Story of our infertility journey – From pause to play

          

We are a couple hailing from Bangalore and married for 7 years now.  We never planned for a family assuming that it will happen normally. Reality hit us somewhere around our 4th year of marriage when the ‘good news’ question was persistently thrown at us. After trying for couple of months, we thought its time to see doctors. This was the beginning of our rounds of fertility clinics, medicines and doctors. When we started with our first doctor (who is supposedly running Karnataka’s leading fertility chain), we were very hopeful with the treatment. Not once we questioned the medicines or line of treatment despite the measly attention given to us. There was absolutely no information on what medicines were given or chosen. IUI was done because the doctor felt like giving it one try before IVF. With ICSI, we got 9 A Grade embryos out of 16 eggs with 2 of them being blastocysts. It was an assembly line procedure – Be on the pill, routine scans done by junior doctors, take some mumbo – jumbo medicines and date of procedure will be announced. The only time when we get to meet the main doctor (who is the main doctor apparently) is only during result time. In 2 years which we spent at the awful ‘leading’ clinic, not once the doctor had the decency to discuss our case in detail. A maximum 10 minutes was spared at the start of the procedure and result time. According to her, the time when she announces our details just before entering the OR for the procedure is transparent enough for the patient. Maybe she has no clue that the patient she is treating is a living human being with basic intelligence and emotions. She even had the audacity of transferring an arrested embryo and proclaiming that I will definitely get pregnant without any doubt.

After wasting 2 years of our precious time and money, we were just stuck in a rut not knowing which path to choose. Constant questioning from friends and family were not helping instead either. Before I know it, I was avoiding family functions, friends who were moving on with their families, go off social networking sites – basically putting life on pause button. Every time I got a negative BHCG test, all hopes would crumble down and it would take enormous amount of strength to pull back and start again. At the end of our IVF cycle (end of 2013), I went to meet our so called fertility expert doctor for final analysis. It was the same day I had to get my 3rd BHCG test report from her. After making me wait for hours, she finally announced that it is negative and that I have something called unexplained infertility’. No logical explanation was given and after 15 minutes, she was not even interested in listening to me. She tried to sell me her latest acquisition – embryoscope and do a PGD analysis which comes with a cost. That’s the day I decided that she is no longer qualified to be my doctor and I am going to find a way on my own. Internet called and I was googling all possible options. Having a baby was almost turning into an obsession. Every waking minute was spent in thinking and researching.

I stumbled upon a blog of an old patient of Dr Malpani – myselfishgenes.blogspot.com. Her writing spoke to me and addressed all of my issues which my doctor was ‘supposed ‘to. Through her blog, I got to know about Dr Malpani and his work and writings. Though I was impressed initially with the vast amount of information, I was cautious because of all the bad experiences in the past. We were also worried that travelling to a different city was a huge financial burden and we weren’t sure of the results. After lot of thinking, we took a plunge deciding it’s now or never. We were sure that if it doesn’t work with Dr Malpani, we will look at alternatives. IVF was draining us emotionally, physically and straining our marriage. I stepped into Dr Malpani’s clinic with my reports and a bag full of questions. It took one meeting to get convinced that if this man can’t help me, then no one can and here is why – Dr Malpani took time to read all the reports including my first ultrasound taken years ago, making notes and asking me questions on every single medical report. Most of the times the only answer I had was – I don’t know or my doctor asked me to. He was also the one to point out that in one of our embryo transfer – an arrested embryo was used. I verified this information with 2 other doctors and they agreed with Dr Malpani. This was very upsetting and I just wanted to cry my lungs out for the trauma we had to endure.

