Saturday, May 31, 2014

IVF success story at Malpani Infertility Clinic

We got married in 2006 and life was quite smooth, we were always open for parenthood so we never did any kind of planning. Initial 3 years passed smoothly and we realised that things were not working out naturally and then we went for some medical help. I started my treatment with a renowned hospital of Vashi, it began with simple treatment for pregnancy and as it progressed I ended up with two failed IUI's. And to be very true I personally got very scared as things were not working out but things didn't stop here I had a lot of pressure, tension still left to be seen.

  We switched our Doctor and the cycle of failures continued thereafter with 5 unsuccessful IUI's. Our mental condition cannot be expressed in words. We were very upset. Then one of my uncles made us meet his friend who being a MR specialised in supplying infertility injections suggested us a Doctor at Thane. In search of every possible result oriented outcome we immediately went there. I underwent a Laparoscopy/ Hysteroscopy over there and as a result of that the Doctor scared us that things were not in our favour.  He said I immediately needed an IVF. I went for Laproscopy in Jan 2012 and the Doctor said if I will delay my IVF after April 2012 then there are chances that the things will go out of our hand. Because we had already struggled in our past this news came as a shock for us and we were not left with any other option except to go with his advice. Once again I spoke to my uncle and this time he just suggested Dr Anirudh Malpani, as we were living  near Panvel I thought Colaba is too far from there. But my uncle simply said you just go and meet him once and then everything is upto you. And finally the day came when we met Dr Malpani and against our belief all our negativity went off within an hour of meeting him. The failures that I met with, in past suddenly faded off and we had a new light of hope.

  Immediately the distance of our home to Malpani's Infertility Clinic became short and I started my treatment with him. I went for my first IVF, things were going fine and even the result was positive that made us really very happy and there was no limit of our happiness. But when I went for my first sonography we got shattered as Doctor informed us that it was an ectopic pregnancy. What could we do we were so depressed that all our hopes took an end. But gathering all our strength we again went to Dr Anirudh and its for sure that meeting him once always makes anyone leave all failures, sadness behind. We decided to take break of 6 months and again started my treatment. Cycle was excellent then before. This time we had even our frozen embryos as well. Everything was excellent but then our luck was against us again and the result was not positive. You all can understand our condition now. Still we had a hope and again in July 2013 we went for our Frozen Embryo cycle considering it our last trial. Dr Anirudh and his team were as always at their level best and thus I ended up this cycle. The day came for my Beta HCG test, collecting all my strength again, praying vigorously as usual, finally all our prayers and hardships were answered and all my test right from Beta HCG to sonography went positive. But still the journey was not easy. During this period of pregnancy I got hospitalised for 3-4 times and the first 4 months of pregnancy were full of tensions. I was completely on bed rest and it was the lucky day of 25th April 2014, when finally God heard our prayers and we were blessed with a cute little baby boy.

  I with my family thank Dr Anirudh and Anjali Malpani plus team for being so patient with us and for all their love and support. We wish them good luck in near future for all their kind work.

Thanks and Regards,
Sarita Laxmikant Shukla

[email protected]

Friday, May 30, 2014

Why hysteroscopy before IVF is not a good idea

Lots of IVF clinics routinely do a hysteroscopy prior to doing IVF . They justify this because they say it's important to have a normal uterine cavity in which to transfer the embryos, and that a hysteroscopy is the best technique available to ensure that the cavity is normal.  They claim that this is a simple procedure, which involves doing minimally invasive surgery , and if by doing this they can increase the chances of pregnancy for even one patient by picking up a problem which would otherwise have been missed, they are justified in doing so.

I do not agree. I think doing a hysteroscopy routinely prior to IVF is practicing mindless medicine – and while cookbook medicine can be profitable for large clinics, it’s rarely in the patient’s best interests.

I agree it’s good for the doctor. Doctors like doing procedures , because they get paid for doing them ! The question is – is it worthwhile from the patient's perspective ?

The truth is that if a vaginal ultrasound scan shows that the endometrium is trilaminar, thick and normal, the chances of finding anything abnormal on the hysteroscopy are extremely low . If the doctor wants to be doubly sure, he can do a sonohysterogram to visualize the uterine cavity even more clearly.

The point is that if we can get the information we need by doing a simple, cheap and noninvasive test, then how are we justified in doing a surgical procedure ? ( The word minimally invasive is a clever oxymoron invested by a smart surgeon – it’s a bit like saying some one is a “little pregnant” ! For the doctor, this might be a minor procedure, but for the patient, every medical procedure is “major”.)

Tests should be tailored to meet the needs of individual patients , and hysteroscopy should be reserved for patients where the ultrasound scan is abnormal or difficult to interpret.

The irony is that if the hysteroscopy result is normal ( as it usually is !), then instead of feeling bad that he subjected the patient to an unnecessary surgical intervention, the doctor is very pleased because he can now tell the patient – your hysteroscopy was normal, which means your chances of getting pregnant are very good ! The poor patient does not even realize that she was subjected to unnecessary surgery !

It’s true that a hysteroscopy can be useful prior to IVF, but it should be used selectively . Thus. when the ultrasound scan result suggests there is an abnormality, a hysteroscopy allows us to confirm the diagnosis , and treat it as well.

The danger of routine hysteroscopy is that doctors have “itchy fingers”. When they insert the telescope inside the uterine cavity, they will often “find” problems ( of no clinical importance, because they are just normal variants) , which then they will “ treat” . This has the benefit that it allows them to charge even more. The downside is that doctors will then do a “metroplasty” or treat a “ subseptate uterus”, but this kind of unnecessary surgery can reduce the patient’s fertility , by causing scarring and adhesions.

If your doctor advises you to do a hysteroscopy prior to doing IVF, you should push back and ask – How will this change my IVF treatment plan  ? and is it possible to get this information by doing a noninvasive test ? Unless patients take the initiative and invest in Information Therapy to protect themselves, we will continue to see lots of unnecessary hysteroscopies being performed.

