IVF-FAQs - When should I test for pregnancy after the transfer?

The two week wait ( 2ww) is one of the most exciting as well as one of the most emotionally draining phases of an IVF cycle.  You are eagerly waiting to know what has happened to your embryos – did they implant or not ? The doctor’s done his best – now  it’s all upto you ! How well will your body perform ?

Most  IVF clinics want you to wait 14 days after the egg collection before doing a pregnancy test (a test which detects the HCG hormone produced by the cells of the developing embryo !)  But you can do a pregnancy test much earlier too. A blood test might tell you whether your embryo implanted or not as early as 7 days after the embryo transfer.  Very sensitive home pregnancy tests ( which detect the HCG hormone in urine ) are also available. They detect HCG even at very low levels – as little as 25 mIU/ml. Such tests appear to be a boon for women who cannot wait to know their result – those who cannot bear the suspense. But such tests are a bane as well ! Sometimes , even if you get a positive pregnancy test at home , or if you detect the HCG hormone in your blood earlier than 14 days past transfer, when you go in for the definitive test (14 days after egg collection) you might end up with a negative result. This can be heart-breaking , because all the dreams you built because of a positive pregnancy test will be shattered. 

A positive pregnancy test which later become negative can happen because of two reasons :
•    Chemical pregnancy – your embryo tried to implant , but failed to successfully embed into the lining
•    The HCG shot which you took for triggering ovulation was still in your body and the pregnancy test detected this HCG , which is why you got a false positive result !
Such false positive tests or short-lived positive pregnancy tests can cause enormous frustration !

You can also get a false negative if you test too early. As a result of this, you might spend the second half of your 2ww in tears, anger and disbelief – none of which will help your emotional well-being. Of course you will feel happy when you get a positive result 14 days after egg collection, but all the stress and negative emotions you go through because of the first negative pregnancy test result can make your 2ww  very unpleasant.

This is why it is wise to wait patiently for 14 days after egg collection before you can do a pregnancy test. 
Read more at : http://blog.drmalpani.com/2011/01/testing-for-pregnancy-after-embryo.html


This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.


 You can email Manju at [email protected]


Her blog is at www.myselfishgenes.blogspot.com

IVF-FAQs - Why did my eggs fail to fertilize ?

This is a heart-breaking situation which some couples face when they go through IVF. You are very anxious to know the day after egg collection as to how many of your eggs have fertilized and how many embryos you have ! But there are some rare instances where none of your  eggs fertilises and you are left with no embryos to transfer. The reasons for complete fertilization failure include :
•     Lab error - technical problems in the embryology lab , such as infection in the culture medium or an incubator malfunction can cause this
•    Sperm problems  –  Sometimes even normal looking sperms can fail to fertilize the eggs.  This kind of fertilization failure due to functionally incompetent sperm can be prevented by using ICSI (a technique where a sperm is directly injected into egg , thus facilitating fertilization).  If ICSI fail to solve the problem then the issue lies most probably with the egg and not with the sperm.  This is because once the sperm enters the egg , the further events that take place are controlled by the egg’s machinery , and not by the sperm’s !
•    Egg problems - Because of poor quality eggs

What do you do when faced with such a situation ? This is a medical emergency !

•    Ask the embryologist whether there was a lab problem. However, even if there was, it’s quite likely that the lab is not going to be completely honest about this. If only your eggs failed to fertilize on the particular day,  while the eggs of the other patients fertilised normally, the chances of a lab error are low.
•    Ask the embryologist to do rescue ICSI. Here the embryologist injects a sperm into the unfertilized egg . While the success rate is low, this can help to salvage the cycle; and will also prove that the problem was with the sperm and not with the egg
•    Try again in another clinic – this gives you a better chance of pinpointing where the problem lies!

Read more at : http://blog.drmalpani.com/2010/10/failed-fertilisation-after-ivf.html


This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.


 You can email Manju at [email protected]


Her blog is at www.myselfishgenes.blogspot.com

IVF-FAQs - If I have repeated implantation failure, does this mean my uterus is defective ? Should I opt for surrogacy ?

When women go through a couple of failed IVF cycles, the first doubt that comes to their mind is – is my uterus defective ? Is it rejecting my beautiful embryos ?  They start believing that implantation is not occurring because their uterus is defective . Their doubt appears very logical , because they can see that their embryos are growing well and are of Grade A quality .  When the doctor says  - Your embryos look beautiful and you have a very good chance of getting pregnant ( something most IVF doctor will say at the time of transfer, when they create good quality embryos in the lab), they start thinking that they are definitely going to get pregnant. When these beautiful embryos fail to implant, they start doubting the ability of their uterus to sustain a pregnancy. It is true that the uterus plays an important role in implantation , but not as much as the embryo does. When you develop a good endometrial lining and if your uterus does not have any gross abnormalities , it normally functions very well, no matter how old you are . However, even Grade A blastocysts which look perfect under the microscope can carry genetic defects which prevent them from implanting successfully.  This means that when both the embryos and the uterus appear perfect, it’s statistically much more likely that the embryo will be defective, as compared to the uterus. Let’s think about this logically. If all perfect embryos were to implant , then why does only one out of the 2 or 3 Grade A embryos which are transferred into a receptive uterus implant ? Why don’t all of them implant and give rise to multiple pregnancies ? If it was endometrial receptivity which played the major rate limiting factor in implantation , then all the Grade A embryos that are transferred to a women who gets pregnant in a particular cycle would have implanted ! The fact that only some of the Grade A embryos implant even in a successful cycle shows that it is the competency of the embryo which plays a major role in achieving implantation – not the uterus. 

