Tuesday, September 30, 2014

Why don't Indian health insurers invest in patient education ?

The Indian health insurance industry is at a crossroads today . It’s been growing at a scorching pace in the last few years, and health is likely to become a huge part of the portfolio of general insurance companies. However, even though the demand has been rising exponentially , no health insurer seems to be making a profit today.

Demand is booming because healthcare is becoming more expensive , and Indians are increasingly aware that they need to buy health insurance to protect themselves when they fall ill. This is a hot area and lots of global health insurers are itching to get into India because the potential market is so promising.

So why are health insurers still bleeding money ? In the past, health insurance was a monopoly which only government companies could provide . It used to be a loss leader, and the premium which the companies charged was completely out of touch with reality , and they were quite willing to lose money on this segment of their portfolio. Even today, after privatization, the claims loss ratios are very high, partly because of the historical hangover ; partly because we still don't have reliable actuarial data on which health insurers can intelligently price their policies; and because the market is so competitive.

This situation has become untenable, as a result of which some private health insurance companies have stopped selling group ( corporate) health insurance policies, because it’s not cost effective for them to do so . This is an interesting paradox - how can you reconcile the fact that over the long term you will end up making lots of money , but in the short term you are still hemorrhaging ?

I think the solution is simple – health insurers need to invest in educating their customers. Patient education has worked extremely well abroad, and this is something which insurers proactively and routinely do all over the world. They understand that this is their best defense against the problems of over testing and overtreatment , which is causing medical costs to spiral out of control. The best way to help patients avoid unnecessary surgery is by making sure patients understand what their options are, so that they make well-informed decisions , and doctors are no longer able to bully them into doing expensive and unnecessary surgical procedures .

Avoidable care has become an epidemic today, because doctors are economically incentivised to perform as many procedures as possible. They don’t get paid to counsel the patient or to be conservative, even if the “do nothing” option is in the patient’s best interests.  If the doctor tells you to do something, most patients will not have the guts to challenge him – they will meekly sign the consent form on the way to the Operation Theater.

This is why Information Therapy needs to be delivered proactively – even before the patient has met the doctor. This will allow him to ask intelligent questions , and he can push back if the doctor advises aggressive treatment which doesn't seem reasonable , according to evidence-based medicine guidelines. This information will also allow him to verify whether his doctor’s advise conforms to established medical practice; and if it does not, he can think of getting a second opinion from a better doctors.

This is why patient education should be an integral part of the health insurer’s business model – it makes business sense for them to prescribe Information Therapy. Not only will it help them to become more profitable more quickly by reducing their claims loss ratio , it will also help them to create a positive customer experience .

If the value of providing patient education is so obvious , then why don't health insurers in India do this ? I have come across multiple excuses so far.

  • We are not in patient education business
  • This is not our core competence
  • Patient education is something which doctors should be doing
  • We don't want to get involved in the disease management space
  • We don't want to second-guess the doctor
  • A lot of this information is so easily available on Google and Wikipedia , so why should be offer it
  • If the information we provide is inaccurate , we  may get sued and we don’t want to take on this additional liability
  • I do not have the budget to do so
  • I need IRDA approval to do this
  • Most of my customers do not have internet access
  • Most of my customers cannot read English

The tragedy is that none of these are good reasons ! They are all flimsy excuses, all of which can be solved , if there is the will to do so.  What amazes me is that health insurers continue to be shortsighted , and go on continue wasting a lot of money unnecessarily . I just hope they wake up and understand why patient education should become an integral part of their offering , before they have to fold or lose their customers to other health insurers who understand that not only is patient education good for their business , it’s good for the health of their customers !

Monday, September 29, 2014

How can you check if your IVF clinic is any good ?

How Malpani Infertility Clinic provides excellent value for money

There are some patients who believe that we charge too much for IVF treatment . They compare the prices at Malpani Infertility Clinic with what their local clinic charges, and feel that we charge a premium. They feel this is unfair. After all, don’t all IVF clinics offer the same treatment ? Then how can we justify charging more ? Is it because we are greedy ?

While it is true that IVF treatment at a good clinic is expensive , it’s actually a bargain as compared to doing IVF in a bad clinic in order to save money .

There are many reasons why we believe our charges are cost effective. For one, they are open and transparent . Unlike the vast majority of Indian IVF clinic, we publish them in black and white on our website, which means patients do not suffer from sticker shock when they get the bill.

We pride ourselves in providing a high quality service, where patients come first. This means that our patients always have access directly to me, without having to go through assistants and juniors. We do not employ any assistants, and while this means we can provide care only to a limited number of patients, this also ensures that the quality of care is unsurpassed. This is also the reason we only have one clinic. We do not travel to any other clinic, and are always available in Mumbai for our patients.

How is the poor patient supposed to make out whether the IVF clinic they have chosen follows best practices ? After all, it’s very hard to judge the quality of medical services because they are intangible. Here’s a simple experiment you can try at your present clinic. Try to contact the head IVF doctor – the brand name doctor for whom you pay your fees, in order to get treatment from the best, and see how long it takes to get a reply.

In our clinic, we guarantee a reply directly from me within 24 hours. Isn't this confidence of always being able to get my advice invaluable? We store all your records electronically so we have instant access to them 24/7, and this ensures we can craft a personalized plan of action for you.

We have a highly qualified , experienced and full-time skilled embryologist ; and we use state-of-the-art equipment to provide cutting edge medical care. This combination allows us to provide high-tech high touch care to our patients. Because of our focus on quality , we ensure we provide personalized attention to all our patients, we don't cut corners .

Yes, it’s true that there are many clinics which charge less than what we do . However, we are not in the business of trying to compete with other clinics for offering the lowest fees. We are proud to compete as regards our quality of care and pregnancy rates. If we need to continue to provide a service which put patients first , we will not compromise on our quality of care by reducing fees , just in order to compete with other clinics. However, we do provide discounts and subsidized treatments to financially deserving patients.

Lots of clinics ( especially the ones which run national chains ) charge less than what we do. They try to compete on price, so that they can attract more patients . Sadly, the price the patient pays in order to save some money is that they often end up reducing their chances of getting pregnant significantly .

Many of these clinics will take short cuts and not follow basic IVF protocols such as documenting photographs of the embryos and providing these routinely and proactively to their patients . In fact, some of these clinics charge the patient a hefty premium for using an embryoscope, by claiming that this increases pregnancy rates. However, in reality they don’t do so ( the point of an embryoscope is that it generates photos of the embryos as these are dividing in the incubator) , and the poor patient is none the wiser, because of the lack of transparency. 

If you’d rather be treated in an assembly line clinic which has lots of doctors in white coats milling around, then Malpani Clinic is not the right place for you. On the other hand, if you’d rather be treated hands on by an IVF expert with years of experience, then we are a great choice.

Want more details as to what makes us better ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

Saturday, September 27, 2014

The problem with PGS - overpromising and underperforming

One of the most frustrating problems in IVF today is implantation failure . We know that the commonest reason for failed implantation is a genetic problem in the embryo , which is why preimplantation genetic screening ( PGS) was considered to be a big advance when it was first introduced 20 years ago. The technology offered the hope that if we could test the embryos to ensure they were genetically normal before transferring them , the IVF pregnancy rate would improve dramatically. After all, selectively transferring only those embryos which are genetically normal would allow us to both increase the IVF pregnancy rate and also reduce the risk of miscarriage after IVF .