Worried that your doctor is doing too many tests routinely before your IVF cycle ? Please send me your medical details by filling in the form at so I can guide you sensibly!

Thursday, May 29, 2014

Gynecologists , infertility and TB

Indian gynecologists seem to be extremely fond of making  a "diagnosis " of genital TB at the drop of a hat !

I saw an interesting patient today . She was completely confused, because she had been to many gynecologists, each of whom had given her a different opinion.

She had done a workup for her primary unexplained  infertility. All her test results had come back as normal. However, during the testing , the doctor had done an endometrial biopsy for her which was sent for histological and bacteriological examination. These reports  had both come back as normal, so she was relieved. However, hr doctor suspected she may have endometrial TB, because she felt that her uterine lining on the vaginal ultrasound scan was “thin”. She therefore sent the tissue for further TB tests. The  TB PCR test  also came back as normal, but she was so sure of her “clinical diagnosis”, that she sent the tissue to a lab in New Delhi, which does an esoteric ( and very expensive !) test for TB, called PAMP ( pathogen associated molecular pattern, a mouthful which means precious little !) Incidentally, this seems to be the only lab in the world which does this test . Any sensible doctor would immediately smell something fishy with this kind of arrangement. After all, if a test is really useful, then why wouldn’t all labs offer it ? However, this test is cleverly marketed as being a very highly sophisticated and expensive test, which apparently no other doctor in the world has the ability to replicate ! They claim that it is a very specialized test , which only they can do ! They send photographs along with the report, to “prove” how accurate their “ diagnosis “ is !

The doctor is very pleased when the test now comes back as positive. She triumphantly points out to this report and is very pleased that she made such a difficult diagnosis . This proves that her clinical acumen is excellent !  She happily disregards the other negative TB tests results and advises the patient should start a 9 month course of antiTB treatment. When the patient points out that she has no symptoms or signs , and that the other TB tests are negative, she says that this just confirms that she needed to run this expensive test to make the right diagnosis, which was “missed” by the other tests. She “ explains “ that genital TB is often “silent” – and calls this “latent” TB !  In fact, some doctors have even coined senseless neologisms such as non-bacterial tuberculosis for these patients ! It’s now impossible to prove to the patient that she does NOT have TB. The poor patient is petrified, because she has been scared into believing that if her TB is not treated, the IVF cycle will fail, or that she will miscarry even after doing IVF.

The patient is now extremely anxious and worried , and she goes to a second IVF doctor for a second opinion . This doctor agrees that it’s highly unlikely she actually has TB, but that it’s not worth “taking a chance” and that it’s best to treat with a course of antiTB treatment, since the test has come back as positive. He feels it’s better to be safe and suggests that it’s fine to take a course of treatment!

The husband is very concerned because he knows that antituberculosis therapy can be very toxic. It involves taking many powerful drugs for many months.  These have many adverse effects, including liver toxicity , and is very reluctant to put his wife on these medications . He then goes to a leading gynecologist for a third opinion, who agrees that the chances of having TB are very low, but suggests that he should so a laparoscopy in order to check if there is in fact any tuberculosis lurking in the pelvis !

He was fed up and frustrated and could not decide what to do next. This is when he came to me. I sat down and explained to him that it’s quite common to have a thin uterine lining on a vaginal ultrasound scan – especially if the scan is done on Day 7 !  This is hardly the right way of making a diagnosis of TB !

I told him that the chances of his wife having genital TB were zero, since both the bacterial and histological tests were negative. I explained what false positive tests are. This means that the test result is abnormal, but the patient does not have the disease. The more the tests which are done, the higher the chances of getting a false positive result !

We are now doing a research study, where we are doing these TB PCR tests for fertile women, who have completed their families and are going to the doctor for a laparoscopic tubal ligation . It will be interesting to see how many of these test results ( in these women who have proven their fertility !) come back as positive !

The danger with misdiagnosing these infertile women as having genital TB is considerable. They get emotionally upset – and I even know of one husband who divorced his wife, because he was scared that having sex with her would mean that he might get TB too !

What’s even worse is that this epidemic of overdiagnosis will lead to the overuse of powerful antituberculosis drugs. Not only do they have significant side effects for the patient, they will result in the spread of MDR ( multiple drug resistant) TB in the community . The inappropriate use of these powerful antibiotics will accelerate the spread of drug-resistant TB in India.

I think it's high time that doctors and patients realized the limitations of these tests. I wish infectious disease specialist and tuberculosis experts specialists would get up and educate gynecologists that these test results have absolutely no value at all !

Have you been " diagnosed " with genital TB ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Wednesday, May 28, 2014

Is your doctor referring you to the best IVF clinic ?

When patients find they need IVF treatment, they expect that their doctor will refer them to the best possible IVF specialist , to maximize their chances of having  a baby. This is why they ask their family physician or gynecologist for a recommendation. They have a relationship with their primary care doctor, and trust that he will send them to the doctor with the best success rates .

In  a perfect world, this is exactly what would happen , and patients would be confident that they are being referred to the best IVF specialists . Unfortunately , the reality is that life is far more complicated. Most patients are aware of the fact that labs offer doctors kickbacks and cuts to refer patients to them. It’s an open secret that pathology labs and imaging centers do this routinely . What a lot of patients don't know is that many specialists also incentivize doctors to send patients to them.

This pernicious practice has become so pervasive , that many IVF clinics routinely offer gynecologists a referral fee to send patients to them. This is usually done in the garb of a “ patient management fee “ or “ treatment supervision fee “ - but no matter what euphemism is used , the fact still remains that it is a financial incentive which is being misused by the clinic to get more referrals.

This means that patients need to start looking after their own interests , and can no longer blindly depend on their gynecologist or GP to refer them to the best IVF specialist . They need to do their own homework for themselves. The good news is that thanks to the internet, it’s now much easier for patients to cut out the middleman, and reach out directly to IVF specialists. All IVF clinics today have their own website , and this means that they are now much more accessible ! This empowers patients to select the right clinic for themselves.

