Why do IVF patients want so many tests ?

I am a conservative doctor, and try not to order too many tests for my IVF patients. I explain to them that tests which do not change their treatment plan are pointless , and represent a waste of time and money. However, I find that many of these patients get a second opinion, and the new doctor orders these tests for them, and patients are happy to do these, even though I have told them the tests were useless.

I used to get upset when patients ignored my thoughtful advice, and felt that my counseling was flawed , and that I wasn't doing a good job educating them.

However, this article in the recent JAMA shows that the problem is not a result of my shortcomings - it seems to be a common human failing for patients to want to do lots of tests !

Researchers find that patients greatly overestimate the benefits and underestimate the harms of medical treatments and tests and say overutilization is largely a function of "poor judgment and subconscious biases" on the part of physicians.

http://www.healthleadersmedia.com/print/QUA-311933/Patients-Clueless-About-Treatment-Risks-Docs-Little-Help

I don't know - an IVF specialist shares the truth

IVF patients have lots of questions.  Why is my sperm count so poor ?  Why was the fertilisation rate so low?  Why didn’t my embryos implant even though they were Grade A embryos?  Why isn’t my uterus lining improving?  Most of the time we don’t have very good answers for them, so the truthful answer is - I don’t know.  Perhaps a better answer would be - We don’t know, because when I tell the patient I don’t know, they sometimes wonder about my competence , and how well informed I am.

Patients have very unrealistic expectations from their doctors.  They expect their doctors to be omniscient and hopefully omnipotent as well - someone who fix all their problems , so that they can stop worrying about their infertility. Their dream is to find a doctor who will be able to give them a 100% guarantee that he will give them a baby.  Their approach is simple -  I’ve come to you, and you’re the best, and I trust and know you'll  give me a baby . I don't need to break my head about what’s happening and why, because I know you'll find the solution . They want a doctor who has all the answers - someone who’s a fount of wisdom , and who can give them the confidence that he knows exactly what he’s doing.

Part of the problem is that this act would then be a sham.  The truth is that biological systems are extremely complicated and messy , and we really don’t have all the answers.  It’s very easy to make a pretense of answering the patient's complex questions by running tests , in order to be able to make a diagnosis to keep the patient happy . The tests give us some answers, but the problem with this approach is that a lot these results are completely irrelevant and pointless . The doctors are then so focused on treating these " abnormalities " that they lose sight of what the underlying problem is.  It’s far better to be honest with the patient and share our ignorance , and tell them that we don’t know. 
There is no reason for patients to panic when we tell them we don’t know.  After all we are not a research institute - we are an IVF clinic which tries to help infertile couples to have a baby . The good news is that even if we don’t know what the problem is, we are very good at crafting solutions which allow us to bypass the problem , and this is all for the best.

As I keep on reminding my patients, the quality of my answers depend on the quality of their questions , and there’s little point in asking pointless questions.  Rather than ask questions such as - Why didn’t the embryos implant ? a far better question would be - What can we do in order to get the embryos to implant the next time?  This way, both doctor and patient can respect each other because the doctor is being frank and transparent , and not pretending to know more than he really does. A good doctor truthfully shares the boundaries of our medical knowledge.  The patient can be comfortable that the doctor’s not hiding stuff or patronizing her by fobbing her off with "pseudo-answers". She can see that the doctor . and is leveling with her and that they can work together to find a solution so that she can have a baby.

I agree that this kind of fuzzy ignorance is not a very comfortable situation to be in, but the reality is that it’s something which we deal with in our daily life all the time.  For example, when we invest in the stock market, no matter what your financial advisor may say or who the talking head expert on TV is, we can never be sure whether the share we buy will go up or down.  Life is full of uncertainties,  and this is as true in IVF as it is in other fields . The sooner we acknowledge this, the easier it will for patients and doctors to deal with this on a mature basis.

When a patient asks me a question, I sometimes deliberately say, “ I don’t know the answer, let’s look it up.”  I’ll deliberately do a search for them , and go to a curated and reliable website, and we’ll read the answer together.

This is contrary to everything I was taught as a medical student , when I was told that it's important to instil confidence in patients by showing off that I know everything.  Some doctors still play games with their patients by pretending to know everything, but I don't think it's possible to fool all the patients all the time anymore !  Some patients aren't happy with my answer, because they don't like being treated by a doctor with " limited " knowledge , but more mature patients appreciate the fact that I am being honest with them.

Need help in making sense of your IVF treatment ? 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 !

[Doctors 2.0] « Le e-learning s’adresse aux patients au-delà de la prévention »

I can't speak French either, but for those of my readers who can, this article describes how we use e-learning to empower patients


http://www.atelier.net/trends/articles/doctors-20-e-learning-adresse-aux-patients-dela-de-prevention_435197

The IVF Gamble

One of my patients wanted to know, “Is IVF a gamble, Doctor”?  She’d already done two cycles, both of which had failed , and she wasn’t sure what he should be doing next. " Does this mean that the patient needs to buy a lottery ticket every time she does an IVF cycle ? And that no one ever knows whether the cycle is going to work or when it’s going to work?  How do I know how many cycles to repeat and how do I know when I should stop?” 

All these are very pertinent questions and the truth is we actually don’t have any good answers to them. Yes, it’s true that IVF is a gamble but then so many things in life are a gamble. Even getting pregnant in the bedroom is a gamble, because human reproduction is not very efficient.  And while IVF tries to improve that efficiency, it has its limitations , because we need to deal with a biological system which we do not have the ability to control beyond a particular point. 

Patients do need to understand what is at stake - and that this is often a gamble which is worth taking.  It’s an expensive gamble, but then on the other hand when it works, the return is well worth it ! It’s important that patients understand the uncertainty involved and also what doctors can do in order to minimise that uncertainty, but beyond a particular point, this is a journey which they need to walk for themselves.

As doctors, we can act as companions, and we can  hold their hand to help them, but we can never be sure when they will reach that destination ; what they will have to do to get there; how long it will take them ; and how many ups and downs and detours they are going to have to go through .

There is a certain amount of luck involved , and this is because we cannot completely control complex biological processes . One way of maximising your luck ( and reducing your risk) is by finding a good IVF clinic.

If patients do their homework, and have been counselled properly and have realistic expectations, this can be quite an exciting journey, because the fruit of the journey - the reward at the end of it, makes it all worthwhile.

How much to risk and how much to gamble, are not decisions which a doctor can make.  Each patient needs to find these answers within their own heart.


Paralysed by uncertainty ? 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 !

The Truth in IVF

One of the common complaints patients have about Malpani Infertility Clinic is that we are very frank and forthright . If we think the patient has a poor chance of getting pregnant, we will tell her this to her face.   A lot of patients don't like this kind of bluntness.  The fact of the matter is I can speak as sweetly as everyone else, but I usually find it is far better to be upfront so that patients have realistic expectations . I prefer this as compared to sweet talking them by being excessively optimistic so that they sign up for the IVF treatment,  and then end up over promising and under delivering. 

It can be hard to know what the patient's response to my frankness is going to be.  Some patients get upset and turned off and say - We would rather go to a doctor who is more hopeful and optimistic.  Now, it's not that I am pessimistic at all. I am an optimist, but I think there is a balance we need to keep, and I don't want to cross the line.  I will never take a patient's hope away, but I will be honest and share the uncertainty which plagues IVF with them .

