Saturday, May 25, 2013

Achieving a pregnancy after tubal sterilization

Patients undergo tubal sterilization because they have chosen not to have any more babies. This is why they undergo a surgical procedure to block their tubes and make themselves infertile. However, as times change, so do people - and many women who had a tubal sterilization find that they want to have another baby - for example, if one of their children dies; or if they remarry.

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Thursday, May 23, 2013

Is there anything I can do to increase my ovarian reserve ?

When a girl is born , she already has the entire stock of eggs she is ever going to produce in her life. Unfortunately there is no new egg production in the ovaries after birth , and we cannot coax the ovaries to produce new egg cells. During an IVF cycle, we just grow some of the eggs which are already present in your ovaries. Please do not believe the stem cell scam for increasing ovarian reserve - it is not sound science !

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Tuesday, May 21, 2013

How to get an effective second opinion

Patients are often confused when exploring their treatment options. This is not surprising , because there are now so many choices ! When they are confused , they turn to their doctor for medical advice. Patients understand that doctors don’t have all the answers , which is why they will often get a second opinion to confirm that the advise which the first doctor gave was reliable or not. For example, if a patient has endometriosis, she goes to a gynecologist who advises her to do a laparoscopy to make the diagnosis and to treat the disease. She is understandably uncomfortable about subjecting herself to surgery, which is why she gets a second opinion from another gynecologist. When this doctors also says that a laparoscopy is the next step, since she has now been to two different doctors , both of whom arte advising the same surgery, she is comfortable that she is on the right track , and goes ahead with the laparoscopy. Unfortunately, this is flawed thinking. The trouble is that when you have a hammer, you end up seeing only  nails ! Lots of gynecologists respond in a reflexive manner when they hear the word endometriosis . Their standard advise is to do an operative laparoscopy , in order to remove the endometrial lesions. Their worldview seems to be that the endometrial deposits cause fertility problems;  and that whenever there is something abnormal, the best thing to do is to just take it out – just like all lumps in the breast need to be removed.

It’s quite easy to sell the patient on the idea of doing a laparoscopy. For one, it make logical sense. Isn’t it important that the doctor take a look inside the belly, so he can see exactly what’s going on ? Also, most doctor emphasise now easy laparoscopic surgery is today. It’s a simple procedure which does not leave a scar. It takes a few hours and the patient doesn't even need hospitalization because it’s”  minimally invasive surgery “.

This is why a lot of patients with endometriosis end up doing surgery – and the surgery actually reduces their fertility ! This is partly because the endometriosis is minor – it’s a red herring which wasn't really affecting her fertility and could have been safely left alone. However, once the doctor is in the OR, he has to complete what he started. Along with removing the chocolate cyst, he also removes normal ovarian tissue , thus reducing the patient's ovarian reserve and causing her to become infertile !

This is the biggest tragedy of going to two ( or more) doctors of the same specialty for a second opinion. They share the same world view – and their advise is likely to be very similar. This is why you should actively seeks out a second opinion from a doctor with a different perspective ! You will get a much more balanced viewpoint, so that you can understand both the pros and cons of a given option. Thus, you should seek out an IVF specialist , who will try to convince you why you should not be doing a laparoscopy , and why you’d be better off doing IVF instead.

It’s true that different points of view may end up leaving you a little confused , because it's hard to sort out what's right. Still, it's better to be confused because you know a lot, rather than make the wrong decision because you don't know any better. This ignorance can come back to haunt you afterwards !

Also, if a doctor says I think you should do surgery , one of the first questions you should ask him is - Can you give me good reasons as to why I should not do the surgery ! A good doctor will understand your question , and will answer this appropriately . He will be able to explain the pros and cons ; share his biases ; and will be able to justify his advise.  Unfortunately, there will be some doctors who will get affronted and upset about the fact that you are challenging their authority .

If your doctor gets angry because you ask questions, this just means that the doctors not very confident about his opinion - and you're actually be better off finding another doctor can give you a more thoughtful,  rational , and well reasoned opinion , which you can be comfortable . If you find you are scared to ask your doctor questions , this means that something wrong with your relationship with him – and you need to fix this before matters gets worse. If the doctors makes you feel uncomfortable when you ask questions, this means the chemistry between you and the doctor is not right, and you’d be better off finding someone else . A good doctor values a patient’s questions , and will do his best to answer them respectfully !

Monday, May 20, 2013

Bad doctors and worse patients

Patients enjoy complaining about doctors . Favourite complaints include:
how long they make them wait;
how much money they charge;
how many tests they order ;
how little time they spend;
how they never explain anything.

This is particularly true when the medical treatment does not go as planned. This is why when an IVF cycle fails , patients have a lot of complaints about their IVF doctor . No doubt some of these complaints are justified - but not all of them are !

When a patient who has failed an IVF cycle comes to me for a second opinion, the first thing I ask is - you please show me photos of your embryos. The standard response is a blank look, followed by - I didn't even know that you could ask for photos of your embryos ! When I reprimand them for not being better informed , they start getting defensive.“  I am not a doctor, so how am I supposed to know that you can take photos of embryos ! “
“ My doctor never gave me any, so what can I do ? “ When I ask why they did not do their homework before starting the IVF cycle, so they would know how critically important photos of the embryos are, because they document the quality of the IVF treatment , the response is – “ Isn’t that the doctor’s job ?”

Patients think I am criticizing them – and they start justifying their lack of information . When I question them , I'm not trying to be critical ; and I am definitely not trying to badmouth the earlier doctor; or make the patient feel bad about what happened in the past. I am simply trying to galvanise them into being more proactive, so that start to take more responsibility for the quality of care they receive ! Patients simply cannot afford to leave everything up to the doctor – they need to do their homework
proactively , before going for treatment.