Even when you go through multiple implantation failures, there is a greater possibility that it is your embryos that are genetically defective , rather than your uterus. This is especially true if you are a women of advanced maternal age or have poor ovarian reserve. This is why older women get pregnant so easily with donor eggs, while they fail to achieve a pregnancy with their own eggs ! So if your uterine  cavity is normal , and if it develops a good endometrial layer, it is wise not to opt for surrogacy. Surrogacy is a good solution only for the very small minority of women whose uterus is damaged or absent. Unfortunately, the innocent uterus is blamed all the time when a couple faces infertility . “She is barren” on “In her uterus nothing grows, not even worms” - these are some of the hurting barbs directed against infertile women - and these break her  confidence in the ability of her uterus to carry a baby !

Can’t we tackle this problem by checking the embryos before transferring them ? Unfortunately, there are no fool proof ways of selecting embryos which are genetically normal as of now; but recent scientific discoveries like “comprehensive chromosome screening (CCS)” appear promising.

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

This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.

 You can email Manju at [email protected]

Her blog is at www.myselfishgenes.blogspot.com

IVF FAQs - If my embryos do not implant , what happens to them ?

The embryo(s) which are transferred to your uterus are just microscopic ball of cells. You cannot see your embryo with your naked eye; you need a microscope , which would enlarge it several hundred times , before you can view it.  When your embryos fail to implant and give rise to a pregnancy, they die and disintegrate. Cells die in the human body all the time, and these dead cells are removed by your body’s scavenging machinery. When you get periods after a failed cycle, only the endometrium which is formed during that particular IVF cycle is sloughed off. Since you took lots of hormones , your endometrial lining might be thicker than usual and you might experience heavier menstrual bleeding or you might have more clots (which appears like a tissue) than you normally do. This doesn’t mean you are having a miscarriage or that the transferred embryo was expelled.

If one of my embryos implant, what happens to the other embryo(s) which was transferred along with it?

The embryos which did not implant die and disintegrate. They are removed by your bodies cleaning machinery. You do not need a menstrual period to remove them from your uterus and neither do they harm your developing baby, so do not panic ! 

This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.

 You can email Manju at [email protected]

Her blog is at www.myselfishgenes.blogspot.com

Why medical care is so poor in India

Every once in a while , I get cynical and skeptical. Newspapers are full of scams and crooks , and the world seems to be a dark and depressing place .  However, I then come across genuinely good people, who renew my hope and optimism in humanity , and I start believing that there is some good in this world after all. The Aravind Eye Care story is a great example of what I mean.

I was invited to give a presentation on how putting patients first helps to improve treatment outcomes at the Prism 2013 conference on health management , which Aravind Eyecare organized. While I had heard a lot of great things about Aravind Eyecare , this is the first time when I actually got to see what they do in real life.
What's really amazing is not that they can accomplish so much on a shoe-string budget, without any external funding or governmental support – what I found remarkable is how humble everyone in the organization is , right from the CEO to the housekeeping staff. They all seem to be imbued with a sense of mission - and it's heartwarming to see that it's possible to do good , no matter where in the world you are.

While they do so much great stuff , what's startling is how modest they are about it  ! Unlike most organizations , who want to extract a pound of publicity for every penny of work they do, the Aravind Eyecare people seem to be exactly the opposite. Their focus is on accomplishing their mission - and do this devotedly it and wholeheartedly, without caring about media attention or publicity.

What’s really ironic is that there are such few doctors in India who are aware about the phenomenal work this organization does. They seem to be much more well known in the US than in India , and I think this is a reflection of how skewed and perverted the priorities of Indian media are. Whenever the media carries a story about the Indian healthcare industry , they dutifully interview the CEOs of Fortis and Apollo – but they do not talk to the CEO of Aravind ! What sense does this make ? When you have a real life story of someone has been delivering healthcare effectively , consistently and efficiently for many years , for a fraction of the cost of what anyone else in the world can do , why aren’t we willing to learn lessons from them? Why do the CEOs of the large corporate hospitals , who are just out to make more profit, hog all the publicity and media attention ?

The irony is that MBA students at Harvard University study Aravind Eyecare , so they can learn what makes them so successful. However, no Indian MBBS medical student has any idea about how Arvind is able to accomplish so much with so little ! If we refuse to learn from our homegrown success stories, it's hardly surprising that Indian doctors will continue doing a bad job of providing cost effective humane medical care.

While spending time with the Arvind team made me proud to be an Indian, I am sad , depressed and unhappy that we Indians give such little credit to the real heroes in our midst !

IVF - FAQs - Part 2. Poor ovarian reserve and IVF

This is part 2 of our IVF-FAQs  and talks about a major hurdle for women doing IVF - poor ovarian reserve.

When a clinic advertises that they have a  40-50% success rate per IVF cycle, it doesn’t mean this applies for every woman who undergoes IVF in that particular clinic. Even though it is hard to predict whether a woman will conceive in a particular IVF cycle or not, it is possible to calculate her chances of success , using certain parameters.

To a large extent, the chances of achieving success depend on your ovarian reserve. If you have a decent number of usable eggs left in your ovary, you are more likely to find success. Your ovarian reserve depends mostly on your age , but there are women who suffer from poor ovarian reserve at a young age as well .

