Tuesday, March 31, 2015

I will be speaking at the FT Digital Health Summit Europe, June 10, London

I will be speaking at the FT Digital Health Summit Europe, June 10, London. Join us: http://on.ft.com/1CYCUjA

Diagnostic tests for infertility

Diagnostic tests are a key part of medical practise today and doctors rely on these in order to make the right diagnosis for the patient, so they can start the correct medical treatment.  Tests are a standard part of the workup of any medical problem, and most doctors follow a protocol when treating patients. This is true for infertility as well, and there is a long list of tests which can be ordered to evaluate an infertile couple.

These include the following:
  • sperm DNA fragmentation test
  • hysteroscopy
  • antisperm antibodies
  • antiovarian antibodies
  • chromosomal study
  • NK cell testing
  • TORCH tests
  • TB PCR

The problem is that there is a wide variation between the testing protocols which different infertility clinics use. Some doctors will order a huge battery of tests for all their patients at the time of the first consultation . This can often be over a page long, and cost thousands of rupees. They include all kind of exotic, expensive and esoteric tests, such as tests for immune function, and genetic tests. This is the " one size fits all " , check-box, bureaucratic approach most large clinics follow , because they have to make sure their junior doctors will follow the protocols blindly. They cannot afford to allow these doctors any discretion in their decision making process, because they are scared that patients will fall through between the cracks. While this approach allows for standardisation, it's very unfair to the patient, most of whom end up wasting a lot of money on unnecessary tests which they don't need.

Some will be selective in their approach, and while they will order only a few basic tests for most couples, they order many more for patients who have failed an IVF cycle.

We have a much simpler approach ,and order only 4 tests, to test the four key components necessary to make a baby - sperm, eggs, fallopian tubes and a uterus. These tests are

  • semen analysis
  • blood tests for FSH,LH,PRL,TSH and AMH
  • HSG ( hysterosalpingogram)
  • vaginal ultrasound scan
This means we can complete the tests in 10 days, and determine the reason for the infertility at a cost of less than Rr 10000 ! We prefer using a well-defined sharp-shooter tactic, rather than adopting a shot gun approach, because all the unnecessary tests often end up creating a lot of unnecessary anxiety.

Many clinics prefer ordering lots of tests, because this is much more profitable for them.

We also we need to remember that doctors need to consider the patient's personal preferences when ordering diagnostic tests.

Some patients want all the tests done  because they feel that this shows how thorough and efficient the doctor is . Many doctors are happy to pander to their wishes, because this means more money for them. Not only do the tests cost quite a bit, it is a mathematical certainty that the more the tests we run, the greater the number of "  abnormalities " we will find , which we can then "treat" . Also, many doctors are happy to play a game of oneupmanship , and they order lots of tests in order to prove to the patient how much smarter they are than the earlier doctors, who failed to " diagnose " all these problems ( such as anti-ovarian antibodies " !)

There are also many patients who get upset when the doctor orders too many tests - or when he insists on repeating the tests from the lab he recommends. They feel , quite correctly, that the doctor is wasting their time and money ! 

This is why it's so important that doctors have a well-organised, systematic approach when doing tests for the infertile couple. If you find your doctor is confused, or seems to order tests on an ad-hoc basis, you must learn to speak up and ask your doctor why they are doing the tests, so that you know exactly what's happening, and why ! Tests can have side-effects, and the best way of preventing these is by arming yourself with information about when the tests can be useful, and when they can be harmful !

The harm of doing tests is that they distract the doctor, who is then more interested in fixing the abnormal test result, rather than in treating your infertility . In our clinic, we adopt a success based approach, where  our focus is on creating solutions which bypass problems, rather than on finding problems !

Worried that your doctor is doing too many tests ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !

Monday, March 30, 2015

How patient complaints help us to improve our IVF services at Malpani Infertility Clinic

IVF is the ultimate customer service business, and we take great pride at Malpani Infertility Clinic in treating our patients with respect.

Of course, it's not possible for us to keep all our patients happy all the time, which is why when a patient complaints, we treat this very seriously.

When a patient complains, our philosophy is that there’s a problem we need to fix – and we can use the patient’s help to do so.  We listen carefully, and try to gain as much information as we can about the problem. Not only does this reassure the patient that we take her concern seriously, we also ask her to suggest possible solutions.

Sadly, some suggestions are not practical, while others may be too expensive to implement. But many are simple fixes, which we can easily incorporate into our practice – and we are happy to do so !

Complaints are important , because we won't know how to improve if we don't know what's wrong. Complaints can also give us ideas for new services !

We value patients who complain because this tells us that the patient wants us to do IVF for her - she still cares about the relationship she has with us, and wants us to fix the problem so she can continue doing IVF with us. The reality is that most unhappy patients don't bother to complain -- they just go elsewhere !

We think a complaint is really a gift.  A patient with a sensible complaint has given us something valuable and useful - something that can help us make our clinic even better !

Patient satisfaction is a critical component of quality patient care in our practice and we are always happy to receive suggestions ( and complaints) which help us to improve.

