Bleeding during pregnancy - is my baby fine ?

Pregnancy can be an exciting time. When you finally see two lines on your urine pregnancy test kit , and your beta HCG blood test comes back as positive, you’re on top of the world that all your efforts and hard work have paid off , and you can now sit back and finally look forward to having a baby.

However not all pregnancies are uneventful and it’s quite common to have spotting or bleeding during a pregnancy . When this happens , you tend to panic. Oh my God , is everything all right ? Am I going to miscarry ? Is the baby going to be defective because of the bleeding ? Am I going to lose the baby ? Will the bleeding harm my baby ?

Your mind starts imagining the worst, and the problem is that there’s very little which you can do about it. The bleeding is completely out of your hand, and you are helpless. The first thing you do is call up your doctor , who usually tells you to rest and relax. But it’s very hard to relax, because you automatically start assuming the worst. Is all your hard work going to go down the drain ? Are you going to lose this pregnancy ? Is everything going to come to naught ? Are you going to prove to be a failure again ? Does this mean that not only can you not get pregnant , but that even after getting pregnant you couldn’t even hold on to your baby ?

When a pregnant woman starts bleeding, it’s important that the pregnancy be monitored very carefully to make sure that everything is fine. The good news is that most of the time everything will be fine . Spotting and bleeding during pregnancy is quite common. It often comes from the uterus or the cervix , and we often cannot even identify its source. It doesn’t harm the baby .

However, when you’re bleeding , it can be extremely scary. This is why your doctor will order both a beta HCG blood test as well as an ultrasound scan to reassure you that all it well. Both of these provide complementary information , and the doctor needs to use both these pieces of information to determine all is well.

It’s important to learn to be able to interpret these results. It’s not that you want to become a doctor, but if you understand what’s happening , and why the doctor is ordering the test,  you’ll be much more at peace with yourself.

Usually a single test result doesn’t tell us what we need to know , and we need to repeat these tests over a period of time to document that everything is well. A well informed patient who understands what the test results mean , and why they are being repeated will be able to understand what the doctor’s plan of action is , and will be much more comfortable .

If you want to make sense of your HCG results and your scans, please visit the website at
www.hcgexpert.in . All you need to do is enter your HCG blood test results and your scan results , and we’ll be able to interpret for you whether your pregnancy is progressing normally or not. 

Sadly, the truth is that not all pregnancies have a happy ending. Some may miscarry, while others may be an ectopic ( tubal pregnancy) .  A failing pregnancy can be an emotional disaster, while an ectopic can be life-threatening. The sooner the diagnosis is made, the better for both you and your doctor. HCG Expert can help you to become a well-informed patient, and reduce the risk of an ectopic rupturing.

What healthcare can learn from the MasterCard Symposium on Clients at the Center and The Client Journey

MasterCard recently held a Symposium on Clients at the Center and  The Client Journey.
http://mastercardfdnsymposium.org/2014symposiumreport/

Their focus was on reaching out to the millions who still do not have easy access to financial services.

It's a very well produced symposium - and a lot of the lessons could be directly applied to providing healthcare for the poor as well !

For example, watch the video debate on - The future of financial services for the poor will rest primarily in highly automated, low-touch models for reaching clients.
http://www.ifmr.co.in/blog/2014/12/19/video-best-way-to-interact-with-clients-high-touch-or-low-touch/

This could easily be reframed as - The future of health services for the poor will rest primarily in highly automated, low-touch models for reaching patients !

Early pregnancy scans- is my baby fine ?

Pregnancy can be a very exciting time, but it can also be every nerve racking, especially when you go for your ultrasound scans, because you’re never sure what the results are going to be and what they mean. Is my baby fine ? How many babies are there ? Is the baby in the right place ? Is my baby growing well ? Is the heart beat okay ? Is the pregnancy progressing well ?

You have many questions and your mind plays all kinds of games with you, especially when you have symptoms – and even when you don’t ! For example, if you don’t have any morning sickness , you start wondering - Is my baby alright ? Or is something amiss ? This becomes worse when you compare yourself with other pregnant women , and find out that what’s happening to you is perhaps not typical of the others.

Since about 10% of all pregnancies fail, your doctor does serial ultra sound scans for you , to reassure you that all is well. This is especially true if you have conceived after IVF.  However, interpreting ultrasound scans during early pregnancy can be quite tricky . The pregnancy grows and develops quickly, which means scan findings evolve dramatically over a few days . What’s normal at 6 weeks is no longer normal at 8 weeks ! It’s usually a technician or a sonographer who does the scan, and they will often not interpret what the scan means, or even share information as to what the scan shows. Their standard reply is - I will do the scan for you , but you will have to discuss the results of the scan and what it means with your doctor, because I am not allowed to tell you.

This creates even more suspense. For example, when you can see a sac on the scan, but you can’t see a baby , what does this mean ? Does this mean that the baby is dead ? or that the baby is fine but because the scan has been done too early the baby is too small to be seen on the scan ? The problem is even worse when the doctor can see the baby, but can’t see the heartbeat. Does this means that the baby is dead ? or it not growing  properly ? Or does it mean that the ultra sonographer can’t see the heart beat because his machine is not good enough or he is not skilled ?

Maybe the heart beat will appear on the next scan , and it’s too early for your baby to have a heart beat as yet. Are you six weeks ? or are you eight weeks ? and how do you calculate the date ? Do you use menstrual age ? or do you calculate the baby's age based on the date of embryo transfer ?

You will google extensively to find out what other women’s pregnancy scans look like , and this can scare you even more, because there is so much biological variability during pregnancy. Thus, some babies will have a heart beat at 6 weeks, while for others it may not be seen until they are 7 weeks  pregnant. You are frantic with worry until you actually get a chance to meet your doctor , but sometimes all the doctor can say is - We need to repeat the scan again next week to make sure all is well.

If you would like to cut down the suspense , we can help you make sense of your pregnancy scan results !

Please visit www.hcgexpert.in and enter your scan findings,  and we’ll be able to tell you if your pregnancy is progressing normally or not. This is a free service, and we hope it will help to reassure lots of women that their pregnancy is fine, so that they can enjoy it properly, rather than worry needlessly !

The older IVF patient

I recently did a consultation with a 42 year old infertile woman. She knew she needed to do IVF, and was mature enough to understand that her chances of success were low because of her advanced age. However, her bigger concern was - Am I too old to be a good mom ? Would I be able to do a good job with bringing up a baby ? Am I being fair on my child by wanting to have a baby so late in life ? Will I be able to provide her with the love and attention which she deserves ? 

She was a very sophisticated, thoughtful mature professional.  She was thinking through her decision of having a baby very carefully. This wasn’t just a selfish desire she wanted to fulfill, no matter what the long term  consequences.

There were issues with her husband as well. For all these years , her husband wasn’t too bothered about having a kid. But now that he was 45 , his midlife crisis seemed to have kicked in, and seeing all his friends playing with their kids , he decided one fine day that he wanted to have a kid too !  While his sperm count was fine , and would remain fine no matter how old he became , she was now too old to be able to have a baby in her bedroom. This caused  her a lot of resentment, that he hadn’t cooperated with her when she was younger and had wanted a kid , and that now when she had biological difficulties , he was asking her to get pregnant which was not something she could do any more with ease. This also caused her regret that she hadn’t been more assertive and vocal when she was younger about asking for her husband’s cooperation in order to get pregnant. I had to sit down and explain to her that she shouldn’t be thinking of herself as a second class mom just because she was older. In fact I personally believe that older mothers are usually better mothers. They are lot more mature, more patient, and more thoughtful they have a lot more to teach their children because they’ve seen a lot more of life. They aren’t as pushy and aggressive as younger mothers, and don’t burden their children with their personal unfulfilled dreams and ambitions. This is often why their kids are much happier , because they them allow to grow up and become whatever they want to become. They allow their children to follow their personal desires and passions , rather than be burdened by what their parents want them to do.