How do you test your reserve ?
1.    Anti-müllerian hormone levels (AMH) in blood, measured on any day of your menstrual cycle. AMH is produced by the antral follicles which are present in your ovary. Read more at www.drmalpani.com/amh.htm
2.    FSH and e2 levels in blood, measured on day 3 of your menstrual cycle
3.    Antral Follicle Count (AFC) –  scanning your ovaries using a vaginal ultrasound probe on day 1-5 of your menstrual cycle will allow your doctor to count the follicles which are between 2-6 mm is size. These follicles are called as antral follicles. The higher your antral follicle count, the better your ovarian reserve, because these are follicles which will grow when you are superovulated. Read more at www.drmalpani.com/afc.htm




What is poor ovarian reserve ?

Poor ovarian reserve or diminished ovarian reserve ( DOR) or oopause is a condition where the amount of eggs which have the potential to give rise to a healthy baby decline.  Most women develop poor ovarian reserve 6 to 8 years before reaching menopause. As women age, their ovarian reserve declines too. But there are some women who develop diminished ovarian reserve much earlier in their reproductive period and their ovarian age does not match their calendar age . In 90% of cases there is no explanation (idiopathic) why such premature ovarian aging happens.  But there are a few explanations for premature ovarian aging . These include :
•    Mutation in genes which codes for proteins that are involved in reproductive function
•    Autoimmune disorders
•    Certain viral infections
•    Chemotherapy or radiation exposure during cancer treatment
•    Surgery on the ovaries to remove cyst , or to remove endometriosis implants

Read more at : http://blog.drmalpani.com/2010/04/poor-ovarian-reserve-as-cause-of.html
http://www.drmalpani.com/ovarianreserve.htm

How does poor ovarian reserve compromise IVF success ?

•    Women with poor ovarian reserve have fewer antral follicles in their ovaries. Antral follicles are the ones which grow in response to ovarian stimulation. This is why they produce fewer eggs when their ovaries are stimulated with gonodotropins (FSH and LH), which reduces their chances of IVF success .
•    Older women with poor ovarian reserve have poorer egg quality too. Older eggs are more prone to genetic errors , like aneuploidy. Embryos formed from these eggs either fail to implant or fail to achieve a healthy pregnancy.

How will I know whether I have poor ovarian reserve ?

There are three important tests which are routinely used in the field of ART for predicting a woman’s ovarian reserve :
•    Measuring Anti-Müllerian Hormone levels (AMH) in blood
•    Measuring FSH levels in blood
•    Counting antral follicles (AFC count) present in your ovaries using vaginal ultrasound

These are very simple tests to perform and the information they provide is pretty accurate. 

I am diagnosed with poor ovarian reserve , will I be able to have my own genetic child ?

Women with poor ovarian reserve have a poor prognosis with IVF treatment. However, younger women who are diagnosed with poor ovarian reserve have a better chance of success than their older counterparts. This is because these younger women still produce some eggs which are of good genetic quality. This means they produce fewer eggs , but the quality of their eggs is comparable to women of their age. This improves their chances of achieving a pregnancy and carrying a baby to term is high too.

If you are diagnosed with poor ovarian reserve, it is wise to try one IVF cycle by stimulating your own ovaries , before deciding what to do. Remember, the final proof of your ovarian reserve status depends on how well you respond to ovarian stimulation during IVF. There are women who have very good AMH levels, and yet they respond poorly to ovarian stimulation - and vice versa. Theoretically, as long as you produce eggs, you have a chance of achieving a pregnancy.  During your IVF cycle, if your doctor finds that even with maximal stimulation, you are unable to produce a decent amount of eggs ; and  if those eggs give rise to very poor quality embryos, you may want to consider the option of using donor eggs. This is a decision only you can make !

You should explore the option of Mini-IVF as well.

This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.

 You can email Manju at [email protected]

Her blog is at www.myselfishgenes.blogspot.com

IVF- FAQs - How does age affect IVF success rates ?

This is part 1 of our IVF-FAQ series.

The woman’s age is the most important prognostic factor which determines IVF success. In sharp contrast, the age of the man doesn’t have a significant impact on the outcome of an IVF cycle. Pregnancy and live birth rate after IVF decline with increasing maternal age because the success of an IVF cycle depends on the number of eggs that can be harvested from the ovaries and their genetic quality.   As a woman ages,  her ovaries age too and old ovaries have poor ovarian reserve. Ovarian reserve is defined by the number of usable eggs left in the ovaries. Aging cause two significant changes in a woman’s ovaries :

1.    The number of eggs present in her ovaries decreases  ( All the eggs that are present in a woman’s ovaries are formed when she was a fetus. Ovaries do not have the ability to produce new eggs and hence we do not know how to renew egg supply once this is exhausted !)
2.    The quality of eggs (their genetic competence and mitochondrial quality ) remaining in her ovaries becomes poor too.

As a result, women of Advanced Maternal Age (AMA) have a poor chance of success with ART treatments. Even if they achieve a pregnancy, the chance of miscarriage is greater than 50% for women who are above 40 years old as compared to the miscarriage rate of 12% for women of 20 years. This high miscarriage rate is due to the presence of chromosomal abnormalities in older eggs. Eggs from older women have higher rates of anueploidy (the presence of wrong number of chromosomes ) and hence the embryos formed from such eggs are genetically incompetent . They often fail to implant ; and even if they do implant, they fail to give rise to a live, healthy infant.