Sunday, March 29, 2015

Stress and fertility - an infertile patient's perspective

Here's an guest post from our expert patient.

There are many stupid things that people tell you while you are TTC- these are the common ones I’ve heard
…maybe you are too stressed , that’s why it’s not happening
…just have sex 15 days in a row
…the day you will ’stop trying’ it will just happen
…don’t monitor fertile days- just enjoy it and it will happen
…Oh, you just miscarried? I’m so sorry. Have you heard of rebound fertility?
…Maybe you should adopt and once you are not worried, you might conceive

Yes, I am under pressure. It has been 4 years of trying with and without treatment- my siblings 6 years younger have babies. I adore children and I would love to have my own biological kids…So, it makes me a bit anxious? Yes! In fact, the longer the TTC journey, the more the problems you see along the way- the more stressful the subsequent cycle is going to be. In fact, if you have friends ( both online and in real life) going through the infertility roller-coaster, you will add their mishaps to your list of things to worry about too.
Anxiety can cause hormonal changes, which could theoretically lead to difficulty with getting pregnant. But when I’m going through fertility treatments all my hormones are medically induced- so how can that be an issue?

Also, can you imagine unmarried teenagers who have had unprotected sex and don’t want to have a baby? They must be so tense! And when they miss a period- even more so. So, shouldn’t these pregnancies spontaneously miscarry? Of course not! It’s obvious that there there doesn’t seem to be a co-relation between stress and conception.

For women who are older or have busy schedules or husbands that travel,  15 days of sex in a row is not an option. It is useful to know your fertile window, as these 3-4 days are your best chances of conceiving normally. So how can you not track these? And how can tracking these make it more difficult to conceive?
As for adoption- that is a whole different world. I love the idea but not as a method to get pregnant !  It is a big responsibility to bring in a child into your home and make it yours in every possible way – to accept it and love it- maybe even more so than you would your own biological child. This is a decision which should be done for yourself and for the future of that child. Adoption should not be considered to be a conception aid!

All in all, I agree that in any life situation stress does not help. It doesn’t do anything positive or useful but it makes you unsettled and unable to function at full capacity. It is a counter-productive emotion. However, it cannot be deleted ( not until you reach nirvana at least) , and it’s not  going to disappear if you choose to will it away !  Pretending that it’s not there is not helpful either – it’s the elephant in the room which need to be acknowledged , so that it can be managed.  Each of us has our own method of managing it, because we’ve all handled stressful situations in the past ( examinations; dating; cooking the first meal; the first time you jumped into a swimming pool…) . I make art; write; pray ; and volunteer ; and you too need to learn what works for you, so you can cope with it.

Finally, just remember stress is a result of infertility and not its cause!

Saturday, March 28, 2015

Preventing IVF patient's complaints

Unhappy patient's are a doctor's nightmare. This is especially true for an IVF clinic like Malpani Infertility Clinic, which depends upon patient's referrals to get new patients. We take pride in delighting our patients,  so that they can refer other infertile couples to use.

Of course, we can't keep everyone happy all the time, and there are going to be infertile couples who are not going to be happy with us - especially when their IVF cycle fails.

Although complaints are based on multiple factors, several common issues underlie most patient complaints. We try to minimize our risk of patient complaints about Malpani Infertility Clinic by paying close attention to these four key areas.

1) Enhancing communication
Communication is a key issue in avoiding patient complaints. Because many patients have difficulty absorbing—or understanding—the information presented to them, we develop resources such as IVF e-learning courses and an IVF comic book, so that they have realistic expectations of the IVF treatment.

2) Practicing cultural competence
Our patients come from a variety of cultures from all across the world. Language barriers can make communicating with the patient quite challenging. Often, patients’ cultural backgrounds affect how they relate to healthcare providers or process information. In certain cultures, for example, asking a physician questions may be considered rude or a challenge to authority. We are therefore very proactive in making sure patients understand that lots of IVF cycles fail, no matter how good the IVF clinic is !

3) We respect the informed consent process
Informed consent is a process, and the “informed consent sheet” commonly seen in medical records is simply the documentation of that process. Not only do we explain the risks and benefits of IVF through our educational materials, we also discuss alternatives to IVF, such as surrogacy and adoption.

4) Explaining all charges and fees up front
We make sure that all IVF costs and charges are clearly explained to the patient. This is why we offer a package fee option, so that there is no sticker shock or unpleasant surprises later on. This is also why we publish our fees on our website, so there is no scope for confusion !

Looking for the best IVF treatment in India ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !

Friday, March 27, 2015

Mumbai-based Urjas Energy Systems raises $100,000 in angel funding

"Urjas does good by generating clean energy. As a social enterprise, it can leverage the benefits of both social capital and human capital, so that investors get a better ROI. I feel social enterprises like Urjas provide a better return on financial capital than ordinary companies," said Aniruddha Malpani, managing director, Malpani Infertility Clinic and angel investor at Urjas.


Embryo adoption - a success story !