One of the concerns many older mothers have is that they may not have enough physical energy to keep up with the demands of a toddler. Yes, it’s true that they may have less energy, but on the other hand they do have other assets which younger mothers don't . They have many more financial assets; a larger house; can afford to hire assistants to help them to bring up their child; and will be able to provide a much better education than most younger mothers can, because they are much better off.

It’s true that their parenting style will be different as compared to a younger woman, but in some senses it can actually be better.

She was very worried that when my child starts going to school, will he be embarrassed about the fact that I will be as old as the grandmothers of his classmates ? Won’t I be completely out of place ?

I reminded her that children love their mothers unconditionally, no matter what their mom looks like, or what their age is. This is why it’s not something she should worry about . Also, you should not worry about what other people will think and say.

You need to follow your heart . The key ingredient in parenting is love, and as long as you can offer this in abundance to your child, both you and your child will be fine.

In fact, having a child will make you much younger far quicker and much more efficiently than anything else you can do , whether it’s Botox or plastic surgery . Your baby will help you rediscover the young child within you. It’s important that you should have no regrets when you are 50 . At the age of 42, you are already regretting the fact that you didn’t have a baby 10 years ago , and I don’t want you to end up repeating the same mistake again. Make a decision which will give you peace of mind that you did your best. If you follow your gut, you will be happy – and happy moms make for happy babies !

Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Is my IVF pregnancy healthy ?

Pregnancy is an exciting time for most women . This is especially true for infertile women who have worked hard in order to have a baby . When they finally get pregnant , they are on top of the world and start dreaming about when they will be able to hold their deeply longed-for baby in their arms.

However, women need to be realistic and understand that not all pregnancies have good outcomes . About 10% of all pregnancies ( whether these are IVF pregnancies or made in the bedroom ) will fail. They may result in a miscarriage or as an ectopic. This risk is highest during the first 4 weeks, which is why patients are often on tenterhooks until they see their baby's beating heart on the ultrasound scan when they are 8 weeks pregnant.

The risk of the pregnancy failing is higher in IVF patients. This is because they are older ( and older eggs give rise to embryos with a higher risk of miscarrying because of genetic defects); and because they may have pre-existing medical diseases , such as damaged fallopian tubes, which will increase their risk of having an ectopic pregnancy.

This is why IVF pregnancies are monitored so carefully , to make sure that they're progressing well. The problem is that sometimes this monitoring is not done properly , as a result of which patients sometimes fall in between the cracks. This is especially true for medical tourists, who travel to another city for their IVF treatment). Sometimes these patients may have an ectopic pregnancy , but this is not diagnosed in a timely fashion because the doctor doesn't think of this possibility . The patients may then end up losing a lot of blood if the tubal pregnancy ruptures.

Also, in case the pregnancy is not viable , it's important to make the diagnosis of a failing pregnancy as early as possible , so that it can be managed appropriately , and the patient can be counseled and given enough emotional support during this stressful time.

The good news is that most IVF pregnancies are healthy , and the monitoring allows us to reassure the patient that all is well. However, the mind plays lots of games during this waiting period, and IVF patients can become very anxious until they hear that all is well from their doctor.

A combination of both hCG levels and ultrasound scans is needed in order to make the right diagnosis,  , and often the sonographer doing the scan may not know how to make sense of HCG levels. This can cause a lot of false alarms needlessly.

This is why we created the website , www.hcgexpert.in. This free website which uses intelligent algorithms in order to help patients make sense of that their hCG levels,  in conjunctions with their ultrasound scan results.

The good thing about hCG expert is that patients can use this tool for themselves . Not only is it free , it also allows us to collate data from lots of patients , so that we can help patients to make a diagnosis of an abnormal pregnancy as quickly as possible .

Doctors can actually refer patients to the website , so that they can figure out this information for themselves . Not only does this empower patients, it also saves the doctor a lot of time , as it’s much easier to counsel actively engaged patients .

HCG expert will allow you to monitor and track your early pregnancy, so you can reassure yourself that all is well, and this will allow you to enjoy your pregnancy !

The unhappy IVF patient

This is an email a patient sent recently , when her first IVF cycle had failed.

I was pleasantly surprised to know that you can see your embryos and even take pictures. That very act creates a connection right before the embryo transfer process itself.

I had my 2nd IVF back in Chennai, Dr. S, and things were out of whack. I had no clue if the embryos were formed, how many were transferred, worst part if the right ones were transferred as the embryo transfer was done for 2 patients in the same room at the same time by her. This is the most horrific experience that I had. And when I asked the embryologist about the environment in which the embryos are formed and how they made sure right ones were transferred, he maintained silence and gave a grim face, which really was very freaky. Later in the cycle I developed UTI with 104F and my cycle failed. I am pretty sure due to unhygienic usage of  instruments. In a way I am glad my cycle failed at that time as I was unsure what was exactly happening, and whether the right embryos had been transferred into me. The whole experience was very unprofessional and scary and has put me off  IVF completely.

That was one of the reasons, this time I wanted to do my own thorough research, especially since I am considering donor egg option,I wanted to be doubly sure of my decision. That's when I started doing research on IVF doctors ."

This patient has learned the hard way that it's crucially important to do high quality research before choosing a doctor.

It's true that every patient does their "due diligence" before selecting a doctor, but often this is done quite shoddily. The key to choosing the right doctor, is making sure you are well-informed about the IVF process; and then " interviewing " doctors ( something which you can do easily by email as well these days), so you can select the one who is right for you. Asking good quality questions, and judging the response to them is a far more intelligent way of finding the best doctor, rather than relying on "reputation" or "word of mouth referral".

Want to make sure you are on the right track ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

A simple inexpensive way to improve communication in hospitals

One of the biggest problems in hospitals today is a lack of communication . This occurs at multiple levels.

Patients and family members don’t not understand what the doctor is saying. Doctors are busy people and are often in  a rush when they are on their hospital rounds. They breeze in and out of the room, and even before the patient can collect his wits, they have disappeared. Patients and caregivers often do not understand medical jargon and are scared to tell the doctor that they have not understood anything he has said. The doctor is blissfully unaware of this lack of communication, and feels he has done a good job.

The communication gap is not only between the patient and doctor – there are gaps between doctor and doctor as well. Typically, many medical specialists are involved in providing care of the patient, and the care often gets fragmented. They are rarely in the room at one time, and this lack of coordination is a huge problem. The right hand does not know what the left hand is doing , and sometimes the information they provide to the patient is different, leading to even more confusion.

This is true for nursing care as well. When shift changes, and a new nurse comes on duty, sometimes the hand-off is not done properly, and patient care suffers because of these gaps. Ideally, the written medical record is meant to ensure that the care is properly coordinated, but this doesn’t always work well. They become voluminous, which means it’s easy to miss critically important information. Also, patients don’t have easy access to their records, which means they are often in the dark as to what’s going on.

This lack of communication is one of the major preventable reasons why medical errors occur.

The problem is compounded when the the patient’s family members are not on the same page, which means that they end up talking to the doctor at different times, thus wasting his time and irritating him. Often, they may disagree with each other and this makes matters worse, because they express conflicting wishes as to what they want done for their patient - often behind each other's backs.

Visitors have lots of questions as well. They are concerned and want to know what happened ? What's the diagnosis ? What’s the treatment plan ? Is he doing  well ? Is there anything they can do to help ?  The poor patient ( or his relatives) have to keep on repeating the same story many times, and this can be quite fatiguing

In a  perfect world, we would be able to get everyone together in the room at the same time, but this is not possible in reality.

Here’s a simple, low-cost solution, which could be implemented easily in all hospital rooms today.

Every hospital room should have a whiteboard, on which everyone is free to write and comment.

The whiteboard would come equipped with markers of different colours and could be used for multiple different purposes.