During one of these Q and A sessions which I had with a patient recently , she got increasingly upset and frustrated . I went to a doctor because he was highly recommended , and I blindly obeyed everything he told me ! This doctor had a great bedside manner; and she trusted him. If he does not give photos to this patients , what do you expect me as a patient to do about this ? How can I question him ? Won’t he get upset because he thinks I am challenging his competence ? The patient then started blaming the doctor for not providing the photos.

Yes, it's true that any IVF doctor who does not proactively and routinely provide photos of the embryos to his patients is a bad IVF doctor . However, a patient who doesn't insist on photos of her embryos is an even worse patient – and perhaps deserves to get a bad doctor !

It’s fine for patients to make a mistake once – but if the patient keeps on going back to the same doctor and not insisting on photos , I think this reflects badly on the patient . After all, IVF is not a monopoly – there are lots of IVF doctors, and patients can take the time and trouble to find a better IVF doctor.

If you stop to think about it, it’s na├»ve to expect doctors to improve. After all , it's not always in their best interest to share information . While some are transparent and will provide photographs of embryos , many prefer taking advantage of the information asymmetry, so their authority as the “expert” is not challenged !

However, it’s definitely in the patient's best interest to ask for photos – and I am not willing to be charitable and forgive patients who refuse to take the time and effort to be proactive. There is a lot at stake when you are doing an IVF treatment – and it’s your duty and responsibility to be well-informed !
There’s no need to be aggressive , but you need to learn to be assertive.  And if your doctor takes offense, this is a red flag – and you should start searching for a second opinion.

If patients don’t start doing this, this is going to be harmful - not only for patients , but for good IVF doctors as well. If the cycle fails, and the patient learns that key information was not shared with them, she will start losing confidence in all IVF doctors , as a result of which the image of all IVF doctors takes a beating.

Monday, May 13, 2013

Success story for a man with globozoospermia

As a referral IVF clinic , we treat many patients who have failed IVF and ICSI cycles in other clinics. Here's a success story from such a couple.

Globozoospermia is a very rare condition , and most IVF clinics in the world will not be able to even properly diagnose this condition, leave alone manage such complex cases. While I am very proud of the fact that we helped our patient to achieve a pregnancy, I am even more proud of the fact that he has become an expert patient, who is very well-informed about his problem ! He now knows more about globozoospermia than most IVF specialists !

Here's his first person account.

We got married in August 2009, and  after marriage we were very happy and enjoying our new phase of life. After one year we thought of next stage of life - parenthood , which is very precious in every couple’s life. But our planning didn’t work. Then we approached the doctor. At that time we were in Kuwait we went to a famous clinic of Kuwait. The doctor suggested for complete diagnosis. The diagnosis resulted in identifying the reason for infertility is due to quality of sperm .However doctor said we can go for IUI treatment , and because of our lack of knowledge about infertility treatment , we underwent 2 cycles of IUI treatment in first half of 2011 with no success.

In June 2011, we shifted to UAE and the first thing we hunted for was the best infertility clinic in UAE .We took all our earlier reports and explained everything about our problem and the treatments that we had undergone previously. Then doctor suggested for a repeat of semen test and the results shocked me . All my previous reports showed semen counts of 30 million and suddenly semen results showed  just 3 million with less than 5% motility with 98% abnormal morphology. He suggested us to go for an ICSI cycle. We went for our first cycle of ICSI in UAE in November 2011. 2 eggs were fertilized .However the doctor mentioned the quality of embryos  was not good and the growth was very slow , possibly because of slow sperms. We waited for 14 days and did the HCG test , but the result was negative. Then we were frustrated and we decided to take a break . I decided to try to improve quality of sperm and went through a nine months  course of homeopathic treatment.

After ten months of treatment we went for a sperm analysis at SRL diagnostics Dubai. The lab analysis showed an improvement in sperm count and motility but reported a new term - 80% Globozoospermia (which means the acrosome or cap on the head of my sperm was missing).

Then one day I searched for the best clinic in India who can give us new hope. We found out about Dr Malpani. We mailed him all the details and the treatments that we have undergone in the last two years. He responded almost immediately to my mail, and I was very happy. Then in my next mail I asked him for an appointment.

We planned for our first cycle of ICSI @ Malpani clinic in October 2012. In our first meeting with Doctor , he asked us what our Plan B was ( if treatment is not successful ).We were surprised and bit confused but later understood the importance of having plan B when he explained this to us. He educated us about our problem. Our ICSI cycle was not successful and none of the eggs got fertilized. Dr called us to the clinic and embryologist showed us the eggs and the video of complete process of ICSI. I was told this is not normal and that globozoospermia was a very rare diagnosis. It was suggested I repeat the semen test with special stains for checking the presence of acrosomes on the sperm @ Dr.Avinash Phalkde, SRL Diagnostics , Shivaji Park. 

I was diagnosed with 98% Globozoospermia. Dr said  I was the first patient he had come across with this diagnosis. He emailed me a few research articles on Globozoospermia and the articles mentioned that lack of acrosome can cause complete fertilization failure after ICSI . There were very few success stories in the world for treatment of globozoospermia. Then we decided to go for plan B (donor sperm) and met Dr in Feb 2013. At this time, Dr explained the option of doing ICSI with about Assisted Oocyte activation using a calcium ionophore . He told us that they would be doing it for the first time in their clinic . We took few days time to make up our mind and then decided to go with the treatment.

We had our 2nd ICSI cycle @ Malpani clinic in March 2013 but this time with AOA with Calcium Ionophore. This time 2 of 8 eggs got fertilized and the quality of embryos was very good. And after 14 days of waiting time it was a great feeling, because  the pregnancy test was positive. We had our first scan  after 7 weeks of pregnancy and we have a bonus because  it is a twin Pregnancy.