After the age of 40, women have about a 10 % chance of conceiving per IVF cycle ; and even if they do the chance of miscarriage is as high as 50 %.  When an older woman uses eggs form a young woman (donated eggs), her chance of conceiving and having a successful pregnancy is as high as that of the young woman ! This indicates that the implantation and developmental potential of an embryo depends mainly on the age of the oocyte , and not on the age of the uterus ! This is why surrogacy is not usually be a reasonable solution for failed IVFs – most of the time the embryos do not implant because of a problem with the embryos (because of genetically incompetent eggs !) and not because of an incompetent uterus.

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

What is your upper age limit for treatment?

We do not have an upper age limit, provided you have realistic expectations ! If you are an older woman and are going in for IVF treatment using your own eggs, you should clearly understand the scientific facts. This will help you to analyze the pros and cons and make a well-informed decision. If you are above 40 and would like to try with your own eggs , you have every right to do so provided you are well-informed. The drawbacks of using old eggs are :

•    The chance of retrieving a decent amount of good quality eggs from an older ovary is low , as a result of which there is a higher chance of IVF cycle cancellation.
•    There is a higher risk for complete fertilization failure – your partner’s sperm might fail to fertilize your eggs because of the changes in your eggs due to old age.
•    Even if fertilization occurs and embryos are formed , more of your embryos have a chance of being genetically abnormal. There is a higher risk of miscarriage because of this
•    The risk of having a genetically abnormal child ( such as a baby with Down syndrome) is much higher as compared to a younger woman

As you age , your response to ovarian stimulation and likelihood of a live birth decreases. If you understand the above facts clearly , and then decide to make a well informed decision , we will be happy to help !


This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.


 You can email Manju at [email protected]


Her blog is at www.myselfishgenes.blogspot.com

Making Healthcare Patient Centered Conference - PRISM 2013

I will be making a presentation at the Making Healthcare Patient Centered PRISM 2013 conference to be held by Aravind Eye Care in Madurai on 23 and 24 March.

Aravind Eye Care is my model of what a good healthcare delivery system should look like - and I am looking forward to learning a lot !

If you want to read more about what makes Aravind great, please read the book, Infinite Vision !

The second IVF baby

Most infertile couples are so desperate to have a child that when their IVF cycle  finally succeeds and they have a baby, they are on top of the world . They believe that their family is now complete ; and that their infertility struggle is finally over. The thought of having a second baby is something which never crosses their mind. Most infertile couples believe that one is more than enough to fill their life with happiness and that they will never want anymore, now that god has fulfilled their much longed for desire.

They will often come back after maybe five or six years, and say quite sheepishly - Doctor , we’d like a second baby now. They are quick to clarify that they don't really want the second baby for their own sake – they are only doing this for the sake of their first baby . They are worried that he's growing up to be selfish , because he doesn't have a sibling to play with . In fact, many 5 year olds start demanding companionship , simply because everyone else in his class is having brothers and sisters , and they want one too !

The best time to start thinking about when you want your second child is when you have just completed a successful IVF cycle . This means you've got an extremely good chance of getting pregnant again , if you choose to do this quickly . Second cycles are much easier once you’ve had a baby. For one, the desperation to succeed is no longer there – the second baby is a “bonus” ! You also know that your chances of success are high, because it has worked once for you. You understand the treatment procedure, which means the fear of the unknown has gone; and because you have a relationship with your IVF doctor, who has already given you your most prized possession, it’s a much smoother ride. The danger is that sometimes the expectations of success can be very high. Do remember that just because one cycle has succeeded does not mean that the second one will ( though it is true that your chances are much brighter than most other patient’s).

If you have frozen embryos, please make sure you request your IVF clinic to store them safely for you. They will charge for this service, but it’s very cost effective to do so ! Since this cohort of embryos has given birth to a baby, the chances of success after transferring them are high.

However, if you postpone the decision too long, the chances of a new fresh IVF cycle succeeding a second time become progressively less , because you grow older . Also, just because one cycle has worked doesn't necessarily mean the second cycle will work the first time around ! You need to give yourself enough time to think this decision through, because it has long-term consequences.

Why donor egg IVF is a better option than surrogacy

Women are much more attached to their embryos than to their uterus. This makes perfect sense. After all , the high point of an IVF cycle is you get a chance to see your embryos. There is no question that embryos are  beautiful , and because they represent potential future babies, many women refer to them fondly as their embies ! The uterus , on the other hand , is not very glamorous. Most women think of it as just a passive container - and one which has often caused them considerable grief during their menstrual periods !
This is why when the IVF cycle fails , women are much more likely to blame the uterus rather than the embryos. They feel that the uterus is defective or damaged and has rejected the embryos. This is why so many of them jump to the conclusion that surrogacy would be their best option , if they have had many failed implantation cycles. Sadly , this is flawed thinking.

We know that most embryos do not implant , not because there is a problem with the uterus , but rather because there is a genetic problem the embryo, which causes the embryos to arrest . Some embryos which are genetically abnormal may continue to develop further , and even implant , but nature will not allow these embryos to grow further , in order to prevent the birth of genetically abnormal babies with birth defects. These will present as first trimester miscarriages. However, from an emotional point of view, a miscarriage after IVF will just reinforce the patient's flawed belief that the fact that the embryo implanted means that the embryo was fine - and that it was her uterus or her body’s immune system  which did not allow the embryo to grow further. This is especially true for women who have failed implantation after comprehensive chromosomal screening or CCS. While CCS will allow us to check the embryos for aneuploidy, and will ensure that we transfer only embryos which have the normal number of chromosomes , it will not allow us to test for all possible lethal genetic defects.