Sadly, what appears to be true in theory often does not work well in real life, because human  biology is so complex . I5 years ago, the only technology to check if embryos were genetically normal or not was using a technique called FISH ( fluorescent in situ hybridisation) . FISH allowed us to check whether the embryo’s chromosomes were normal or not. However, because it used to fluorescent dyes to  label the chromosomes, the number of chromosomes we could check with FISH was very limited. As a result, even embryos which appeared to be normal on FISH had  chromosomally abnormalities, which led to IVF failure and miscarriages.

PGD using FSIH was hyped up a lot when it was first introduced. The clinics which offered this marketed themselves as offering cutting edge advanced technology, and lots of patients were lured into doing PGD with the hope that their pregnancy rates would improve.  However, controlled clinical trials clearly showed that PGD / FISH did not increase IVF pregnancy rates – and in fact, could cause them to drop ( because the embryo biopsy procedure could damage the embryo). However, lots of patients had wasted a lot of money unnecessarily on false hope.

Of course, the same IVF scientists then claimed that the problem was not with the PGD , but with the FISH technology. Genetic technology had improved considerably, and they believed that using more advanced technology such as CCS ( comprehensive chromosomal screening ) or NGS (next-generation sequencing ) for genetic testing would allow us to select the normal embryos with greater accuracy. They labeled FISH as being old-fashioned and unreliable, and started selling the benefits of array technology, which allows us to check all the chromosomes – not just  the 6 or 7 which FISH allows us to screen for.

While it's true that CCS is better than FISH, the fact still remains that it has its own limitations. However, we are now seeing a new marketing blitz , with lots of hype about how PGS/CCS will improve IVF pregnacy rates and should be offered routinely to all IVF patients.

The one fact which a lot of doctors will still not share with patients is that a chromosomally normal embryo is not always a genetically normal embryo. This might seem confusing , but even an embryo which appears to be chromosomally normal ( euploid) may still have lethal genetic defects which we cannot pick up. These may cause the embryo to arrest after transfer ( leading to a failed IVF cycle); or result in a miscarriage.

The problem is that when doctors misuse words , patients get confused between genetically normal and chromosomally normal embryos. When they fail to get pregnant even after doing PGS/CCS; or if they miscarry after a PGS/NGS cycle, they feel cheated .

This is why it's important that doctors learn to use words precisely ; and that patients have realistic expectations as to what the technology can offer them. Other wise we will end up with the old problem of overpromising and under delivering , which plagued PGS in the past, and caused a lot of patient unhappiness because of shattered dreams.

Not sure if you need PGS or not ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

Friday, September 26, 2014

Are patients powerful or powerless ?

In the past, it was the doctor who had all the power. When the patient was ill, he was scared and helpless. He went to his doctor  and trusted that the doctor would use his expert skills and knowledge to help him get better. All the medical knowledge was locked up in medical books and journals, and patients were not able to make well-informed decisions for themselves, because they did not have the information they needed to do so. The relationship was one of unequals, and the doctor was trusted to play a fiduciary role. Doctors were happily perched on their pedestals – and patients derived a lot of comfort from the fact that medical professionals were available to snatch them from the jaws of death.

Things have changed a lot today, thanks to the easy availability of online information written for patients. However, even though the doctor does not have a monopoly anymore on medical knowledge, and the glut of information has created its own set of problems for patients. Patients don’t know which information is reliable and whether they can trust it or not. Many websites say diametrically opposite things, leaving the poor patient even more confused. They don’t know whether they should trust their doctor – or the website. When should they get a second opinion ? Suppose this confuses them even more ? Or should they just leave everything upto the doctor and hope for the
best ? Can they be sure their doctor  will put their best interests first ?

Individually, patients are often scared and helpless, no matter how well-informed they may be, and how many websites they have researched . They want to find a doctor whom they can trust, because they are often too emotionally upset to be confident that they will be able to  make the right decisions for themselves. They are vulnerable and know that they can be exploited by quacks and unethical doctors.

This is why they don’t want to try to second guess their personal doctor or challenge his decisions. They’d rather accept his advise as gospel truth. They are scared that if they refuse to toe his line, he may get upset and fire them or abandon them in their time of need. After all, it’s much easier to take the path of least resistance and leave everything upto an expert. We all want a mother figure who will kiss us and make us well when we are sick, and we’d like our personal doctor to play that role for us.

On the other hand , groups of patients have lots of power ! Together , a community of patients can make or break a doctor’s reputation and his practice . This is why individual patients need to tap into the collective power and wisdom of a patient community , so they can leverage its strength . Thanks to the Internet , it’s become much easier for patients to share their expertise and experience . Empowered patients can get much better medical care if they are part of a group, rather than if they are alone and isolated. There is strength in numbers, and smart patients make use of this.

Patients also need to remember that it’s not a one-way street. Just like they can benefit from the collective wisdom of the patient community, they need to learn to give back, to help others as well, when they get better.

Going forward, this is the most cost effective solution for ensuring that patients have a better experience with the healthcare system. This is a win-win situation for both patients and doctors – and good doctors help to set up these patient communities and guide them, so they become autonomous and independent. They can then refer their new patients to these communities , allowing them to tap into the wisdom of the crowd.

Thursday, September 25, 2014

Engaging with the patient’s relatives

One of the reasons I really like the Narayan Hrudalaya Caregiver program is that it highlights the important role which the patient's relatives can play in a hospital setting , if empowered to do so.

The one group of people who constitute the majority within a hospital is not the medical staff or the patients - it's actually the patient's relatives , friends and caregivers . This is an enormously important group – not just because they pay the bills, but simply by virtue of their large numbers . They have potential for doing so much good - as well is doing so much harm. Thus, if they perceive that the patient is not receiving timely medical care ; or that the medical staff is rude or unavailable, it is these people who can beat up the doctors and burn down the hospital.

On the other hand, when the hospital does a remarkable job at providing high quality medical care, these are the same people who spread the message about how good the hospital is and how good its doctors are . Word of mouth marketing is very powerful, and these delighted relatives are great ambassadors for the hospital.

It’s high time hospital staff started respecting the patient's relatives , and made good use of them - not only to prevent problems from occurring , but also to ensure patients get the best possible medical care. This is a captive population which is stuck in hospital because their patient is ill. It’s such a shame that instead of making use of their goodwill and intellect, they are treated so shabbily today in most hospitals.

Most hospitals have fixed visiting hours , and relatives are made to feel unwelcome, rather than being treated as respected guests. They do not have easy access to the doctor, and often have to wait for hours to see him to get answers to even their basic queries..

There are  two important things hospitals can do to engage the patient’s family.

They can help to educate relatives about the medical care which is being provided to the patient , so they understand what's going on . Family members are understandably worried and concerned , and the more the hospital takes them into confidence and uses them as allies , the better the care they can provide. It’s equally important to explain to them what needs to be done after discharge, thus reducing post discharge complications and readmissions.

Secondly, when relatives are in a hospital, they are extremely aware of their own mortality. They are much more receptive to messages on health education and preventive health care , and hospitals can tap into this and use this opportunity to teach the entire community about what they can do to stop themselves from falling ill.