If you find that all websites look the same, try sending an email and asking for an opinion on your problem. This should allow you to judge how professional and competent the clinic is ! Do you get a generic answer from the receptionist ? Or do you get a reply from the specialist which is specific to your problem ? Also, you should find out which IVF clinic doctors select when they need IVF treatment for themselves ! This is a good way of finding the best IVF clinic.

Want to be sure you are at a good IVF clinic ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Tuesday, May 27, 2014

Aligning the interests of the patient and the IVF clinic

One of the concerns IVF patients have is that they feel that IVF doctors may cause their IVF cycles to fail, in order to extract more money from them.

They feel that their interests and those of the IVF doctor are not aligned . They know that the success of an IVF cycle is not 100% , but their worry ( often unexpressed) is that because the doctor makes  money by doing more IVF cycles , he may actually deliberately cause the cycle to fail, so that he can charge the patient for the next IVF cycle.

This is a shortsighted and distorted perspective. In reality , the interests of a good IVF clinic are completely aligned with those of the patient .  Why do we need to ensure that we do what's in the patient's best interests ? The reason is simple - doing what is in the patient's best interest also happens to be in our best interests !

We only have one IVF clinic in one location . This means the patient knows they will always find me here,  and that I'm not trying to maximize my income by running around from one clinic to another just in order to see more patients . This way, I can focus on the patient sitting in front of me , without having to worry about having to supervise other clinics or having to constantly commute.

This is also why we don't employ any assistants. This means our relationship with our patients is very hands on and is one-on-one . They get the direct benefit of the extensive yours of experience and expertise we have in doing IVF . This is why we have made a conscious decision not to delegate any part of the IVF care to an assistant. This allows us to ensure that all our patients get equally high-quality IVF care – not just the VIPs !

Because we do only IVF and nothing else , this means that IVF is our bread-and-butter . We need to ensure we have a high success rate, so we can continue treating new patients and doing even more cycles going forward . Our best source of references are our existing patients , and the greater the number of pregnancies we achieve, the more the patients they will refer to us. Since we do not offer kickbacks or commissions to referring doctors and gynecologists , we need to make sure that our success rates remain high , so that our happy patients can send us more IVF success stories , and help us to create even more IVF babies !

This is why we also offer
a guaranteed pregnancy treatment option.

This option will help you reduce your emotional risk and your financial risk

Want more information ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Monday, May 26, 2014

The top mistakes patients make when selecting an IVF clinic

Infertile patients know that IVF is a complex and expensive treatment . It requires a lot of experience and expertise in order to maximize the success rates. They also know that different IVF clinics have different success rates , and that there is a big difference between the pregnancy rates of a good clinics versus a bad clinic. This is why they spend so much time trying to find the best IVF clinic with the highest success rate.

However, inspite of this, many patients do a poor job in selecting the right IVF clinic . There are multiple reasons for this .

Firstly , some patients still naively believe that all IVF clinics are equally technically competent.  This can be a major mistake. For example, most IVF clinics in India still do not even have a full- time embryologist, and have to batch their patients in order to use the services of a travelling embryologist.

Patients need to invest enough time in Information Therapy and doing their homework , so they can learn to ask intelligent questions about their IVF treatment, rather than just unquestioningly accept whatever their doctor tells them. Sadly, it’s only when a cycle fails that the realize the importance of being well-informed – but by this time, the damage has already been done

 Most patient still select clinics based on convenience – they choose the clinic which is closest to them. While this does make dealing with the logistics a lot easier, it also means that while this may be a sensible short-term decision, if the local clinic has a poor pregnancy rate, they will end up wasting a lot of money.

Most patients are happy to go to their family doctor or gynecologist and request them to refer them to an IVF clinic. They naively trust their local family physician , and believe that he will refer them to the IVF clinic which is best for them . Little do they know that today a lot of family physicians and even gynecologists will refer patients to IVF clinics which offer them a kickback to do so.

This means that sadly patients can no longer trust their doctor to look after their best interests, because he is busy looking after his personal financial interests.

One of the reasons patients cannot differentiate between a good clinic and a bad clinic is because they do not bother to invest time and energy in learning the what differentiates a good clinic from a bad one.

Here’s a simple tip. A good IVF clinic routinely provides photos of embryos to their patients. Any clinic which does not do this is not likely to be a good clinic. When patients think about how much time and money and energy they are investing in their IVF treatment, they should be willing invest a little bit in Information Therapy as well , so they can learn what makes a good IVF clinic good.

Need help in finding the best IVF clinic ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Sunday, May 25, 2014

Transferring too many embryos

Many IVF clinics in India continue to routinely transfer four or five embryos during the IVF treatment, even for young patients who are doing their first IVF cycle . This is worrisome , because the risk of these patients having a multiple pregnancy after the transfer of so many embryos is extremely high . Many will end up having triplets , when they run the risk of having babies with lifelong disabilities because of their preterm birth. Others will end up miscarrying after a selective fetal reduction. The IVF doctor , on the other hand, will proudly count the pregnancy as being a success, when in real life, it’s actually been a disaster for the patient. This is because the doctor does not have to provide the pregnancy care or look after the preterm babies, which means he is often blissfully unaware of the adverse consequences of his actions.

The fact that the clinic is willing to transfer so many embryos is actually a sign that this is not a good
clinic ! This is because they don’t have enough confidence in their lab, and are forced to resort to transferring so many embryos , in order to artificially inflate their success rates. A good clinic is able to create good quality embryos which have a high implantation rate.

Patients contribute to the problem by pressuring doctors to transfer more embryos, because they feel this will improve their chances of having a baby. Most are so fed up of not ever getting pregnant, that they are willing to risk the possibility of a multiple pregnancy, and feel that anything is better than not getting pregnant. Little do they realize that by doing so they have pushed themselves from the frying pan into the fire. Please remember that transferring more embryos does not increase success rates – all it does is increase the risk of a multiple pregnancy . More is not always better !

A good clinic will usually transfer just one embryo ( if it's a top-quality blastocyst ) . For selected patients ( for example, those who are older , or those who have failed many IVF cycles, they may be justified in transferring more embryos).