All kudos and all credits to Dr Malpani for suggesting AOA with Calcium Ionophore. We thank Dr Malpani from the bottom of our heart.

Sunday, May 12, 2013

Internet reviews about doctors: threat or opportunity?

This is an article which I wrote for the Indian Journal of Medical Ethics. This was a comment on the paper, Daniel Strech. Ethical principles for physician rating sites. J Med Internet Res. 2011;13(4):e113). doi:10.2196/jmir.1899

For most doctors (though perhaps not for the readers of this journal), the field of medical ethics remains an abstract subject which is of interest only to academics. However, ethics is applied to the resolution of conflicts in real life. This interesting paper uses the timeless principles of medical ethics to help to resolve a very modern conflict: how can we make sure that physician rating sites serve a useful purpose without causing harm?

The introduction of the Internet has already changed the way most of us find information, make phone calls overseas, keep up with the news, stay in contact with our friends, book airline tickets, etc. It has already had a major impact on the doctor-patient relationship in the United States, and it is just a matter of time before it  plays an equally important role in the lives of Indian doctors and patients. While the technology has many benefits, it creates conflicts as well, because it gives patients a much bigger say in their own medical care – a concept most doctors feel threatened by, because it is so unfamiliar and new. One of the controversial areas is the sprouting of physician rating sites, which allow patients to rate, comment on, and discuss doctors' performance online, visible to everyone. This can be a mixed blessing, especially when patients are not happy with their doctors and use these rating sites as a platform to vent their frustrations.

This is a timely paper, because there are now many physician rating sites. Some have been created by private agencies, while others have the blessings of government organisations and health insurance companies. Although these have attracted a lot of attention from patients as well as the popular press, there has been very little discussion about these sites in medical journals, even though they are likely to have a significant impact on the way we practise medicine. While government and health insurance company representatives are vocal in their support for these sites because they believe they encourage transparency, many physician representatives argue against them because they are worried that they could compromise physicians.
This paper purports to have two aims. First, it offers a structural framework which can be used to debate the ethical principles behind these sites, thus providing a useful starting point for further decision-making and discussion: what should physicians and policy decision-makers take into account when discussing the sites and their impact on the doctor-patient relationship?

Because there is very little direct evidence of the harms and benefits of these sites, this paper also discusses how evidence from the related area of public reporting of physician performance can help to guide research in this new field.

The paper uses the three basic ethical principles of patient (and physician) welfare, patient autonomy and social justice.

In theory, the availability of information about the quality and competence of physicians (as assessed subjectively by their patients) can help patients stay away from bad doctors, thus helping them to get better medical care and enhancing patient welfare. The provision of online doctors' report cards encourages transparency of medical performance, and this could also result in greater public trust in the healthcare system.

While discussing the principle of welfare, the authors remind us that we also need to consider the impact of these sites on physicians' well-being. While the majority of reviews of these sites appear to be positive, negative reviews can cause both psychological and financial harm to the doctors concerned.
Physician rating sites also encourage patient autonomy, because they empower patients with information. The authors look at this benefit through the interesting prism of improving the patient's health literacy at three different levels: functional, interactive and critical.

As regards the third principle of social justice, the fact that these sites are online means that only patients with access to the Internet can use these services. This means they can actually worsen the digital divide between the haves and have-nots.

The most interesting question these sites raise is: do they provide reliable and useful information? Or is it possible to game these sites, as a result of which the ratings can no longer be trusted? Can doctors manipulate them by requesting their happy patients to provide positive reviews? Or can disgruntled patients ruin a doctor's online digital reputation by posting negative, biased and dishonest reviews about him/her on multiple sites? How can patients trust the information that these rating sites provide? And what can doctors do when they encounter negative ratings which they feel are unfair and biased?

The most useful nugget of information I found in this paper is tucked away in a table, which describes the five basic conditions which need to be met in order for a physician rating site to be useful. These include: transparency, justification, participation, minimum conflicts of interest, and openness to revision. Most sites have not been able to meet these conditions. Indeed, there is a lot of scope for improvement in how these sites are created and maintained, and paying attention to these basic principles will help to ensure that the next generation of physician rating sites provides value for all stakeholders in the healthcare ecosystem.
I enjoyed reading this paper because it discusses an issue which is very close to my heart. However, I feel the author has done his readers a disservice by unnecessarily complicating the issue. He has used a rather formal, heavy style so that making sense of the article is an uphill task. Just because this article is written for an academic journal does not mean it should be hard to understand. Perhaps the fact that the author is from a non-English speaking country may explain why the language is not lucid.

After reading this article I encourage physician readers to google their own names to see what their patients are saying about them. It is going to be increasingly important for doctors to manage their online digital reputation, because whether we like it or not, our patients are going to talk about us. We must learn what our patients feel about us. Ignorance is not bliss; in fact it can actually be harmful.

Patients have always had opinions about their doctors; after all, this is how a doctor's reputation develops. Traditionally, this was by word of mouth, a slow process, and it could take a doctor a lifetime to build a reputation. Physician rating sites have accelerated this process dramatically.  However, while many patients will swear by their doctor, there will be others who will swear at them.

While it is all very well to take the moral high ground when talking about the right of patients to freely express their opinion about a doctor, I can vouch from personal experience for the fact that negative reviews can raise one's hackles quickly. While some such reviews may be well-deserved, others are unfair because they have obviously been penned by disgruntled patients, venting their bile. Others may even be planted by the competition.

Can we censor these sites? Let us not fool ourselves; the horse has left the stable. It is a fact that we will need to learn to live with patient complaints – including the ones posted online on doctor rating sites, for all to see.