I think this is kinder in the long run , and I prefer to think of the long-term consequences of my actions, rather than look for a quick short term win by luring the patient to sign up for an IVF cycle by offering false hope. It is much easier for IVF patients if we keep their expectations low, so that even if their cycle fails , they don't go to pieces and it is easier for them to recover.  My mantra is - Hope for the best and prepare for the worst.

Interestingly, there are some patients who actually appreciate my frank and forthright approach . They say, " Doc, when you told us the truth we felt bad, but at least this way we felt bad only for a day , and we are not going to keep on feeling bad for the rest of our life because you levelled with us and told us what the reality is . It's easier for us now to come to terms with the situation , so that we can carry on with our life.  "

Learning the truth can be stressful , and it's not easy for me to have to tell patients bad news, but I think it is far better that as a professional I be honest with them so that they can then come to grips with facts and move on with their lives.

The one thing I will never do is take away hope from a patient, but on the other hand I will try my best not to give them false hope.  As I tell them, there is always a solution for any problem, and we need to work together to find a solution which is right for them.


Need help in moving forward ? 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 !

When IVF Doctors Disagree

Patients think of IVF as being a medical science,  where everything is in black and white . They naively believe that all IVF doctors, irrespective of where they practice, will look at a patient's medical record  and then formulate a treatment plan which will be exactly the same , no matter who the doctor is. 

Unfortunately the fact is that medical practice is not just a science, it's also an art, and a craft . When doctors disagree, this often leaves patients confused and upset , because they are not sure whom to trust , and it's hard to deal with uncertainty . Thus there will be some doctors who will insist on routinely doing a hysteroscopy for all patients before an IVF cycle.  Others feel that this is not required if the vaginal ultrasound scan shows the endometrium is normal. 

This means that if a patient who does an IVF cycle at one clinic and fails, and then goes to another doctor for a second opinion, and this new doctor says - " Your cycle failed because your doctor didn't do a hysteroscopy", the patient is going to feel cheated . She will complain that the earlier doctor was negligent , and that the reason she didn't get pregnant is because the doctor did not bother to do a hysteroscopy. She jumps to the conclusion that her earlier doctor was sloppy , careless and incompetent because he did not test her properly before doing her IVF treatment. She many even feel that he was out to make money by doing IVF, which is why he took a shortcut which resulted in the failure !

This reasoning is flawed.  It is not compulsory to do a hysteroscopy before IVF , and whether or not the doctor had done the hysteroscopy, this was very unlikely to have changed the outcome of the IVF treatment.  However once that seed of doubt has been planted in the patient's mind, she loses confidence in the doctor . The problem is that once she loses confidence in one doctor, she loses confidence in all doctors . She starts treating all of them with suspicion and wonders whether they know what they are doing. 

The fact of the matter is that doctors disagree because each of them has personal preferences , and this quite acceptable. The problem arises when doctors do not explain what they are doing and why they are doing it.  This is not because doctors are trying to hide information from patients - it;s just they are very busy , and because many believe that patients should trust them, and accept whatever advice they give them, without counter-checking .

When there is a discrepancy between what one doctor advises and a second doctor's opinion , this doesn't mean that one is wrong and the other is right.  Patients need to be mature enough to understand tthat there are multiple ways to skin a cat . They need to appreciate that no one doctor has a monopoly on knowledge . If there is a difference of opinion, this is not because one doctor is clueless, or the other is smarter or better informed, but it's simply because that there are no black or white answers in IVF  ! Patients need to do their own homework , so that they can find the treatment path which they are most comfortable with.

Need help in making sense of conflicting advice from different IVF doctors ? 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 !

Why I love being an angel investor

I just attended a Board Meeting of Bibox, where Madhu and Sandeep presented the cutting edge work they are doing in sparking innovation in school children using the Bibox kit.

They help children to sharpen their "Innovation Quotient" by improving their creative, collaborative, communication and critical thinking abilities . They have created a cool 21st century tool to create winners of the future. 


I am very proud to be a part of this exciting "Make in India" initiative !

If there is a child in your family, and you want to see her bloom, please check out the kit at 
http://www.bibox.in

Why Not Grow Embryos to Day 10 in the IVF Lab ?

We know that pregnancy rates are better with day 5 embryos rather than day 3 embryos because the chances of a day 5 embryo implanting are better than those of a day 3 embryo implanting.  This is because if we grow the embryos to day 5, we allow the embryos to compete amongst themselves so we can pick and choose the best embryos and then select and transfer this.  So, if day 5 is good, isn't it logical that day 7 will be even better ? Perhaps we should be growing embryos to a later stage in the lab before transferring them?  Intuitively, yes, but there is a problem with this approach. 

The truth is there are limitations for how long we can grow an embryo in a lab.  Now, this doesn't mean that our in vitro conditions are any inferior as compared to in vivo conditions, especially at least until we reach day 6, because in vitro embryos on day 6 look exactly as good , and are as functionally competent , as in vivo embryos up to day 6.  The problem is that by the time the embryo reaches day 7 or day 8, it needs to start acquiring nourishment from the maternal blood supply by burrowing into the trophoblast and establishing a blood supply . It's not possible for us to do this in vitro, that's why our ability to be able to grow embryos after day 7 becomes fairly limited, and this is the reason why we use a day 5 cut-off.  The good news is that by day 5 we are fairly good at picking those embryos which have a good chance of implanting and becoming a baby.


Want to learn more about blastocyst transfer ? 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 !

Overconfident IVF experts

IVF specialists come in all shapes and sizes.

Some are conservative. They respect their patients , and are open and transparent with them. They share both their knowledge and ignorance , and are happy to discuss the limitations of IVF technology and the fact that the outcome of any IVF cycle will always be uncertain.

However, others are brimming with confidence. They are happy to get on the latest bandwagon, and will enthusiastically push the latest trend, by promising their patient that the newest fad they have started using will help them to have a baby.

Most IVF patients will be immediately drawn to these doctors, because people typically gravitate towards certainty, confidence and the latest fads. Patients love doctors who are confident, even if this is only a facade. As Daniel Kahneman wrote : “Overconfident professionals sincerely believe they have expertise, act as experts and look like experts. You will have to struggle to remind yourself that they may be in the grip of an illusion.” A lot of it is false and does not stand the test of time. However, patients have short memories, and as long as it is presented confidently large numbers of sheep, err people, will follow.

You to learn enough about IVF so that you don't get fooled into wasting a lot of your money on unproven and untested treatment, just because these are new and have been marketed cleverly. Sometimes negative knowledge - learning what not to do - is just as important as figuring out the right way to do something. Moving forward in the right direction by avoiding stupidity, particularly if the " treatment" activity can potentially result in a big mistake, is a simple solution.

Want to make sure you don't get carried away by the latest IVF fad ? 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 !

Repeat IVF Cycles

Women who are doing their second IVF cycle will often find their experience very different from their first IVF cycle.  In some senses , the second IVF cycle is a lot easier because patients have already been through a cycle, so they understand exactly what's involved, and have dealt with the failure. They understand that not all IVF cycles work , and because they have been able to bounce back from the failure , they find they are emotionally resilient , and can cope with these ups and downs.  They also have a relationship with the IVF clinic  team, so it is easier for them to connect with them.

Often the response in a second cycle is better , because we understand how the patient's body  behaves , and we can tweak her treatment protocol based on what we have learned in the first treatment cycle.  However, the one thing which makes every cycle difficult, no matter whether it is the first or the fifth is that dreaded two week waiting period ( 2ww) . It's the uncertainty which can be draining - the not knowing whether this is the cycle where they are finally going to get pregnant , or whether it's going to be another failure. It's stressful for patients - and it's stressful for us as well, even though we have been doing IVF for over 25 years.