A clinic which routinely transfers an excessive number of embryos is a bad clinic because they are not confident about their embryo implantation rates.

In a good clinic, 50% of top quality blastocysts will implant successfully. This means their implantation rate is 50%. The reason the other blastocysts do not implant is because they have a lethal genetic problem ( which we cannot identify) causes them to stop growing and prevents them from implanting.

This is why we still cannot predict which blastocyst will become a baby.  This is also why transferring three blastocysts would give an extremely high success rate – but would also result in a very high number of multiple pregnancies.

A good clinic which has a high pregnancy rates because it creates top quality embryos with a high implantation rate will discourage patients from transferring  too many embryos , because they are confident they will have a high pregnancy rate even after transferring just one or two embryos. Even better, the spare embryos are not wasted. The supernumerary embryos can be cryopreserved safely, and used later on to complete your family !

Worried that your IVF doctor wants to transfer too many embryos and that he is takig the risk of a multiple pregnancy too lightly ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Saturday, May 24, 2014

How can we make sure doctors see their patients on time ?

One of the commonest complaints patients have about doctors today  is that they make them wait for hours on end , without any good reason . Most doctors seem to be quite disrespectful about the patient's time and are quite casual about frittering it away. Perhaps it’s because they have poor time management skills – or because they get a high seeing how many patients are waiting to see them. Some doctors are workaholics, and are happy to use their reception area as a waiting room , where patients are taught to be patient . Of course, in many cases it’s just that there too few doctors for the large number of patients which have to be seen, but in some cases it’s just that the doctor is not bothered .

This is a tragedy , and can cause patients to become angry . A patient who has been waiting starts becoming impatient, and often this will cause the consultation to start off on the wrong foot.

Part of the problem is that doctors who give appointments and stick to them have to deal with the problem of “no-shows” – patients who take an appointment, and then don’t bother to turn up without even having the courtesy to inform the clinic and cancel the appointment.  This is a big problem for doctors who are punctual and scrupulous about their time management , because they are then forced to twiddle their thumbs until the next appointment comes in. This is why doctors are forced to overbook, to protect themselves from patients who cannot be bothered to respect the doctor’s time. In order to protect their productivity and reduce their down time, they make patients wait, so they can continue making use of their time and seeing patients, even if one or two do not show up.

I can offer a creative solution to solve this problem . Doctors should block one hour every day, where they offer premium appointments with the guarantee that the patient will not have to wait for more than 10 minutes. They can charge double for these prime slots, which can be offered online. Patients who value their time,  and want to be sure that the doctor will see them as scheduled, will be happy to pay the premium for these prime slots. If the doctor fails to see the patient as promised, the consultation will be done free of charge. This will also incentivize the doctor to ensure he respects his patient’s time and runs on schedule.

This system creates a win-win situation for both patients and doctors . Patients who don't mind waiting will continue doing so, whereas those who don't want to wait will be able to be make sure that the doctor sees them on time by paying a premium for this service .

Friday, May 23, 2014

A simple process patients can use to find the right doctor

Our clinic is only in Mumbai, and our website attracts couples from all over the world. Since many of them cannot afford to travel to India , they often request me to refer them to a reputed and reliable local IVF clinic for their treatment.

I am very reluctant to do so , for many reasons. If I suggest a particular name, this means that I trust this doctor will do a good job with the IVF treatment. However, it’s hard for me to be able to vouch for a doctor I have never met. It’s not that I am not willing to share information , it's just that it becomes very difficult to know how professionally competent other clinics are.

More importantly, I am a big believer in the fact that the chemistry between the patient and doctor plays a very important role in IVF treatment. Trust is an integral part of the doctor-patient relationship, and this is too important to be outsourced !

Because trust is so intangible and personal, the patient needs to find a doctor they can trust – and they can only do this if they search on their own. Sadly, patients often mistrust their instinct. They feel intimidated by doctors and do not feel they can judge their competence. While it is true that it’s very difficult to judge the doctor’s medical competence, it’s not difficult to assess their compassion and empathy during the consultation. If the chemistry is right, even if the doctor does not have a big brand name, this is something patients should factor in when making such an important decision.

Patients need to go through process of finding the right IVF clinic for themselves , rather than taking a shortcut and blindly accepting another doctor’s recommendation. While recommendations are useful in compiling a short list, you still need to do your own homework for yourself !

The questions patients need to ask are pretty basic. How well equipped is the clinic ? How long have they been doing IVF ? What is their success rate ? Do they have a fully staffed IVF lab ? a full time embryologist ? Does the doctor travel a lot ? Do they have an army of assistants who provide the actual care ? How accessible is the doctor ?

IVF patients have many choices today, and by doing their homework , they will be able to make the right decision for themselves.  Here’s the process I recommend.

Interview at least two different IVF clinics. One of the questions you should ask is – Why should I come to you as compared to going to the other doctor ? While some doctors may take offense at this question ( which is a black mark in itself , because this suggests the doctor is not very confident about his skills ), a good doctor understands that patients are confused and need help in making such a vital decision.

They will do their best to explain to the patient why they the right for them – without bad-mouthing the other doctor !  This kind of personal interview provides valuable information – both explicit and implicit . If you get good vibes from the doctor and feel comfortable that you are being treated with respect , you can be confident you are on the right track. It’s true that all doctors are on  their best behaviour during the first consultation, but how well they get back to you with your test results will give you a good idea of how well they follow systems and processes. Do they reply to your emails ? Are your phone calls returned ? You should test this before actually signing up for your treatment !

This means you need to use an intelligent mix of both publicly available information ( website, patient reviews, published success rates) and your gut feel when selecting an IVF clinic. Selecting the clinic which is right for you will improve your chances of success considerably !

Thursday, May 22, 2014

Why doctors take pleasure in reporting abnormalities of no clinical importance

Modern medical practice seems to be based on ordering tests and scans , and relying on these in order to make a diagnosis - not on the old-fashioned taking a history or doing a clinical examination.