Patricia underwent IVF at Dr Malpani's clinic in Mumbai, in January 2010. As she was already post-menopausal at the time, she could not provide her own eggs, so used an embryo created from an egg and sperm provided by Indian donors.
Patricia says she was not concerned about having a child who would be a different race to her.
'There are lots of benefits of having IVF in India,' she said. 'The clinic is very modern, very clean and well run and it is very successful. Women in their seventies have been able to have children.

'I always felt I had a lot of love still to give. I'd encourage other women in my position to investigate this as a possibility for having the family they want'
'It is considerably cheaper than having embryo transfer in the U.S. I paid $8,000 for treatment in India, compared to $23,500 in America.'


Thursday, March 26, 2015

My early IVF pregnancy - inner musings while waiting for the next ultrasound scan

Here's an  update from our expert patient, whose is 5 weeks pregnant, and whose ultrasound scan confirms she has an intrauterine pregnancy
There is nothing you can do now, but wait and hope.

I want to feel truly happy and dance with joy. I want to register for a prenatal yoga class. I want to share my good news with friends and family. I want to buy a crib for the nursery and paint a mural on the wall. I want to call my best friend and plan my baby shower… but I have to wait.

In a 24-hour long day for 8 long weeks- I worry that I am not thinking positive enough, that the duvet is increasing my body temp at night, that everything I consume must be organic, that I’m not drinking enough fluids, that I should refrain from intercourse till I check with my doctor, that ‘no-caffeine’ is probably best, that my breasts are not feeling as heavy as they were yesterday, that I am not feeling any nausea… the list is endless and the worry is pointless. I know this and I do it anyway.

As DrMalpani says, “At this point, there is nothing you can do to hurt or help the fetus” and I have to remind myself consistently of that. There is nothing I can do to make my baby survive…  and it makes me feel very helpless. In life, I’ve always been told that if I work hard enough, I will succeed. If I become a wonderful person, I will attract such people in my life. But rarely was I ever told that luck plays such an important part in the outcome of things. So, after a twin miscarriage of having seen then lost both heartbeats- how do I refrain from thinking that history is going to repeat itself? Does the fear actually make it happen? Or que sera sera, irrespective of my feelings?
The above verse, which is among the most famous verses in Mahabharat, is one of those explanation Lord Krishna has given when Arjun does not want to fight the war.In this case Krishna tells Arjun that no matter what is the result of the war, he should not be worried about it. His duty is to fight, then he has to fight. He wins or loses that is not important. Even if he dies during the war, he will attain heaven because he has correctly performed his duty.

I must do the deed and not worry about the outcome. I can change the deed or how I do it but I cannot control the outcome. I can’t control what will happen to me but I can control what I feel about it and who I become because of it.

And I can be kind enough to myself that I allow myself a few moments of worry and a few thoughts of when I finally hold my baby and how it will feel every day…

Fertility Problems: Should You Be Tested?

Are you worried about your fertility ? When is it safe to continue to trying in your bedroom ? And when should you seek medical assistance ?

This is a complicated question, and the free Healthwise Infertility Decision Aid will help you make the right choice !

Wednesday, March 25, 2015

IVF medical records belong to the patient ! Why do doctors hold on to their patient’s medical records ?

Whenever patients come to me after a failed IVF cycle, the first thing I ask for is a copy of their IVF medical records . Sadly, the commonest answer is still – We don’t have a copy – the doctor never gave us one, and we didn’t even know that we were supposed to get one.

Many IVF clinics continue to hoard their patient’s IVF medical records, and I get very upset with this malpractice. It’s important that patients have a complete copy of every medical treatment they receive – and this true whether they do IVF, or undergo knee replacement surgery !

Medical treatment needs to be open and transparent, and it’s important that patients know exactly what was done during their IVF cycle. This is invaluable information, based on which we can tweak the treatment protocol to improve their chances of success in their next cycle. By refusing to give patients their IVF medical records, doctors are doing them a major disservice. Sadly, IVF clinics seem to use this as a tactic to hold their patients hostage, so that they will not go to another doctor or seek a second opinion. They feel that by hanging on to their patient’s medical records, they will reduce the risk of their losing their patient to another clinic.

They feel that this way they will be able to force the patient to continue taking treatment with them . This is extremely shortsighted on the clinic’s part, and patients get upset and angry when doctors refuse to be open and transparent . Not giving the patient their medical record is also illegal, and exposes the doctor to the risk of being sued.

Even worse, when patients sense that doctors have clamped up and are refusing to give them their records, they start suspecting the worst. They lose faith in that doctor – and will then no longer trust any doctor, because of the behavior of one particular IVF clinic .

Doctors need to understand that the patient’s medical records belong to the patient, and they  should not adopt a confrontational approach . They should be happy to hand over copies of the IVF records – and this is something which every good clinic does routinely and proactively., We always keep a copy of the record, so we know exactly what we have done for the patient, but the original is always given to the patient.

IVF treatment is expensive , and patients have paid lots of money for their treatment . It’s completely unfair , unethical and unacceptable for doctors not to give patients their medical records . If your doctor refuses to do so , you should send him a written request. If this is ignored, then send a legal notice through your
lawyer .