There's always that suspense and that uncertainty , and we wait for the HCG results with as much anxiety as our patients do , because we want all our patients to get pregnant . When the cycle fails , in spite of all the hard work and effort which both the clinic and the patient have put in,  our hearts breaks a little bit , even though we know that we have done our best , and that no other clinic could have done any more . We feel bad that when the patient has come to us with so much confidence and trust , in one sense we have let her down by not being able to give her a baby. 

But both the patient and our team need to pick up the pieces , and move on with our lives. At the end of the day , we need to have peace of mind that we have given the patient the best possible medical treatment so that she has had the best shot at getting pregnant.  In order to do this, we spend a lot of time in educating and counselling our patients  even before they come to the clinic through our website. During the treatment , we are very open and transparent with sharing documentation , so that expectations are aligned and it's easier for our patients to deal with some of the uncertainties which IVF holds for all of us.


Need help in bouncing back 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 !




 

I Cannot Give my Wife a Child !

The young man sitting in front of me was crying.  'I have failed my wife, Doctor, I have failed to give her a child.  My sperm count is zero which means I'm shooting blanks which means she will never be able to become a mother.  Really, I think she should just leave me and marry someone else.  I don't think there's much point in living if I can't have a baby.' 

I could see that the poor guy was at his wit's end.  He had just been told by a doctor that his sperm count was zero and he'd never be able to have a baby.  And of course, he was miserable and unhappy, and because he loved his wife so much , a lot of his pain was because of her sadness because she could not become a mother . He felt that he was letting her down by not being able to produce any sperm.  I allowed him to finish crying and then explained to him that this was not something which was in his hands.  It was a problem - a medical problem like any other medical issue . Hearts can fail, livers can fail, kidneys can fail, bones can break and the testes may not produce sperm for some men. 

It is important that he needs to be kind to himself, and not make a bad problem worse by beating up on himself. His problem of azoospermia did not happen because of anything he did or he didn't do.  These were things which were completely out of his hand.  I also reminded him that his wife didn't marry him only for his sperm - she married him because she loved him, and just like he wouldn't leave her in case her tubes turned out to be blocked and she couldn't have a baby, there was no reason for him to worry that she would leave him just because he had a zero sperm count. 

He was smart enough to understand all this with his head, and he felt I was patronising by telling him to stop worrying. " Doctor, it's easy to give this advice, but only someone who has a zero sperm count will understand the damage this is doing to my self esteem  and my ego . I don't think anyone else will be able to empathise with me , and appreciate what I'm going through.' 

I had to explain to him that even though his count was zero, we still had treatment options to help him to have a baby. Unfortunately his previous gynaecologist hadn't been very well informed about all the newest treatment modalities available for the infertile man . I explained to him that we could actually extract sperm from his testes , and use these to get his wife pregnant.  He brightened up considerably when he found out about this option and said, " I would be more than happy to try , and I do hope that it works.  "

I think sometimes we underestimate the emotional impact of the diagnosis of infertility on the man.  We are so focused on what the woman goes through that we forget that men have feelings too.  And just like women have a biological urge in order to have a baby, men have this hardwired within themselves also.  It's a basic evolutionary urge to propagate so that we can then pass on our genes to the next generation.

And when you find that your cannot do so,  there can be considerable heartbreak and trauma, whether you are a man or a woman.  Often it's easier for women to find support , because they can talk to other women, but who does the poor man talk to ? He can't afford to break down in front of his wife,  because he is supposed to be strong and her bedrock of support . He he doesn't want to see him weak and helpless. It's very hard to talk to guys or other men , because most of them are completely clueless about this particular problem and in fact are quite likely to make fun of him because he is shooting blanks. 

We need to understand the pain which an infertile man goes through, and help him to cope with this extremely stressful time in his life with a little bit of tender loving care.


Do you have a sperm problem ? We can help ! 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 !

How can I find an IVF doctor I can trust ?

I received an email from a distressed patient. " Doctor, I have already failed three IVF cycles and don't know what to do next. Who can I trust ? How do I know whether one IVF doctor is any better or worse than the other ? They all say they have the latest technology, they all have very similar websites, and they all claim extremely high success rates . It's very hard for me to know who’s good and who’s bad ?"  

Yes, this is true, but the fact remains that because there is so much at stake, it’s very important that patients not just gift their trust to any Dr Tom, Dr Dick or Dr Harry, just because he has a MD
degree ! In  fact, it's even more important for patient to do their homework and verify and counter-check, before making such an important decision.  Costs can vary widely, and not every expensive IVF clinic is good - and neither is every low cost IVF clinic bad. You need to be able to trust your IVF doctor , but your doctor needs to earn  your trust.   You need to verify the doctor’s claims - trust is too valuable to be given away without checking whether the doctor deserves it or not.

Of course, this involves a certain amount of effort on your part , because you need to do some digging , background checking and some homework . It's only  when you've done this homework, will you be able to differentiate what makes one doctor better than another . Armed with this information , you can then ask the doctor intelligent questions , so that you can then select the doctor who’s right for you.  It can be a challenging exercise, but please don't underestimate your ability to do so.  You are smart , and there is lots of information available online about IVF
treatment .

You need to use both your head and your heart when making this decision. You need to consider both the quality of the facilities which the doctor offers, as well as your gut feel when you talk to the doctor.  What vibes do you get from the clinic ? Is the chemistry between you and the doctor good ? Does this doctor seem to care about his patients ?  Is he open and willing to share information ?  Will he provide me with a shoulder to cry on?  It's hard to know what will happen when push comes to shove , but you need to trust your intuition.

Just like you do your due diligence when buying a car or deciding which movie you want to watch, you need to use the same kind of process when selecting an IVF clinic.


Need help in finding the right IVF  clinic ? 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 !

Finding the right IVF doctor

Patients come to us from all over the country , and they often ask me if they can do IVF in a clinic in their own hometown. We’re quite happy to offer them this option, because it's much easier for them to take treatment locally , as compared to travelling all the way to Mumbai.  Also, it's quite likely to save them money. However, while it may reduce their cost, they don't want to save money at the expense of reducing their chances of success. A low cost IVF clinic may also be a low success rate IVF clinic.

However, the problem is that it's very hard for them to judge how good or bad the local IVF doctor is. Today, IVF clinics are mushrooming left , right and center. Every gynecologist seems to be starting an IVF clinic in every nook and corner of India. How are they supposed to judge whether the clinic is any good or not? This can be a challenging exercise - and they want me to make a recommendation . It's impossible for me to do so intelligently, because I don't know most of these doctors, so how can I vouch for them ?

Some will select a "brand name" chain of clinics, but this can be dangerous, because though they may look great on paper and on their website, often the doctors in these chains of clinics turnover rapidly , and the doctor who treats you may be polished and have a great bedside manner, but may have very little hands-on skill or expertise in doing IVF.

What is the poor patient to do? Here are 2 simple tips , but these will work only if you are willing to do your homework .  Ask the doctor direct pointed questions ( for example, Why don't you recommend a blastocyst transfer routinely ?) , and then see how well he answers them. If a doctor respects you and explains his approach, this is a good sign and suggests that he will continue treating you like an intelligent adult during the treatment. If , on the other hand , he gets irritated or angry by your question during the consultation , you should worry a lot . This is a red flag , which means he's not likely to entertain your questions during a treatment cycle, and may not be open or transparent or share information with you .Even worse, if your cycle fails , he’s quite likely to abandon you because he doesn't want to be bothered by your "silly questions" .