The doctor could use it to explain to the patient what is wrong with them and how he plans to fix it. An image is worth a thousand words, and this could help to overcome lots of misunderstandings. Ready made anatomical medical magnetic stick ons could be used for doctors who are artistically challenged.!

The doctor could write down the proposed treatment plan; and the other medical specialists and nurses could modify and edit this. For example, there could be a daily list of medications which need to be given, along with the time they are meant to be administered. Once the medicine is given, it could be struck off the list. In case there is a delay, the family member could gently remind the nursing staff about this oversight.

Checklists could be easily incorporated on the board. This is especially valuable before a planned operation , for example; or at the time of discharge, when there are multiple moving parts which need to be synchronized to ensure that they work properly.

Patients could write down their concerns, so  that the doctor can address them on his rounds. This ensures that they don’t forget to ask a critical question; and this way they don’t need to bother the doctor by pestering him queries on his mobile. This board Would help to make the patient better organized as well !

Warnings ( for example, allergies) could be highlighted on the board, so that everyone is aware of them.

Patients often forget the instructions which doctors and nurses and therapists give them. These could be written down on the board, as a list of Dos and don’ts, to make sure they are remembered correctly.

It would be easy to develop ready made templates for common problems which could be stuck on the
board , as needed.

A section of the board would be reserved for the patient and the family members. Here they could write down their story ( of what happened, for example) and what help they need, so they could share this with friends and loved ones.

More importantly , they could write down their doubts and concerns. Not only will this help to make patients feel empowered, the hospital staff would get a chance to hear the patient’s voice directly. This would prevent problems from escalating, and help to improve patient satisfaction.

The board is environmentally friendly, as it can be reused daily. If a long term record is needed, patients could take photos of the board, and share them as needed.

A whiteboard is be a very simple tool to get everyone on the same page, and every hospital room should have one !

Choosing the right doctor - the plight of the perplexed patient

My father just fractured his femur , and has been admitted in hospital . His surgery is scheduled for today.

I have now learned first hand, the hard way, what a difficult time the patient’s family members have in selecting the right hospital and the best doctor, especially during a medical emergency. Even though I am a doctor, it’s still very hard to be sure whether I am on the right track and have made the right choices. Inspite of the fact that  I am part of the medical network in Mumbai, and have lots of “medical connections” , there’s still so much uncertainty I need to handle. There are so many questions I am having a hard time finding the right answers to.

How do we know who has the best “surgical hands” ? Who does the largest volume of these operations ? What’s their complication rate ? Should we choose a surgeon based on his reputation ? Is it truly deserved ? Or is he a brand name doctor who maybe too busy to make postop rounds or provide personalised care , so that we are then forced to deal with his assistants? Are we better off choosing a much more senior doctor who is a family friend , but is not as well known ?

What kind of replacement surgery should he have ? A THR ( total hip replacement  ? ) a hemi arthroplasty ? what kind of artificial hip should we use ? metal only ? bipolar ? Should cement be used for fixing the orthosis ? Now I maybe a doctor, but this is stuff I am completely clueless about. Who should make these decisions ? The surgeon ? the patient ? should they do this jointly after discussing the pros and cons ?  Or are these technical minutiae which are best left for the surgeon to make a call about ? Lots of questions, and there are still no clear answers.

Just like any other patient, I do a google search to find clarity . Being a doctor means that it’s easier for me to do a google search and make sense of the medical information I retrieve. However, what do I do with the information once I have found it ? It’s surprisingly hard to discuss this with the orthopedic surgeon , even though he is a professional colleague ! The guidelines suggest that cement should be used routinely for all the replacements, but these are UK guidelines and I don’t know if these apply to Indian patients ( because of anatomical differences in bone structure).  The surgeon  feels that cementless surgery is better. He is a very senior surgeon, and I don’t want to offend him. He is a family friend and our comfort level with him is high. I don’t want try to teach my grandmother how to suck eggs, but I don’t know on what basis he is making his decisions . Is it based on his vast experience ? Or is it that he is still using an old-fashioned technique and has not kept up with the times ?  It’s true that expert surgeons know when to “break the rules”, and it’s possible that he is individualizing the  treatment for my father’s particular problem, but how do I as a patient know whether his decision is right ? Should we follow evidence-based guidelines, based on the cumulative experiences of hundreds of surgeons from all over the world ? Or should we let the doctor decide, because he knows best what works well in his hands ?  I am scared to broach some of these topics with him, because I don’t want him to get upset. ( On the other hand, my brain tells me that any surgeon who gets upset with these questions is not a good surgeon, and maybe we’d be better off not going to him !)

Though I have lots of friends who are surgeons, it’s hard to find out what they really think of his surgical skills. Doctors are very reluctant to bad-mouth other doctors or make comparisons and explicitly say Dr X is better than Dr Y !

Ideally, the surgery should be done within 24 hours of the fracture, but because he was very busy operating , we have had to postpone this by a day . Was this a sensible thing to do ? Should we have pushed for doing this more quickly ? Gone to another hospital ? Found another surgeon perhaps ?

Sadly, the hospital we selected doesn’t seem to have standardized treatment protocols. Every orthopedic surgeon in the hospital follows their own treatment regime and it seems to be quite haphazard. These are not full-time doctors, which means a lot of the hands-on care is provided by juniors and assistants. Often one department has no clue what the other one wants. For example, there’s seems to be no coordination between what the blood bank wants ( 4 units of blood and 4 units of plasma) and what the surgeon told us we would need ( 0 units of blood). One tries to act like a hawk and make sure the “I”s are being dotted and the “t”s are being crossed, but it’s hard to be sure if everything is going according to plan.

We try to fill in the gaps by reading and asking other doctor friends, but this sometimes makes things even worse ! Getting conflicting advise just adds to the confusion and it seems much easier to leave everything upto the surgeon – after all, isn’t he the one in charge ? But then, on the other hand, being a passive patient is never a good idea ? Hasn’t it been proven that alert, activated and empowered patients get better medical care ? How do we define the line between asking intelligent questions and being intrusive ? Will he get offended if we push too much ? Or isn’t it true that a good doctor worth his salt should be willing to engage and be open ?

There is a major need for openness and transparency, and health insurers could fill in this gap so well. They already have outcomes data, and it should be possible for me to call a helpline and get answers to some of these questions. The insurer could act like a patient advocate, and coach me as to what questions to ask and help me to find the answers, and select the best doctor. Sadly, health insurance is another mess ! The hospital doesn’t accept the Mediclaim policy my father has, which means we need to pay in advance, and then submit our claims. This is an onerous procedure, which involves filling out multiple forms, and has to be done in defined timeline. And the agent from whom we bought the policy is not accessible, so we have to fend for ourselves !

Friends and relatives are concerned and offer well-meaning advice and their support is welcome.
But making the decisions is a lonely exercise and often a thankless job. There are so many worries, and it’s so hard to be able to talk to someone to confirm I am on the right track. You are always second guessing yourself and hoping and praying that the outcome will be good !

What patients dislike most about doctors

Consumer Reports asked 1,000 Americans to rate typical complaints about doctors on a 1 to 10 scale with 1 meaning "you are not bothered at all" and 10 meaning "you are bothered tremendously."

Doctors often guess that the commonest complaint patients would have would be " long wait for doctor ".

This is indeed bothersome , but not as much as an "unclear explanation of my medical problem," which was number one on the list of patients' gripes with a score of 8.3 on that 1 to 10 scale.

( Other complaints included being "rushed during office visit" (7.8); "side effects (of medication) not fully explained" (7.6); and "doctor takes notes on PC not looking at patient" (6.2).

Doctors need to remember that the number one complaint patients have is that they feel their doctors keep them in the dark.

It takes time to explain to the infertile patient what's wrong with her , and what the infertility specialist can do to fix it. Sadly, the one thing IVF doctors are always short of is time. Since doctors will not be able to create more time in their already packed schedules, they need to use technology in order to allow patients to self-serve themselves the information they need.  This way, rather than the doctor have to sit and repeat the same explanation for every patient, they can create tools which the patient can use to learn more about their medical problem. Not only will this save the doctor a lot of time, so that they can focus on the other pressing concerns of the patient, it will also ensure the patient is better informed about their treatment options.