It makes a lot of business sense for hospitals to invest in educating patient's relatives . This offers an excellent return on investment . It is simple and inexpensive to do , and it provides great word-of-mouth marketing . If the relative is impressed with the quality of medical care their patient is receiving, then when they fall ill, this is the hospital they are likely to select when they need medical care themselves , because they are likely to have a soft corner for that particular hospital , and actually seek it out . It makes much more sense for hospital marketing departments to market to the relatives, friends and visitors within the four walls of their hospital , rather than waste money by trying to bribe doctors to refer patients to them.

Social media in healthcare

I was part of the panel on the role of Social Media in Healthcare at the Social Media Week conference in Mumbai.

Patients are all going online today  - and it's high time doctors joined them there, so that they can engage with them more effectively. Online media can help to increase trust between doctors and patients.

Wednesday, September 24, 2014

The patient as the CEO

As an IVF specialist , a number of patients with complicated problems are referred to me by their gynecologist. I usually talk to the patient and study her file before reading the referral note, so that I don’t get biased , and can provide a sensible opinion as to what I feel the right course of action for this patient should be.

Today I saw a 36-year-old woman who had had a myomectomy done for the removal of a 7 cm size posterior wall fibroid six months ago . She had started having heavy menstrual periods after the surgery, which is why she want back to her doctor. He did a D&C, which showed she had complex endometrial hyperplasia . She went for a second opinion to another doctor who asked a senior pathologist to review the slides. This was now reported as early Stage 1 endometrial carcinoma .

He advised her to do a hysterectomy , but she didn’t wasn’t to, because she had just got married and wanted to have a baby.

He referred her for an MRI, so the radiologist could evaluate the extent of spread of the cancer.  The scan was reported as showing myometrial invasion, which was surprising, because the pathologist had noted that this was a preinvasive cancer and the basement membrane was intact, which meant that the malignant cells had not penetrated the endometrial lining.

This was obviously a challenging case , with different opinions coming from the radiologist and the pathologist . I  reviewed the films , and even though I am not a radiologist, felt that the “ extension “ which the radiologist had reported on the MRI scan was in exactly the same site where her earlier myomectomy had been done . This meant that it was hard for radiologist to judge from the MRI images whether the difference in the tissue texture at that site was because of an extension of the cancer or because of scaring because of the earlier surgery . The fact that the pathology report had shown that the basement membrane was intact suggested that this was not an invasive carcinoma .

I explained this to her , and said that you might want to consider treating the endometrial cancer medically with high doses of progesterone, and doing an IVF cycle , because time is at a premium for you now, given your age.

The conservative management of early endometrial preinvasive carcinomas has been well established. These very early-stage cancers don’t behave like typical cancers, in that they do not spread to other parts of the body. The problem is that the moment the pathologist uses the word cancer , patients panic and want the offending organ removed immediately.

From a doctor’s perspective, the safest thing to do is to remove the uterus . No one can criticize that particular approach , because it's the standard textbook advice . If , on the other hand , the doctor , for the sake of preserving the patient’s fertility, advises saving the uterus, and then tomorrow , God forbid , the disease spreads , the doctor would be liable for medical negligence , because the patient could say that by failing to remove the uterus , the doctor allowed my cancer to spread – something which could have been prevented by doing a hysterectomy .

The referring gynecologist’s opinion was that I should freeze her eggs in her next cycle, after which he would do a hysterectomy; and we could then transfer these into a surrogate later on.
This was a perfectly viable option. My advise was this in view of her age, we could go ahead and transfer her embryos into her own uterus. Surrogacy is an expensive treatment option , and my major concern was not so much her uterus, as the fact that because of her age, her ovarian reserve was likely to be compromised.

In one sense she was lucky to have so many options – but this also left her head spinning, as she was now completely confused as to what to do next !  She had 4 different opinions from 4 different specialists – the pathologist ; the radiologist ; her gynecologist; and me ! She was a well-informed intelligent patient, and had done a lot of research on the internet, which meant she now had even more opinions to choose from.

I sat down with her and explained to her how to makes sense of all this conflicting advise, so she could move on to the next step. She needed to search authoritative medical websites, such as PubMed, so she could track down medical journal articles to find out what her treatment options were.

She would then need to print this out, and then , armed with this information , she would have to go back to her primary care doctor – her gynecologist, who would then help her to make the final decision.

I suggested she make a list of all the doubts and questions in her mind, and then go back to the pathologist and radiologist, so they could explain their perspective and rationale and review their opinions.

This is where the role of the patient becomes so important ! A lot of these decisions are not written down in black and white , and when it’s not clear as to what the next action steps are, and especially when there are multiple options, the patient's preferences are of overriding importance. We need to respect these, because it’s the patient who needs to live with the consequences of her decision. We are always uncertain as to what the outcome will be , and as doctors, we can just provide our opinions, but we need to let the patient have the final say.

These are challenging patients , but these are the patients we can learn a lot from - especially if they are well-informed and educated , and are willing to do their homework for themselves . They can make the right decision for themselves, using all the various consultants and specialists .

The problem with having so many specialists today is that they are often not coordinated, and care gets fragmented . This is why documentation and sharing information become so important . I told her she needs to print out all the various opinions; make a list of all her doubts; summarise these on one page; and include xeroxes of medical journal articles. In medicine, often the right hand does not know what the left is doing, as a result of which specialists are often clueless as to what is happening in other fields.  If she took the trouble to organize her records, not only will her doctors be aware of what the state-of-the-art thinking is in managing her particular disease, they would also be suitably impressed that this is a well-informed patient , who was capable of making decisions for herself , and would treat her with the respect she deserves

Isn’t all this asking too much from the poor patient , who is likely to feel overwhelmed by this daunting task ? How can she be expected to make sense of all these complexities , especially when the specialists themselves don't agree with each other ? Not only does she have to worry about her disease, she now has to sit and coordinate the care she receives from all her specialists .
Yes, it can be a huge challenge, but the point is that it is the patient who is the one who has the most at stake . I think the problem is that both doctors and patients underestimate the skills and abilities of patients to be able to select for themselves . It’s natural for the m to be confused initially, but it’s far better that they then start drilling down deeper and exploring all their options, rather than live in a fool’s paradise because they didn’t know any better. This way they have peace of mind that they made the best decision for themselves.

While this can be difficult , let's not forget that patients have dealt with difficult challenges in their lives before , and it's not as if we abandoning them . Doctors are always available to hand-hold and guide them, but they need to take responsibility for themselves , rather than abdicate it . This kind of decision is too important to leave up to a doctor, and patients need to step up when faced with these kind of complex challenges , and respond appropriately . The patient is now the CEO of her medical care team , and she has to make sure all her doctors work together to fulfill her personal goals.

Tuesday, September 23, 2014

Doctor versus Dr Google

Both patients and doctors often find Dr. Google very frustrating . Patients are happy to get information from Dr. Google, but they often get lost and confused because different websites provide. diametrically opposite information . They don’t know which website to trust ! Even worse, when they ask their doctor for help in order to make sense of this conflicting information , most doctors often get angry and upset . They feel that patients are wasting their time by asking them these irrelevant questions - especially when the information on some of these websites is pure rubbish and hocus-pocus. Sadly, it’s often the sites with the most quackery which are most attractively designed, because their job is to lure the unwary patient into buying the services and products they hawk.