He was clear on how he wanted to deal with me and gave me a customized treatment plan. For the first time in 3 years, a doctor took almost an hour to understand me and my history. Though my husband was skeptical, we kicked off the treatment. One cycle later I got diagnosed with a sub mucous fibroid in my uterus which was impairing my pregnancy chances. This never came up in my previous scans and IVF cycle making things crystal clear on gross negligence of my so called ‘Fertility expert’ doctor. Though I never had PCOD, I had a lot of fibroids (adenomyosis) resulting in painful periods. Dr Malpani explained the situation and after removal of my fibroid, we started our ICSI cycle. During the egg retrieval stage, my husband was extremely worried on me getting OHSS. Since we don’t live in Mumbai, we weren’t sure whom to turn into during emergency. Things went well and we got 9 blastocysts which means we had 5 shots at getting pregnant.  Before every transfer, we were shown the embryos inside the lab and my husband was present inside the OT during the transfer. Dr Malpani was a phone call or email away and I had all my doubts answered – even the silliest ones. When the second transfer failed, we found ourselves again at cross roads. Though there was no doubt on Dr Malpani’s competence, we were trying to make peace with fact that we will never have any biological children or maybe time to search alternative options again. But fate smiled on us and we got lucky on our 3rd attempt. If all goes well – fingers crossed, we will be parents to our twin babies in April.

To the person reading our story – Few facts to compare between your clinic and Dr Malpani (which we did)

1)    Not many fertility clinic / doctors take time out to know the patient personally or understanding their case history. Dr Malpani does the opposite. This is important because as the doctor treating you should treat you like a human being and not a patient / case file.

2)    Medicines are not explained before hand and neither the procedure. At Dr Malpani’s clinic, every medicine and every procedure is explained on its effectiveness, useful ness and why it is required including the side – effects.

3)    Patients are treated as dumb human beings, not intelligent enough to understand the fertility science so that doctors can play God. You almost think twice before asking a doubt forget expressing displeasure. Dr Malpani provides various avenues to educate his patients and the reason I know so much about my body, medical treatment and IVF is all because of him. Had he not made this effort to write relentlessly, I would have never known about him or IVF at all.

4)    I was asked to take anesthesia for embryo transfer which is a simple outpatient procedure. I was made to falsely think that the transfer is going to be very painful and to avoid pain, I insisted on going under each time. In 3 years I took anesthesia 7-8 times. It took a lot of convincing from Dr Malpani to get my consent for a no anesthesia transfer. His whole team including him made sure that I am comfortable at every step during the transfer. This kind of personal attention is extremely rare. The nurses were extremely cautious about me and not once they pulled away from me. I will be always grateful to all of them for the genuine care they gave me. Only an IVF patient can understand what it is for someone to boost your confidence during the procedure.

5)    Fertility clinics give a picture of the embryos once the transfer is done as part of their discharge summary. Dr Sai who is the embryologist at Dr Malpani will show and explain your embryos before the procedure inside his laboratory. I have never seen this level of transparency with even best of the hospitals. This shows the level of expertise and technical competence of Dr Malpani’s team.

6)    Husbands are allowed inside OT which is a boon for women undergoing the procedure. I for one cannot thank Dr Malpani enough for thinking about his patients comfort. Having your husband or any known person beside during the procedure will be comforting and relaxing and you tend to feel less threatened by all the other activities.

7)    Fertility clinics have a very stereo typical clinical approach for transfers but Dr Malpani ensures to talk to you during the procedure. He does not make it look all serious but constantly checks on you while doing his work. You are made to feel like you are a part of the whole process and everything happens with your consent.

8)    Fertility clinics run offers like pay for one cycle and get another free. Packages will be discussed first. For middle class people like us – it does sound attractive but you get what you pay for. IVF is expensive so you have to make sure that you are getting your money’s worth. No doctor can guarantee a 100 % success rate, hence do not fall prey to such bogus money making schemes!

We continue to share our experience with almost every other similar couple we come across because we genuinely believe that Dr Malpani gives a 100 % to each and every patient. Thank you Dr Aniruddha and Dr Anjali  Malpani for pressing the play button of our lives. We will always be grateful for everything you did for us.

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Why Do IVF Patients Shirk from Asking Their Doctor Questions?

While I was consulting with one of my patients, I wanted additional information about her previous IVF cycle and asked her- “Did you ask your doctor why he selected that particular dose of HMG injection for your super ovulation?” She seemed visibly puzzled and said “How can I question my doctor? Isn’t that rude? Won’t he get offended if I ask him questions? I don’t want to upset him by challenging his authority.”