Unfortunately, this seems to be the only way in which some doctors will start improving their behavior. Sadly, they continue getting away with unacceptable behavior , which is not good for their patients, or for the entire medical profession , because all doctors then get tarred with the same brush. Patients need to speak up – for their sake, and for the sake of the other patients as well !

Worried that you won't be able to understand your IVF record ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !

Tuesday, March 24, 2015

The best place to have a baby - indeed !

Here's a heart warming success story from one of our patients.

We got married really young in April 2006. At an age of 23 and 21 as husband and wife; having a baby is the last thing you are thinking about. Coming from a big – really BIG Marwadi Joint family.. the pressure of having a baby was immense right  from our  very first anniversary. But both me and my hubby were sure of what we want from life – and when! So we let 4 yrs pass by like a honeymoon.

( I always knew I had PCOS – but was well aware that people still do conceive naturally )
In 2011 – after 5 yrs reality started hitting us! We had had unprotected relationship for almost a year – and there was no sign of pregnancy! We immediately got in touch with one of the best infertility specialists in South Mumbai. The only background check we had of her was – shes very very experienced, senior, old, worked very well for my in-laws, cousins, extended families etc – NOTE: all who had natural pregnancies and consulted her as a gynaec!

•    We went through 4 follicle cycles with her. The pressure started building like crazy.
•    We were then suggested a laparoscopy/ hysteroscopy – results all clear and we wondered what was going wrong.
•    Next in line was – a cycle of IUI – which was undertaken by her assistant – and totally fruitless.
•    Have to mention that all those several meetings with the Doc – required us to wait in her clinic for a minimum of 2 hrs and maximum of 4 hours. And while we waited – we spotted several other couples with a file of IUI or IVF in their hands. In the beginning we didn't want to discuss our stories or details of the current treatment – but slowly as we started talking to others waiting in the queue we realized we were all sailing in the same boat of IMMENSE ANXIETY, PRESSURE, FRUSTRATION, FAILURE and all those things that will NEVER work in your favor of conceiving a baby!
•    Then the doc suggested that a minimum of 3 or 4 IUI is considered practical before we jump in for the big buck of IVF!

THAT'S IT! We knew this was not going to work anymore! It all seemed like a Money Making Racket! Or a super professional system of mentally torturing couples!  We decided to take a break for a few months.

We went through a phase of severe depression! Being married for 6 years, having consulted and following up with the so called best infertility specialist in town for almost 2 years, watching all our friends who got married after us – pop babies out one after the other – None of this was easy! I remember spending nights simply sobbing in my husband’s arms!

In the middle of all this mess – one of our cousins suggested we should consult Dr. Malpani for his opinion on the case. We immediately took an appointment and the beautiful journey began!

We were amazed to see his clinic so warm and welcoming with the cutest baby pictures adorning the walls. No long queues, no waiting for hours. Within 15 mins we were inside his cabin – speaking directly to Dr. Aniruddha Malpani. Within just 25 mins of the conversation and looking at our previous test reports – he told us very surely and confidently that it is IVF that we need! And there’s no scope/ need / reason to go through any other treatment. He made us extremely comfortable. He insisted on reading and gaining our own knowledge instead of blindly following any doctor’s advice. I have to admit – we were outright Impressed! Suddenly all the pressure and stress seemed to get diluted! We still weren’t sure if we will finally have our baby – but were very sure that we were at the right place with the right doctor!

December 2013 we met him – Jan 2014 my Father passed away – March 2014 our IVF cycle started – April 2014 – I was PREGNANT! December 2014 – we gave birth to the most beautiful girl ever!!
I can never forget how prompt Dr. Malpani was over the phone calls and over the emails. All our doubts were taken care of very nicely. Even his medicine prescriptions were detailed ones – with printed sheets telling you what each of those medicines are prescribed for. I almost mistook him for a friend my age – when he called to check how I was post the embryo transfer. 

The nurses at his clinic took care of me like a baby.

I remember Dr. Anjali cracking up a joke and making the atmosphere happy - while I was still semi conscious after the egg retrieval.

All in all an extremely personalized attention received – with a lot of precision and warmth.  No space for any stress or doubt.

THANK YOU Dr. Aniruddha Malpani,  Dr. Anjali Malpani and your entire team from the bottom of our hearts -for making our dream come true , literally! :) :)

Need help in crafting your own IVF success story ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !

Monday, March 23, 2015

Day 2 versus Day 5 transfer

We prefer doing Day 5 transfers because it allows us to select the best embryos , and this increases the chances of a pregnancy. Allowing the embryos to grow in vitro to Day 5 allows them to “ compete “ with each other, so we can transfer the best ones to the uterus.