The problem with a lot of these tests is that they will pick up a lot of minor abnormalities , which are of no clinical importance . In fact, the more expensive the test ( either because it’s brand new or uses highly sensitive technology), the better the chances of the results coming back as abnormal ! While a lot of these abnormalities are often found in normal health people as well, doctors tend to get very excited when they find these.

Lots of doctors take pride in finding and highlighting these abnormalities - and there are many reasons they do so.

For one, doctors are trained to look for problems, find abnormalities and make a diagnosis. Remember that doctors do not see healthy people – they only see ill patients ! Since they are often clueless about the natural history of a  disease and the prevalence of the abnormality in the general population, they tend to overdiagnose and overtreat.

During training, they are taught to take pride in finding lesions and abnormalities which other doctors have missed. If you are trained to do something , you tend to do it and it takes time to develop the maturity to understand the harmful consequences of some of this training. with Doctors can be very competitive and love playing the game of one-upmanship ! If one doctor finds something another one has missed, it proves to them that they are better than the rest !

Also, the fact that the doctor has ordered a test means he needs to justify the expense of the test to the patient. The best way of doing this in highlighting the abnormality, thus proving to the patient how competent and efficient they are.

Thus, it is very common to find small ovarian cysts or tiny fibroids when vaginal ultrasound scans are done for infertile women. This sets up a positive virtuous cycle for the doctor, who can claim that he has finally made the right diagnosis, and is now justified in doing additional procedures to solve the problem. He can suggests additional procedures to correct the problem . Unfortunately , from the patient's point if of view, this becomes a negative vicious cycle , because a lot of these abnormalities are just incidental findings which are of no clinical importance and are best left alone. However, patients now become the worried well , and start obsessing about these little incidental findings . They allow themselves to be subjected to unnecessary interventions and procedures , which actually end up causing more harm than good - for example , laparoscopic surgery to “treat” a small cyst.

The sonographer will highlight these abnormalities by printing them in bold or in italics. When the patient reads the report, she gets understandably upset and does a google search which confuses her even more, because so much of the information available online is unreliable. When she finally sees the doctor, he triumphantly points out the abnormality and says that once I treat this, you’ll get pregnant !

The reason we are seeing an epidemic of overtesting and overtreatment today is partly because of the way doctors are economically incentivized to practice medicine .  They get paid to order tests and do procedures, and as rational humans, this is what they do.

Unfortunately , none of this is in the patient's best interest . The biggest tragedy is that the poor patient doesn't even realize that they have been subjected to unnecessary testing ! When the test is abnormal , they are happy their doctor has been clever enough to find the problem and “treat “ it. When the test result is normal, they are reassured that “ all is well” !

It’s only senior and more mature doctors who understand the importance of masterly inactivity. Unfortunately, doctors don’t get paid to do nothing – and not enough patients have the maturity to understand that only the superior doctor will advise a hands off approach.

Intelligent patients, who invest in information therapy , understand that it’s best not to worry about very little abnormal squiggle on an ECG -  and that often the best medical treatment is to do nothing.

Intelligent patients can try to protect themselves from overtreatment by getting a second opinion , but sadly this also doesn't often work very well , because the doctor who provides the second opinion is also incentivized to perform a procedure , rather than do nothing. This is why it’s best to get a second opinion from a retired surgeon , who has years of experience and expertise , and who doesn't operate anymore, because he will be able to explain to you why a hands-off approach is in your best interests.

Wednesday, May 21, 2014

Why Health insurers should provide EMRs free to doctors and hospitals

Health insurance executives have two major complaints about hospitals and doctors .

1.    They overtest and overtreat insured patients, in order to maximize their profits
2.    Their documentation is very poor

This is why it’s very hard for insurance companies to check that the medical care which was provided was medical appropriate or not. They are forced to invest a lot of money in fraud detection and utilization review , in order to ensure that the care which was provided to the insured patient was exactly what the patient needed – and not more just because the insurance company is paying for it .

However , as a result of this emphasis on paperwork and forms which need to be submitted to the insurance for processing the reimbursement claims, hospitals and doctors are very unhappy with insurers. Doctors hate filling up forms, because they are more interested in taking good care of their patients and helping them to get better.

This sets up a confrontation , and doctors feel that they are now being forced to spend more time filling out forms , in order to comply with the insurance company’s unreasonable requirements , rather than in taking care of patients . This has now become such a burden, that lots of doctors have started to refuse to accept insurance payments , because of the heartburn and angst it causes them.

One solution to this problem would be that insurance companies should provide their doctors and hospitals with EMRs. This way, data which the insurance company needs ( both to process the claim and ensure that they care is appropriate) will become a desirable side effect of the clinical encounter, during which the doctor is taking care of the patient.

This way, instead of having to separately fill out forms just in order to get reimbursement , this data which the insurance company needs will be automatically generated while the doctor is taking a history and doing an examination.

Hospital information systems and EMRs have now become cloud-based which means it’s very inexpensive for insurers to do so. Because of the advantages of scale,  they can do this very cost effectively .

This creates a win-win situation for everyone – the doctor, the patient and the hospital. The doctor and hospital are happy because they can provide better care using the latest medical technology , without having to spend for it from their own pocket.

It’s good for the insurance companies , because the medical record system can be designed so that it automatically provides them with the metrics which they need to monitor the quality of care, in order to ensure that the clinical care which is being provided is of high quality . Also, since the data collection is online and being done in real time, the documentation cannot be fudged or manipulated later on. This will also help to reduce fraud.

Patients will also benefit, because they can access their own medical records online , through a patient portal ! This will empower them because they now have instant access to their medical details, 24/7, no matter where in the world they are !

If health insurance companies started providing hospitals with online cloud based EMRs,  this would help everyone in the healthcare ecosystem .

Tuesday, May 20, 2014

Health insurance companies versus doctors

Health insurance companies  and doctors ( which includes the hospitals which employ these doctors) seem to be headed on a collision course in India today. This is an ugly situation which seems to be getting progressively worse , because of the confrontation which seems to be occurring on a daily basis over the reimbursement of patients’ medical expenses when they submit their claims to their health insurance company.