If women were mice , this would be an easy problem to solve scientifically. We could put the woman's embryos into another woman's uterus; and we could cross test by putting donor embryos into her uterus. Unfortunately it's not possible to do this in real life, which is why we have to depend on our clinical experience. It has been shown time and again that the success rate with transferring good-looking embryos into a surrogate’s uterus is no better than with transferring the same embryos into the patient's uterus. This is hardly surprising , since the defect is not with the uterus , but with the embryos. However, it can be hard to think logically , when your heart is breaking. Also, since most of us are quite fond of our personal DNA, and have a completely understandable urge to want to propagate our genes, it's quite easy to understand why women who have failed multiple IVF cycles want to explore surrogacy, rather than using donor eggs, which would have a much higher success rate.

Doctors are also quite happy to comply with the patient’s request. After all,  the customer is always right – and surrogacy is much more profitable than any other IVF treatment , so why spurn the patient’s request, when it’s so remunerative to keep her happy ?

What went wrong ? Why did the IVF cycle fail ?

When an IVF cycle fails , the first question the patient asks the doctor is  : What went wrong ?

This can be quite an irritating question for the doctor because the reality is that even in a perfect IVF cycle , where everything goes right , the success rate will be less than 50 percent. However, when the patient chooses to phrase the question in this particular manner, it suggests he is implying that the doctor was incompetent ; or negligent ; or did something incorrectly ; or wasn't proficient enough. This upsets the doctor and sometimes doctors start getting defensive. Rather than giving the honest answer that we do not know why one particular cycle succeeds and why another one fails , they will order a battery of very expensive tests , to try to pacify the patient that they are on a quest to find the answer to this unanswerable question.

Mature doctors will sit down and explain to patients that we really don't have the technology to determine what happens to the embryo after we transfer it into the uterus. This is hardly surprising,  given the fact that we are transferring a microscopic ball of living cells inside the uterus. Human reproduction remains an inefficient enterprise , whether it’s being assisted in the clinic, or whether it’s being done in the bedroom.
However , not all patients are mature enough to understand the limitations of medical technology and science. Rather than explain the limitations of our science , it's much easier for the doctor to order a battery of tests. This often pacifies the patient , who thinks that now the doctor is on the right track ; and once she has figured out the abnormality and treated this, she will achieve success.

This is delusional thinking. After all , if there was a test which could provide this information , then every sensible IVF doctor would do it before starting the first IVF cycle itself. Why would they wait for failure to order the test ? After all , we don't want any of our patients to fail ! I’d be very happy if all our patients got pregnant in the first cycle itself. These happy patients would refer lots of other patients to me, keeping me extremely busy - and I would not have to answer questions such as – Doctor, What went wrong ?

However, because patients aren't willing to listen to the truth , doctors sometimes resort to manufacturing answers. This is actually a disservice to the patient , who ends up wasting a lot of time and money chasing red herrings , and not getting any closer to their goal of having a baby . Patients need to do their homework  before starting IVF, so that even if the cycle fails , they don't go to pieces and start looking for a scapegoat. They need to understand that even if nothing goes wrong, not every IVF cycle will end in a baby !

Doctors, patients, trust and respect

We all know the importance of a good doctor-patient relationship . If the chemistry between the doctor and the patient is right , the chances of a good outcome improve dramatically ! On the other hand, if you are not on the same page, this can cause a lot of angst and unhappiness both for the patient and for the doctor .

There are two key ingredients for making sure that you can create a healthy doctor-patient relationship. The first is trust. You need to be able to trust your Doctor. You cannot afford to give away your trust just because he happens to be a medical professional ; or has a long string of degrees behind his name; or because he has a fantastic reputation; or because he works in a five-star hospital.. He needs to earn your trust - and the only way he can do so is if you verify that what he's telling you is correct . A good doctor understands the importance of trust , and will work hard in making sure you can trust him ! Trust is a two-way relationship , and just like the doctor needs to work hard to earn your trust, you need to be careful about whom you are willing to entrust your life with !

The other important ingredient is respect . It is understood that the patient needs to respect the doctor , but it’s even more important that you find a doctor who respects you ! A good doctor is one who is a professional and who respects all his patients - but again there's a lot you as a patient can do in order to earn your doctor’s respect !

Show him you have done your homework and are well informed
Be well organized.
Ask intelligent questions – carrying written lists will help you ensure that you don’t forget any !

Good doctors enjoy working with patients  - and they take pride in treating intelligent patients !

Should foreign gay couples be allowed to opt for surrogate children from India?

The Union Home Ministry's new guidelines which restrict foreign gay couples from seeking surrogacy services in India and make it compulsory for a heterosexual couples to be married for a minimum of 2 years before seeking babies via surrogacy, have sparked a row of controversy in the country.

Digital Doctors in India

'Indian doctors go online more than US ones'

Apart from the ubiquitous white coat and a stethoscope , Indian doctors now have another favourite accessory-the internet.
A survey looking at the net-surfing habits of Indian doctors shows over 90% of those interviewed turned to the World Wide Web for information , entertainment or transactions (see graphic ). Doctors were big subscribers to professional networking or personal networking sites.

http://articles.timesofindia.indiatimes.com/2013-03-10/mumbai/37597803_1_indian-doctors-medical-education-programmes-survey

How to become a good IVF patient !