It’s an easy decision to transfer on Day 5 as compared to Day 2 , when there are lots of eggs and lots of embryos . However, what do we do for poor ovarian responders – patients who grow only 3-4 eggs, and we have only 2  embryos on Day 2 ?  There’s little point in growing them further in vitro, because we only have 2 embryos to choose from, so why not go ahead and transfer both on Day 2 ? After all, if we try to grow them to Day 5 and they stop growing ( arrest in vitro), then the patient will have no embryos to
transfer , which means her chances of getting pregnant will be zero. Isn’t a bird in the hand worth two in the bush ?

The decision boils down to a personal preference – should we  take a short-term approach  versus a long-term approach ?

Let’s consider the short term option first, where we transfer the embryos on Day 2. We don’t want to take a risk, and if we transfer, and the patient gets pregnant, she will be happy – and so will the doctor. However, if she doesn’t get pregnant, we’ll never know why the cycle failed. Was it because the embryos arrested on Day 3 ? or 4 ? or because there was an endometrial problem which prevented implantation. By transferring too early, we have lost the golden opportunity  to answer this key question about embryo competence.

If we decide to grow to Day 5, and we get good blastocysts, every one is happy, because we’ve followed text book protocol, and the patient has peace of mind she’s received the best possible treatment.

What happens if the embryos arrest in vitro and there are none to transfer on Day 5 ? The immature patient will be unhappy and angry. She will kick herself – and her doctor – for not transferring the embryos on Day 2 ! She may always feel – perhaps if I had transferred them on Day 2, they would have continued to grow in utero and would have implanted. By leaving them outside, I frittered away my chances of having a baby. She may even blame the doctor for the failure of her embryos to grow !

Transferring on Day 2 is much safer for the doctor as well, because at least he can give both himself and  the patient the pleasure and satisfaction of having had a transfer. Sadly, this pleasure can often be only transient – and when the cycle fails, the patient is back to square one. However, for many IVF doctors, the end point of an IVF cycle is the embryo transfer, and if they achieve this, they can proudly tell the patient – we did everything humanly possible – the rest is in God’s hands. This way, even if the cycle fails, at least the patient doesn’t blame the doctor. She blames her fate, and happily comes back for a second cycle, because she doesn’t realize she has received poor medical care.

The problem is that being willing to wait to grow the embryos to Day 5 requires a very competent doctor, who knows his IVF lab is excellent, and who is confident that if the embryos will cleave in utero, they will do so in vitro in the lab as well; and one who knows that if the embryos are going to arrest in vitro, they would have arrested in the uterus as well. This requires a very mature patient as well, who is willing to put up with the short term pain of not having a transfer, because she has now learned valuable information about the competence of her embryos , because they arrested in vitro and failed to form blastocysts. This way she knows that the problem is her egg quality, and she can then start considering alternative options  for her next cycle more intelligently based on this knowledge ( such as using donor eggs).

Patients need to be wise enough to understand that the endpoint of an IVF is not always only a baby . An IVF cycle provides invaluable diagnostic information , which can help us to formulate a treatment plan for the next cycle, to maximize the chances of success. These patients can make a much better, well-informed mature decision , if they are will willing to accept the risk of the short-term pain . This kind of patient will not blame the doctor because her embryos arrested.

However, this approach requires a lot of patience and maturity , from both the doctor and the patient. Patients can become quite agitated if the embryos arrest, and this is why patient counseling is so important.. Doctors need to be open and transparent, and give patients photos of their eggs, and arrested embryos, so they can see exactly what happened in the IVF lab. This way , the doctor does not need to get defensive, and he can honour the patient’s personal preferences.

The trade-off is between short-term pain and long-term gain , and sometimes valuable information from an IVF is lost , because some doctors are focused on just transferring the embryo back into the uterus.
However, this is a just a short-term milestone you have reached – but means you are no closer to your final goal – of having a baby.

However, doctors who are not confident about their lab’s ability to grow embryos to Day 5 will often push patients to transfer them on Day 2.  Then, when the patient does not get pregnant, they can label this “failed implantation”; run a battery of expensive tests, to “diagnose” the problem; and even advise an expensive
( and completely incorrect )  treatment such as surrogacy, to overcome the problem of failed implantation.,

We counsel our patients that it’s best to grow to Day 5. Yes, there is a risk there will be no transfer, but the fact that the embryos arrested in vitro provides useful information, which we can use for the next treatment cycle, to maximize the chances of success. If the embryo does arrest in vitro, this makes it easier for the patient to come to terms with the fact that she has a problem with her egg quality ; and this can help her to consider using donor eggs for her next cycle.

On the other hand, if she transfers on Day 2, she’s never sure whether the problem was with her eggs, or with her uterus ! This is why it’s so important that you find a good IVF clinic, which has a robust IVF lab, and routinely grows embryos to Day 5 .

Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !

Sunday, March 22, 2015

Why don't health insurance companies return the patient's medical records to them ?

My father recently had hip replacement surgery. The surgery went well, and we submitted the insurance claim to his insurer, New India Assurance, through their TPA, Medicare TPA. We had to submit all the original medical records, along with the bills and the claim forms. We did so, and after 4 long painful weeks of silence, the TPA reimbursed 70% of the total bill, without even bothering to give an explanation for why they failed to provide a 100% reimbursement.