Some doctors tell their patients – Please stop wasting your time ( and mine !) by scouring the
Internet . I am your doctor – just trust me and I will do what’s right for you. Some doctors get angry when they find that their patient is counter-checking their advise by going online, because they feel that this means that their patient is trying to act like a smart-aleck by pitting his knowledge against the doctor’s years of heard-earned wisdom.

While it's true that a little knowledge can be dangerous , and that we don't want patients to become half baked doctors , it's also equally true that ignorance is not bliss and that knowledge is power . We need to encourage our patients to find information for themselves . The fact of the matter is that doctors have a limited amount of time , and it's impossible for us to educate and inform patients efficiently within the 10-30 min of face-to-face consultation time we get with them.

A good doctor should be happy that his patients are looking for information on their own . This means the patient is responsible and is actively engaged in trying to get better ! If the information he finds corroborates everything the doctor has told him, the patient is going to get even more confidence in his doctor and this can only strengthen the doctor-patient relationship .

The smart patient needs to understand that doctor and Dr Google actually complement and supplement each other , and the intelligent patient learns to make use of both these resources well.

The great thing about Dr Google is that it’s available 24/7 – and is free. There’s tons of information – which is part of the problem ! A lot of the information is very poor quality, and many patients are not sophisticated enough to separate the wheat from the chaff.

Doctors , on the other hand , have a limited amount of time , and if patients do their homework prior to seeing the doctor, they would be  able to make more efficient use of their doctor’s time , creating a win-win situation for everyone .

I wish doctors would take ownership of their responsibility to providing reliable trustworthy information to their patients, and do this by publishing their own personal websites . If they did this, there would be no need for patients to go to Dr Google at all – they would much rather get their information from their personal doctor’s website !

A good doctor would encourage his patients to find information - and will help them by telling them which sites are reliable, so they don’t waste their time and fill their head with myths and misconceptions. This could easily be done by email, so the patient doesn’t even need to come to the clinic.

The best doctor would  provide the information which the patient needs on his own website , so the patient does not even need to ask ! This could just be a simple curated list of reliable websites. This will help prevent doctors from getting frustrated when patients come to them with pages and pages of internet printouts which are completely unreliable.

Doctors dislike patients who cross question them or cross-examine every bit of advice they provide, simply because they have read something on the internet which differs from their advise. Dumping 50 pages of internet printouts on this doctor’s desk to prove how well-informed you are is just going to turn off your doctor and aggravate him !

Good patients will prepare a one page summary of their understanding of their problem, and ask the doctor for his opinion. The best patients will condense everything they have learned, and then share the hard-earned fruits of their research with other patients by publishing their own blog and website.

Older doctors don’t like these patients because they feel that their authority is being challenged – that even though they have spent 10 years studying medicine and practicing it for 20 years, these clueless whippersnappers have the temerity to question their advise !

This is not a comfortable feeling for lots of doctors , who are used to adopting a paternalistic role, and have been used to treating patients who never had the courage to ask questions ( even though they were full of doubts). The older generation meekly adopted a “doctor know best” approach,  but those times have now gone.

Both doctors and patients need to understand that doctors don't always have all the answers – and that it’s better for patients and doctors to share both areas of knowledge as well as ignorance , so that they can work together to find the solution which works best for that particular patient.

Confused by Dr Google ? Or by your doctor ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly!

Monday, September 22, 2014

The abuse , misuse and overuse of surrogacy

 I was counseling a patient who had failed many IVF cycles . She was completely fed up and wanted me to do surrogacy for her. We have an active surrogacy program , and it's very profitable for me to offer surrogacy because it’s far more expensive than a regular IVF cycle . However, it’s my personal opinion than surrogacy is a treatment which is best reserved for patients whose uterus is absent or damaged .

For most women with the distressing problem of repeated failed implantation , the probability that there is a problem with their uterine receptivity is very low , especially when we have checked that their uterus is normal ( with the help of a transvaginal ultrasound scan which shows they have a thick, trilaminar endometrium).

This is why the uterus using a gestational surrogate makes no logical sense because it cannot increase pregnancy rates .

To use an agricultural metaphor, the seed has a far more active role to play as compared to the soil. We know based on extensive research that the reason for failed IVF cycles and recurrent miscarriages is far more likely to be a defective embryo because of a lethal genetic defect, rather than an endometrial problem.  Sadly, we still don’t have the technological ability to be able to document these genetic defects, and this leads to a lot of confusion. Thus, if an embryo fails to implant after PGS/CCS has shown it to be normal, patients jump to the flawed conclusion that the problem is with their uterus, which is “rejecting” the embryo. The reason this is erroneous is that PGS/CCS only allows us to count the number of chromosomes – it cannot test the normality of all the genes !

However, most doctors are quite happy to offer surrogacy as a solution , and this makes a lot of logical of sense to the patient. They feel that if the doctor transferred good looking embryos into my uterus and they still failed to get pregnant, this proves that their uterus is defective and is rejecting the embryos.

Their belief is strengthened by all the rubbish which floats around on the internet about immunological dysfunction causing recurrent implantation failure .

It’s often hard for me to explain to them why surrogacy's actually not the right solution for them , and why they would actually be better off considering donor egg IVF or embryo adoption . Patients come to doctors with preconceived notions , and they don't really want to engage in a debate with the doctor. Most would much rather find a doctor who was happy to do whatever they wanted . After all, they are willing to pay for the treatment , so why should the doctor object ?

The problem with surrogacy is that it deprives the patient the joy of experiencing pregnancy herself. The unfortunate women who are born without a uterus don’t have a choice in the matter, but it’s sad that they deprive themselves of this unique experience simply because of preconceived misconceptions.

I think my role is not merely just that of being a technician . I am a professional , so that I need to offer my personal opinion . I may not always agree with the patient, and some of them get upset when I do this. They would rather find another clinic who accedes to their requests . Of course, it’s much easier for me to do this as well, and by educating my patients , I am aware that I'm actually turning away income ! However, I think that it’s in their best long-term interests that they understand their alternatives , and then choose the option which is correct for them .

Sadly , I find a lot of patients want to do surrogacy simply because they are fed up of going through the ups and downs of IVF cycles. They can no longer emotionally cope with this kind of roller coaster ride , and would much rather just outsource the entire pregnancy to someone else.

What they fail to realize is that the implantation rate in a surrogate is not 100% either – and just because they are an arm’s length away does not  make the IVF treatment for them any easier . In fact, it can sometimes be scarier, because they are never sure what the surrogate is doing, and whether she is taking as good care of their baby as they would !  The fact that they have unrealistic expectations of the success rate of the surrogacy treatment cycle causes lots of heartburn when the cycle fails , especially when they have spent so much money , and done it with such high hopes and expectations.

Is your doctor pushing you to do surrogacy ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

Sunday, September 21, 2014

Free IVF app to plan your IVF treatment calendar

IVF treatment can be complex and time consuming  and patients have to juggle lots of stuff - doctor's appointments, medications, shots, blood tests, ultrasound monitoring, leave, home, travel, finances....

We have refined and polished our IVF app , My Fertility Diary, which runs on android smartphones , to help IVF patients manage their IVF treatment in a more organised fashion.

We are now looking for volunteers who are willing to be beta testers for this new version. We would like you to provide us with feedback so we can fix any bugs; and provide additional features to help IVF patients reduce their stress during their treatment.

If you are interested, please email me at [email protected] so I can send you the beta version of the app.