The second question patients should ask head on is - Why should I come to you and not Dr. X . This is a very valuable question, because it allows you to learn a lot about the doctor's attitude . If the doctor bad mouths his competitor, this is a black mark. A good doctor would be respectful , not only towards the patient , but towards other IVF doctors as well , and rather than try to out the other IVF doctor down , he will try to explain what makes him better or special or different.

With these two simple questions , you will be far better equipped to find a doctor who is right for you. The good thing is that you don't need to worry about how many bad doctors you need to eliminate in order to find that one good doctor - the one person who is right for you . Because there are so many options today, your ability to find the right doctor is high , if you're willing to put in the time and effort to do so. It can be a time-consuming exercise, but it well worth doing it , so that you have peace of mind that you've taken treatment at the right clinic.

Also, please confirm that his clinic is registered with the ICMR. This will ensure that they meet the basic minimum criteria laid down by the Govt of India. Every IVF clinic should be happy to share their registration certificate with you. If they do not do so, this is a red flag !


Need help in finding the best IVF doctor ? 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 !

Free Animated Cartoon on Making Babies - What to Expect when you aren't expecting

Check it out at http://www.ivfindia.com/what-to-expect-movie/babymaking.html

Decoding Medical Gobbledygook - free book on Improving Health Literacy from Dr Malpani

Should you treat the endometriosis before doing IVF ?

Lots of patients who have endometriosis are infertile , and they are not sure what they should do. Should they treat the endometriosis first? or should they treat the infertility first? Often the advice they get is conflicting !

A gynaecologist who specialises in laparoscopic surgery will tell them that we need to treat the endometriosis first,  before you can do anything further. They say that even if you need IVF,  we first need to remove your endometriosis surgically . The rationale for this apparently is that if the endometriosis remains behind , it will interfere with the IVF treatment cycle and reduce IVF pregnancy rates. This seems to make sense, but is actually quite illogical.

If you have endometriosis and need IVF , there is no need to do anything about the endometriosis per se, because the endometriosis is outside the uterine cavity and is not going to affect the embryos , which need to implant in the uterine cavity . In fact, unnecessary laparoscopic surgery can reduce your chances , because removing the chocolate cyst causes damage to normal adjacent ovarian tissue , and this reduces the ovarian reserve even further. As it is , patients with endometriosis have reduced ovarian reserve, because endometriosis eats into their ovaries , and doing surgery just makes a bad problem even worse.  When patients do the surgery, and then go for IVF, they find that they are not able to grow good quality eggs, because the surgery has reduced their ovarian reserve. They then complain that the doctor performed unnecessary surgery, only in order to make money !

A recent Human Reproduction paper, published in March 2015, " Surgical diminished ovarian reserve after endometrioma cystecomy versus idiopathic DOR: comparison of IVF outcome" , Audrey Roustan, et al) proves that the chances of IVF success are decreased in women with diminished ovarian reserve after cystectomy for endometrioma. This is especially true for women with bilateral endometriomas.

Why is there such a difference of opinion ? The reason is because of the over-specialisation in medicine today. Each specialist has a very myopic view, and is focussed only on his specialty. After all, when all you have in your hand is a hammer, you are likely to see only nails. Because gynecologists don't have any training or experience in IVF, they don't realise the inadvertent harm they end up causing their patients by doing this surgery.

The surgery can be quite gratifying for the surgeon, and  the before and after laparoscopic images are quite impressive, because the surgeon removes the adhesions and clears the pelvis. However, while the pelvis may look much prettier after the surgery, this is not very useful because it does not help to improve fertility.

So what is the poor patient to do ? You are likely to be confused, because you are getting such conflicting advice. After all, there are patients with endometriosis who do conceive after laparoscopic surgery ! And if the surgery can help you get pregnant in your own bedroom, and save you the expense of doing IVF, then isn't it worth considering ? And isn't Dr Malpani likely to be  biased towards advising IVF because he is an IVF specialist ?

The trick is simple - it lies in selecting the right patient for the right treatment. Thus, patients with endo who have a normal AMH level and a normal antral follicle count ( which suggests they have normal ovarian reserve) could consider trying surgery, if they are young, and their husband's sperm count is normal. The surgery may offer them a window of opportunity and if they understand the pros and cons, then it's an option worth exploring.

Ideally, endo patients should be treated by a multidisciplinary team of doctors, where both gynecologists and IVF specialists can provide their viewpoint, and the patient can balance both perspectives  and then make up her mind.

However, IVF is often a better option - for example, if you are older, your ovarian reserve is poor, your tubes are damaged , or your husband's sperm are abnormal. If you do need IVF, then you should could just go ahead , and not waste your time doing laparoscopic surgery before the IVF cycle .

What if you have a chocolate  cyst ? Will this affect your IVF treatment ? If it’s less than 3 cm , we can leave it alone because it doesn't affect IVF treatment at all . If it large , we can aspirated it before we start your super ovulation . This means it can be treated non-surgically .

Similarly, there's no need to suppress your endometriosis medically with GnRH agonists such as Lupron before starting IVF.  This temporary suppression jst wastes time and does not improve IVF pregnancy rates.

Just because you have a cyst on your ultrasound scan ; or have pelvic pain , this doesn't automatically mean that this needs to be treated. The good thing about IVF is it's a very effective shortcut, that bypasses all the problems , and maximizes your chances of getting pregnant quickly . The beauty is that once you do get pregnant with IVF , you will get dramatic relief of your pelvic pain, and your endometriosis will usually regress while you’re pregnant , and while you're breast-feeding as well.

Not sure whether you need IVF or laparoscopic surgery for your endometriosis ? 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 !



 

Gujarati edition of How to Have a Baby - free download !

Marathi editon of How to Have a Baby - free download !

Hindi edition of How to Have a Baby - free download !

Failed IVF implantation - what should you do when all the results are normal ?

A failed IVF cycle cause a lot of anguish, both for the patient and for the doctor.  It's very frustrating when the cycle fails, and the first question the patient asks is - Why did it fail, doctor ?
Doctors are under a lot of pressure to answer the question, which is why they order a panel of tests to try to pinpoint why the embryos did not implant.

Sadly, the truth is that our tests are of very limited use in this setting. We do know that the commonest reason embryos do not implant is because they have genetic defects within them, which cause them to arrest. This is Nature's defence mechanism, to prevent the birth of an abnormal baby.  However, the genetic tests we have available today are quite crude.  Thus, tests such as PGS/CCS/NGS only allow us to count the number of chromosomes - we cannot analyse defects at the gene level as yet.

The big danger is that testing is not benign . Great potential exists to harm the patient by doing unnecessary tests, many of which produce false positive results. Thus, doctors will do a test for TB PCR, and "treat" completely normal patients with nine months of toxic drugs .  Others will check for " NK cell activity" and treat patients with expensive IV immunoglobulins, of unproven efficacy. Our first sacred oath as physicians is to “do no harm,” and we should approach such " therapies " with skepticism. A " pseudodiagnosis " can end up wasting a lot of time and money !

My advice to patients who have had a failed IVF cycle and have had a workup done by an IVF specialist with no clear answers is this:  Please accept the fact that we may not be able to provide you with answers. Instead of responding with despair, please rejoice that everything is normal . Count your blessings that there are no problems ; and understand that even though our technology is not very good for identifying problems, IVF is great for providing solutions by bypassing them . And just because 1-2 IVF cycles have failed does not mean that the next one will as well - all you need is patience, motivation and resilience. The rewards are well worth it !