Even worse, even after processing they claim, they have held on to the original medical records, and have not returned them to us.  This is completely unacceptable . The medical records are the property of the patient, and they contain valuable medical information, which is worth its weight in gold.  It makes no sense for the insurer/TPA to hold on to these records. They should return them promptly, once the claim has been settled. If they want to keep a copy for their records, they can xerox these, or digitise them.

Patients need to fight back, and insist that insurers and TPAs return their original medical records to them !

IVF patients, Startup founders and failure

IVF patients should start thinking of themselves as entrepreneurs because this will help them to cope better with the IVF emotional roller coaster ride. In one sense, the IVF ride is very similar to the journey which a founder has to go through. After all, for every founder, their start-up is their baby , and they invest a lot of time, money and energy into making is it successful, just like every IVF patient puts in a lot of time, money and energy into maximising their chances of IVF success, so that they can have a baby.

Read the complete post at https://www.linkedin.com/pulse/ivf-patients-start-up-founders-failure-dr-malpani

Saturday, March 21, 2015

How being a doctor helps me to become a better angel investor:

It is not very common for doctors to become angel investors and I find that I am the only doctor in my angel investing groups, India Angels Network, Mumbai Angels and I3N.  Most angel investors seem to be either businessmen , entrepreneurs, or finance professionals , who take up angel investing either to give back, or as an additional source of income. 

I found angel investing  quite challenging initially , because it was hard to understand some of the business jargon. I am more comfortable discussing ECGs and MRIs, as compared to MVPs and USPs! I cannot create business models or Excel spreadsheets , and I still have to struggle in order to make sense of a profit and loss statement or balance sheet, but these are skills which I can learn , and over time I am getting better. 

So how does being a doctor help me become a better angel investor?  For one thing , as a doctor, I run my own IVF clinic, so to that extent at least I am an entrepreneur, and since I run a small business, I have to deal with the same challenges most start-up founders do.

I need to deal with hiring employees , training them and firing them; balancing my books; buying equipment; running a website ; and creating patient delight . Being a doctor is a full-time job, just like being a start-up founder is, and I find that I have to juggle multiple balls in order to ensure my clinic runs properly . This helps me to be a little more empathetic , when my founders run into trouble , or have difficulty coping with some of the challenges which being a start-up throws at them.

Because I have dealt with these challenges myself personally, it is easier for me to understand their road-blocks, and perhaps provide them with some of the emotional support which they need.  Being a doctor also means that I understand a little bit about what makes people tick . I can use what I know about applied psychology and emotional intelligence to be able to establish a better rapport with the founders, and hopefully this is of value to them.

Finally, as a doctor, I have to read quite a bit in order to help improve the quality of services I provide to my patients. In order to run my own website, I have to learn about technology, digital marketing and how to reach out to patients . These are some of the same challenges my founders face ( just substitute the word customers for patients) , and because I have tackled them and I know what some of the possible barriers and solutions are, I can share this information with them.

Interestingly, being an angel investor helps me to become a better doctor as well. I learn from the experiences of my founders and I can apply this knowledge to improving the way I run my clinic. They teach me productivity hacks, which help me to become a little more efficient.  I can leverage their digital skills and marketing experiences , and apply these to my own practice , and my personal life.  As an angel investor, I have multiple opportunities to learn , and since I invest across all domains, I find that everything is grist to my mill.  This allows me to be curious and read a lot , and I can then utilise all this learning not only for helping my founders to become more successful , but for helping myself to become more productive as well.

Some of my patients worry that if I start spending so much time on angel investing, I will no longer be able to provide them with good clinical care . I actually think the quality of medical services I will be able to provide them will become better , because I will be able to enhance my efficiency using some of the technological tools, tips and tricks which my founders teach me.  Thus, I marry my patient's medical needs with the technical expertise of my founders, to develop clinical apps, which help my patients take control of their IVF treatment .

Hopefully , I will be able to set up a positive virtuous cycle , so that as I become more experienced and make more mistakes, my medical expertise will not only help me to become a domain expert for those of my start-ups which happen to be in the healthcare space, but will also allow me to add value across multiple domains , not only for my founders but for my patients as well, and for my own clinic too.

Friday, March 20, 2015

What I wish I knew before starting fertility treatments

A new post from an expert IVF patient !

As a " struggling to conceive woman " at 31, when I was contemplating fertility treatment , unfortunately I spoke to only quick success stories before heading to a clinic. Women, who I knew had twins with first attempt IVFs or conceived by simple flushing of tubes or IUIs or just taking clomid. This made me sure that like these women, I just needed a nudge to speed things along. After all, unexplained infertility with a 30-day cycle and perfect sperm count for DH, meant that we would get there with just a slight push, didn’t it?

However today I know that for my case and a lot of others, fertility treatments are a journey. Some end up as being long-winded convoluted dark holes with twists and turns, while others are short tunnels with the light right there . You never know which journey you will be embarking on - all you can do is hope that you ride with be short and sweet !