Why do some embryos arrest ?

It’s extremely frustrating for patients when the clinic calls them with the information that what was a beautiful 4-cell embryo on Day 2 has arrested on Day 3 and remained a 4-cell embryo, instead of dividing further to become a 8-cell embryo.

Why do some embryos arrest in vitro ? And why do so many good looking embryos fail to implant after transfer ? And why do some of the ones which do implant end up in a heart-breaking miscarriage, rather than a beautiful baby ? The amount of inefficiency which riddles human reproduction is mind-boggling. ( In fact , it seems to start right from the fact that men need to produce millions of sperm in order for one of them to be able to fertilise the egg ! )

One way of making sense of this is to hypothesize that each embryo’s life expectancy is encoded in its DNA . This is a concept we are familiar with when we consider life and death after birth. We know that there will be some people who live upto the age of 100 – but lots will die at the age of 70 – and a few unfortunate ones will die at the age of 2.  While doctors have to write down a medical cause of death on the death certificate, and we are distraught when learning of the death of a friend’s child at the age of 10 because of leukemia, the fact remains that life expectancy seems to be a random lottery , and we cannot control this.

While we use terms such as lifestyle risk factor and heredity to explain this, a far more useful concept is the term heredity, coined by Dr Manu Kothari. This means that in a “herd” ( a population , for example, a group of children), their life expectancy can be plotted on a bell-shaped curve. Where an individual will figure on this curve is still not something we can determine, but this rule of thumb is a useful way of understanding this randomness. You could try plotting the life span of your father’s classmates, for example, or that of your family members, to see how true this is.

This means that in a given group of people ( and the larger the sample size, the better this rule works),
a certain proportion will keep on dying off at a particular age , because of their genetic predisposition to do so, no matter what we do.

If this is true after birth, then isn't it logical to expect exactly the same kind of variation before birth as well, in the embryonic stage ? Just like there will be some babies who will die at the age of two hours , and some at the age of two years , similarly there will be some embryos which arrest ( die) at the age of 48 hours, while some will arrest on Day 4.

We need to think of this as a continuum , starting from the point of fertilization . This means that the embryo’s life expectancy is hardwired into its DNA , and because this is such a random process , that particular embryo could die within 24 hours ; or after 25 years ; or may live upto the age of 85. Of course, the relationship is complex, and in some cases a bad lab can kill off good embryos ( just like too much smoking can reduce life expectancy).

We still haven't been able to tease apart exactly what affects life expectancy ( though we do know that the length of the telomeres on the chromosomes correlates with aging ).  Once we understand some of this randomness , we would have a better appreciation of the fact that human reproduction is not a very efficient enterprise , and this is why IVF still does not have a success rate of 100%, even when everything seems to be perfect. Our fate seems to be hardwired in our genes , and there's precious little we can do about it at present.

Saturday, September 20, 2014

Why do doctors continue using intramuscular progesterone ?

All IVF clinics routinely provide luteal phase support after the embryo transfer. This consists of a combination of both estrogen and progesterone , which are used to prepare the endometrium for embryo implantation .

In the past , progesterone was given in the form of intramuscular injections. Progesterone is an oily preparation , and needs to be given deep intramuscularly, with a fat needle. Not only is the injection painful, because the absorption is poor, the shots will often leave tender lumps in the muscles  , and these take many days to resolve. Often the butt is so sore that the poor patient cannot even sit down anymore.

Many patients who have been given intramuscular progesterone will refuse to do a second IVF cycle, simply because the progesterone shots have left them so miserable . Often, the thought of taking the injections again is far more painful than the idea of having to cope with a failed IVF cycle. This is true for the poor husband has well, who hates having to give his wife these excruciatingly painful injections. Many of them feel it’s not worth having a baby if they have to put their wife through that kind of pain.

Fortunately , thanks to technology , we now have far better preparations for progesterone . This includes micronized progesterone , which can be administered vaginally, in the form of either a gel or a suppository . These formulations have been  available for over 20 years, and we stopped  using intramuscular progesterone in our clinic 20 years ago.

What amazes me is why some clinics continue to inflict so much unnecessary pain on their patients by insisting that they continue taking intramuscular progesterone. If IM ( intramuscular) progesterone were proven to improve IVF pregnancy rates because it’s more effective than vaginal progesterone, I would have understood. However, the truth is that it is no better – and this has been proven in many clinical trials. This is because the absorption from the intramuscular route is much worse . Also, when the progesterone gets absorbed into the bloodstream , it is metabolized in the liver, which breaks it down, as a result of which the levels of progesterone which reach the target organ – the uterus - are reduced.

In contrast, when we deliver the progesterone vaginally, it is directly absorbed and much higher levels reach the uterus – which is where we want it to act ! Some clinics measure blood levels of progesterone, but this is quite pointless, as we are interested in the tissue levels of progesterone in the endometrium – not the blood levels.

Ironically, some patients seem to prefer the IM route . They seem to have a medieval hangover which leans them to conclude that if it is painful, it must be more effective ! 

I cannot understand why doctors continue to inflict unnecessary pain on their patients by prescribing IM progesterone ! Is it just because this is what they have been used to doing, and therefore plan to continue doing it, no matter what the clinical evidence is ? Or is it that because most IVF doctors are men , they are blissfully unaware of how unkind they are being, and fail to understand how much damage they are inadvertently inflicting on their poor patients ? Patients expect injections to be painful, and will rarely complain about this to their doctors, because they feel they cannot afford to trouble their doctor with such trifles.

If I were an IVF patient , I would never take intramuscular progesterone - I would insist that it be given vaginally. I see no reason why we should subject our poor patients to unnecessary pain !

Not happy that your doctor is still prescribing IM progesterone shots ?
Please send me your medical details by filling in the form at
http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

Friday, September 19, 2014

Managing your Doctor

Even in this day and age, where the medical profession seems to be vilified almost daily by the media, most patients still trust and respect their personal doctor. They see them as being professionals with medical expertise , which they can tap when they are ill and want to get better . They are usually quite passive and are happy to do whatever the doctor advises. This means in effect that it is the doctor who sets the agenda for the consultation .

This works well, especially for most bread and butter problems, where both doctor and patient are on the same page , and have the same expectations . The problem , of course , is that doctors are not mind readers , and if there is a difference between what you expect from the doctor and what the doctor is willing to provide , both doctor and patient are likely to be extremely unhappy with the consultation.

However,  unless you express your displeasure , there is no way that the doctor will know that he has not done a good job . Part of the problem is that patients do not provide feedback and when they are unhappy with the doctor’s treatment plan, they usually keep quiet and don’t tell him this. They nod their head, and the doctor is pleased that they are going to follow his advise when they walk out of his clinic. However, they have no intention of doing so, and this can be frustrating , not just for the patient ( who feels the doctor does not understand him ) but for doctors as well.

Noncompliance is a big issue , and doctors feel that if the patient was not going to follow their advise, then why did he waste their listening silently to him and not speaking up ? If the patient has concerns, the doctor can explain his perspective and clear the patient’s doubts. However, he can do this only if the patient speaks up. This can allow him to modify his treatment plan so it’s easier for the patient to follow.

However, most patients are scared to talk back to their doctor. They are scared that the doctor may take offense, which is why they bottle up their fears and worries. This is a shame, because it represents a waste of both the patient’s time and the doctor’s time as well.