When patients have a health insurance policy and undergo medical treatment, they expect that the insurance company will pay for their medical care.  After all, this is why they took out the insurance policy in the first place !

This is why many hospitals will do the surgery for patients with insurance coverage in good faith, and will not insist on being paid in advance. When the surgery is complete, they submit the claim to the insurance company  and expect them to reimburse this promptly. However, when insurance companies refuse to do so , on what seems to be a flimsy pretext ( such as an incompletely filled form), hospital managements start feeling that  insurance companies are crooked because they want to hang on the float by refusing to clear their payment.

Hospitals believe that insurance companies are using these excuses to delay payment , in order to maximize their own profits . Not only does this cause a lot of heartburn for hospitals, they find that they then need to start employing a small army of clerks to keep up with the games the insurance companies play.

Doctors and hospitals often cannot afford to deal with all this paperwork , which distracts them from providing high quality care to their patients. They are just not equipped to deal with the bureaucratic hurdles the insurance company makes them jump through, and many will just give up on the claim and write it off. However , they will stop accepting insured patients in the future, and will insist on being paid in advance ! This harms the poor patient.

Insurance companies are quite happy to swamp doctors with lots of paperwork , because they can easily afford to do so . Hospitals , on the other hand , are in the business of taking care of patients , and when they find they have to waste so much energy and time in getting insurance companies to pay their dues, they get upset and agitated .

However, we also need to look at this from the insurance company’s perspective. Insurance company executives think of themselves as being in the service of reducing financial risk for their customers. They are happy to provide a financial safety net when the patient falls ill , and take pride in processing clean claims promptly. They treat their customers as valued clients, and understand that because health insurance is a competitive market, the better the service they provide to their customers, the more they will profit.

The problem is that they perceive many doctors and hospitals as being crooked . It is true that there are a few bad eggs in the medical profession, and hospitals and insurance agents will often conspire to cheat the health insurance company. The insurance company is seen as having deep pockets, and they will commit outright fraud, by submitting inflated claims; and even completely false claims, by claiming to have done surgery on non-existent patients !

Insurance company executives are not stupid. They know that many hospitals and doctors pad their bills and overcharge insured patients . They find the lack of transparency on the part of hospitals extremely infuriating . How can hospitals charge one patients Rs 20000 for a cataract surgery, while the other one is asked to pay Rs 100000 , just because he is insured ?  Hospital bills are designed to be complex and opaque – and this lack of transparency makes it very difficult for insurance companies to be able to model their business. Even worse, they know that lots of doctors do a lot of unnecessary testing and surgery , just because the patient is covered by insurance. Doctors used to be able to get away with these kind of malpractices in the past, when insurance companies used to turn a blind eye to them , because the amounts were small. However, as medical inflation is pushing healthcare costs through the roof, insurance companies are pushing back . In this confrontation , it is usually the innocent patient who suffers ; and it's often the good doctors who are unfairly penalized , as the insurance companies turn on the screws and make their processes ever more stringent, in order to cut down fraud.

This situation is likely to far uglier before it improves. Health insurance companies and doctors often seem to be worlds apart, and they find it difficult to seek common ground. Doctors think of insurance company executives as being office bound pen-pushers , who don’t have a heart , and don’t understand the complexities of real life medicine. They believe that all insurance companies understand is paperwork. Insurance executives think of doctors as being money hungry crooks, who are out to make a quick buck at the expense of the company. Each of them remembers only the exceptions . Thus, insurance company executives discuss the crooked hospital which was caught cheating and siphoning off crores , by claiming to do surgery for patients who were never even admitted; while hospitals complain about the insurance company which refused to pay for a clean claim, just because the forms were not submitted within 7 days  !

My fear is that we seem to be headed down the route of the US healthcare system, where the payers and providers seems to be locked in fighting an ongoing battle, which gets uglier year after year.

Monday, May 19, 2014

Fixing Indian healthcare

Now that Mr Narendra Modi  has become the new prime minister with such a thumping majority , the entire country is very hopeful that India will be able to progress much more rapidly than in the past, as a result of good governance .

One of the major problems is healthcare , and there is no question that being able to provide high-quality healthcare to over a billion Indians is a big challenge . Indian is a poor country and there just aren't enough doctors to go around . Actually, this challenge is an opportunity, and  we need some “out of the box” thinking to fix it. It’s obvious that if we continue doing what has failed to work in the past, we are doomed to continue to fail.  It would be foolish to continue this wasteful exercise – and this is a great opportunity to create new solutions, which can provide value for money.

This is a wicked problem , and we need to remember that constraints can actually spur creativity and innovation . Indians are great at extracting the last ounce of value, and we can make even a small amount go a long way , because we are so frugal.

The trick is to flip the problem on its head , and instead of treating the large number of patients as being a burden, we need to think of ways of using their potential to solve the problem.  If patients are the largest untapped healthcare resource, the fact that we have over 1 billion of them is a huge opportunity !

What can we do in order to tap into their creativity , to help them get the best care possible ? For example, in India, every hospitalized patient usually has family members who help to provide nursing care for them. Rather than treat these relatives as unwelcome obstacles, how can we make better use of their skills, so they can reduce the nurse’s workload ?

A huge problem today is the poor quality of medical record keeping and documentation . While the Govt is willing to spend thousands of crores in order to fund health care for the millions who live below the poverty line ( for example, through schemes such as the RGJAY, Rajiv Gandhi Jeevandayee Arogya Yojana at ) , it’s a very complex task to make sure this money reaches the right hands.

It’s well known that the healthcare industry can be extremely corrupt , and because of the huge amount of fraud which riddles it, a lot of the money ends up going to hospitals which lie and steal. For example, many private ( and government hospitals as well) raise claims for performing surgery which was never even done in the first place ! Hospitals fudge records, and it’s hard for the administration to ensure that the government is getting a good return on the money which they are spending on healthcare for the poor. Is it just ending up lining the pockets of  corrupt doctors and hospital owners ?

