most difficult times cannot take away the happiness from you unless you yourself decide to let it go!

I have learned that struggles are what make you and keep you human!

I have learned that infertility doesn’t kill you , it only serves to make you stronger, if you don’t allow it to weaken you.

I have learned that it is only the everyday small happinesses  in life which matter - nothing else does.

I have learned that a failure teaches you many more valuable lessons in life than success does.

I have learned that if you enjoy the best times of your life , you are also bound to accept the hard times too!

Developing these positive philosophies in your mind despite your difficult situation will help you to be cool-headed. This in turn will help you to tackle the other hard times you are sure to encounter in your life ! Treat your IVF journey as a learning experience, which will teach you to become a better human being !

Being spiritual

Being spiritual helps us to accept life as it is. When you have faith in a higher power , you tend to let things happen , rather than strive futilely to make things happen. This removes the stress from your mind and you become more philosophical in your thoughts. You will realise that a lot of what happens in your life is not in your hands ; and you learn to wait patiently , so that it will happen in its own time. When you stress yourself by assuming that the only acceptable outcome of an IVF cycle should be a baby , then you are prone to suffer if the cycle fails . Instead , if you believe that God will give you a baby when the time is ripe , you are much more likely to bounce back from the depression of a failed IVF cycle. Spirituality also keeps you connected with other people , because you go to religious places, meet people, and exchange your beliefs, happiness and struggle. This in turn increases your coping skills. When you are spiritual , you aim to live a life filled with love, compassion, forgiveness, hope and inner-peace. Spirituality is usually connected to God or religion but you can lead a spiritual life without depending on the these concepts, because spiritualist has to be internal ! However, do remember that while  spirituality can greatly enhance your emotional resilience , there are certain religious practices which end up instilling guilt, self-pity and unnatural expectations! This can destroy your peace of mind and self-confidence. So beware of the dangers in your religious practises as well!

Help others

Helping others is the best way to help yourself , and is also the best way to build your emotional resilience! Extending a helping hand to people going through infertility has helped me a lot with my personal infertility struggle. I publish a blog , where I write about IVF and infertility. I frequently hear from people who are kind enough to say that my writings give them hope and strength. I also get e-mails from people who read my ezine articles. When I talk to them, hear their struggles and heartbreaks, hopes and aspiration I get a lot of strength , because I realise that I am not alone. When I use the knowledge I have gained during my IVF journey to guide them through the infertility maze , I get a lot of personal satisfaction. This gives me a high which provides me with a boost to help me cope better with my daily tribulations. When I was confronted with infertility soon after our marriage, I was ignorant about everything. There was no one to give me sorely needed information and hope. I was afraid to talk about it to anyone. There were days I felt gloomy and fearful. There were times when I used to think, ‘How nice it would be, if there is someone who could sit and talk with me , and guide me through this’. Because of all the suffering I went through , I know that people experiencing the crisis of infertility need emotional and intellectual support. When I provide it to people who are in a similar situation like mine , I feel I am helping myself! I have learned to help , not because I know a lot but because I know exactly how it feels to have no knowledge about infertility! When I guide others I feel I am doing something worthwhile and it increases my self-esteem several fold. It also shifts my mind from thinking and obsessing about my own infertility. I feel more confident and my ability to cope with infertility related stresses have increased because of this. Everyone can help someone else ! Share what you have (money, knowledge, and kindness) with people who need them the most. The best help you can do to someone is to spend some of your valuable time and to lend an ear to their sufferings. When you help others your own miseries take a back seat in your mind and your self-esteem increases. A high self-esteem is necessary for a good mental health and a healthy mind can cope with the adversities of an IVF cycle much better!

Ask for help! 