You can use these free online IVF patient education tools ( which include videos, a comic book and an e-learning course) at www.ivfindia.com

Is your doctor too busy to explain the risks and complications of IVF to you ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you  properly !

In a national survey, Consumer Reports asked 1,000 Americans to rate typical complaints about doctors on a 1 to 10 scale with 1 meaning "you are not bothered at all" and 10 meaning "you are bothered tremendously."
Seminar audiences of physicians often guess "waiting," or "inconvenient office hours." They're indeed bothersome to people but not as much, it seems, as an "unclear explanation of problem," which was number one on the list of patients' gripes with a score of 8.3 on that 1 to 10 scale.
Other complaints included being "rushed during office visit" (7.8); "side effects (of medication) not fully explained" (7.6); "long wait for doctor in exam or waiting room" (7.6); "inconvenient office hours" (6.5); and "doctor takes notes on device, not looking at patient" (6.2).
Let's deal with that number one gripe: unclear explanation of problem. Here are some tested tips for avoiding this complaint.
- See more at: http://www.physicianspractice.com/patient-relations/patients-biggest-gripe-about-physicians?GUID=AB4B24A7-E20B-4821-BB45-205C1FB7EB5C&rememberme=1&ts=18122014#sthash.iA25TgyW.dpuf

In a national survey, Consumer Reports asked 1,000 Americans to rate typical complaints about doctors on a 1 to 10 scale with 1 meaning "you are not bothered at all" and 10 meaning "you are bothered tremendously."
Seminar audiences of physicians often guess "waiting," or "inconvenient office hours." They're indeed bothersome to people but not as much, it seems, as an "unclear explanation of problem," which was number one on the list of patients' gripes with a score of 8.3 on that 1 to 10 scale.
Other complaints included being "rushed during office visit" (7.8); "side effects (of medication) not fully explained" (7.6); "long wait for doctor in exam or waiting room" (7.6); "inconvenient office hours" (6.5); and "doctor takes notes on device, not looking at patient" (6.2).
Let's deal with that number one gripe: unclear explanation of problem. Here are some tested tips for avoiding this complaint.
- See more at: http://www.physicianspractice.com/patient-relations/patients-biggest-gripe-about-physicians?GUID=AB4B24A7-E20B-4821-BB45-205C1FB7EB5C&rememberme=1&ts=18122014#sthash.iA25TgyW.dpuf

In a national survey, Consumer Reports asked 1,000 Americans to rate typical complaints about doctors on a 1 to 10 scale with 1 meaning "you are not bothered at all" and 10 meaning "you are bothered tremendously."
Seminar audiences of physicians often guess "waiting," or "inconvenient office hours." They're indeed bothersome to people but not as much, it seems, as an "unclear explanation of problem," which was number one on the list of patients' gripes with a score of 8.3 on that 1 to 10 scale.
Other complaints included being "rushed during office visit" (7.8); "side effects (of medication) not fully explained" (7.6); "long wait for doctor in exam or waiting room" (7.6); "inconvenient office hours" (6.5); and "doctor takes notes on device, not looking at patient" (6.2).
Let's deal with that number one gripe: unclear explanation of problem. Here are some tested tips for avoiding this complaint.
- See more at: http://www.physicianspractice.com/patient-relations/patients-biggest-gripe-about-physicians?GUID=AB4B24A7-E20B-4821-BB45-205C1FB7EB5C&rememberme=1&ts=18122014#sthash.iA25TgyW.dpuf

In a national survey, Consumer Reports asked 1,000 Americans to rate typical complaints about doctors on a 1 to 10 scale with 1 meaning "you are not bothered at all" and 10 meaning "you are bothered tremendously."
Seminar audiences of physicians often guess "waiting," or "inconvenient office hours." They're indeed bothersome to people but not as much, it seems, as an "unclear explanation of problem," which was number one on the list of patients' gripes with a score of 8.3 on that 1 to 10 scale.
Other complaints included being "rushed during office visit" (7.8); "side effects (of medication) not fully explained" (7.6); "long wait for doctor in exam or waiting room" (7.6); "inconvenient office hours" (6.5); and "doctor takes notes on device, not looking at patient" (6.2).
Let's deal with that number one gripe: unclear explanation of problem. Here are some tested tips for avoiding this complaint.
- See more at: http://www.physicianspractice.com/patient-relations/patients-biggest-gripe-about-physicians?GUID=AB4B24A7-E20B-4821-BB45-205C1FB7EB5C&rememberme=1&ts=18122014#sthash.iA25TgyW.dpuf

How PCOD can fool the gynecologist

I often see patients who have PCOD who have not been diagnosed properly. Typically, the textbook describes PCOD patients as being obese; hirsute; and having irregular cycles. However, not every patient with PCOD has all these classical symptoms. Many patients with PCOD are lean; and have regular cycles, which means many gynecologists and GPs don’t even think of the diagnosis when they see them. We all know that the eye only sees what the mind knows.

These patients then end up getting poor medical care, as a result of which their chances of getting pregnant go down considerably .

Thus, these patients are often mis-labelled as having unexplained infertility, which is a convenient waste paper basket diagnosis to lump all patients who don’t fit any other convenient diagnostic bucket. These patients are then often advised to do IVF. However, when the doctor starts the superovulation with the standard dose of FSH injections , the patient grows too many follicles. The doctor then gets flustered,  because this is not something which he anticipated ; and because doctors are so scared of the complication of ovarian hyperstimulation , they cut down the dose of HMG. They end up “coasting”  these patients, and the trouble with this is that these patients end up getting poor quality eggs because of the lack of appropriate FSH stimulation.

Because the eggs are of poor quality, the number and quality of embryos also drops considerably. Even though these patients grow lots of follicles , and the doctor is able to collect lots of eggs , the doctor then blames “poor egg quality” as the reason for the unexplained infertility, and advises the patient she needs to do donor egg IVF ! Remember that patients with poor ovarian reserve who have poor quality eggs will usually grow only a few follicles – quantity and quality usually go hand in hand.

This is why it’s so important for patients to become well-informed, so that they can discuss the possibility of their having occult PCOD with the doctor when they find they are growing lots of follicles during superovulation.

It’s easy to confirm the right diagnosis once the doctor thinks of the possibility. The tests requires are quite simple – an AMH blood test ( the AMH level is elevated in these women); and an increased antral follicle count.

Once the right diagnosis has been made , the chances of getting pregnant are very high, because these patients have high ovarian reserve, and can grow lots of good-quality eggs and make high quality embryos when they are superovulated properly.

Taking birth control pills before an IVF cycle reduces pregnancy rates

Many IVF clinics routinely put their patients on birth control pills ( oral contraceptives)  prior to starting an IVF cycle.

This sounds very counter-intuitive  -  after all, why would you want to suppress the fertility of an infertile patient even further by using anti-fertility medications ? Many patients are understandably puzzled about why they need birth control pills, and are worried about their  side-effects.

The reason that doctors have used birth control pills prior to starting IVF is 3-fold.

1. They believe that by suppressing the follicles prior to starting superovulation, the follicles which grow during IVF will be a synchronous cohort. The hope is that by putting on the brakes prior to gunning the accelerator, all the follicles will be at the same point when the superovulation starts, so that hopefully they will all grow at the same rate. They believe that this will also reduce the chances of cyst formation.

2. They believe that this will improve ovarian response to the superovulation. The logic is that
"  resting " the ovaries before starting Gonal- F/ Follistim/ FSH/HMG will help the ovaries to respond better.

3. They use this in order to "program" the cycles. This is very useful, especially for clinics who need to batch their patients together. By regulating the cycles of lots of patients by putting them on birth control pills, and stopping this on a fixed date, they can cycle large batches of patients together for IVF, thus increasing the clinic's throughput and efficiency.