The standard approach is a typically bureaucratic one. Once fraud is discovered, the government than treats all doctors as being potentially crooked. They crack the whip by demanding better quality care and accurate documentation ( for example, the doctor now needs to submit a photo of the patient along with the hospital medical record, to prove that care was actually given to them). Over 93% of RGJAY claims submitted by three municipal hospitals , which are run by the government  itself , are still pending !

Honest doctors are very upset with this bureaucratic backlash. They feel they are already overburdened with clinical tasks, and being forced to submit reams of paperwork will just increase their workload and reduce their productivity.

They resent the fact that the time and energy which they need to devote to taking care of their patients is being siphoned away in filling out forms. (  I can personally vouch for this. The administrative overheads are a huge burden on the doctor, and we are forced to pass these costs on to our patients, who will be the ultimate sufferers).

This is becoming an adversarial situation – which actually represents a huge opportunity. The government can start providing free EMRs (electronic medical records ) using cloud-based computing to all hospitals and doctors. This will make it easy and efficient for doctors to maintain accurate records of all the procedures , treatments and prescriptions which they provide to their patients . This could be a basic bare-bones system , which could even work on their smart phones and tablets . It wouldn't require much of an investment in hardware , because it uses cloud computing . The hospital would not even need to buy computers if they did not want to.

The good news is that a lot of clever startups have developed innovative solutions , and hopefully the government of India will use these . Rather than using a top-down approach , and forcing doctors to adopt these technologies , we need to use a bottom-up approach . We should focus on the success stories - the positive deviants. We need to identify the clinics and hospitals which are using these EMRs efficiently to document and deliver high-quality medical care . These doctors are living examples of how technology has helped them to improve their productivity – and they can serve as KOLs ( knowledge opinion leaders) to influence other doctors , and spread the message . These evangelists can help to get other doctors to start adopting EMRs, so that more patients can benefit from it.

it would be easy to translate this software and records into local languages. More importantly, patients would then have access to their personal medical records through patient portals . We can then empower patients with information therapy, so that they are confident they are getting the right medical care .

It’s sad that we continue to underestimate the ability of patients to heal themselves . Using technology , we can create win-win situations , which will allow India to become a leader in the healthcare space . We have lots of medical expertise and a large number of world class doctors. We are also the IT powerhouse of the world. It’s a question of marrying these two together , so that we can use their collective intelligence and creativity to improve the health of a billion Indians. This can set up a positive virtuous cycle, where better health allows citizens to become even more productive!

Sunday, May 18, 2014

The soil fertility specialist !

We take pride in being IVF specialists and helping couples to have babies.

My father is a much more ambitious fertility specialist ! He runs Malpani Trust where Deepak Suchde , one of India's leading organic farming specialist, helps farmers to make their soil more fertile using Natueco farming.

Modern day farming methods which use chemicals as pesticides and fertiliser have caused the soil in many farms all over India to become barren. The poor farmer has unwittingly dug his own grave. Natueco farming can help to heal the farmlands of India, and restore their fertility - at zero cost !

What is your IVF success rate ?

This is the commonest question patients ask an IVF doctor. The truth is that the quality of an answer depends upon the quality of the question, and this is often a pointless question.  While clinics are good at telling you what their success rates are with a selected group of women , this information does not necessarily apply to you as an individual – and you really only want to know what your personal chances of success are !

A far better question would be – How many IVF cycles will it take for me to get pregnant ? This is far more relevant for the individual patients.

A success rate of 40% to 50% is meaningless for the individual patient . For you, the outcome of an IVF cycle is either 0% success or 100% success ( and 200% if you get twins !)

However , once you know what the clinic’s cumulative conception rate , you then have a much better sense of judging how many treatment cycles you are likely to have to do in order to get pregnant.

Often, the doctor can give you a far more accurate answer at the end of the first IVF cycle.  He can analyse the results of this cycle , and this will give him a much better sense of how you respond to superovulation and how good your embryo quality is .

While the doctor will not be able to give you an exactly precise number as to what your chances of success are , he can much predict how many cycles you are likely to need in order to take home a baby much more accurately. This will help you estimate how much time, money and energy you will need to invest in your quest for a baby.

Need to know more about how to maximise your chances of IVF success ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Saturday, May 17, 2014

Day 3 versus Day 5 transfers - which has a higher success rate ?

English: Blastocyst on day 5 after fertilizati...
There’s still a lot of confusion as to whether Day 5 ( blastocyst) transfers are better than Day 3 transfers. A lot of patients believe that blastocyst transfers have better success rates .

As IVF lab culture systems improved and doctors were able to reliably and consistently grow embryos in the lab to Day 5, we were very hopeful that this would result in improved pregnancy rates . After all, growing embryos for longer would allow us to transfer them back into the uterus at the “optimal time”. In vivo, Day 3 embryos belong in the fallopian tube and blastocysts belong in the uterus, so that isn’t it logical that mimicking nature would improve IVF pregnancy rates ? While there was a lot of enthusiasm when blastocyst transfer was first introduced ( as is common with any new technique in medicine, which is always greeted with hype and hope), over time we realized that this simplification was not necessarily true.

Let’s consider a Day 3 embryos which is destined to implant. Keeping it for 2 days extra in the incubator and transferring it on Day 5 is not likely to improve the chances of it implanting, so why should we expect that merely growing embryos for 2 extra days in the lab would improve pregnancy rates ?

The problem in IVF today is that we still cannot identify which embryo will implant successfully. The major benefit of a Day 5 transfer is that it allows the Day 3 Grade A embryos to “compete “ with each other in vitro, so that we can select the best one more intelligently by observing it for an additional 2 days

This allows us to reduce the number of embryos we need to transfer in order to achieve a pregnancy. Thus the major advantage of blastocyst transfer is that it allows us to reduce the risk of a high order multiple pregnancy.