Along with helping others, getting help from others will also help in building your emotional strength when going through an IVF cycle. When you are in fear and pain , every small problem you face appears to be big and unsolvable. Talking to someone who has gone through what you are going through helps a lot. When starting an IVF cycle , everything appears like a puzzle. You will be scared about all the injections you take and the medical procedures you go through. You will be scared of your doctor and all the medical jargon he uses when talking to you. You will be petrified that your IVF cycle may fail. You will also have several questions in your mind-what to eat, what not to eat, how long should I rest after embryo transfer, will not taking rest affect my chances of success, will stress cause my embryos not to implant  and so many more. The best way to feel better and stronger emotionally is to talk to someone who knows the procedure well. This will put your mind at peace. Your doctor may well be the best person to talk to , but unfortunately doctors do not have time to answer all your questions. Infertility bulletin boards are full of knowledgeable ladies who will help you with all the questions and fears you have. I would be more than happy ! If you write to me , I will be happy to help you as much as I can.When going through an IVF cycle do not hesitate to ask for help. Remember, when you take help from someone else, you are helping that person too!

Start with a clean slate

Have a clear mind and clear thinking - this is the most important requisite to keep you strong and sane when doing IVF. By the time you start IVF, you would have been tormented enough with your infertility struggles. This might have turned you into a very different person (bitter and suspicious). You might have lost faith in almost all the medical procedures used to treat infertility - and may not trust doctors either. When you start an IVF procedure , you should have faith in that medical procedure, you should have faith in your doctor , and you should have faith in yourself! But most people start the procedure with many uncertainties in their mind , and the scientific complexity combined with the enormous cost of the IVF procedure magnifies their doubts. Instead of thinking - I am going through a procedure which will give me the best chance of having my deeply longed for baby , many start thinking – is this doctor doing his job right? Will he steal my eggs or embryos and sell them ? What if this doctor causes my cycle to fail because he is careless ? Is he crooked ? What if he doesn’t transfer the embryos, because he wants to make me come again and again for money? I have failed so many times in my attempt to conceive a baby, will this IVF cycle ever work? etc. If you are a person who is prone to think like this, the entire IVF procedure will be like a torture for you. When you carry an aura of negative energy around you, you tend to repel all the people who are important for your mental and physical well-being. To add to the insult, if your IVF cycle fails , you tend to blame everyone and everything for your failure. You will not be able to accept the failure with a strong and calm mind. The end result will be depression, disbelief, anger, and self-pity. When going through an IVF cycle,  forget your past bitter experiences with infertility. Do your homework sincerely , so you can select a competent clinic. Select a good doctor. Once you do so start your IVF procedure with a clean slate and happy mindset, do not allow your mind to play games with you.  It is OK to doubt , but do so only when you have solid proof.  It is wises to believe than to live in disbelief!

ABC model of Rational Emotive Behavior Therapy

 Recently I was introduced to a book called ‘A Guide to Rational Living’ by Dr.Malpani. It teaches readers to recognise the impact of their thought processes and beliefs on their emotional well-being. The fundamental concept of the book is that our emotions are the result of how we respond to an adverse event , and not the event itself. If we canchange our beliefs , , we can change the way we feel about the event too! Albert Ellis , a trained clinical psychologist and the author , proposed the ABC model of REBT. This model helps us to make sense of our problem and deal with it effectively. For example , what kind of beliefs do we accumulate when an IVF cycle fails and how does this affect us? And how can we change the way we think , so that we feel better?

Adverse event – IVF failure

Beliefs– I am a total failure. I will never have a baby. While everyone around me gets pregnant easily , I am cursed to suffer like this.

Consequence– Depression, poor self-esteem, lack of self-confidence

But if you train your mind to think in the following way after an IVF failure , you will feel much better and will gain the ability to bounce back quicker and stronger.

 Adverse event – IVF failure

Beliefs– A failed IVF cycle is painful but it is not my personal failure. I have done my level best and I should be proud of myself for going through this difficult procedure. The success rate per IVF cycle is only 40%. If this cycle doesn’t work it doesn’t mean I will never be able to conceive using IVF. There are many women who have succeeded after many IVF failures. I still have bright chances to get my pregnant in my next cycle. It is true that many women around me get pregnant easily , but everyone has their own suffering to go through. Is there anyone in this world without suffering?  My challenge in my life now is to conceive a baby. I will go through this struggle and try my level best to succeed in my quest .