Empower yourself and fight back , instead of depending on the hope that you will “get an answer” if you just find the “right doctor.”  Above all, realize that no answer is better than the wrong answer !

Not sure what to do after your 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 !

Cost effective IVF treatment

IVF represents the best chance for having a baby for most infertile couples. IVF treatment has a high success rate, and can be cost-effective, because it shortcuts time , so that instead of waiting for multiple cycles in order to get pregnant , one cycle of IVF maximizes the chance of conceiving. Even better , IVF allows us to bypass lots of hurdles which occur naturally , and is often the final common treatment pathway for many infertile couples .

The problem with IVF is that it's so expensive ! This is especially true in the US , where IVF treatment costs an arm and a leg . IVF  treatment in India is far cheaper, because even though we use the same equipment and have the same success rates, doctors in India charge much less than what US doctors . Because we can afford to do IVF treatment for a fraction of the cost of what it would cost in the US , lots of patients come to India for medical treatment.

Of course , one can't look at only the cost of the cycle - one needs to balance this with the success rate. Part of the problem is that sometimes patients are so focussed on getting the cheapest rate, that they end up going to the IVF clinic which also has the lowest success rate. When poorly informed IVF patients go doctor shopping , without knowing what the hallmarks of a high quality clinic are , they often get cheated, and end up receiving poor quality medical care. The focus should not just be on how much you're spending, but it on how cost-effective the care is !

Even if you "save" money by doing IVF at a low cost IVF center, and you then end up getting poor quality care , you're actually far worse off than when you started. Complaining afterwards that the clinic did not even you give you photos of your embryos does not help . Poor quality clinics usually provide poor quality documentation, and this is commonest complaint patients have about these low cost IVF clinics. Not only does poor care does not give you a baby , to add insult to injury , you end up frittering away your money , a little at a time.  Not only does this deplete your bank balance and prevent you from getting high quality IVF care at a better IVF clinic , it knocks your self-confidence down , and you lose faith in all IVF doctors. After all, if your experience with one IVF doctor is bad , you're not likely to trust any IVF doctor in the future !

The trick is not to go in for the cheapest IVF clinic, but to do your homework and find one which is cost-effective. This doesn't mean that the most expensive IVF clinic is the best either , and it's important for patients to find clinics which offer the right balance . This is why you need to do your homework , so that you can find clinics that offer reasonably priced IVF treatment, with a high success rate , allowing them to have the best of all possible worlds.

The important thing is not whether the IVF treatment is cheap , or what the cost of a single IVF cycle it. What you should really be looking at is the cost for a baby - how much does it cost for you to take a baby home? This is the most important figure , but it can be extremely hard to calculate this figure .
Finally, when you calculate cost , it can’t just be in terms of how much money you spend, but also how much time and  emotional energy you are investing in the pursuit to have a baby.

You need to find a clinic which offers cost-effective treatment , at a fair price , which maximizes your chance of getting pregnant because it provides personalized hands-on care , and respects you as an individual.

Want to find the right IVF clinic ? 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 !

Hindustan Times articles - are health apps good for your health ?

Experts in India said that apps are nothing but complementary tools for facilitating good health or even treatment. “Apps cannot replace doctors or a healthcare provider, it can only complement. But after all that a patient has to rely on the expertise of a doctor,” said Dr Aniruddha Malpani, IVF specialist.


Health apps can be thought of as being medicines. While they can be self-prescribed and used " over the counter " ( OTC), they work much better when they are prescribed by a doctor. Apps can have side- effects too ( for example, some users start using them obsessively !) The doctor needs to learn how to prescribe apps ; when to prescribe them; whom to prescribe them to; and how to monitor their use.

http://www.hindustantimes.com/mumbai/studies-argue-if-health-apps-can-impact-our-well-being/article1-1337668.aspx

Why patients need to find an IVF doctor they can trust

I'm very pleased when IVF patients do their homework and arm themselves with information so that they can have realistic expectations of their treatment. It's important that they try to drill down , and understand what their treatment options are. For example, I feel every IVF patient should know the difference between a day three and a day five transfer , and the pros and cons of both, so they can make well-informed decisions. It's much easier to partner with these patients, because we can factor in their preferences and opinions, and this helps us to maximize their chances of getting pregnant.

However , there is a fine balance between being blissfully unaware, and trying to play doctor.

Some patients carry their homework too far , and end up confronting the IVF doctor. For example, they will challenge every recommendation their doctor gives them. While it's important to be assertive, being aggressive does not help - and this is a line which patients and doctors both need to respect.

Now presumably the doctor you have selected is an expert , and has thought through carefully about the treatment plan he has crafted for you. ( I agree this is not always true, and many assembly line clinics will use a "tick-box", one-size-fits-all generic treatment plan for all their patients. If you think this is happening in your case, please push back and find  another doctor !)

However, there are some patients who will do a Google search , find alternative options , and then ask the doctor, Why are you suggesting a short Lupron protocol? This website from the USA suggests that a long protocol is better ! Why aren't you using that for me ?

It's important to clarify your doubts, but taking a confrontational attitude is not helpful . Patients need to find a doctor they can trust , and while it's important to verify what the doctor is saying, this doesn't mean that you should treat everything he says with suspicion either ! There's lots of information online but a lot of this information is not provided in the right context. Knowledge is power, but you need to convert that knowledge into wisdom first . This is why you need to find a doctor who you can trust , who understands what your individual problem is ; and who will then define a protocol to maximize your chances of getting pregnant.

If you cannot trust your doctor , and if you do not feel that your doctor has your best interests at
heart , then you should find another doctor. If you find that you need to crosscheck every suggestion he makes with Dr Google, then this is a sign that perhaps this doctor is not the right one for you.

While you don't need to blindly trust your doctor, at some point you need to understand the boundary between being a patient and being a doctor. Once you trust your doctor, you should give him the freedom to make the professional medical decisions - after all, this is what his job is, and that's what you are paying him his fees for !

Cross questioning him all the time will not only irritate the doctor, it will also end up leaving you very confused. The reality is that there are many ways of superovulating a patient , and it's not that one way is always better than the other . In fact, the reason there are so many protocols means that no single protocol works best all the time for every patient ! It's important that the doctor uses a protocol which he's comfortable with , and with which he has had good results because he is experienced with utilising it, rather than trying out the newest and latest protocols , because that's what a particular website or a particular IVF clinic does.

The trouble with a lot of new protocols is that they have steep learning curves , and in fact pregnancy rates can drop sharply while the doctor is trying to master these protocols . The patient would be far better off if the doctor uses a protocol he's comfortable and confident with , rather than try something new because that's the "flavour of the month". Sometimes, old is gold !

Need help in understanding your IVF protocol ? 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 !

Coping with IVF stress

There is no question that doing IVF is stressful.  It can be hard to deal with this stress because the major problem with the IVF cycle is the uncertainty of the outcome. No matter how hard you work, no matter how good your doctor is, no matter how beautiful your uterus is or how gorgeous your embryos are , you can never be really sure whether the cycle will end in a baby or not.  This uncertainty can be nerve wracking for the patient. 