The good news is that these doctor rating sites can actually help doctors to become more patient-centric. Hopefully, we will start treating our patients better, because we know they can harm our reputation by going online and posting negative reviews. Doctors should read the patient feedback stories at doctor rating sites to educate themselves as to what patients want from their doctors. The good news is that what patients want from their physicians is not all that different from what good physicians want to offer their patients. Patients are generally not unreasonable, high-maintenance consumers; they simply want doctors who care, listen, and know what they are doing. By reading the positive ratings, doctors will have role models of good physicians to emulate, and by reading the negative ratings, they will learn what to avoid. Smart people learn from the mistakes of others, and we can learn a lot about what a medical encounter feels like from the patient's perspective by browsing through these websites. They will help us become more empathetic doctors if we are mature enough not to take the negative ratings too personally.

In the big picture, these rating sites are a great opportunity for the medical profession to be open and transparent with patients. Medical associations should set up doctor rating sites to ensure that the basic information which patients need about a doctor (clinic location, credentials, professional qualifications and so on) is available. Also, these sites will be comprehensive because they will provide information on all doctors. If these are seen to be fair and frank, patients will be happy to refer to them as an authoritative source of information on doctors, rather than waste hours scouring dozens of unreliable and incomplete sites. It is also a good way of identifying the bad eggs in our profession, those who end up giving all of us a bad name. Even though we know who these are, we often prefer to participate in a conspiracy of silence and to turn a blind eye to their antics. Rating systems will allow the truth to come out in the open more quickly, helping with self-regulation of the profession.  The Medical Council could take cognisance of repeated complaints about a doctor, and take action to prevent problems from flaring up.

Saturday, May 11, 2013

Infertility and Mother's Day

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

Many infertile women who are struggling to become mothers view Mother’s Day as a curse, because it cruelly reminds them of their inability to become a mother. While the rest of the world celebrates motherhood, they suffer from Mother's day blues.

Just stop and think about this picture - did the lady ever carry a baby in her womb ? No – but even though she never gave birth, she will always be fondly remembered as Mother Teresa. When we think of Mother Teresa, we remember :

her caring ways;
the selfless service she rendered to the poor and needy;
the love and compassion she showered on suffering souls;
the dedication she showed in the work she did;
the sacrifices she made did to make this world a better place.

It’s these qualities which prompted people to call her "MOTHER" affectionately , and not the fact that she had undergone the biological process of giving birth !

Mother's day is a celebration of all the sterling qualities that exist in a human being - LOVE, AFFECTION, DEDICATION, SACRIFICE, COMPASSION, and EMPATHY.

Being infertile actually brings out these latent qualities which lie within all us. Can you show me an infertile women who doesn't love children ? Being infertile teaches you empathy – and all of us learn a lot from adversity.

Infertile women are usually much more caring – and can reach out to a fellow soul in pain because they are suffering themselves.  The truth is that carrying a baby for 9 months doesn't make anyone a mother - caring does !

Is there anyone else who knows how precious motherhood is than we do :)

So, my dear friends, have a very Happy Mother's Day ! Every one of us deserves as many Mother's day wishes as any other women !

You can email Manju at [email protected]

Her blog is at

Friday, May 10, 2013

Video Guide to PCOS ( Polycystic Ovarian Syndrome)

Reaching out to patients directly

Hospital CEOs are smart and understand that in order to fill their beds and to maximize their revenue, they need to reach out to patients directly. This is after all what marketing, advertising and branding is all about . However, these are expensive propositions – and though these traditional methods have been used for many years , they don't work well for multiple reasons. This is why lots of hospitals incentivize doctors to refer patients to them. This can be in the a form of kickbacks , cuts, “referral fees”, “assistant charges” “ medical consultant fees” or commissions . This works initially,  but is a broken model for multiple reasons .

For one thing the hospital is effectively signing away 10 percent of their profit to the doctor . Even worse, he's not likely to be loyal at all , because if another competing hospital offers 15 percent, the doctor will then start sending his patients to the other hospital !

CEOs realize that they need to establish a direct one-on-one relationship with their patients, rather than go through a middleman. This is a challenge,  and he needs to know how to do this cost effectively. After all , his priorities are to provide high quality medical care , and he has a limited budget . He has to chose how much money to spend on marketing, branding and advertising – and which channels to use . There are multiple opportunities , but because one of them is right under his nose, he often fails to see this !

When a patient is admitted, the focus is on providing good medical care. Unfortunately very little attention is paid to the needs, wants and desires of the people accompanying the patient – the patient's friends, relatives and neighbors who come to visit the patient in hospital . All these visitors are potential future customers and clients , because they're all going to fall sick at some point ! If they have a good experience when they come to the hospital as visitors, this will create a positive experience, so that when they fall sick at some point in the future, they're much more likely to choose this hospital , rather than go somewhere else.

What can the CEO do to make sure that all the visitors have a wow experience , so that they are happy to talk about how great the hospital is ? If we assume that the technical care which is provided by the medical staff is good , then you only need to do so basic simple stuff so that visitors feel like valued guests, rather than as barely tolerated pests !

However, because hospital CEOs are so focused on things like maximizing bed occupancy , keeping their doctors happy, and buying new equipment , that they don’t spend enough time thinking about what they can do to provide a better experience to the visitors who come to his hospital !

Thursday, May 09, 2013

Healthwise awards Dr Malpani the Patient Champion Medal

The most neglected person in the hospital

Hospitals are designed for doctors. They have been created so that the doctor can collect all his patients under one roof , and provide medical care to them in a setting which maximizes his productivity and efficiency. They provide the doctor with easy access to medical equipment, labs, technology, consultants , specialists, nurses and assistants. Unfortunately , hospitals are not very friendly places for patients , who will often feel lost and uncomfortable , because they are scary places ! The good news is that a lot of work is being done on improving the patient experience within the hospital. Studies prove that improving patient experiences is good, both for the patient and for the hospital and for the medical staff.