However, a recent study ( Does hormonal contraception prior to in vitro fertilization (IVF) negatively affect oocyte yields? http://www.rbej.com/content/11/1/28#B11)  has shown that the use of birth control pills prior to IVF cycles actually reduces the number of eggs collected in donor egg IVF cycle.

The deleterious effects of birth control pills for women with poor ovarian reserve who are doing IVF is likely to be even more !

It's high time IVF clinics stopped applying IVF superovulation protocols mindlessly,  especially for women with low AMH levels. These women need individualised superovulation, to maximise their chances of a pregnancy.

Need help in making sure your IVF superovulation protocol is optimal ? Please send me your medical details by filling in the form at http://www.drmalpani.com/second-opinion so that I can guide you better !

Why are so many IVF patients are unhappy with their IVF clinic ?

I just received this email from a patients.

" I , AV , 39years along with my wife , BN, 41 years have been married for the past 2 years. Hence we right away though of IVF treatment considering our age. We have been doing IVF treatment in a clinic in Bandra Mumbai for the past 18months. We have done 3 cycles for collection of embryo and so far we have had 2 failed embryo transfers. At this moment we are left with 7 A grade embryos 3 B Grade  embryos and 1 C grade embryo . Our last  failed attempt being done in the month of November 2014. we are planning  to come down to Mumbai again in the last week of February 2015

Our biggest problem has been that we did not get any real direct interaction with the doctors. Our assistant doctors also kept on changing every time we went there for a pick up or a transfer. At times information was passed on to us through the nurses and we were not sure if we were getting the right answers...

We find ourselves in a lot of turmoil right now... feeling that the time is running  out for us...
we would like to know if you can help."

It breaks my heart when I receive emails like this. While it's true that IVF doesn't have  a 100% success rate, IVF patients should have a good experience during their cycle, so they have peace of mind they received the best medical care. Treatment is expensive , and patients deserve hands-on personalised care.

Sadly, the experience this patient described is remarkably common , and seems to be par for the course. Patients put up with this poor quality care because they don't know they should expect better. They meekly accept whatever the clinic staff tells them , and are very reluctant to ask questions. They are scared that if they rock the boat, the medical staff will punish them by ignoring them or providing even worse care. After all, patients are very vulnerable and don't want to be seen as being troublemakers.

However, when patients put up with this sub-standard care, everyone suffers. Patients lose confidence in the medical system, and are not willing to trust any IVF clinic whatsoever. Because of their bad experience, they conclude that IVF treatment is a waste of time and money, and resign themselves to their fate.

The good news is that not all clinics are the same !

If you aren't happy with the quality of care you are getting at present, and feel that your doctor is not giving you enough personalised attention , please don't get disheartened or give up.

We don't employ any assistants in our clinic, which means we take care of all our patients ourselves. Our care is very "hands-on" and thanks to our many years of experience, we can individualise your treatent plan to maximise your chances of success. We take pride in treating our patients as VIPs ! We provide comprehensive services under one roof, including PGD and TESE. We don't do any unnecessary testing; and do not waste your time and money.

Want to find out more ? Please send me your medical details by filling in the form at http://www.drmalpani.com/second-opinion so that I can guide you better !

Managing IVF Failure - a guide for gynecologists from Dr Malpani

This is talk I gave to gynecologists at a Conference on IVF organised by Shivani Scientific recently in Mumbai.

IVF failure can be heart-breaking - both for patients and doctor !

Need help in recovering after a failed IVF cycle ? Please send me your medical details by filling in the form at www.drmalpani.com/malpaniform.htm so that I can guide you better !

Embryo Biopsy for PGD

PGD stands for preimplantation genetic diagnosis, and is an advanced technique which allows us to prevent genetic diseases such as thalassemia, sickle cell anemia, hemophilia and Duchenne muscular dystrophy.

It's also useful in allowing us to select genetic normal embryos in older women. This is called
PGS ( preimplantation genetic screening) and uses CCS ( comprehensive chromosomal screening) for aneuploidy screening.

However, embryo biopsy is a complex technique which requires a lot of skill , and can be challenging to master.

This video shows Dr Sai, Chief Embryologist at Malpani Infertility Clinic, doing a trophectoderm biopsy for four Day 5 embryos ( blastocysts) . You can see that it's a very delicate procedure, and it's very easy for an unskilled embryologist to kill an embryo while doing PGD ! This is why you need to find an experienced and skilled IVF lab if you need PGD.

The biopsied cells are sent  for genetic testing; and the normal embryos are transferred into the uterus, thus ensuring that they are disease-free.

When IVF doctors lie

Fortunately for IVF doctors and patients , most IVF cycles go as they are supposed to . The patients grows eggs, these are retrieved; and good quality embryos are transferred into the uterus. Even if the patient does not get pregnant, when the  doctor shows them photos of the good quality embryos he has transferred , both are happy that the treatment was carried out properly, whether or not the cycle results in a pregnancy.

However, things don’t always do well, and we find that sometimes some doctors resort to lying when this happens . For example, if the doctor is not able to collect any eggs at the time of the retrieval; or if the eggs fail to fertilise; or if the embryos arrest in the lab.


In these situations , rather than level with the patient and tell them the truth , doctors often try to cover up and hide reality from the patient . This is partly because patients have not been counseled properly , as a result of which they have unrealistic expectations of the IVF treatment . Often when doctors are signing up patients for IVF treatment, they overpromise and quote extremely high ( and inflated) success rates , to try to lure the patient into taking treatment at their clinic , rather than going somewhere else .

This can come back to haunt them later, especially when there are technical problems during the IVF cycle.

It’s true that bad things can happen during an IVF cycle. For example , a trainee embryologist can kill all the eggs while doing ICSI; of the embryos may die in the lab because of power failure; or the embryos may divide properly because of an infection in the culture medium; or the transfer maybe technically difficult because of cervical stenosis, as a result of which the doctor is not able to negotiate the catheter through the cervix and fails to deposit the embryos into the uterine cavity.

When these untoward events occur during an IVF cycle , it’s far better that the doctor be honest and upfront and tell the patient exactly what the problem is . Of course there will be short-term pain , because the patients will be rightfully upset, and it’s not much fun for the doctor to manage an unhappy , angry and resentful patient . However, it's far better to tell the patient the truth , because at least that way the patient can learn from what went wrong, and this allows the doctor to do a better job during the next IVF cycle.

However , doctors are not always straightforward , and in order to cover up their technical deficiencies, they will try to fool the patient  by spouting jargon or blaming the problem on some irrelevant red herring, such as “weak eggs” or “abnormal sperm”.

This is very shortsighted , because patients are smart , and they will try to get more information about what actually transpired, by talking to other patients ; asking the nurse and the embryologist; and checking online.

If they find out that the doctor lied to them , they are likely to be extremely angry and vengeful , and this will end up spoiling the doctor’s reputation . This is why it's so important that doctors learn to be open and transparent . However, it’s much more important that patients learn to be well-informed , and demand accurate information proactively from their doctor for each stage of their IVF cycle , so that they have peace of mind they have received the best quality medical care.

Need help in making sense of your IVF medical records ?  Please send me your medical details by filling in the form at http://www.drmalpani.com/second-opinion so that I can guide you better !

IVF pregnancy vs natural pregnancy

There are still lots of misconceptions about IVF , and one of the biggest myths is that an IVF pregnancy is different from a natural ( bedroom) pregnancy .

Thus, they believe that thee pregnancies are high risk; need lots more monitoring; and that patients who get pregnant after IVF need “bed rest” to ensure a healthy outcome.

They are worried that because the embryo was “created artificially” in the IVF lab, this is an “artificial” pregnancy, and needs special handling. Thus, there is this strange idea that the fetus can “fall out” of the uterus ( through the same passage through which it was inserted) if the patient does not sleep in bed all day long !