Patients need to learn how to manage their doctor. Some doctors are extremely well organized and efficient , and sometimes the doctor-patient chemistry is so good that there are no issues as well. However, we don't all live in a perfect world , and  sometimes we need to do step up and do what is needed to help the doctor to help us. Patients cannot afford to leave everything up to the doctor. It’s best to assume positive intent, and the more the patient applies his mind and uses his own skill set in order to improve the consultation , the happier both doctor and patient will be . Remember that happy patients make for happy doctors !

Need to know how to manage your IVF doctor more effectively ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

Thursday, September 18, 2014

The exception which proves the rule in IVF

It’s true that medicine is a complex biological system , and this is especially true of IVF . However , there are certain rules of thumb ( also called heuristics) which are extremely useful when we practice reproductive medicine .

Thus, we know that if the patients embryos fail to implant, 90% of the time the problem is with the embryo rather than with the endometrium . Similarly, when we encounter the distressing problem of failed fertilization after IVF, the problem is because of sperm dysfunction, rather than an egg problem. WE also know that the patient’s embryos are all of poor quality in a good IVF lab, the problem is much more likely to be with her eggs rather than with her sperm.

These heuristics are extremely useful when counseling patients when things don't go well. They help us to plan our next action steps , and we can be confident that we are providing good advice , even though we don't have specific evidence for that particular patient . These rules are based on experience with many other patients , and empirical evidence is quite reliable since medical science has so much experience with IVF today.

However , there will always be exceptions to these rules. The problem arises because doctors love these exceptions . They are fascinated by complicated cases – by patients who are outliers. This is because doctors get bored by the routine, run-of-the-mill problems. They are always on the lookout for the new and the unusual – something who can challenge their curiosity and perhaps results in a paper they can publish !

They believe that not only can they learn a lot more from these exceptions, they can use this knowledge to advance medical science- after all, how much more can you learn from the ordinary case ? They treasure their exceptions, and this is why doctors are fascinated by zebras !

However , as regards patients , it's much more important for them to know what the rules are , because their problem is much more likely to be what occurs commonly , rather than something which is extremely rare . Unless patients are willing to be guinea pigs, they should assume that their problems are similar to everyone else’s.

Because doctors are fascinated by what is uncommon , they love ordering extensive tests, in order to pinpoint the particular problem for that individual patient . This is especially true for clinicians who are also research scientists. While this may be acceptable in a university setting, or during a trial, this is inappropriate in a clinical setting. It often represents a waste of time and a drain of that patient’s resources, because these tests are exotic and expensive . Infertile patients can’t afford to go to doctors who enjoy chasing red herrings to satisfy their intellectual itch !

Not only is this wasteful, it does not help the patient either , because it doesn't usually change her treatment options . Hunting for zebras is an intellectual challenge for doctors. They love playing a game of one-upmanship and treasure these war stories to show how much better informed they are than their colleagues. However , this may not always be in your best interests !

Not sure if your problem is the exception which tests the rules ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

Wednesday, September 17, 2014

HELP is looking for a social entrepreneur !

JOB TITLE: Chief Operating Officer

REPORT TO: Medical Directors

PURPOSE: To empower Indian patients by promoting Information Therapy


Your mission will be to market, disseminate and promote the use of Information Therapy tools in India.  Community Health Research Program is a NGO which is the Indian licensee for the Healthwise Knowledgebase in India.  Healthwise is a non-profit organisation in the USA, where it is the market leader in developing patient educational content .  You will head a small team and will be responsible for making sure things get done ! You need to develop and implement a business model which is sustainable and scaleable.

You are a social entrepreneur who wants to heal a sick healthcare system by improving doctor-patient communication. You understand the need to put patients first, and have to ensure that it makes business sense for health insurers and hospitals to do this, so that the model is sustainable and scaleable.

1.  Medical Graduate - MBBS
2.  Masters in Business Administration
3.  Proven marketing , sales and networking skills

Please send  me your resume at : [email protected]

You can learn more about HELP at our website, www.healthlibrary.com

Check out the Healthwise Knowledgebase at http://www.healthlibrary.com/healthwise !

Healthcare Achievers Awards

New India Assurance presents the Healthcare Achievers Awards, an initiative with The Times of India, to celebrate the achievements of the Indian Healthcare industry. The award aims to bring together key stakeholders of the Healthcare industry on a common platform, ignite ideas through healthy discussions by way of sharing best practices and inspire innovation in this field.

There is a panel discussion on "Enabling Patient Centric Healthcare" 22th September 2014. The panel will discuss having a patient focus approach in today's cost and technology driven times. This hi-profile panel comprises of distinguished panelists from government, industry dignitaries, reputed doctors, and renowned subject matter experts.


I am very excited that  a leading health insurer has taken this initiative ! It makes business sense for health insurers to invest in patient education, as this reduces overtesting and overtreatment . By highlighting the efforts of good doctors and hospitals, the medical industry can learn to emulate good practises which Put Patients First. 

The IVF coverup

I just saw a couple who had done IVF earlier at another clinic. They were told that their cycle failed because their embryos were of poor quality - and that the reason for the poor quality of their embryos was either that their eggs were not good enough, or that the sperm had a lot of abnormalities.

They were advised that they need to use either donor eggs or donor sperm. The moment the doctor blames abnormal sperm as being the reason for poor quality embryos, this should raise a red flag that you are getting poor quality advise . The fact of the matter is that no matter how poor the quality of the sperm, if ICSI is being done in a high quality lab by a skilled embryologist, you should good quality embryos.

Abnormal sperm morphology or high sperm DNA fragmentation are very rare causes of poor embryo quality, and if your doctor trots these out as the reason for your ICSI failure, then there is a high chance that a coverup of the truth is in progress.

While it is true that poor quality eggs can result in poor quality embryos , it is also equally true that often it’s poor IVF lab conditions which cause poor quality embryos , especially in a young woman with a normal AMH level, a good antral follicle count and a good ovarian response.

It’s possible that the embryologist is not experienced; or that the incubator doesn’t function properly ; or that the culture medium being used is substandard.  Unfortunately, many labs do not follow basic quality control standards, and most clinics are pretty much free to do what they like, since there is no regulation or supervision.

This is why, rather than be honest with the patient and frankly admit that the reason the embryos were of poor quality was because the lab was not good enough, IVF doctors need to be creative and manufacture reasons for why the embryos were of poor quality . They can get away with this because there is a complete lack of transparency about IVF treatment . Most doctors don't even bother to tell patients how many follicles are growing on the ultrasound scan ; what their sizes are; or how many eggs were retrieved. They hide even basic information, such as how many embryos were formed, or what their quality is, by refusing to give them photos of embryos .

This means patients are pretty much at a loss , and are pretty much forced to accept whatever their doctor chooses to tell them. When they have poor quality embryos and then hunt for a second opinion , they then find out that their doctor wasn’t forthright or straightforward. They are understandably  upset , but once they have lost confidence in one IVF doctor, their confidence levels in all IVF doctors goes for a toss and they are very reluctant to try another cycle.

This is why patients need to do their homework proactively and learn to ask high quality questions before starting the cycle. While the outcome is always uncertain , patients need to be sure that the IVF clinic they select is following the right processes properly and that they will share information with them proactively.