However, even more neglected than the poor patient is the hospital visitor. Most hospital will allow visitors only during specific visiting hours , at which time the hospital overflows because there are so many other visitors who are forced to come to visit the same time. Most visitors are treated as a necessary evil . There are lots of do's and don'ts as to what they are allowed to do and what they are not. They are usually treated as dirt by the staff, which is why most visitors are quite intimidated about going to the hospital.

Actually this is such a huge opportunity which hospital management is neglecting , by not focusing on the needs of the patient’s visitors ! Visitors need to be treated as a valued guest in a hospital setting , because all visitors are going to be potential patients at some point . Hospital visitors are very aware of their own mortality , and are much more likely to be receptive about their health and illness prevention . It always amazes me why hospital managements don't recognize this ; and why they don't spend a little bit of time , energy and effort in making visitors feel welcome. This is an extremely worthwhile investment,  because when these visitors fall ill (as all of us will some day ), they are likely to remember the hospital which treated them with respect and care , and are far more likely to select this hospital for their healthcare needs. Hospitals have a captive population of visitors, but instead of capitalizing on this , they often neglected and ignore – or even worse, ill treat them !. This is a huge opportunity which is waiting to be exploited - and the good news is it's very easy to engage this population. Thus , while they are waiting, they can be given educational materials to read; and patient education videos could provide information about the medical services the hospital provides. Smart hospitals could give all visitors a free health education DVD – or a book on how to take care of common medical problems. This is a great branding exercise – and is a very cost effective way of acquiring new patients for the future !

Wednesday, May 08, 2013

Can the level of HCG in blood tell me whether my pregnancy is a healthy one or not ?

Yes – but only to a certain extent.  The HCG ( human chorionic gonadotropin) hormone is a remarkable molecule which is very unusual because it is produced only by the cells that will become the placenta of the developing embryo (trophoblast cells). Once the embryo implants in the uterine lining, these cells start producing HCG . It takes a few days for the HCG hormone to build up in the body to a level, which is high enough for it be detected in the blood or urine of pregnant women. Normally, you do your first pregnancy test (HCG blood test) 14 days after embryo transfer.  At this point, if the embryo has implanted, you will also get a positive urine pregnancy test. The HCG hormone level in the blood doubles every 48-72 h. If the HCG level doubles well, this indicates that the cells of the embryo are dividing well , suggesting that the pregnancy is progressing normally and is healthy.  This is why monitoring the HCG blood levels during the first few weeks  helps to make sure that the pregnancy is advancing as expected. A drop in HCG level during this time is a sign that the pregnancy is not healthy.  Make sure that you measure your HCG level in the same lab each time to avoid discrepancy in the results.

However, do remember that because the HCG is produced by the trophoblastic cells of the embryo, just because the level is rising well does not always mean that the pregnancy is healthy. Thus, while a drop in HCG confirms the pregnancy is doomed, a rising HCG level provides limited information.
Also, once the HCG level crosses 1000 mIU/ml, a vaginal ultrasound scan provides much more useful information than just the HCG levels,  because it allows us to actually visualize the development of the growing embryo.

What is a chemical pregnancy ?

Sometimes, the joy of being pregnant can be very short lived. You might get a positive urine pregnancy test, or a positive blood pregnancy test, two weeks after (or even earlier !) your embryo transfer. But, to your agony, the subsequent pregnancy tests you take  might reveal a dropping HCG value ; or your urine pregnancy test may become negative. This is a very hard situation to face because you feel disheartened and cheated. Such a pregnancy, which dissolves quickly, is termed a chemical pregnancy. This means your embryo implanted in your uterine lining , but failed to develop further. This is quite common and occurs because the embryo is not competent enough to grow further. Please do not blame your life-style or other activities for this ! A chemical pregnancy cannot be prevented by any means what so ever - taking extra progesterone,  avoiding certain foods,  avoiding intercourse or taking strict bed rest cannot prevent a chemical pregnancy, so please do not beat up on yourself !

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

Tuesday, May 07, 2013

The unhappy hospital CEO

Dr Desai is a bright young hospital CEO . After finishing his M.D. in internal medicine he completed his MBA and now runs a 100 bed multispecialty hospital. The hospital is doing well , but he is unhappy . He knows that his hospital has excellent equipment and that his doctors are very skilled and competent. However, he is concerned that his bed occupancy is still low. He wonders what he is doing wrong and why more patients don’t come to his hospital.

One major problem is the competition. Most patients prefer going to the big brand-name hospitals such as Apollo and Fortis, because they have much larger marketing budgets , and can spend much more on advertising and creating brand-name recognition. This is why it’s easier for them to attract patients – and there’s no way he can spend so much money on advertising !

What can he do to make sure that patients will come to his hospital, rather than go somewhere else ? He knows that even though his hospital is smaller, the quality of clinical care is actually much better , because it's much more like a focused factory . They only do certain procedures , but they do these extremely well , which means they can provide high quality services much more cost effectively than the larger hospitals.

Thus, his hospital does not offer expensive and esoteric treatment options such as transplantation. Now while transplantation programs attract a lot of headlines and seem to offer cutting-edge medicine , in reality they impact only a very small proportion of patients However , to run a transplant program requires a lot of infrastructure and expenditure , and because the large brand name hospitals are so focused on promoting these high profile specialty departments , they spend a disproportionate amount of money on these , as a result of which their other more basic departments ( such as general surgery and obstetrics ) will often get second-class treatment.