She went on to say that since she doesn’t understand any of these medical terms, she felt it would be out of bounds to question her doctor. And even if he did answer her question, she wouldn’t be any more enlightened, as it would be nothing more than medical jargon.  “ He is the expert after all, and who am I to cross- question him ? “

Different Times Call For a Different Approach

In my opinion, this isn’t much more than a carry-forward from the good ol’ days- when family doctors were revered and trusted completely to make the right decisions for their patients. At that point of time, there was no Internet and no easy access to information and doctors were the only ones who had access to the medical books and journals that held credible information. Even if patients did try to do their own research, they wouldn’t really have met with much success.

Myopic Approach

However, in this day and age, this attitude is nothing less than archaic. Most people don’t even have a family physician and just end up going to a specialist based on which part of their anatomy is acting up. The problem is that most specialists are very myopic in their approach to treating patients.

They rarely consider the fact that the patient’s problem might have its roots in an organ system different from the one they specialize in.  They have a very disjointed approach to treating their patient and don’t really understand what the latter’s preferences are.

Why Doctors Get Indignant, Offensive and Defensive

The even more important fact is that now patients have easy access to vast resources of credible information via the Internet and many are able to have an intelligent discussion with their doctor. These well-informed patients tend to keep doctors on their toes and consequently are also the ones that doctors may end up respecting. But not all doctors appreciate being questioned.

The minute they feel their patient is overstepping the line (which the doctors themselves have drawn), they make every effort to put the patients in their place. Others will just dismiss websites and say that they are full of garbage and that any online information is unreliable. At the other end of the scale are the doctors who tend to become offensive and will simply tell the patient to look for another doctor if they feel they can’t trust him.

What Really Matters

In my opinion, doctors who get defensive the minute they are questioned aren’t really good ones. It’s normal for patients to have a lot of questions when they are sick, and it’s the doctor’s job to ensure that their patient’s curiosity is satiated and that all their fears are allayed. A doctor, who is unwilling or unable to do this, is simply not doing a good job. 

For their part, what patients must keep in mind is that they should do their homework and ask intelligent questions. Good doctors encourage questions ; better doctors help you to ask better ones; and the best ones will pre-empt them by answering their patient’s FAQs on their website. This will help you form an effective partnership that will help you get the kind of treatment you want.

Need help in getting pregnant ? 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 !

Being obese reduces your fertility

If you’re attempting to get pregnant or are about to start trying, it’s important to know that being obese can have a negative impact on your chances of conception , as well as of having a healthy baby. Any woman who is planning to get pregnant soon might just want to commit to a regular exercise plan as well as a healthy diet.
Not many realize this, but losing even some of that weight can have a positive impact on your efforts.

The Indicator

The BMI (Body Mass Index) is the common measure of whether an individual is overweight. You can calculate your Body Mass Index by dividing your weight in kgs and by the square of your height in meters. A BMI between 18.5 and 24.9 is said to be healthy; having a BMI that is between 25 and 29.9 is considered overweight while anyone with a BMI over 30 is said to be obese

The best way to lose weight is to embark upon a regular exercise routine and consume a nutritious diet that is low in calories. It’s important that you do not starve yourself, and make sure that your body is getting all the essential nutrients. Having a healthy pregnancy and a healthy baby is a lot about being healthy yourself.
If you aren’t too sure about how you can lose weight, you can get professional help from a physical trainer and a nutritionist; this can help you lose weight the healthy way.

Losing weight can be a challenge , but there are lots of apps which can help you. If you have PCOD you could also ask your doctor to treat you with metformin. This can help you to lose weight. The good thing about making a serious attempt to lose weight is you are now taking positive steps to regain control of your life !

Just as being overweight can impact your fertility, being underweight can also reduce a woman’s fertility. It can lead to hormonal imbalances which in turn can impact ovulation and your chances of getting pregnant. . Patients with anorexia nervosa have such  low body fat that they may stop getting their menses altogether.