Being an IVF specialist is very satisfying, and we enjoy helping couples to complete their family ! However, we do expect our patients to do their homework , and our ideal patients are intelligent people who understand what we are doing for them - both our abilities and our limitations. We prefer these patients because they: listen to us carefully and ask pertinent questions participate in their treatment and take informed decisions understand that we are working towards their success work in tandem with us and contribute with good ideas are patient and understand that results take time take our advice seriously and respect that we walk the talk.

 While there's a lot of information about the criteria which patients should use to identify a good IVF doctor, there's very little on what patients can do in order to be come good patients !

Here's an article which teaches you to become a good IVF patient !

How to cope with the 2 ww

The 2 week wait after the embryo transfer can be the longest 2 weeks in your life !

 After the embryo transfer, it can be very hard to live through the two week wait. Patients are emotionally very vulnerable, because there is a lot of anxiety as to what the outcome is going to be. They are uncertain as to what they can do to increase the chances of success - and their major fear is that they may inadvertently do something which will reduce the chances of their embryo implanting. There is so much conflicting information out there regarding how diet, activity and stress affects embryo implantation, that patients are confused - and this just adds to their stress levels !

Read more about what you can do to cope better during the 2ww !

Not all doctors are equal

Patients spend a lot of time and energy in finding the right doctor, Patients know that this is a critical decision , and that finding the right doctor can make a world of a difference to the final outcome of their treatment. Most patients assume that all doctors are technically qualified and equally competent – but this is not true ! Some doctors will have superior technical skills; some are great at marketing themselves; some are entrepreneurial and are proficient at raising money; some can build great teams; while others will have a stellar bedside manner.

It can be hard for the patient to figure out what makes one doctor better than another – after all, they have all graduated from medical school and are qualified and certified. Some naively believe that doctors who work in a five-star hospital must be better, but this is not true. Not all doctors are equal – and not will be surgically gifted .

How much time and  energy you need to spend in finding a doctor depends to a large extent upon what kind of medical problem you have; where you live; whether it’s an emergency; and how much you can afford to pay. . If you have a common garden-variety run-of-the-mill problem , pretty much any doctor will do – after all, most problems are self-limited and get better on their own, often inspite of the doctor ! There’s no need to hunt for a world authority if you have a simple pneumonia, for example.

However, if have a complex or rare problem , it does make sense to invest a lot of time and energy in finding out what your options are. It's very hard for patients to judge the technical competence of the doctor , which is why most patients have to depend on surrogate markers of medical ability. This is often the bedside manner of the doctor ; how empathetic he is ; whether he speaks nicely to you ; and is willing to spend time with you , explaining what you need to know. While the best doctors will have both an excellent bedside manner as well as superior technical skills, it's also true that there will be some great surgeons with superlative technical skills who are rude or brusque; while there will be some doctors who may have a great bedside manner , but are technically incompetent. How is the poor patient meant to figure out ?

This is extremely challenging , which is why patients shop around and get a second opinion from doctors; doctor  friends, family members who are doctors, and nurses . Thanks to the internet, it’s much easier to hunt for the right doctor ! Sitting at home, you can find out a lot about the doctor. What are his qualifications ? Where did he train ? What do other patients think about him ? While this is obviously not foolproof method , it does give you a lot of background information before you start digging deeper, so you can prepare a comprehensive list of prospects you need to contact. For example, you can look for who’s publishing research articles about your disease , by doing a search at PubMed, which is an index of all the medical journal articles in the world. This will give you a good idea of where in the world the researchers at the cutting edge of the field are.

It’s a little known secret that all doctors have special interests, and are especially good at treating patients with a particular problem. Try to find out a doctor who has a special interest in your particular problem  - he will treat you with much more love and care !

You also need to trust your intuition - the chemistry between you and your doctor should be right , and your philosophies should match. This is the only way of creating a win-win situation , where you are happy and have peace of mind that you got the best possible medical.

Why is it so easy to brainwash doctors ?

Most patients ( and family doctors as well) have high regards for the skills which medical specialists possess . Because they see a lot of patients with one particular problem , they develop a lot of technical expertise in one particular area . However, this actually creates a new set of problems. Because they have so much depth of knowledge in that particular field, they are pretty clueless about what's happening in other parts of medicine . They tend to become fairly rigid and dogmatic as they get older, and their attitudes harden, just like their arteries do.

As they get older, they start thinking they have all the answers. After all, aren’t they the doctor’s doctor ? Don’t other specialists refer patients to them ? Aren’t they invited to give talks at conferences ? Don’t pharma companies pander to their whims and fancies because they are considered to be KOLs ?

They are no longer willing to accept patients’ opinions , or the viewpoint of alternative medicine practitioners . This is a disservice for the doctor himself , because as long as you keep your mind open , you are likely to learn new stuff. The moment you close your mind because you think you know everything , your ability to learn becomes much less . It’s unfair for the patient as well , because there may be multiple ways of treating a particular problem , and it's not possible for an individual specialist to have a monopoly on knowledge.

It’s surprising that they become so rigid in their views . Because they are highly educated and well trained, one would expect them to be able to keep an open mind . Ironically, it’s the fact that they require so many years of training to become specialists that causes them to become so rigid ! Medical college training is a bit like going to bootcamp. You are subjected to brainwashing, until you learn to adopt the social and cultural norms of the medical profession. As you progress through medical training, you adopt the maneersims and traits of your professors. You start to think of yourself as being a specialist – some who has trained hard for many years, and has tons of expertise and knowledge , which makes you superior to the poor layperson or the patient who has come to you , asking for help.