This means that these departments, which provide  the bulk of the common medical care which most patients require , end up being treated with much less loving care then the high-profile departments . Even worse, they often over-charge, because they need to subsidise the glamorous high-tech departments such as robotic surgery or transplantation surgery.

The CEOs’ problem is – how can I explain these facts to potential patients ? How do I show them that even though our hospital is not so large , we are much better at taking care if them because we don’t have all the fancy bells and whistles. This is quite a challenge , and something which he's been grappling with.

How can he reach out to patients directly ? The traditional route was to go through their family physician, who was often the point of first contact when patients fell ill. In the past, patients would trust their family doctor to guide them and select the right specialist and the best hospital or them. However, times have changed – and many patients don’t even have a family physician any more !

The answer is simple – go to where the patients are – and all patients are online now ! They are hungry for information and will spend lots of time in trying to understand their disease; research their treatment options; and get a second opinion. The good news is that if he focuses on addressing their needs, he can capture a large proportion of these affluential patients.

Dr Desai is confused. Our hospital already has a website , which means it’s easy for patients to find us. What else should we be doing ?

This is part of the problem. While it’s true that Dr Desai’s hospital does have a website, it gets very little traffic, because the website just talks about the hospital and the services it offers. It offers very little information on what the patient is interested in -  his symptoms; or his disease ! However ,writing high quality medical content specifically for patients can be a very difficult and time consuming to create.

The good news is that he can now instantly license over 30000 pages of reliable updated trustworthy patient education content from the world leader in patient education, Healthwise Knowledgebase !  After seeing the demo at, Dr Desai is convinced that this is a very cost effective investment, which will help him:

Engage  with online patients
Encourage them to call his hospital as the provider of first choice
Build trust
Increase patient satisfaction
Build loyalty and stickiness

Monday, May 06, 2013

Why don't you ask your Doctor ?

I enjoy providing a free second opinion as an IVF expert . I find patients are often confused and need an expert to provide them with an unbiased, objective second opinion, so they know they are on the right track. However, I sometimes get frustrated when patients ask me questions which they should be asking the IVF doctor who is treating them ! After all, it is their doctor’s job to provide answers – and often I do not have enough specific medical details to be able to provide intelligent answers.

So why do patients turn to me for a second opinion ? Why do they find it hard to ask their own IVF doctor these basic questions ? One of the reasons is that patients feel intimidated. They are reluctant to “waste the doctor’s time” because they know that their doctor is a very busy person and has lots of other patients to
see . They also don't want to appear to be foolish or ignorant , which is why they continue nodding their
head , even though everything is going about the head , and they are  completely clueless as to what the doctor is talking about.Few patients have the courage to be honest and upfront with the doctor and say – I don't understand !

Part of the problem is cultural. Patients are used to asking questions – and doctors aren’t used to answering them ! This is particularly true in India , where the schooling system encourages rote learning, and the teacher is treated as the expert who is the fount of wisdom and has all the answers . When these children grow up to become adults, they retain this attitude or unquestioning obedience to authority figures.

Patients will often not ask the doctor any questions because they don’t want to be seen as being
disrespectful . Some patients are just not very good at asking questions – they simply don't know how to frame their questions !

Doctors will compound this problem. They are often unapproachable and intimidating – and when the patient tries to ask questions , they will often brush these off – or will sometimes be downright rude and refuse to answer them. It’s easy for them to put patients “ in their place” .

These replies include–
  • It’s too complex – you will not understand;
  • I am the expert – just leave it all to me !
  • Why are you asking these questions – don’t you trust me ?

Once patients have experienced these kind of putdowns, they are understandably very reluctant to ask any other questions – and will not ask other doctors questions either, because they assume all doctors are the same ! If things go well, then there is no problem, but if there is a poor outcome, patients are very resentful and will vent their frustration on the doctor.

This reluctance on the part of patients to ask questions and on the part of their doctor to reply to them represents a great opportunity for clever entrepreneurs to act as an information intermediary , so that patients are able to get answers to their queries.  The best way of doing this is by providing an online platform . Doctors can leverage the technology to digitally deliver information to patients, without eating into the precious face to face time they have with the patient. For example, doctors can create a series of videos to answer the common questions patients ask them, and upload these their website. Patients can view this on their smart phone , even before the patient comes to the clinic !

Saturday, May 04, 2013

The problem with Indian hospital websites

Most leading Indian corporate hospitals take pride in the world-class medical services they offer. They tom-tom the fact that they have state of the art technology and skilled doctors who offer extremely cost effective medical care . They boast that they perform advanced surgeries at a fraction of the cost which hospitals in the USA charge. While this is true, what amazes me is how much of a blind spot Indian hospitals have regarding their websites

While it’s true that may have exactly the same 128 slice MRI scanners and robotic surgery facilities which Mayo Clinic has, their websites are light years behind. The public face of a hospital is its website, and the websites of Indian hospitals are pathetic . While they are cleverly designed, their content leaves a lot to be desired because they flout the first rule of marketing !

While Indian hospital websites have lots of information about the hospital , they have precious little information about what the website visitor is interested in - information about his symptoms, his diagnosis; and his treatment options . This is the reason why even though there are so many millions of Indian patients online – and thousands of Indian hospitals have their own websites, these patients have to go to to get the information they need ! This is a huge wasted opportunity – and is especially ironic, considering the fact that India is considered to the IT powerhouse of the world.

Unfortunately, Indian hospitals are not leveraging this technological expertise in order to reach out to patients through their website. Perhaps this is because hospital CEOs feel that not many Indians have internet access, which is why they have not bothered to explore this channel.  This is extremely shortsighted. I'm sure most hospital CEOs will agree that when someone in their family falls ill, the first thing their wife done is a google search to find out more information about the problem . Isn’t it logical that the kind of affluential patients whom they want to attract will do exactly the same thing ? There are now over 200 million Indians who access the internet through their smartphones, and this number is increasing exponentially. These are high net worth individuals with deep pockets – exactly the kind of patient whom these corporate hospitals want to target !