Of course an IVF pregnancy is a “precious” pregnancy because the could has worked so hard in order to get pregnant. This is the justification a lot of doctors use to do many more scans and prenatal blood tests, because they don’t want to take “any chances”. Sadly, all this overtesting leads to overtreatment, and most of these patients end up with unnecessary caesarean sections. This is ridiculous ! All pregnancies are precious for the mother – whether they start in the bedroom, or in the IVF lab ! This kind of mindset only ends up worrying the patient needlessly , and doesn't add any value to her life.

Remember that just because the embryo has spent a few days in the IVF lab does not change the biology or physiology of the pregnancy !  It really makes no different to embryo whether it grew in the fallopian tube, or in the test tube ! Once the embryos reaches the uterus, it’s exactly like any other pregnancy . The embryo has no memory , and once the embryo has implanted , it's exactly like any other pregnancy I

We need to keep on emphasizing this fact that there’s absolutely no need for bedrest or any special diet or any precautions after the embryo transfer. There’s no need to create a list of “ don’s and don’ts – these just add to the patient’s stress levels , without improving success rates!

Conceptually, IVF allows the doctor to bypass the natural hurdles the infertile couples encounters in their bedroom ( such as a low sperm count or blocked tubes). However, once the hurdle has been overcome, the final pathway is common to both IVF pregnancies and natural pregnancies.

Sadly, instead of allowing the IVF patient to enjoy her pregnancy, we fill her mind with fears and anxieties, so that she broods and worries needlessly. This is unkind and unfair.

Assembly line vs boutique IVF clinics

Patients are often not sure what kind of IVF clinic to choose . They want a clinic which has a high success rate ; which is fully equipped with the latest technology; and where the doctor treats them with compassion and empathy . They are looking for a combination of high technology and high touch – and preferably at an affordable price !

Today, patients often end up choosing between large assembly line brand name IVF clinics. They have lots of patients and long waiting times; and in order to handle these patients , they employ lots of doctors and lots of nurses . There is little personalization, and the patient is often forced to wait for hours on end if they want to see the brand name senior doctor. This means the patient rarely gets to see the same doctor twice – they usually end up having to deal with whosoever the doctor on duty happens to be on that day.

They are not able to establish a personal one-on-one relationship with the doctors, and usually end up feeling that they are being treated as a number. These clinics are forced to follow very rigid protocols,  and they are not able to personalize the treatment they provide.

These clinics have the advantage of being very busy, and because they have large volumes of patients, they are usually well-equipped , and are able to provide a full range of services .

A boutique IVF clinic on the other hand is a much smaller operation . They have fewer patients , as a result of which the care they offer is much more personalized and hands-on. The doctor knows each patient by name, and can tweak and individualise the protocol for each patient’s unique needs. Sadly, some of these clinics don’t have enough experience and expertise, because they don’t see a sufficient number of patients, as a result of which they are sometimes not able to offer the full range of services which the patient needs

It can be hard for the patient to evaluate the technical quality of services the clinic provides. This is why it's important that you do your homework , so you find the clinic which is right for you. If you are the kind of patient who is impressed by super-busy doctors who handle lots of patients, because you believe that the popularity of the doctor is an index of their competence, then you should select a busy clinic where lots of activity . After all, any clinic which attracts so many patients, must be good, right ? Hundreds of patients can’t be wrong, can they ?

On the other hand, if you want a clinic where you are treated as a special human being, and you want personalized attention, then you should search  for a boutique clinic. Your best option is to find a “focused factory” which marries the best of both worlds, because they are fully-equipped, and have all the expertise needed under one roof. They have high success rates, and can provide personalized care as well.

Need help in finding the best IVF clinic  ? Please send me your medical details by filling in the form at http://www.drmalpani.com/second-opinion so that I can guide you better !

When patients make mistakes

When we talk about medical errors, we usually focus on mistakes made by doctors or the medical staff. However, the truth is that patients often make mistakes as well.

There are many reasons for these mistakes.

Sometimes, patients are confused , because the doctor did not explain things properly . They don’t understand the doctor’s medical jargon, and are scared to cross question the doctor or are reluctant to display their ignorance. They therefore continue to dumbly nod their head, and the doctor is misled into thinking that the patient has understood.

For example, a patient was supposed to take 0.2 ml sc of Lupride, and she ended up taking 2 ml by mistake, because she did not understand what the decimal point meant. Mistakes like this are upsetting and irritating for both patient and doctor. The patient is scared that by taking too much medicine, she may end up causing harm to herself by the overdose; or that she may have to cancel the cycle because she has messed up her medications.

The doctor is irritated, because he feels that he did an excellent job explaining to the patient exactly what to do, and that if she didn’t understand, why didn’t she just ask him for clarification and cross check with him , rather than pretending to understand. Doctors sometimes forget that patients can be quite intimidated by them !

We need to understand that all of us make mistakes , and it’s best to be charitable and understanding – after all, no one goofs up deliberately !  Rather than start assuming that all patients are idiots, these mistakes can actually be great learning opportunities.

The fact is that patients make mistakes much oftener than we realise, and they often cover these up because they are scared that their doctor will get angry and upset , and will shout at them. If you are a good doctor, and the patient has enough confidence in you , she will let you know when she made a mistake , and then it's up to you to resolve it.

Sometimes these are minor issues, which can be safely ignored. However, sometimes these mistakes can create major problems, but these can be tackled only if the patient is willing to confide in her doctor.

Interestingly, sometimes these mistakes can be serendipitous events, which can actually help to advance medical science ! Thus, if the patient takes a lower dose than the one prescribed, and still has a good therapeutic response, the doctor may start prescribing the lower dose to all his patients, because it may be as affective as the standard recommended dose.

This is especially true when patients are taking alternative medicines. They will often hide this information from their doctor, because they are scared he may get upset with them for doing non-standard treatment.  However, if they get better and share this information , the doctor can learn from their experience, if he is willing to keep an open mind. Maybe he can even start advising other patients to try out alternative medicines !

Patient education can play a very important role in reducing the errors which patients make inadvertently, and it's important that doctors and hospitals invest in tools and techniques which help patients to become better informed.

The responsible IVF patient

Some of my readers criticise me for criticising other doctors. They feel that by highlighting the deficiencies of some IVF clinics, I am washing dirty laundry in public ; and that these lacunae will undermine the confidence which patients have in their doctors.

I think this is unfair.

What I'm trying to do is to emphasize what good doctors do, so that patients can then judge for themselves whether the doctor they have selected is doing a good job or not.

It bothers me when doctors take advantage of a poor patient’s ignorance. Selecting the right doctor makes a world of a difference to the chances of IVF success, and patients need to be well informed, so they make the right decision, and select an IVF clinic which is well-equipped, efficient and competent.  Making a poorly informed decision because of ignorance can prove to be extremely expensive for the patient. Patients can’t afford to leave everything up to chance.

My message is simple - patients need to take personal responsibility for what happens to them - they cannot afford to leave everything up to God, or upto the doctor, and then blame him if the cycle fails.

It's important that patients realize that they do have the power to do lots of stuff which can change the IVF outcome . If they learn to exercise this power responsibly, even if the cycle fails, they can learn from their mistakes , so that they can learn to become better patients , and then seek advice from the right doctor.

It’s OK  for everyone to make mistakes , but repeating the same mistakes and failing to learn from them is unpardonable . Sadly, this is often something I see patients doing . They fail cycle after cycle , without understanding anything . They fail to do anything to change the outcome , and just leave everything up to the doctor, or upto their fate.

While it’s true that IVF failure is often because of bad luck, and one can't change one’s luck, there are lots of things which can be changed , to improve the odds of success. You need to learn to improve your luck by being smart , and you begin to be smart when you seek the right advice from the right doctor.

By taking personal responsibility, you can increase your chances of IVF success !