Here's my list of top 10 things I wish someone had told me before I stepped into a clinic--

1-    You never know how long this road is. Be in for the long haul- this could take a while. I remember reading a blog of a 10X IVF survivor and thinking she must be crazy! But I realize now, that it’s hard to stop as long as you have eggs and no insurmountable issue and you don’t want to give up…
2-    Choose a doctor that has his eye on the goal and doesn’t make baseless diagnoses- I remember my first doctor refused to go ahead with my FET as my TSH level was 4.1 in his test and his accepted level was 4. He referred me to an endocrinologist and after giving a detailed medical history and retaking the test, the level was 2.2! So I almost cancelled a cycle based on the clinics error…
3-    Choose a clinic with a fantastic embryology lab that knows how to get the best possible embryos. The lil cells need to stick and make the 37 week long journey- so you need the best.
4-    Research- make yourself smart about the procedure, be realistic about your chances of success and keep asking questions- you are paying the doctor for his services. You need to make sure you get the best possible care.
5-    Keep impeccable records- From your first blood report to your last ultrasound- it is all relevant. Keep images of your embryos and scans- hopefully you’ll never need it again but if you do…
6-    Remember that a Positive HCG  is a brilliant start but not the end- after 12 weeks you can breathe so much easier and then share your news happily and fearlessly.
7-    Don’t forget your partner Men suffer as well- they just do it differently. In all your self-pity and self-focus, remember infertility is a couples problem and you need to lean on each other through it all.
8-    Find something spiritual to focus on- Hope and persistence is something you will need time and again. Find it in whatever form you can and lean on it as much as you need to.
9-    Find a way to put your problems into perspective. Volunteer at homeless shelters, orphanages, women’s shelters, in war zones- figure out that even though it feels larger than life today, in the large scheme of things infertility is not the worst that can happen to a human being.
10-    Learn to be kind to yourself- guilt, beating up on yourself and hopelessness are emotions you can well do without.

Lastly, stay positive. I write this on week 5 with one embryo working towards developing in my uterus. Speak to a variety of people- first-time success stories, 3-year success and 10-year stories and remember that one way or the other- all their stories end with a beautiful baby!

Thursday, March 19, 2015

“’I don’t know’ are three of the most underused words in IVF

" What’s really interesting about IVF – and I think this is true for a lot of fields whether you’re in physics, math, chemistry, history, or whatever it is – the more you learn, the you more you realize how little you know.”

IVF doctors need to learn humility and accept the fact that there's a lot about human reproduction which we do not understand. We should stop pretending to be wiser than we are. We need to be transparent with our patients and tell them truthfully when we are not able to answer their questions. The questions are often very simple ( Doctor, why did my embryos fail to implant ?) but the answers are mind-bogglingly complex. However, rather than level with the patient, most doctors prefer to take an intellectually dishonest shortcut. They order pointless untested tests ( which are expensive and of unproven clinical value), and when the results come back as abnormal, they triumphantly tell the patient - We now know the reason for the IVF
failure ! The reality is that the so-called abnormality may be of no importance, and is often just a red herring.

This leads to avoidable care , which is a result of  “magical thinking - convictions that both doctors and patients tend to hold , despite evidence that should lead to more nuanced beliefs.”(  Institute of Medicine president Harvey V. Fineberg ) . " Some examples of such thinking are the beliefs that technology is always good, that new technology is always better than older technology, and that uncertainty is intolerable."

This attitude causes arrogance , overtesting and overtreatment. We cloak our ignorance with technology and pseudoscience.   The truth, as any good IVF researcher will tell you, is that  the more you know, the more you know that there is even more that you do not know. 

Sadly, there is so much pressure to commercialise the research, that these tests are marketed with a lot of hoopla and hype, through press releases , medical journal articles, and keynote speeches at medical conferences . It's surprisingly easy to take doctors for a ride, because most of them have never been taught to be sceptical and critical. Many naively believe that every journal article contains the unalloyed truth, because they have failed to read the essay,  Why Most Published Research Findings Are False. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124 

In her blog Less is More, Dr. Otte suggests a “just right” or “Goldilocks” approach, and this ‘not too much and not too little’ approach aims to strike a healthy balance. Doctors need to use the right amount of medicine, focusing on patient-centred, evidence-informed practice. That way, we can just focus on doing more of the things that are known to have positive outcomes with patients, and not end up causing unnecessary harm.

IVF doctors who do not get more humble as they 1) get older, 2) grow as a person, or 3) learn, are not paying attention.  No matter how hard IVF specialists work,  because IVF is so complex and there are so many known and unknown variables which affect embryo implantation, that there will always be much that we do not know.  The best IVF specialists have been able to develop systems that deal effectively with the fact that IVF is a probabilistic process, and will help the patient to navigate the journey with realistic expectations. It actually requires a mature physician who is confident about his own competence, to be able to tell the patient - I don't know !

I find that patients prefer doctors who are honest and who level with them.  While some patients crave certainty and want a doctor who has all the answers, the truth is that patients also know that doctors are not omniscient ! Patients are smart, and while you can fool some of the patients some of the time with fancy medical gobbledygook , you can't fool all of them all the time.