I agree that while it's no fun coming to me for IVF , not having a baby can be stressful too ! The right time to come for IVF treatment is when stress of trying to make a baby in the bedroom is more than the stress of coming to me.  I tell my patients that coming to Dr Malpani should actually be a stress relief mechanism . IVF represents your best chance of having a baby , and we are going to give you the best shot possible , so that you can achieve your goals as quickly as possible. 

This is why we spend a lot of time counselling our patients,  preparing them for the ups and downs of the IVF cycle . We try to hand hold them as much as possible, but no matter what we do, patients have to tap into their own emotional resilience . For some patients, it can be one of the most stressful things they have ever done in their life . For other patients , who are more mature, and who have seen more of life, they find that because they have dealt with a lot more difficult situations in the past, they can cope with the IVF cycle with ease.

I think this is the key -  that it's not so much the stress of the cycle itself, as compared to how the patient chooses to cope with the stress .  Complaining about the injection pain or feeling sorry for yourself just makes matters worse. Mature patients go through an IVF cycle without batting an eyelid, because they take the approach that they should be grateful that at least they have the financial means to be able to take advantage of this technology !

Patients need to find that internal strength within themselves , and for the ones who do that, coping with an IVF cycle becomes much easier. Having realistic expectations of success helps to make the ride much easier !


Need help in coping with the ups and downs of IVF treatment. 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 !

Why IVF doctors need to spend more time talking about failure to their patients

Infertile patients think of their IVF doctors as advocates, because they believe they are armed with the best knowledge available, and they trust that their doctor will do what's best for them.

Doctors are usually very happy to talk about their success stories  ( for example, a common ploy is to describe a complicated patient who is now pregnant after treatment at the clinic). This strategy is very helpful in building up the patient's confidence, so she feels that this is the right doctor for her.

However, the elephant in the room is the topic of IVF failure , and many doctors try to sweep it under the carpet. However, we don't only talk about our success rates - we also discuss failure rates with our patients at the first consultation.

Some patients complain that Dr Malpani is negative or pessimistic.  This is not true. I feel it's important to discuss failure frankly and upfront , so that patients have realistic expectations of the IVF process, and learn not to focus solely on the outcome.

Whether the patient brings up the topic or not, the possibility of failure is one which haunts the IVF patient. They are often scared to talk about it, but it does keep them up at nights. Not talking about the possibility only adds to their stress levels, because they are then forced to bottle up their worries inside them.

I feel that talking about the possibility of IVF failure will only increase the trust patients have in IVF doctors, and a good doctor will take the time to discuss what the next course of action will be , in case the cycle fails.

Need help in coping with 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 !



 

Knowledge Makes IVF Treatment Easier - Why you need to become an expert patient

As a patient, you need to invest energy in doing your homework about your IVF cycle , and learning about the medical details and the technical minutiae. This will make your IVF treatment easier , and much more interesting as well .  You can actually play a game , because if you know what the next steps are going to be, you can prepare for these . You could even compete with your spouse, to see who knows more ! Even better, if you know what's going to happen , you are not caught unawares if things aren't progressing as expected, and can ask intelligent questions and prevent complications.

Thus, if you are taking super ovulation drugs , you know you will start having a vaginal discharge , which is actually a good sign because this means that your follicles are producing oestrogen which is causing your cervical mucus to become stringy and thin. This is not a sign of a vaginal infection , so you don't need to panic unnecessarily. 

Similarly, when you know that the doctor is doing ultrasound scans to track the growth of your follicles , you can eagerly forward to seeing the screen and admiring your growing follicles.  Not only does this make the IVF treatment much less stressful, it also gives you a sense of control , because you know what the next steps are going to be, and you don't get blindsided by unpleasant surprises.  

Equally importantly , if things don't go as planned , you will know that something is amiss , and you will be able to discuss this with your doctor , so that he can explain to you what they can do to tackle some of these unforeseen problems.  Going through IVF can be stressful, but knowledge is power , and you can use this knowledge to make your IVF treatment easier to deal with. 

You can also share your knowledge with the other patients in the IVF clinic , so that you can help them to traverse their IVF journey with greater peace of mind . Being generous with your knowledge will help them - and the best way of helping yourself is to help someone else.  Sometimes there are all kinds of silly niggling doubts which trouble IVF patients.  Patients are often scared to ask the doctor any questions, because they feel the doctor is too busy , or may get irritated if they pester him with their queries.  If you are a well-informed patient, you can be the go-to person in the IVF clinic so that the other patients can come to you and ask you questions . You can help them resolve their doubts, so they can continue their IVF journey being troubled by unimportant worries which don't allow them to sleep well at night .

Rather than complain that the IVF doctor doesn't tell you anything, you need to become proactive, and learn as much as you can about IVF on your own. The more you know, the more your doctor will respect you !

Our free IVF e-learning course at www.ivfindia.com can help you to become an expert IVF patient ! If you need more help, 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 !

Failed Implantation - the wastepaper basket diagnosis

When patients come to me for a second opinion after failing an IVF cycle in another clinic , the first question I ask them is - What did your doctor tell you as to why the cycle failed?  I get lots of different answers.  Some of them say that the doctor never bothered to explain ; or that the doctor never met us after the failure. However, the commonest answer is - The doctor told us the reason for the failed IVF cycle was failed implantation. 

Now, this is  a complete non sequitur.  All the doctor has done is use a fancy medical label in order to pretend that he has made a " diagnosis" .  Actually, this label is a cover up for our ignorance.  Failed implantation is just a descriptive term for the fact that the patient did not get pregnant after the embryo transfer because the embryos didn't implant.  It really does not tell us why the embryos didn't implant ! Did the doctor feel the embryos were of poor quality?  or that the endometrium was too thin?  or was the embryo transfer technically difficult? 

It is very easy to fob off poorly informed patients with these fancy medical terms . When a doctor uses medical jargon like this , he positions himself as an expert and deliberately tries to distance himself from the patient, so as to tell the patient - I am the expert, you're just a patient and you won't be able to understand all the complexities as to why the failure occurred, so don't ask me pointless questions because the answer will just go over your head. Just let me do what I think is right for you , and don't bother me with too many questions. 

I think this is a very immature approach . Doctors need to level with their patients , and it's perfectly fine for doctors to be honest and tell patients that we don't know why the embryos failed to implant, even though they were of good quality and your uterine lining was fine. After all, medical knowledge has lots of lacunae , and technology has its limitations . We are still not capable of answering these questions, even though we'd love to be able to to !

A more truthful analysis would be -  Let's review your cycle together. These are the things which went well, and these are the things which didn't go well. Therefore , we will make the following and changes in your next cycle , so as to maximise your chance of getting pregnant.  Patients appreciate being treated with respect as intelligent adults by their doctor and if doctors learn to do this, they will find their patients are much more loyal and faithful to them.

Need help in making sense of "failed implantation" ? 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 !

Why IVF patients need to speak up and complain when they are unhappy

Most IVF patients tend to be quite docile and meek. Even when they are not happy with the care they are receiving, they usually keep quiet. While they may complain vociferously about the IVF doctor behind his back, few have the courage to speak up and register their displeasure with the IVF clinic directly.


Thus, we hear lots of complaints about other IVF clinics when patients to come to us after a failed IVF cycle elsewhere. And I am sure our patients must be having complaints about the care they have received at Malpani Infertility Clinic when they fail an IVF cycle in our clinic and go elsewhere.


However, complaining about Dr Malpani behind my back is not very helpful - either to me; or to the unhappy patient; or to the other patients who come to us.