Since this is so valuable, then why not just transfer  only Day 5 embryos ? Why do some clinics still offer Day 3 transfers ? Some clinics have poor quality labs, and are not able to grow embryos reliably until Day 5. This is especially true for clinics which do “batch IVF” where the visiting doctor is available for only 1-2 days during which he has to complete all the transfers, before he moves on to the next clinic.

Some clinics offer the option of a Day 5 transfer, but not routinely for all patients, because the risk is that the embryos may arrest in vitro , so that there are no blastocysts left to transfer on Day 5. This is why these clinics will insist that the patient have at least 3 Grade A embryos on Day 3 if they want to opt for a blastocyst transfer. This minimizes the risk of cancelling the transfer. They want to be sure that they will have at least one embryo to transfer , because cancelling the IVF cycle because there are no embryos to transfer can be emotionally traumatic for the patient, who is likely to blame the IVF clinic for this problem. ( On the other hand, if the clinic does do the transfer and the patient fails to get pregnant, at least she will not blame the clinic for the failure and will attribute it to her bad luck or her destiny).

Let’s consider a patient who has only one top quality Day 3 embryo. Should the doctor transfer this on Day 3 ? Or wait till Day 5 ? The doctor may say it’s best to transfer on Day 3, because waiting till Day 5 will not help to improve the chances of success, so why bother ? Also, it’s in the doctor’s best interests to at least reach the stage of embryo transfer, so that patient is happy that she has reached this important milestone. However, I'm not sure this is the best approach for the patient. Once the embryo has been transferred, the patient is subjected to the horrible 2ww.  In a bad clinic, which is not confident of its lab facilities, it may make sense to transfer the embryo on Day 3, because the doctor is not sure the lab will be able to grow the embryo to Day 5. However, in a good lab, it makes sense  to wait till Day 5. If the embryo is going to arrest , we might as well know this before the transfer, rather than subject the patient to 2 weeks of suspense and misery. By doing a Day 3 transfer, all we’ve done is prolong her uncertainty. Of course, she may be happy that at least her embryos were transferred, and she may even “feel pregnant” after the transfer, but this is short lived happiness.

However, if the lab is good, and the patient is mature enough to accept the fact that if the embryo arrested in vitro, it would have arrested in vivo as well (which means she wouldn’t have got pregnant with the Day 3 transfer either) , it makes much more sense to do a blastocyst transfer . This way, rather than always being uncertain as to the reason for the failed implantation, we’ll know that the reason for the failure is because the embryo was not of good enough quality to develop further and become a blastocyst. While the failure to have embryos to transfer can cause considerable short term emotional pain, on a long term basis, it can provide valuable answers, which allow patients to move on with their life. Thus, they can consider using alternative options such as donor eggs in their next attempt, rather than remaining stuck in limbo, and repeating failed cycle after failed cycle.

Confused as to which is the best option for you ? Please send me your medical details by filling in the form at so I can guide you sensibly ?

Friday, May 16, 2014

IVF success story at Malpani Infertility Clinic

We got married in 2005 and all was well till 2008, we never bothered about not being parents as we had thought of not having a child at least for couple of years just to enjoy the phase. But we didn't do any planning as  we were open for parenthood also.  The life was very comfortable and we enjoyed every bit of it. In between we consulted doctor and everything was quite normal. Some medication were prescribed and was followed properly. But nothing has changed and still we did not bothered much. But the pressure started mounting up when there was no sign of conceiving after couple of years. Then we consulted another doctor outside Goa and under went all the check ups and followed by treatment. Unfortunately  nothing came positive our way. Every month we traveled nearly 500 Km  twice or thrice according to the requirements of the treatment. This continued for almost 6 months,  3-4 cycles of IUI's failed  and we were exhausted! You can imagine the stress that we had gone through in travelling, treatment, expenses, staying out of home etc. There was lot of expectation from the family, many suggestions use to come very often to meet other doctor, visit temple do puja etc. As i am working in Goa we lived here without our family. By then we started facing irritation to meet our own family and friends , started avoiding all the functions, social meetings etc to just to stay away from the unwanted questions and suggestions. Decided not continue any further treatment. Valuable 8 years passed and no sign of our aspiration becoming reality.

I am really thankful to my immediate boss who has supported me through out these days, further insisted not give up hopes and suggested to meet a doctor in Mumbai. He himself arranged an  appointment with a senior most doctor Dr. Soonawala. Dr. Soonawala being one of the best gynecologists in India studied our case and treated for 3 months and finally referred us to Dr. Aniruddha Malpani of Malpani Infertility Clinic.

It was a great feeling at the first meeting of Dr. Aniruddha Malpani, we have never been so comfortable with any of the doctors throughout our  treatment. Dr. Malpani impressed us in the very first meeting with his talkative command and encouraged us to be calm and face the situation as it comes.  He explained the procedure in a convincing manner and cleared all our doubts.  As we had also decided to go for for the last chance of luck we were very calm and heard him very patiently and decided to come back to him for the treatment very next month.

We have gone through the procedure of IVF in the month of March 2013 and my wife conceived in the very first attempt!  We had broken out with joy after the confirmation and there was no word to thank Dr. Malpani and team. 

But there were hurdles in the initial stage of pregnancy, my wife had to be admitted for 3-4 times which was more painful than getting conceived. We were scared of miscarriage as my wife was repeatedly facing problem but finally the day has come she got admitted for delivery on November 15th. It was a long wait since 9.30 in the morning to 7.30 PM , I was so worried, I think I must have prayed 100 times, she delivered  a healthy beautiful baby girl and our entire family had celebrated the moment.

Now  our daughter is 6 months old and absolutely took off all our depressions and has filled us up with happiness. It's all because of the kind support of Dr. Malpani and team and we will remain grateful to them rest of our life. I would like to give a message to couples like us -  please don't lose heart, be patient, get the advise from the doctor, trust him and leave rest all to the God and wait for the result,you will not be disappointed.
I wish all the very best to Dr. Malpani and their team and pray that they continue their good work. 

Satish Bhat

[email protected]

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