Many doctors refuse to answer the patient’s legitimate questions by airily dismissing them. “ You don’t need to worry about all these details. They are too complex, and you will not understand any of it, so why bother ? We doctors know exactly what we are doing, and you just need to trust us !”

Patients are overpromised success when they first attend the clinic, because the doctor wants them to sign up for an IVF cycle. However , when the cycle fails, the doctor becomes a completely different person. He often blames the patient’s eggs for the failure, and patients can't understand why the doctor is now saying something which is so diametrically different from what he did when they started the cycle . Because of these conflicting messages, they lose confidence in IVF clinics, and this is why IVF clinics end up getting a bad reputation.

It’s easy to understand why doctors are very reluctant to tell patients the truth when they think there has been a problem with the quality of care they provided . It’s hard to tell a patient – I am sorry, you didn't get pregnant because our IVF lab wasn't good enough !  However, patients are stupid, and doctors cannot fool all the patients all the time. They will check with other patients and with the clinic staff as to how many patients got pregnant, and when the doctor tries to cover up the truth , they can smell that something fishy is going on. When they do find out the truth, they are very resentful and angry that the doctor lied to them.

Are you worried that your IVF doctor is not being honest and open ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly.

Abnormal sperm are not a cause of miscarriages or IVF failure

Animation of the structure of a section of DNA...
Sperm DNA fragmentation index does not correlate with the sperm or embryo aneuploidy rate in recurrent miscarriage or implantation failure patients

This article is now available free online and is worth reading.

Lots of IVF labs now do sperm DNA fragmentation testing; and when the IVF cycle fails, they
" blame " the sperm for the implantation failure. This makes sense  to the patient - after all, doesn't the sperm contribute 50% of the genes to the embryo ? And if the sperm's DNA is abnormal, then doesn't it logically follow that the embryo created by these sperm is also likely to have abnormal DNA , which means it's more likely to result in implantation failure ?

This paper shows that this reasoning is flawed - and that there is no correlation between abnormal DNA in the sperm and IVF failure.

Here's the abstract - and you can read the full text as well. Please share this with your doctor !

BACKGROUND The aneuploidy rate is higher in poor-quality sperm samples, which also have higher DNA fragmentation index values. The aim of this study was to assess the relationship between sperm DNA fragmentation in samples from infertile men belonging to couples with recurrent miscarriage or implantation failure and the aneuploidy rate in spermatozoa as well as in embryos from patients.
METHODS This prospective study evaluated DNA damage and the aneuploidy rate in fresh and processed (density gradient centrifugation) ejaculated sperm as well as the aneuploidy rate in biopsied embryos from fertility cycles. 
RESULTS A total of 154 embryos were evaluated from 38 patients undergoing PGD cycles; 35.2% of the embryos were chromosomally normal. Analysis of the same sperm samples showed an increased DNA fragmentation after sperm preparation in 76% of the patients. There was no correlation between DNA fragmentation and the aneuploidy rate in embryos or in fresh or processed sperm samples.
CONCLUSIONS Sperm DNA fragmentation is not related to chromosomal anomalies in embryos from patients with recurrent miscarriage or implantation failure.

Tuesday, September 16, 2014

Panel on Impact of Social Media on Healthcare in Mumbai

What IVF patients can learn from Goldilocks

One of the hardest decisions an infertile patient needs to make is to decide which IVF clinic to select for their treatment . There is a bewildering array of choices , and patients are understandably confused .

Should they choose the clinic which is the closest to them ?
Or the one which is cheapest ?
Or the one which is the most expensive (after all , if it charges so much , it must be better ) ?
Should they go to the one their family doctor recommends ? Or is he referring you to a clinic because he has a vested interest in doing so ,as they give him the biggest kickback ?
Should they go to the one which is the biggest ?
Or the one with the best d├ęcor and ambience ?
Or the one which comes up No 1 on google or has the flashiest website ?
Should they choose the one which advertises heavily in magazines and on TV ?
Or one which they just read about in the newspaper ?

I'd like to make a simple suggestion. As with everything else in life, there is always a sweet spot with IVF clinics as well ! You don’t want one which is either too big or too small .  Like Goldilocks, you need to find the bed which is just right for you.
While a large clinic has the advantage that it has lots of people , expertise and equipment under one roof , it often becomes an impersonal assembly-line treatment factory, so that patients are often treated as being a number. These clinic are often very commercial , and are more focused on throughput and the number of patients they can see , in order to maximize their turnover , rather than on providing personalized hands-on patient care , customized to your special needs.

The danger with small clinics is because they don't see too many patients , they often don't have enough expertise to deal with rare problems over with complications .

Similarly, you want a doctor who adopts a conservative middle of the road philosophy. You don’t want someone who overtests and overtreats and offers the “latest” treatment, simply because it is the fashion of the month - you don’t want to be treated as a guinea pig, under the pretext of being provided with cutting-edge medical care . Not everything which is new is effective , and it takes time for science to realize what works , and what doesn't .

However, if your doctor wants to try out the latest stuff on you, you are the one who has to pay the price, because you may end up receiving lots of ineffective and very expensive treatment , just because it is new .

One the other hand , you don't want an old-fashioned doctor, who keeps on doing the same stuff he has been doing for the last 10 years, simply because he cannot be bothered to keep up . Thus if your doctor doesn’t routinely provide blastocyst transfer; vitrification; and embryo photos, you should worry a lot !

You need to find someone who has the right balance – someone who follows the Buddhist philosophy of the Middle Path.  Wise doctors understand that just because stuff is new doesn't make it better , but they are willing to keep up with the times , and provide his patients with the benefit of the latest advances after they’ve been scientifically proven and validated in lots of clinics all over the word .

They are not interested in being the first to do something , just because he wants a newspaper article - he just wants to be the best , and therefore provides evidence-based care , using proven well-established techniques .

Are patients sophisticated enough to be able to find the right clinic ? Here’s a simple short cut you can use to make sure your clinic is good !

Check to make sure they provide embryo photos routinely. This is something which is extremely simple to do - any IVF patient can easily ask for this. Good IVF clinics provide photos of the embryos to all their patients . This helps clinics to remain honest , and it encourages openness and transparency . Every good clinic does this as it allows them to document they have provided good quality care.

However, remember that this is a condition which is  necessary but not sufficient  ! This means that every good clinic does this routinely , but just doing this doesn't necessarily mean that this clinic is your best choice !

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

Monday, September 15, 2014

Setting an agenda for the clinical consultation

The doctor-patient consultation is the bed rock of clinical medicine , but what's amazing is that in spite of the fact that it's done so commonly , it’s often done so badly. How often have you left the doctor’s clinic, completely confused about the instructions which were provided, because there were so many of them and you were scared to interrupt your doctor while he was talking ?

A consultation should be organized just like a one-on-one business meeting – and business meetings are usually orchestrated , because everyone is prepared. The doctor’s time is precious and needs to be utilized efficiently ; and the best way to do that is to set up expectations before the consultation, so that everyone knows exactly what needs to be accomplished . The easiest way of doing this is to have an agenda, so that both doctor and patient are prepared. It makes no sense to blindside the doctor in the last minute of the consultation with a new problem – this frustrates both the doctor and the
patient !