If my patient complains to me ( instead of about me, to someone else), then at least I have the opportunity to try to fix the problem. After all, if I don't know what the complaints are, how can I resolve them ? If I can resolve the complaint, the other patients who come to me will not have a chance to complain about the same issue,  and this is a step in the right direction for everyone involved. Yes, it's true that I may ignore the complaint, but at least the patient is no worse off.  She has got a chance to blow off steam, and by giving me chance to address her complaint, she is taking constructive action. You don't need to be aggressive - you just need to be assertive. In fact, complaining can help the unhappy patient as well, because it helps her to vent , instead of bottling up her distress.

The trouble is is that when something goes wrong with medical care, patients are not as likely to complain as they would if we got bad service in a store or restaurant. They may worry that speaking up will undermine their care, offend the doctor and nurses or interrupt the IVF treatment. Many patients may be too angry or too afraid to confront the doctor especially if they are still receiving medical care from him . Others may think, “What difference does it make? The problem has already happened. It’s too late to do anything now.”

However, speaking up and complaining is important because:

    action can still be taken to improve the situation after the fact
    action can prevent the problem from becoming worse
    action can prevent the problem from happening to others

You need to speak up - not just for your sake, but for the sake of other patients as well !

Have complaints about your IVF treatment, and not sure what the problem is ? 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 !

Living each day one at a time- a skill required for an IVF couple

This is why I love being an IVF specialist - I learn so much from my patients every day.

Here's a guest post from our expert patient.

An infertility journey was never a part of my chosen life plan. Chartered accountant at 22- check. Be settled in a good job at 23- check. Find perfect partner by 25- check. Buy a home by 30- check. Have a family with two kids at 32 – no check… 34… no check… then what?

Life had a different path in mind. Things had gone according to my plan with a few hiccups and a few bonuses so far but it was time for some lessons. And somehow- I was forced to accommodate these detours and everyone around me had to learn to do the same. If infertility has taught me one thing- it’s this- look back only for lessons learned, look forward only for hope, live each day one at a time- putting your best foot forward.

I faced it all- unexplained infertility, IUIs, IVFs, first trimester losses- what seemed to be unlucky but deep enduring lessons all in all. The past can be frightening and others’ stories, even more so. The future can be terrifying- the unknown can create a chill run down your spine because you never know what’s in store. But today- today is beautiful and we all need to learn how to enjoy that.

When I was infertile, I felt that once I got pregnant, I would be on top of the world, and would never ask God for anything ever again . I was willing to give my right arm and leg to have a baby. I am pregnant now, and it's a great feeling. However, pregnancy also brings its own set of challenges,  as I am sure parenting will. It's not as if all  the problems disappear once you have  a baby ! I have learned that with every day, we exchange a new set of problems for the old ones, and God gives us the strength to cope with these as well.

How can you enjoy today successfully? Find joy in small things is my favorite mantra that seems to work most days. A simple sunrise or sunset, a good song, planting your garden, the smell of a flower, a movie, loud laughter, a good book, sailing, time with your nieces and nephews, a prayer session, a favorite meal, a yoga or zumba class, a shopping expedition, a card session, there are so many little pleasures that can be had if you just stop focusing on what you can’t have (or simply can’t have right now). And then be patient, do the deed- whatever it may be- and let there be hope. Also, the company of wonderful ears can be a big support- then whether you choose friends, family or a professional life coach or therapist is up to you- but I think it can really help.

Yes, I guess there will always be bad days- but who doesn’t have those? Even those people with seemingly everything have those. A blurb I recall (in my own words)-  Young Girl: “I hate Facebook, every time I log in it seems like everyone has a partner, house, pet or baby- I feel so under-accomplished…” Wise Woman replies “Yes- that’s because they don’t post pictures of arguments, broken roofs,dog shit on carpet and spit up on couch! Everything has a price- you just don’t always see the tag…” 

So- you don’t want to live your life by others accomplishments and standards. Accept your own challenges and live them day by day. Spend time being grateful for what you do have and keep the faith strong!

Is IVF treatment at Malpani Clinic expensive ?

One of the common complaints patients have about Malpani Infertility Clinic is that we are expensive.  It can be hard to argue with this perception - after all, how does one decide what the right price for IVF is ?

One way of estimating the "correct cost", and judging whether we are expensive or not, is by comparing our charges with those of other IVF clinics . It's true that we do charge more than some clinics, but then it's equally true that we charge less than others ! What's the right number ? What should patients use as a yard stick ?

I feel that it's not fair to look at just the costs , and then complain about how much we charge . We are open and transparent about our costs, and we charge what we tell the patient we are going to charge. This means that the patient is aware of the cost she is going to incur when she does the IVF treatment at our clinic , and she should really have no complaints when this is the amount she has to pay . This is why we share our charges and costs with patients , and we publish this on our website as well, so that there are no surprises afterwards.  This is also why we offer total package costs , which are all inclusive , and which cover the entire procedure, so there are no unpleasant add-ons or surprises afterwards.

Because this information is on our website in black and white ( unlike most other IVF websites, which are very coy about their fees),  patients who take the trouble to read this know exactly what is going to happen ; how much they are going to have to spend ; and when they need to pay.

Yes, IVF treatment can be expensive, but a baby can be priceless , and our focus is on giving our patients cost effective treatment , to maximise their chances of having a baby.  Our focus is not on trying to reduce our costs by cutting corners , but to cleverly  use the right technology , which will help us to produce good quality embryos , to improve the chances of our patients having a baby.

One of the reasons IVF treatment is expensive is because everything we use is imported and disposable ( use-and-throw), and these costs need to be incurred in order to provide high quality care. 


We also take pride in not employing any assistants, so that the care we offer is very personalised and hands-on.

Want more information on how we can help you realise your dream ? 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 !

The Advantages and Disadvantages of Doing IVF at Malpani Infertility Clinic:

There are lots of IVF clinics in India today and patients have lots of choices.  Should they go to the one closest to them?  Should they go to the one that is the most expensive?  Should they go to the one which is cheapest?  Or the one which advertises the most? 

One of the commonest questions patients ask us is at the first consultation is - Why should we come to you?  What makes Malpani Infertility Clinic any better or any worse than other clinics ?   This is a very valid question - after all, the chances of IVF success do depend on selecting the best IVF
clinic !

Now every IVF clinic thinks they are the best, and so do we, but I start off first by listing the disadvantages of coming to us, so they are aware there is a downside to our services - after all, everything in life is a mixed blessing.  Perhaps one of the biggest disadvantages of coming to us is that we are at a single location , which means we are only present in our single clinic in Colaba in Mumbai . This means that if patients want to take treatment from us,  they have to come to us - we won't be coming to their town to treat them.  Another issue is that we are expensive - perhaps not the most expensive clinic, but one of the pricier IVF clinics.

In one sense though, both of these are actually advantages.  The fact that we are in a single location means we are here all the time . We don't have to travel to other places , which means that when the patient comes here, the patient is confident they will find us here.  This is the reason why our care is so personalised; there are only two doctors in our clinic, Dr Anjali and me; and just one Embryologist, Dr Sai. All our care is very hands-on, and because we have chosen not to employ any assistants we do everything one on one ourselves. This way patients have the advantage of all the accumulated years of experience which the three of us have together. This allows us to use all this expertise to maximise your  chances of getting pregnant . We think is this far better for the patient, as compared to other IVF doctor who run around and have five different clinics , because they are trying to treat as many patients as possible. 