Patients put their doctors on a pedestal, and this reinforces their opinion of themselves as being special !  Because you have spent so many years learning a particular topic , you understand all its arcane details and technical niceties the ins and outs . You spend hours studying fat medical textbooks and poring over medical journals , which no one else can make sense of . Because you work in a prestigious hospital, everyone defers to your opinion, and listens to what you have to say . Also, because you are a doctor, you tend to associate with other doctors , as a result of which you reinforce each other's viewpoints .

You adopt a particular worldview – and because you do not interact much with people outside your own specialty , constant inbreeding just reinforces dogmatism ! Because getting into medical school is so competitive, doctors are often intellectually arrogant, because they could clear all the examination hurdles, which the other students could not. Doesn’t this confirm they are smarter than everyone else ? This is why they don’t listen to alternate points of view – after all, if the other guy is not as intelligent as you, what’s the point of wasting time talking to him ?

Pharmaceutical  companies play a big role in reinforcing this attitude, because they spend so much money massaging the doctors’ ego. Doctors start getting used to this red carpet treatment. – and this is just made worse by the fact that there are so many patients who treat their doctor as god !

 I do not think doctors want to harm patients – it’s just that their parochial and narrow worldview is constantly reinforced by the people around them – both those in the profession , and those outside . As a result of their arrogance, they indulge in groupthink and start assuming they have all the answers ! This is why they will not respect the patient’s perspective – or that of an alternative medicine practitioner ( whom they often dismiss as quacks).

Fortunately , there are enough senior doctors who understand that we don't have all the answers , and are willing to keep an open mind and listen to their patients. It’s because of these doctors that that medical science continues to evolve and make progress – otherwise we’d be stuck in a rut!

I am proud of my patients

Most doctors treasure their professional reputation , and this is why we take great pride in the fact that so many of our patients are expert patients. They are well–read, empowered and educated, and know their own mind. I am honoured and humbled by the fact that they have chosen to entrust their IVF treatment to us!

I am also very happy that many of my patients have now started sharing their experiences online . This is great , because it gives me an insight into what infertile patients go through and helps me to become more empathetic . Not all patients are articulate , but when an expert patient writes about her experiences, it opens a window into the hearts and souls and minds of all infantile patients .

I'm proud of the fact that they have started writing thanks to my prodding and pushing - and am happy to take a little bit of credit for this !It is good for patients to do so - it helps them to unburden their souls ; and sharing their expertise with doctors helps doctors to improve !

Even more importantly, they are helping other infertile patients by talking about their experiences. The best way of helping yourself is to help someone else – and by sharing their knowledge and expertise with others, they are improving the level of knowledge in the entire infertility community proves .

When these expert patients come to me for treatment, I'm delighted that they have selected me as their IVF doctor , given the fact that they could have chosen anyone in the world. The fact that these expert patients are willing to place their faith and trust in my professional abilities is a matter of great joy for me , and we do our best in order to fulfill their expectations !

A national chain of branded IVF clinics in India

Many venture capitalists ( VCs) are interested in investing in the Indian healthcare space. It has become a hot area now, because there is no much inefficiency; and because it promises so much scope for growth. IVF  especially is a very exciting market , given the fact that it's so underdeveloped , and there is so much potential for scaling up – not just to meet the needs of Indian infertile couples , but also because of reproductive tourism .

This is why venture capitalists have invested quite a bit of money recently in entering the Indian IVF market, but most of these ventures have fallen flat on their face. They want to rapidly setup a pan – India network of IVF clinics, in order to make the most of the first mover advantage and capture the space ! While it’s true that the opportunity is huge, just throwing money at the problem does not help. The key question is – What  makes an IVF clinic successful ?  While you can fool some of the people some of the time, if the clinic does not achieve a high pregnancy rate quickly, it is doomed to fail.

There are two things which need to be emphasized. IVF is a very hands-on treatment – it is not something which can be delegated or outsourced to someone else . Successful IVF clinics are run by a person who is extremely anal-retentive - someone who's obsessed with attention to detail . If you want to run a chain of clinics, you then need to design and implement systems and processes which are replicated identically across all the clinics, so that all the centers have equally good success rates. The biggest problem today is the large amount of variability within IVF clinics , so that even within one city, one center will do well , while another will flop, even though they seem to be following exactly the same processes ! This can be extremely hard to understand - and very frustrating for the doctor as well. WE still do not know what causes this kind of variability ! If we do not understand this, how we implement quality control systems to make sure that that doesn't become a problem ?

This attention to detail means that the IVF doctor needs to be do IVF as a full-time practice. It's not possible to have a gynecologist who does IVF on a part-time basis , and will also do some hysterectomies and endoscopies side-by-side , in order to maximize his income. This is why it needs a full-time dedicated doctor to head the IVF center.

While starting a chain of IVF clinics does not need deep pockets ( it’s not very expensive to set up an IVF unit, and the return on investment is phenomenal !), the VC needs to have patient money – it needs someone who will understand that it takes time to successfully replicate the model across geographies.

The danger is that VCs are so focused on growing the topline and the bottom line, that they are in a huge hurry so set up a large number of centers very quickly . This is easy to do , because it doesn't cost much money to start an IVF clinic, but if the centers don't have well-defined systems and processes , they will not achieve a pregnancy. This will end up damaging the reputation of the entire chain. The good news is that smart VCs are willing to learn from the mistakes of the “first movers” !