The doctor uses a disease framework, and his agenda is to analyse the patient’s medical history; do a clinical examination; order tests and make the right diagnosis so he can prescribe the correct treatment. The patient, on the other hands, has fears and concerns, which he may not be able to articulate clearly. Is this a serious problem ? Will I get better ? Will the treatment be expensive ? Can I continue going to work ? There are a hundred worries running through his mind, which he may not even be aware of. It’s important that doctor can patient share understanding , so they can participate in joint decision making.

We need to use exactly the same principles of defining an agenda before a business meeting to make sure that the doctor-patient consultation is equally productive and effective . It’s important to structure this in such a fashion that everyone is on the same page.

The problem is that often the doctor has a particular agenda in his mind, which maybe completely different from the patient’s . The patient often just wants reassurance , while the doctor is focused on making the right diagnosis and ruling out serious problems. As a result, they both end up dissatisfied with the consultation. The patient feels that the doctor did not understand because he did not bother to hear his concerns !

Patients need to define what their expectations are from the consultation before it actually starts . This might seem obvious when we talk about business meeting, but this is not true of most consultations. Patients need to remember that doctors are mind – readers.

Often, the patient takes a submissive role in the process, and expects the doctor to take charge of the consultation, because he is a professional.  However, patients also need to play an active role if they want to going to make sure that the consultation meets their expectations .

For simple bread and butter problems, such a structure is not very important, and most consultations go through smoothly . However , having a structure is especially important if you have a complicated problem , or if you are not happy with the quality of care you're getting .

It's also good discipline for both patient and doctor to set an agenda. This will help to make sure that their interactions are more effective . This can start before the consultation - for example , when you are taking an appointment . You can send the doctor an e-mail , so that you can explain to the doctor exactly what your concerns and what you'd like to discuss with the doctor. The doctor can also be suitably prepared, so you can make optimal use of your time together.

The doctor needs to learn from the patient , and a well-organized patient will write down his concerns. The transfer of information is much more efficient when everything is written down, as it prevents miscommunication. Similarly at the end of the consultation , the doctor can provide a written summary of everything which was discussed  as well as what the next action steps are, so both doctor and patient are sure that the patient understands what is happening. This way, they can move on to the next step efficiently , without wasting time and without causing unhappiness .

During a consultation, the doctor is taking notes, summarizing the medical history; his diagnosis; and his treatment plan. I feel it’s equally important for the patient to be taking notes as well ! Both doctor and patient should share their notes, to make sure there is no communication gap.
The consultation is the commonest activity which a doctor  performs in his professional life , and we need to make sure that this is structured properly , to improve his efficiency and improve patient satisfaction. However, this is not something which he can do by himself. Patients also need to take an active part in improving the consultation !

Need help in talking to your  IVF doctor ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

Saturday, September 13, 2014

Bells and whistles and IVF treatment

When we review the treatment protocols of patients who've done IVF in other clinics , I am often amazed by how regimented and stringent their treatment is.  This seems to be especially true for patients who have taken treatment in IVF clinics in the US . Thus, when they are being superovulated with HMG injections , they are often ordered to take their injections at a specific time every day.

They are given a long list of instructions which they have to follow scrupulously . While this keeps the poor patient on their toes, I don’t think it makes any difference at all to the final outcome. Thus, when patients are given Menopur and Follistim, for example, they are told to take 2 amp Follistim at 8 am sharp and then 2 amp Menopur at 4 pm sharp. Not only is this unkind for the poor patient ( who now needs to take 2 separate shots, it also plays havoc with their daily schedule and disrupts their life). In reality , this kind of rigorous scheduling makes no biological sense.

When the HMG/ FSH is given subcutaneously, it is first deposited in the subcutaneous fat. It then gets absorbed slowly from here and enters the bloodstream , after which is acts on the ovaries to stimulate follicular growth. Given the pharmacokinetics of these drugs, being flexible in the timings of the shots could not affect their biological activity.

However , by ordering patients to take their shots at a specified time , patients are so scared that they will miss the “perfect “ time, that they end up fretting an fuming about something which is of no clinical importance. Thus, if they are stuck in a traffic jam and take their HMG injection 2 hours late, they are  very worried that this delay will have ruined their chances. Even worse, they are reluctant to share this information with the doctor, because they are worried that the doctor will fire them for being so careless. Not only does this add to their stress levels, they are petrified that it’s because they did not follow the instructions to a T, that they will end up messing up their IVF cycle results. This is especially true when the cycle doesn't go well – and patients will often blame themselves, by concluding that it’s because they did not follow orders properly, that their eggs did not grow properly. This needless complexity just adds to their woes - and they cannot understand what's really important and what's just fluff.

The fact of the matter is that in a biological system , these minor variations are unimportant. A lot of it is excess baggage and "show-baazi" to impress the patient about how meticulous the clinic is. I think it’s far more important that clinics learn to be kind to their patients !  Ironically, some patients are extremely happy to rigidly follow a regimented schedule . They feel that any  clinic which is so particular about specifying timing is obviously very detail oriented , and will have a high success rate.

Quite frankly , this is rubbish ! The timing of the HMG injections for superovulation will not affect their biological activity – there is a wide window during which they can be given, and a few hours here or there will not make the slightest difference. Patients need to learn what instructions are critically important – and which ones they don’t need to stress over. Thus, while the timing of the hCG trigger is extremely critical, because there is no window of opportunity to mess up, fortunately for the daily HMG shots, this is not important, so patients should stop obsessing and worrying about it.

This is the kind of practical "real-world" research study which patients can do . They can compare the outcomes of women who rigorously scheduled their injections, versus those who didn't bother, to see if it makes a difference ! Pharmaceutical companies  are not going to bother to do this - but the outcome of such a study would be extremely useful to patients.

Want to make sure you are getting good quality medical care from your IVF clinic ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

Friday, September 12, 2014

The magic of vitrifying IVF embryos

Can you make out which blastocyst is fresh ? and which one was vitrified and then thawed ?

Since I am an IVF specialist, I am a  scientist , and scientists don't usually use words like magic lightly. However, the fact of the matter is that vitrification really works magic when done properly.

In the past, when we had to freeze and store embryos, we would use the slow freezing method. This was always very stressful , because no matter how good the embryos and how skilled the embryologist , about 50% of the cells of the embryo would die , no matter what we did. This was because of ice crystal formation within the blastomeres, which would kill the cells.

With vitrification , on the other hand, which uses ultra-rapid freezing, because this problem of ice crystal formation is bypassed , there is no damage to the cells . In a good clinic, with a skilled embryologist , the surviving is nearly 100% when good quality embryos are vitrified.

In fact, the pregnancy rates after transferring vitrified embryos is actually better than with fresh embryos ! This is not because vitrification improves embryo quality, but because these embryos are being transferred to an endometrium which is optimally prepared to be receptive , thus increasing implantation rates. In a fresh cycle, often the endometrium is not as favourable for implantation. This is because the hormonal injections used for superovulation will often affect endometrial receptivity adversely.

However, vitrification is not always magical, because the results with vitrification to a large extent depend on the skill of the embryologist . There is a steep learning curve associated with vitrification , and lots of junior embryologists often end up killing the embryos , because they haven't mastered this challenging art.

This is why it's so important that you should ask for photos of your embryos – both before vitrification – and after thawing. In a good lab, it’s not possible to make out which embryos are fresh, and which have been thawed after vitrification !

Want more information on embryo freezing and how it improves IVF success rates ?
Please send me your medical details by filling in the form at
http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

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