The other problem is that CEOs feel that since we already have a website, then why do we need to bother about content ? Isn’t it enough that if patients do a search on Apollo Hospital, they will find us ? Yes, that’s true, but patients don’t do searches for the name of the hospital. They do searches on what is of interest to them – their symptoms or their disease !

Try doing a google search on keywords such as angioplasty; risks of bypass surgery ; or knee joint replacement. It’s quite disheartening to realize that Indian hospital websites rank very low on the google search page. Or try using to compare the web traffic which gets as compared to ! There’s absolutely no reason why the websites of Indian hospitals should not get more traffic than the websites of US hospitals – after all, they can do online marketing far less expensively than US hospitals  ! And what about the wasted opportunity for attracting medical tourists ?

Indian hospitals need to get up and realize that if they want to attract patients – both those from India and from the rest of the world, they need to improve the content on their sites. Most patients are online – and until hospitals get their act together and start providing the information which these patients want , they will lag behind and lose these patients to more digitally savvy hospitals . It’s high time Indian hospitals invested the money , time and energy it requires to create a world-class website !

Friday, May 03, 2013

Why aren’t patients better informed ?

It breaks my heart when I see how poorly informed patients are about their medical problem . I believe that patients need to become experts about their disease, so that they understand all their options and can select the best treatment for themselves , in partnership with their doctor. In this day and age , when there’s so much information which is so easily available online , then why are patients still so poorly informed ?

It’s not just a question of the digital divide or the lack of access to the internet ! It’s not just the uneducated patients, but often the well-educated ones ( who are online all the time) , who are pretty clueless about their  treatments.

The commonest excuse is - I don't know because my Doctor didn't tell me. This is the worldview of the passive patient – one who expects the doctor to do everything for them . When things go well , they are happy to place the doctor on a pedestal – but when things go badly , these are the very same patients who curse the doctor , and feel that he's a mercenary who is only interested in making tons of money and doesn't care about his patients . They feel frustrated when the doctor doesn't share information with them - are quite happy to blame the doctor for their own personal lack of initiative in finding out stuff for themselves,

In all fairness, there are patients who do try to get the information for themselves by doing their homework,  but they often get lost and confused because they are  not sophisticated enough to separate the wheat from the chaff. There's too much information out there , and because a lot of the information available online is unreliable or biased, they don’t know what to trust.

It’s true that doctors are partly to blame for the sad state of affairs . Enlightened doctors understand that it's in their best interest to make sure that patients have all the information they need - and they want patients to access this information . Clever doctors proactively provide information to their patients , to create loyalty and trust. However, most doctors are do bogged down in providing clinical care, that they are just not able to do this efficiently. However, as doctors get busier and busier , and more and more frustrated because of inadequate remuneration , and patients get more and more demanding, there is a lot of scope for creating information intermediaries who can provide reliable information to patients at their point of need . It makes a lot of sense for health insurance companies to invest in this space, to make sure that the information which the patient wants is available to them when they want it - preferably through their smartphone .

This information can be provided prior to the visit ( for example, for symptom analysis, to help the patient understand what the diagnostic possibilities are); while the patient is waiting in the clinic; and just after the visit ( when patients need help in translating what their doctor said !)

Health insurance companies can no longer think of themselves as just being financial service providers who will help to reimburse for medical expenses and provide financial assistance when the patient falls ill. This is a broken model . They need to be much more proactive and understand that their role is no longer just limited to illness care.  Enlightened health insurance company will focus on improving health care , and a very effective way of doing this is by making sure that patients are well informed. This is a big opportunity for clever entrepreneurs - and the good news is that lots of entrepreneurs are exploiting this.  Insurance companies need to invest in these, to help them improve their profitability !

Thursday, May 02, 2013

IVF success story for couple from Bangalore

Each of our patient's success stories provides us with the motivation and burning desire to keep on improving the services we offer . Sharing their joy is an immense source of personal satisfaction - and makes all the hard work we put in so worthwhile !


I always envied but enjoyed reading success stories on infertility struggles. Longed I would be writing one and help someone believe in their dream during this struggle.

We were already nearing our 30s when we got married. And I had always thought like many of us that as soon as we want we will have babies. But we were not so lucky after all. So after a few months I started worrying though my husband felt I was being paranoid. I had no gynac history earlier but the mere age factor with my being overweight was worrying me. So after 6 months of actively TTC we decided to see a doctor locally (BTW we are based out of Bangalore). She seemed to be just starting her own fertility practice but based on general reviews she seemed a good doctor. We first met her in Jun’11 and initial meetings were nothing but blood tests and investigations more from my side. She suggested we kept trying naturally as the hormonal tests were all normal. Meanwhile my husband’s tests came back as low motility but not alarming. We were both put on medicines to improve egg and sperm quality and that started our fertility journey. As days passed by, we realized how much of an investment this was both financially and emotionally. But each month we faced disappointment.

After a few medicated cycles of TTC naturally she suggested IUI (Sept’11) but that wasn’t a success and she felt my cervix wasn’t dilated enough so I may need a hysteroscopy to rule out any problems before IVF. The hysteroscopy suggested some scarring in the tubes and she ruled that the tubes may be blocked. The TB PCR test which followed came back positive based and AMH tests also suggested a low number adding to our worries. With these we were told our egg quality was very poor and also I would need immediate TB treatment and that IVF was our only hope. Her husband happens to be a doctor on Infectious diseases and so I never thought of taking a second opinion.  I started off on the TB treatment from Nov’11 and continued under her oversight until end Dec when she repeated the TB PCR which came back negative this time. She felt we were ready for IVF and we should start the very next cycle. Though I wasn’t convinced on stopping the TB treatment so early on without explanations, all I knew was I was getting closer to doing IVF which probably gave me the highest chance of having a baby. So we went by her advice and started our first IVF cycle in Jan ‘12.