This is a great time to setup a national IVF chain . There are lots of advantages to having centralized operations , because this gives you economies of scale ; and marketing and branding can be controlled centrally. A high quality brand , built patiently over time, will inspire confidence in patients , who would rather go to a clinic which provides high tech,  high quality care. Most IVF clinics today are run by doctors in solo practice – and their results often leave a lot to be desired.

Equally importantly, the IVF chain cannot afford to be personality dependent – it  should not be run by a single doctor. It should be doctor independent, because it’s not possible to have a single doctor run around and try to trouble shoot of fire-fight when problems arise ( as they inevitably will !)

The key is to have a central head of quality control, whose full time job is to monitor each center closely, to ensure that they are all doing the same thing, each time. The problem with IVF doctors is that they tend to have large egos.. They think they know all the answers, and refuse to change their set ways. They always want to tweak protocols, to improve their success rates. This is a recipe for disaster ! The flagship center needs to provide training, so that each center will be a clone of each other, even though the doctors are different. Only a strong head of quality control can do this – and he will need to police each center on an ongoing basis, to prevent any variation. This is an expensive proposition , which means you need to overinvest in technology , people and equipment in the first center, but it’s only when you do this that you can be sure your fifth center will be identical to the second ! Trying to cheat will end up harming the replicability – and once one center has poor pregnancy rates, this will damage the reputation of the entire chain. Once the brand image takes a beating, it's extremely hard to repair this.

The bottom line is – it’s possible to set up a chain of IVF clinics in India, but an IVF clinic is not an eyecare clinic or a pathology lab. Cataract surgery is very cut and dried , which makes it very reproducible. However, doing IVF treatment is slightly different, and we cannot use a cookie cutter model when setting up an IVF chain. There is still quite a bit of magic sauce in IVF treatment, which means it requires a lot more supervision and handholding to be able to carry out successfully.

The other danger is that in the pursuit of numbers and profits, each center will try do too many cycles. The optimal number of IVF cycles a clinic should do is about 1000 cycles per year. This makes it busy and profitable – but still manageable enough , so that the care remains personalized.

Creating a national IVF brand is both a challenge and an opportunity. Anyone who is willing to do it properly is likely to reap rich rewards ! He will also be able to create a model which will be hard for anyone else to replicate.

Does HLA sharing cause pregnancy losses ?

I recently heard from one of my friend who is going through IVF to have her child. In the course of her treatment , she went through two pregnancy losses, one at 12 weeks and one at 5 weeks. As usual, a battery of tests were performed on her by her IVF specialist to find out where the fault lay- why did the miscarriage happen ? Of the several tests performed on her, two tests came back positive. She was told her NK cells in uterus are elevated ; and that her HLA haplotype (what the heck is that?) was very similar to her husband's. On seeing her results, her doctor told her that it was a waste of time and energy in trying to get pregnant via IVF. He told her that she would never succeed in carrying a baby to term ; and that she needs a surrogate to carry the baby.

This was a great shock for a woman who was already going through hell in order to have a baby ? Going through IVF is a physically and emotionally draining pursuit. Facing a miscarriage after successful IVF is heart-wrenching. In this situation, how will you react when you are told that there are some killer cells in your uterus which are waiting to devour your precious embryo ? How would you feel when a doctor tells you that you share so much in common with your husband that you cannot carry a baby to term ? Normally, when someone tells you that you have something in common with your partner , you feel happy , but now there is a person telling you that too much sharing means that your joy of having your baby is at stake.

These kinds of diagnoses steal your confidence and the trust you have in your reproductive system and your ability to carry a baby!) . They make you miserable, as you do not know do what to do next. I am sure many of us are completely clueless about what HLA is and what natural killer cells (scary name !) are - I was , even though I am a biologist In fact I bet that most doctors who perform such complicated tests on you will be unable to explain to you what HLA is ; and how it is connected to miscarriages !If you insist on knowing more, you will be provided with a pamphlet which is full of Greek and Latin.

If you want to make more sense of HLA testing, read more at http://www.drmalpani.com/hla_sharing_between_partners.htm

This is an excerpt from our forthcoming, book, The Expert Patient's Guide to IVF. This being authored by our expert patient, Manju and me.

 You can email Manju at [email protected]

Her blog is at www.myselfishgenes.blogspot.com

IVF failure - what to do when your IVF cycle fails

This is a guest post from one of our expert patients !

If your path to the discovery of the fact that you are infertile has been anything like mine, then you would have gone through a roller coaster of emotions.... namely shock, anger, acceptance and finally you would have made a decision to act. Well at least in today's times there is a possibility to "act", but wait a sec, there is still no guarantee of a positive outcome.

If you know anything about statistics, you can use a decision tree to map out the IVF process; if you are a statistics freak you can even populate it with probability scores to help you decide the best approach. While it's easy to map a statistical model , the IVF process is more complex mainly because emotions are involved - and we all know that women are very emotional creatures. It is not easy to handle the stress of unknown outcomes; particularly when the issue is so personal. While the IVF process gives us infertile couples hope, the journey to a successful cycle is paved with lots of hurdles. Add emotional highs and lows and you can see how even one cycle can turn out to be a harrowing experience.

I have experienced a failed IVF cycle and when asked how I remained positive through it all I thought about my approach. I discovered that I did a few simple things that helped me maintain my cool and remain upbeat. I share this with you in the hope that your IVF cycle doesn't turn into a depressing and unpleasant experience for you.

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You can read the rest of her wise advise at
http://www.drmalpani.com/ivf_failure_story.htm

I learned  a lot  - and I am sure you will too !