Need help in making sense of your IVF medical  treatment  because your doctor doesn't have enough time to explain what's going on ? Please send me your medical details by filling in the form at http://www.drmalpani.com/second-opinion so that I can guide you better !

Off label promotion of cabergoline for treating endometriosis

Endometriosis is a distressing disease , and difficult to treat . Even though it’s so common, we still don't know what causes it , and most medications just provide temporary suppression . We can’t cure it, which is why doctors are looking for new ways of tackling this disease . Pharmaceutical companies spend a lot of money in doing research in order to find new treatments, and everyone would be very happy when we can find something which works . However, developing a new drug is very expensive, and takes a lot of time and money.

Doctors are also happy to try new approaches, and a medical journal paper described a new way of treating endometriosis , using an old drug called cabergoline. The hypothesis was that some patients with endometriosis have high prolactin levels , and since cabergoline reduces high prolactin levels , it may help in treating endometriosis . Also, in vitro studies have shown that cabergoline reduces angiogenesis ( new blood vessel formation) by reducing levels of VEGF ( vascular endothelial growth factor).  The study was a small one, and showed that cabergoline was slightly more effective in reducing the size of a chocolate cyst ( endometrioma) as compared to the standard treatment which uses GnRH agonist injections.

While it’s promising that doctors are trying out new approaches to treating endometriosis, the problem is that this is only a small single study , which measures only a reduction in the size of endometriomas, which is quite a pointless result from the patient’s perspective. These studies need to be repeated by other doctors, to see if the drug helps in relieving the pelvic pain of endometriosis; or in improving their fertility before we can start recommending it in clinical practise. This can take time, and needs patience.

However, the tragedy is that when pharmaceutical companies come across a drug which is already being used for treating other diseases , and they find a paper which shows that it can also be used for treating endometriosis , they are very happy to promote this drug for that disease. This called an off-label use of the medicine, and while it’s quite ethical for doctors to prescribe this for their patients, it’s not ethical ( or legal) for companies to do so.

The problem is that when this drug is being actively promoted by MRs, gynecologists often don’t bother to read the fine print, or take the trouble to understand the limitations of the research. They fail to factor in the fact that a 25% reduction in the size of an endometrioma is of  very limited clinical importance – and that GnRH agonists have been shown to be quite ineffective in “treating” chocolate cysts, so there’s little point in comparing cabergoline with the GnRH agonists for this indication ! However, they are quite happy to do whatever the MR suggests. Doctors are always happy to prescribe medicines, because it gives them ( and their patients) the satisfaction that they are doing something ( even if it maybe ineffective). They get carried away by the “research” published in a foreign medical journal”, and are very pleased that they are doing something “new and different” for their patients.  Because the drug can be taken orally, doctors will tend to overprescribe it, because of the active promotional campaign being carried out by the pharma company. While this is good for the company  ( because it’s an expensive drug), it’s very unlikely that the poor endometriosis patient will benefit.

I'm not saying that cabergoline may not help patients with endometriosis. My point is that it has not been adequately documented to be proven to be an effective treatment for endometriosis , and until this is done, it should not be promoted to unsuspecting doctors and hoisted on clueless patients.

It seems that the pharma company is misusing one single article published in a medical journal in order to increase its drug sales. Rather than do this, they should promote clinical trials, to assess the efficacy
( or the lack of efficacy) of cabergoline in reducing the pelvic pain in patients with endometriosis, so that doctors learn when the drug is useful, and when it is not, so that they can prescribe it intelligently/

Why doctors get poor medical care

One would assume that doctors would get the best possible medical care . After all, being insiders, they understand the medical system ,and are likely to get VIP care from other doctors, who are their professional colleagues. They understand a lot about medicine, and will know exactly what the best medical treatment is; and who the best specialists are for their illness. Doctors will leverage this “inside” knowledge to get the best treatment when they fall ill.

However, this is not true , and surprisingly doctors often get poor care. One of the reasons for this is the VIP syndrome . Because the doctor is a professional peer,  he is likely to be overtested because the tests are often done free for doctors. Sadly, this then leads to overtreatment, because the treating doctor goes out of his way to do his best for his colleague. Ironically, this also sometimes leads to  shortcuts being taken, because the doctor is given preferential treatment, and allowed to “jump the queue” , rather than being forced to follow the standard protocol.

Also, because it is assumed that a doctor knows what’s happening, the treating doctor may often not provide an explanation for what he is doing, and why he is choosing a particular course of action.

Sometimes doctors suffer from “medical student syndrome” and when  a doctor falls ill, he starts thinking he has the most esoteric illness in the world. Sometimes the pendulum swings to the other side, and because the doctor-patient does not want to rock the boat, or be a “ bad patient” ( because so many doctors have the reputation of being difficult patients) , he does his best to be compliant and passively follows whatever advise the doctor-doctor gives him.

This is why the doctor-patient is hesitant to speak up because he doesn’t want it to appear that he is challenging the authority of the doctor-doctor. He doesn't ask too many questions, and may not express his personal preferences, and he is worried that this can damage the chemistry between the two of them. The treating doctor may also wrongly assume that because his patient is a doctor, he knows and understands everything which is being done, so he may not take the time to provide a complete explanation.

The other problem is that the treating doctor goes out of his way to make sure everything goes like clockwork. Because it’s an honour to treat a colleague, he needs to make sure there is no mishap or oversight. This means that he often adds a lot of unnecessary bells and whistles to his treatment,  to make sure that everything possible which can be done is done, and the patient is getting “state of the art” cutting edge treatment. Thus, doctors will recollect their uncommon complications, and then go out of their way to make sure the same fate  doesn’t befall the doctor sitting in front of them. This can actually make things worse , because more is not always better !

Why doesn't the UK medical system trust patients with their own medical records ?

I have a patient who lives in the UK who needs to have an HSG done , because she needs a ZIFT treatment at our clinic. She has found a X-ray clinic who is happy to do the HSG for her, but they are refusing to give her the X-ray or the report. They insist that they will FAX the report only to the referring doctor – me . The problem is that we stopped using FAX over 10 years ago , and I can't believe that doctors continue to use such outdated technology – after all, email is far more efficient, and can be just as secure as a FAX !

However , what I find even more perplexing is the fact that the  UK medical system is not willing to trust patients with their own medical records ! This is something which makes no sense to me . She’s paying for the test – and it’s her body, which means her medical records are her property. Why can’t they just give her the HSG and report, so she can do with it as she sees fit ? She can email them to me – or get a second opinion from another doctor ; or share them with her sister-in-law , who happens to be a doctor in the US .

I can't understand this old-fashioned paternalistic attitude, where testing centers and diagnostic clinics insist that reports will only be shared with the referring doctor. I think this is unacceptable in today's day and age , and I still can't understand why progressive countries like the UK are still stuck in the Middle Ages as far as their willingness to share medical information with the patient is concerned .

Are they worried that the patient will misuse this information ? This makes no sense – after all, it’s her information, so how can she misuse it ?

I understand the concern that patients may not be able to make sense of their medical reports, and may get worried or scared needlessly in case it is abnormal. This is why they need a doctor to help them interpret the report intelligently.


However, this does not mean that we should hide information from our patients, or censor it, or limit their access to it. Patients have the right to know what is happening to them , and especially when the patients wants her report and X-rays, I think it's unethical to refuse to give this information to her .

Perhaps one solution would be to get a permission letter from the doctor , which “ authorizes” them to “ release “ the report to the patient , but this is a completely ridiculous approach to take . Patients should be free to see their tests for themselves , and then use this information the way they want to, rather than having to depend exclusively on their doctor for access to their own medical records and reports.


The UK healthcare system waxes eloquently about the need for patient centricity and patient empowerment – and the first step in this direction is to share information with the patient. We need to respect our patients, and say – Yes, we trust you , and if you want your reports, here they are . If you need any additional information , we will be happy to provide it !  The present approach says, Yes, we have your reports , but we don't think you're smart enough to make sense of them, and because we can’t trust that you will be able be to understand them, we will send these reports to your doctor, who will then tell you what to do.