Consequence–Emotional resilience, renewed hope, confidence and increased self-esteem.

 So, try changing the way you think about an IVF failure. This will help you to gain immense emotional strength!

You can talk to Manju by emailing her at [email protected]

Her blog is at :

Wednesday, September 12, 2012

IVF ( PESA-ICSI) Success Story for man with absent vas deferens

We are a couple from Hyderabad .I am 37 years and my wife is 32years.We were married since last five years.She can not able to conceive because of my infertility problem ( absent vas deferens).  We suffered a lot mentally .I was in touch with Dr Malpani since last 3 years by email.Even though we never visited their hospital he used to give online suggestions regularly.As I am working in Hyderabad and at that time it was difficult to get the leave we thought we will go for the treatment in Hyderabad itself.So We visited a clinic in Hyderabad and they said that the only way is to go for IVF and they said that we will definitely get the success if we opt for 3 cycle scheme.We also spent a lot of money on various medical tests.We opted the same and went for the treatment.Every time they said this time it will be successful.But all the 3 times the result was negative and we lost all our hopes and come to the conclusion that it was not possible for us to enjoy parenthood.

By that time as last try we contacted Dr.Malpani over the mail and took an appointment and went to Mumbai.In our first meeting itself he gave a very good confidence of success.Their treatment is very simple and the only tests they did were a scan and a blood test.He told that us definitely she will conceive but it is not possible to say in how many chances.We opted for the 4 cycle money back guarantee scheme.To our surprise he said he will give in writing that if we do not get the success he will refund all the money.By that word itself we came to a conclusion that we are going to hear a good news as no clinic any where gave that assurance.He also gave the same on a stamp paper in writing.

Finally we went to the clinic in November 2012.To our surprise we got 23 eggs of which 14 were mature. We got 13 embryos of which 9 embryos were A grade.Dr Malpani is very transparent and he showed our embryos to us and also gave photographs of embryos.They transferred 3 and froze 6 embryos.We waited for 15 days which is a very long wait for us for the 1st BETA HCG test.But it turned to be negative.We were in shock for 3 months and we were in a dilemma that even after getting good embryos , why did it fail . After that , due to my professional commitments , we went out of India for 2 months.

Again we visited the clinic in July  2012 for the frozen Embryo transfer.It was done successfully under ultrasound guidance and I was present during the ET . We did 1st BETA HCG on August 11 and it was positive with the value 584.5.We do not have any words to express our happiness. This was the most memorable moment of our life after waiting for a long 5 years.We have done our 2nd beta HCG on 17th Aug in which the count was 2995 and 3rd on 20th which count was 9445.

On 20th August we did a scan and we were delighted by the Scan report in which they confirmed we have twins. My wife is now in the 8th week of pregnancy

The staff also cooperated us very well and gave a lot of confidence. At Dr Malpani's  clinic we got very good quality embryos , which enhances the chances of pregnancy.

I would like to convey thanks one and all the members of the Dr Malpani clinic for their support during the time of depression

Mr and Mrs Rao

[email protected]

Tuesday, September 11, 2012

Natural cycle IVF

Patients with poor ovarian reserve ( diminished ovarian reserve or DOR) can be challenging patients to treat. They do have a few eggs left ; and some of them even get pregnant on their own. However, when we superovulate them for IVF, their ovarian response it quite poor; and they often end up growing just 2-3 follicles, inspite of aggressive superovulation.

Natural cycle IVF ( or gentle IVF or minimal stimulation IVF) can be a good option for patients who are poor ovarian responders – especially patients who ovulate on their own. However, it can be difficult to monitor their cycles; and it’s important to find an experienced expert if you want to explore this option.

It’s possible to do natural cycle IVF au naturelle – with no stimulation whatsoever. Some clinics wil use gentle superovulation, with low dose HMG or letrozole.


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