The IVF cycle couldn’t have been better – everything was good and even better than planned. We retrieved 7 eggs but resulted in 3 very good quality blastocysts (top quality as per the doctor/embryologist). Her clinic never rated the embryos and we never got a chance to see them as well. But given that everything was going well we were happy. We decided to transfer 2, 5-day blasts even against our doctors wishes as she felt this would certainly result in multiples. After the toughest 14 days of my life the results came back negative. We were lost and had no answers on what went wrong. She mentioned that my egg quality was very poor and hence expectations could not be high – this statement being completely ironical to our conversations during the cycle when everything seemed better and beyond expectation and we had transferred 5 days blasts. We waited one cycle in between and decided to go for a frozen cycle with the 1 blast left and even this was unsuccessful. During our follow up meeting the doctor kept stressing on how poor the quality of our eggs were and also that we should think about donor eggs. My husband was particularly very disturbed with the discouragement and quick alternates suggested without even spending justified time on treatment.

We were so worn out with the treatment that we decided we would take a break in March’12 and try naturally even though she suggested this held no hopes for us. But even on a financial level we weren’t in a position to go any further with the treatment. We stopped all medications and decided to adopt a healthier lifestyle by adding some yoga into our daily lives along with some ayurvedic medicines. To our total surprise we conceived naturally in July’12 but unfortunately the HCG numbers started dropping and before week 6 we miscarried. Though the miscarriage was traumatizing the fact that we conceived gave us a lot of hopes so we continued to try naturally.

After a few months of being unsuccessful we felt it was time to relook at our treatment options. I had always read about Malpani Clinic from the time we started TTC. But being based out of Bangalore and financial constraints we could not consider it as an option. When we had enough funds to start a cycle again we began looking at alternates at the end of 2012. I came across the Malpani’s site and sent out a general query with my history and was pleasantly surprised to see a reply the same day! Hopes were raised to start a fresh cycle with a strange kind of confidence in the doctor couple. We were in Mumbai early Feb’13 and our first meeting with Dr. Anirudha Malpani went quite well. We were explained the facts straight given our history and the treatment mode was explained. The basic infrastructure, the staff and the doctors themselves represented the quality of the treatment we were to expect at the clinic. After our experience in Bangalore, each day at the Malpani clinic gave us new hope and filled us with positivity. The scans and procedures were handled by Dr. Anjali herself and should mention she was very patient with all our questions and probing. Our retrieval and transfers were smooth – 8 eggs retrieved and resulting in 6 embryos (All were grade A embryos). We were suggested a 3 day transfer of 3 embryos – 1 morula and 2 6-cell embryos. We were shown our little babies before being moved to the transfer room and also got to bring their pics back home.

We were back in Bangalore soon after the transfer and eagerly waiting for our beta tests. I did secretly take HPT at home and I could see a positive after day 7 of transfer. Our beta results came back positive and follow up tests were also good. We were on top of the world at our 6 week ultrasound when we saw our little bundle of joy with a steady heartbeat! Words cannot describe our feelings and we continue to be in this trance of having achieved our dreams! Now we almost complete our first trimester and are eagerly awaiting our next ultrasound.

Having an offspring is probably a couple’s biggest dream and we are so indebted to Dr. Anirudha and Dr. Anjali for helping us get to our dream. The entire treatment was very transparent, well documented and well explained. Special mention to the staff at their clinic who are so encouraging and never fail to bring a smile on our face even during the most stressful phases of the cycle. When we were being suggested to freeze our remaining embryos before the transfer, those words still keep ringing in my ears when the senior nurse , Sister Pramodini, said “Beta, once you have your baby after this treatment you can come back to us after one year to have the second one!”

We wanted to give her a hug for her words! Overall we could not have asked for more from our experience with the Malpani’s. Except we did regret having waited for so long to meet them - but better late than never.
That’s what we have to say to all those couples who are still on the waiting side – believe in your dreams, in almighty and this great couple! 

My email ID: [email protected]


Wednesday, May 01, 2013

The other side of the stethoscope

Everyone acknowledges that improving doctor-patient communication will go a long way towards improving healthcare. A lot of misunderstandings occur because of communication gaps, which is why there has been a lot of emphasis on teaching doctors how to communicate better with their patients . Doctors are being told to learn how to be empathetic ; and they attend courses on how to improve their soft skills ; and are exhorted to improve their health literacy skills , so that patients understand what they are talking about .

However, I think patients also need to understand what their doctor feels and thinks - after all,  communication is a two-way street . When you are a patient you may not have much control over the doctor’s bedside manners – or how good or bad his empathetic skills are. However, you do have control over how you can communicate with him – and it’s worth polishing these skills !

Rather than simply expect the doctor to do all the work and expect him to be kind and empathetic it makes much more sense for you to be empathetic and think a little bit about what it feels like to be a doctor. Try putting yourself in his shoes and think about what he must be feeling ! If you do this , you'll understand a little more about what makes your doctor tick – and it’s help you to be a little kinder to your doctor .

The great thing about doing this is that it will automatically help your doctor to become much kinder to
you ! The best way of building a winning doctor-patient partnership is by learning to respect your doctor, so that  you no longer just treat him as a professional, but rather as a human. If you do so , he will reciprocate and treat you not just as a patient to whom he is obliged to provide medical care, but as a human being !

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