Patients do have complaints about us - after all, I don't think it's possible to keep everyone happy all the time. This means that while it's true that there are some patients for whom we are not the right IVF clinic, for educated, well-informed patients who have perhaps failed an IVF cycle elsewhere, and who want to take treatment in a clinic which will provide personalised, hands-on care, we are a good choice . Our patients know that they'll be able to talk to us every single time they come here - and that I respond to all my emails personally and quickly We have a high success rate , and we take pride in the fact that we can deal efficiently with challenging patients who have failed IVF cycles elsewhere.

We take pride in treating our patients as intelligent adults, and we respect your personal preferences and choice.


Looking for a boutique IVF clinic which specialises in pampering patients ? 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 !

Why every IVF patient needs to become an expert !

Most patients are not very interested in learning all the ins and outs of IVF.  After all , why should you care about the technical minutiae of IVF - you just want to have a baby ! You hated biology in high school - and you can't make sense of all the polysyllabic technical jargon the doctors spout . And does it really matter if you don't understand the different between a follicle and a cyst ? Isn't that the doctor's job ? Why should you break your head trying to make sense of it ?

Most patients are very happy to entrust their care to an IVF specialist , who understands all the bits and bobs of doing IVF . They want him to take charge, so he can do what is right for them.  Now this works very well if you are lucky and you have found a good IVF specialist. But what happens if your IVF doctor is not very good ? And how is a patient supposed to differentiate between a good doctor and a bad doctor ? After all, they all look the same, don't they ?

The whole point of becoming an empowered, expert, engaged activated IVF patient doesn't mean that you need to spend time in the laboratory learning how to fertilise your eggs yourself.  What it does mean is that you take the time and trouble to understand enough about the IVF process , so that you can judge whether your IVF doctor is going a good job or not. Is his advice sensible ? Does it fit in with accepted medical parctise ? Or is he promising too much ?  Is he overtesting ? overtreating ? doing too little ?

Unless you do your homework, you are not going to be able to judge the quality of the doctor's decisions . The truth is that having a baby is so important , that you can't afford to leave everything up to the doctor . You must learn to take an active interest in your  treatment. 

As we all know, the squeaky wheel gets the grease , and the more well-informed you are, the better the quality of the questions you will be able to ask your doctor. Your doctor will respect you more, and this is the best way of ensuring that the quality of care he will provide you with is high.

Want to learn more about IVF in a painless fashion ? Check out our free IVF e-learning course  at www.ivfindia.com.

Need more help ? 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 !

Complaints about assembly line IVF clinic

In order to increase their business, some IVF clinics in India take out full-page ads in the newspapers ( even though advertising is unethical and illegal according to the Medical Council of India). These ads are very attractive, and they promise the moon to infertile couples.

This IVF clinic offers all kinds of sweetheart deals - at a rock bottom price. It's very tempting for patients to check out the IVF clinic so they can have a baby ! After all, why waste your heard-earned money if an IVF clinic is willing to do IVF for you at a 50% discount. And the fact that they can take out a full page ad must mean they are rich and successful,correct ?

These ads are targeted at the poor , who are extremely gullible. They do not even understand the difference between an ad and an article, and believe that the fact that they read this in a newspaper must mean that it is legitimate , trustworthy and reliable.

Sadly, the treatment they offer is of poor quality. One of my patients told me - Dr Malpani, the IVF clinic is a like a railway station - they do over 1000 IVF cycles every month ! There is no personalisation of care; no privacy; very little quality control; and the documentation is pathetic.

Of course, the fact that they are flourishing means they they are providing a much needed service. However, this does not justify cheating patients, or not conforming to basic medical standards, just because the treatment is cheap. They are quite unethical, and will often use donor eggs, donor sperm and donor embryos to maximise the patient's chances of success, without even bothering to inform the patients about what they are doing.

I am happy that they are making IVF services more affordable, which means that even poor couples can consider trying IVF treatment . However , cutting corners is a dangerous game to play, and this can end up damaging the reputation of all IVF clinics in India.

IVF patients need to complain when they receive poor care - but because the patients who go to this clinic are so poor and powerless , they will never do so , which means the clinic will continue to get away with murder !

Not sure which IVF clinic to trust ? 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 !

The confused infertile man with a low sperm count

I received this email today.

I have a low sperm count ( severe oligoasthenospermia). We have seen 3 urologists so far and each giving us different opinions. The first was found a cyst in the prostate and a grade 1 varicocele on right testes and a grade 2 varicocele on left testis. This doctor asked us to proceed with TURP. When we visited the 2nd urologist and mentioned this to him, he said that TURP is completely out of the question and he suggested that we do a varicocele surgery instead. Last month, we underwent an IVF ICSI procedure and that was unfortunately negative. Yesterday we met with the 3rd urologist who checked the reports and he said that the varicoceles are not very significant so there is no need of the varicocele surgery at the moment. However, he feels that there is a blockage in the tubes leading to the prostate and the cyst in the prostate is causing this. He recommended repeating an ultrasound to confirm the diagnosis and if this is the case then to proceed with surgery to remove the blockage. If not, as an alternate, he suggested repeating the IVF ICSI cycle but collected sperm through the TESA procedure. What would you suggest? That we undergo surgery to remove the blockage or repeat an IVF ICSI cycle with TESA?

It's extremely common to see infertile men who are completely  confused as to what they should be doing. They complain when they receive such conflicting advise and don't know who to believe or trust.

Sadly, most IVF/ICSI specialists are typically gynecologists, who have no idea how to deal with male infertility. Most of them don't even know how to examine an infertile man, and their standard knee-jerk reflex when they see a man with a low sperm count is to refer him to a urologist or andrologist.

Now while a urologist is supposed to be a specialist in the treatment of genito-urinary problems in the man, most are specialists in dealing with the urinary system, and know surprisingly little about male infertility.

Andrologists are specialists in dealing with male infertility, but it's only the ones who work in an IVF clinic who can call themselves true male infertility specialists, because the treatment for most male infertility problems requires ICSI, which can only be done in an IVF lab.

Because of their lack of exposure to the newest advanced reproductive techniques, most urologists are clueless about treating the infertile man, as documented by the above real-life example.

For a man with a low sperm count ( oligospermia) , there's really no point in testing for a varicocele. Even if he has  a varicocele , surgically treating it will not help to improve the sperm count, which means doing the test is completely pointless, and will just mislead him.

Similarly, testing for a block in the male reproductive system by asking for a TRUS ( transrectal ultrasound) in a man with a low sperm count is completely useless. The fact that there are sperm in the semen proves that there is no block ! If there was a block in the male reproductive system ducts, the sperm count would have been zero . In  fact, a TRUS should only be done in azoospermic men with low semen volume , an acidic pH and a negative fructose, to look for an ejaculatrory duct obstruction. It should never be done otherwise.

This is why it's so important that tests for the infertile man be done selectively, after looking at his semen analysis report. However, most urologists are not well-trained enough to understand the value of proper testing. Like most specialists, they tend to over-test and order lots of pointless tests. Now these tests may throw up some abnormalities, but these are of no clinical important and should not be "treated" ! In fact, treating them will just make the problem worse ! Doing the TURP ( transurethral resection of the prostate) can actually cause retrograde ejaculation.

Similarly, if there are sperm in the semen, there's absolutely no need to do a TESA ( testicular sperm extraction). We can use the ejaculated sperm , and there's no need to subject the man to the unnecessary expense and pain which a TESA entails.

Do you have a sperm problem and are confused as to what you should be doing ? 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 !