A more mature approach is being frank and saying - We don't know exactly what the problem is, but we can work together to craft a solution to bypass the problem. Patients and doctors can then forge a partnership , to help them reach their goal of having a baby .

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

Wednesday, March 18, 2015

Endometrial receptivity assay and other endometrial function tests - are they of any use ?

Failed implantation is one of the most frustrating problems IVF doctors and patients need to deal with. We are good at making gorgeous looking embryos in the lab , but most of them never become babies ! Why is this ? Is the problem with the embryo ? or with the uterine lining ?

In order to improve the chances of transferring healthy embryos, IVF labs now use  advanced genetic technology ( such as CCS and NGS for PGD) , to select the chromosomally normal embryos. However, not all of these embryos  implant either ! Doesn't it then logically follow that if a normal embryo does not implant, this means the problem is with the uterine lining ?

This is why so much research has been done on developing endometrial  function tests, to optimise endometrial receptivity, and improve the chances of IVF success.

Thus, Yale has  developed the EFT ( endometrial function test) ; IVIomics has developed the ERA
( endometrial receptivity array) ; and CCRM does a test called Beta Integrin 3 which tests for the missing protein that is the "glue" for implantation.

All these tests harp on the importance of the "soil" in facilitating embryo implantation, and because there is so much competition, they are being hyped and marked as "breakthrough tests" to improve IVF success rates.

The problem is that no one really knows whether these tests are helpful or not. However, because infertile women are so desperate , they are happy to serve as guinea pigs . To add insult to injury, they have to fork out huge sums of money for the privilege of getting these tests done ( even though they are research tests only, and not of proven clinical value).

For example, even if the test picks up a problem, does this mean that the "abnormality" is consistent  and occurs cycle after cycle ? After all, we all know that there's lots of biological variation and we should not jump to conclusions based on just one abnormal result. Ideally,  the test should be repeated in the next cycle, to see if the result is persistently abnormal , but because the tests are so expensive, this is hard to do in real life. Also, both doctor and patient are so happy that they've finally pinpointed the reason for the failure, that they are happy to go ahead with the "treatment". Yes, some women will get pregnant after the treatment, and both the patient and their doctor will be happy to give credit to the test for the success, but who knows whether the "treatment" really helped or not ?

The problem is that the concept of an "unripe soil" makes biological sense , and because we have so little to offer, doctors are happy to proceed along the lines of "Well, in theory this should help, so let's try it and see ! "? The tests are promoted with lots of clever marketing, by using emotionally evocative terms, such as " personalised embryo transfer ". This means makes intuitive sense - after all, isn't every patient different ?

The problem is that all these tests are patented  to protect "intellectual property" , which means there's  no external independent validation. It's hard to blindly believe what the manufacturer says.  They claim that the tests are backed by "10 years of research and published medical journal articles " - but this doesn't mean anything. In fact, because they have invested so much time and money on this research, they are compelled to show a return on their investment for financial reasons !

In fact, the very fact that there are so many tests is testimony to the fact that we don't know how well any of them work. So how do we know whether to do something ? or nothing? “When many cures are offered for a disease,” wrote Anton Chekhov, “it means the disease is not curable.” If past experience or data suggests that multiple solutions are possible but none are reliably successful, nothing may be the best strategy.

There is no way to properly validate these tests, and each RE and researcher has their own beliefs. In fact, many of these beliefs are very deeply held, because they are based on "intuition " rather than evidence . Doctors are not always objective, and get wedded to their beliefs very easily.  We need to remember Mark Twain's words of wisdom , "It ain't what you don't know that gets you into trouble. It's what you know for sure that just ain't so."

The common justification for these tests are - " Infertility testing is not a perfect science, and will improve as more becomes known.  Infertility, is a multifactorial pathology. Scientists' progress is a never-ending story, and if we wait until all is clear, we will never test and never treat. Infertility patients cannot wait for that. They should and ought to be given the benefit of less-than-perfect studies, if it's helpful even for 1 in ten patients." This sounds very benign, but is a dangerous and unscientific attitude to take. It will just promote quackery , because the hidden sub-text is - So what if it's not been proven to help - let's try it and see if it works !

In 1949, Georgeanna Jones, MD, first described luteal phase deficiency (LPD). It was believed that this condition explained why the endometrium was unreceptive to the embryo, and prevented it from implanting. In fact, this was a condition which REs treated "routinely" for many years. However, data today show that 6-10% of women who are fertile demonstrate an inadequate luteal phase, which is why the ASRM published an opinion in 2012, The clinical relevance of luteal phase deficiency: a committee opinion, which states that "LPD as an independent entity causing infertility has not been proven".

I think we need to be honest with our patients. Let's tell them we don't know why embryos don't always implant - and that just because a test comes from Yale or Iviomics , or uses a lot of genetic jargon, doesn't mean it's reliable !

Confused and don't know what to do next after a failed IVF cycle ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !

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