This is the height of condescension , and it seems to be a hangover from the past, when the approach was – The Doctor Knows Best. Isn’t it time we moved on ?
.

The importance of documentation in an IVF cycle

IVF cycles don't always go as planned, and this can be frustrating for both doctor and patient. However, even if the cycle fails, all is not lost. The question we need to ask is – what went right? what went wrong ? what did we learn from this cycle ? and what can we do differently in the next cycle, to maximize the chances of success.

In order to answer these questions , we need reliable documentation. We need to know how technically proficient the clinic was and whether the quality of the treatment provided was upto the mark. Please remember that just because the treatment was done at a “good and reputed ” clinic doesn’t mean it was done properly. After all, all patients believe that the clinic they go to is good – otherwise they would never go there for treatment in the first place !

The technical minutiae of the cycle need to be analysed carefully.  Was the superovulation regimen appropriate ? Were the follicles monitored properly ? Was the HCG given at the right time ? Were the lab conditions good ? Were the embryos of good quality ? Was the transfer easy ?

In order to answer these questions intelligently, we need detailed medical information about the IVF cycle, which is why documentation is so important. Good clinics provide this routinely and proactively, but often you as a patient may need to insist on getting copies of your medical records. Remember that your records are your property and that you have paid for these !

You need images of your ultrasound scans, so you can see how many follicles you grew. You don’t need to insist on images of every scan, but it’s useful to have pictures of the mature follicles before the hCG trigger was given . You should also ask for an image of the scan after the collection is over, as this will prove that all the follicles present were aspirated properly. While egg collection is usually an easy procedure, sometimes it can be technically difficult ( because of obesity or pelvic adhesions), as a result of which the doctor may not be able to reach the ovary and is therefore not able to collect any eggs at all. When all goes well, the images don’t matter, but if your doctor is able to collect only a very few eggs even though you had a large number of follicles on the scan, this means that you need to find a more experienced doctor , who is an expert at doing egg collections ( for your next cycle)

If the doctor tells you all your eggs are immature or poor quality ( a reason many doctors will trot out to justify IVF failure), then you should insist on photos of your eggs, so you can get a second opinion from a specialist.

Similarly, if the doctor is not able to find any sperm when doing a TESE , he should give you photos of the dissected tissue as seen through the microscope. If this shows that he was able to recover adequate testicular tubules and there is lots of tubular content, then you can be reassured that the procedure was carried out properly and that the failure was not because of poorly performed surgery.

The most important documentation every IVF patient should routinely demand is photos of your embryos. After all, if you have good-quality embryos , a lot of the other stuff doesn't matter at all.

It is true that if your cycle is successful, then all the documentation is of academic interest ( though you can use it later on to show your child how hard you had to work in order to become a parent !)  However, if your cycle fails, then high quality documentation  can make a world of a difference in helping you to decide what to do next. Since you cannot predict in advance whether your cycle will fail or not, you need to collect your medical records proactively, while the cycle is going on.

Remember that these records are invaluable if you need to change your doctor. These images will allow the doctor to learn from your earlier cycle, so he can make intelligent decisions as to what changes he needs to make in order to improve your chances of getting pregnant.

Why should patients bother about all these technical details ? Isn’t this the doctor’s job ? The sad reality is that lots of IVF doctors don’t bother to share information with their patients. This is why patients need to take a proactive approach  ! You need to take an intelligent interest in your treatment to make sure that you know exactly what's going on .

Sadly, when things don’t go well, a lot of doctors become very defensive . They try to hide stuff , and refuse to be honest and transparent. They provide specious excuses, by saying that it’s “not clinic policy” to give the patient their medical records: or that they don’t take embryo photos as this may damage the embryos ! This is ridiculous and unacceptable . Embryo photos are basic medical documentation , and IVF medical records need to be provided to all patients.




Need help in making sense of your IVF records ?  Please send me your medical details by filling in the form at http://www.drmalpani.com/second-opinion so that I can guide you better !

TESE which is the best technique ?

Patients with non-obstructive azoospermia ( NOA) can be very challenging to treat if they are not willing to accept the use of donor sperm. Since there is no test to differentiate between partial testicular failure and complete testicular failure, we need to explore their testes surgically, to see if they have pockets of sperm production. If they do have even a few patchy areas of normal spermatogenesis, we can recover testicular sperm from these tubules, and use them for ICSI.

For patients with obstructive azoospermia, we can pretty much stick a needle anywhere in the testes and recover lots of sperm. However , this is not true in patients with NOA,  because even though there is no sperm production in the majority of the tubules, we may still be able to find some sperm ,if we are willing to be patient and to look long and hard.

There are many ways of recovering sperm from the testes, ranging from the simple, noninvasive needle biopsy (testicular sperm aspiration ) , to an open microsurgical testicular sperm extraction, where the surgeon cuts the scrotum, delivers the testes, and then examines the surface of the testes using high magnification with the help of an operating microscope, in a procedure called testicular mapping , in order to look for areas of normal sperm production.

You can read more about TESA at
http://www.drmalpani.com/articles/tesa-testicular-sperm-aspiration


The truth is that if there is complete testicular failure, we will never be able to find testicular sperm, no matter what method we choose. Since we don’t know in advance whether the testicular failure is partial or complete, doctors basically take two diametrically opposite approaches .

There are some andrologists who are extremely aggressive , and will do an open surgical biopsy under the operating microscope for every man . They claim that this allows them to find sperm more reliably, and that this technique can work even in men where multiple needle biopsies may fail. I find this hard to believe .

The fact of the matter is that a closed needle biopsy allows us to sample testicular tubules from multiple sites just as effectively as an open biopsy can. Cutting open the skin doesn't help us to extract more testicular tubules; and examining the surface of the testes through an operating microscope does not allow us to identify where the normal seminiferous tubules are ( since these may be deep within the testes).

I can understand why andrologists prefer doing open testicular mapping . They can charge much more for using an operating microscope – and some doctors will charge over US $ 5000 for this procedure ! A closed needle biopsy is much quicker and simpler ( and kinder for the patient) , but some andrologists claim that it’s not as good as an open biopsy , because it’s hard for them to charge US $ 5000 for a simple needle biopsy, even though the truth is that it’s as effective in recovering sperm, if these are present !

I think we should remember the first rule in medicine – first, do no harm. It makes sense to prefer minimally invasive procedures, rather than doing extremely aggressive surgery. The doctor should start by first doing closed multiple needle biopsies when doing TESE. If he can recover enough testicular tissue from each of these sites, then there’s really no justification to cutting the scrotal skin and doing an open biopsy, because the chances of finding any sperm by doing an open biopsy in these patients is virtually zero. If the needle biopsy is technically easy ( which is usually the case if the doctor is experienced and the testes is firm), and the embryologist is happy with the amount of testicular tubules the doctors has retrieved, then there’s no point in being more aggressive.

More is not always better , and in fact going ahead and unnecessarily cutting open the scrotum and then the testis can actually cause harm, because this can disrupt the testicular blood flow and cause testicular atrophy. Especially in men with small testis , this kind of aggressive surgery can precipitate testicular failure because of the testicular damage the procedure itself causes .

A closed needle biopsy ( which is not the same as a fine needle aspiration !) is much kinder than an open biopsy ; does much less harm, and is much less expensive . However, in the very small minority of men who have small soft testes, where the tissue is jelly-like, we may not be able to extract enough testicular tissue using a needle. In these men, an open biopsy may allow us to retrieve testicular tubules more efficiently than a needle biopsy. However, this is such a small proportion , that it's hard to justify doing an open TESE for every man with NOA.

Confused as to which is the best option for you ? Need help ? Please send me your medical details by filling in the form at http://www.drmalpani.com/second-opinion so that I can guide you better !