How Obesity Affects Fertility

Obesity affects fertility as it causes hormonal imbalances as well as problems with ovulation; this is particularly true for obese women who are having their first baby. Obesity is connected with PCOS (poly-cystic ovary syndrome), which is a very common cause of infertility. This hormonal condition is prevalent in infertile women, and affects up to one in 5 women of reproductive age. An early diagnosis, the right treatment and living a healthy lifestyle can help optimize fertility

Babies that are born to overweight/obese mothers are much more likely compared to health weight women, to grow into obese children & adults, and they will have more health problems too.

Some Figures 

•    Overweight women are doubly at risk of pregnancy-related diabetes while obese women have 8 times the risk in comparison to women who have a healthy weight.
•    An obese woman is at a higher risk of having a miscarriage compared to one with a healthy weight.
•    Infants who are born to obese women are also more likely to be much larger for their age

With all these facts and figures in view, there is no doubt about the fact that women who are planning to have a baby should focus on losing some of their excess fat and treading the path to good health before they tread the path to parenthood.

Need help in getting pregnant ? 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!

Do IVF drugs cause cancer?

Infertile women have to tackle a great deal of emotional turmoil; adding insult to injury is the range of misconceptions related to the use of infertility drugs. Some people even believe that doing IVF will increase their risk of getting ovarian cancer. What’s the truth ?

It isn’t difficult to understand why women would consider this to be the case- it sounds logical! We are aware that breast cancer is a tumor that is hormonally dependent, and during IVF treatment, the woman’s estrogen levels are very high. In addition, the patient is also given a number of hormonal injections to boost the production of eggs in her ovaries.

If this hormonal stimulation helps in the production of eggs, it’s logical to conclude that this overactivity in the ovaries can up the risk of cancer later on too. Its goes without saying that husbands are also very scared about what effect these drugs have on their wives and they don’t want her health to be put at risk in their pursuit of having a baby.

What do the data show?

It isn’t an easy task to assess whether there is a rise in cancer risk after doing IVF; this is because there are just too many variables to take into account, including:

• An individual’s life style
• Their family history of cancer
• Their exposure to carcinogens

All of these are very likely to impact the results and it isn’t easy to conduct these studies. A recent study involving 9175 Finnish women showed that the general risk of cancer or the risk of hormone-related cancer was not increased by IVF (PMID:22343550).  There was another study in Lancet which examined the incidence of ovarian and breast cancer in 10,358 women who had been referred for IVF between 1978 and 1992.  They reached the conclusion that the ovarian stimulation procedure during IVF doesn’t increase the risk of breast cancer in women. It was also found that there was no significant rise in ovarian cancer post stimulation for IVF. PMID:7475593).

Time Tested Results

Keep in mind that the IVF hormonal injections are essentially natural hormones; these are promptly excreted from your body and don’t  really linger and cause trouble later. Over the last 30 decades, more than 2 million IVF babies have been born across  the world and there has been no increased prevalence of ovarian and breast cancer; and this is a very reassuring fact.  Doing IVF does not increase your risk of developing cancer at a later stage.

So why is this misconception still so prevalent ? Here’s a possible reason. We know that 1 in 10 women will develop breast cancer at some point in her life. Now, if she develops breast cancer after doing IVF , she is likely to conclude that it was the IVF which caused her to develop breast cancer. The truth is that would have developed breast cancer, whether or not she had done IVF !

Need more information? 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!

TB PCR testing confuses gynecologists and infertile patients

Genital TB and how PCR is confusing gynecologists from Dr Malpani

Bedrest after ET is a bad idea

Most doctors ask IVF patients to take bed-rest after the embryo transfer ( ET). Some will prescribe strict bed-rest, where the patient is not even allowed to get out of bed; while others will confine patients to house arrest.

The truth is that there is no need to rest after the ET. Once the embryo is inside the uterus, it's safe and secure - think of it like a pearl snuggling in an oyster ! No external physical activity or diet is going to harm it. This is true whether the embryo spends 5 days in the fallopian tube ( after having sex in the bedroom); or 5 days in the IVF lab !

Bed rest can actually be harmful for the patient. Muscles become weak; the mind plays games; and the back starts to hurt , when you force someone to sleep in bed. Even worse, it reinforces the impression that a woman doing IVF is a patient. The reality is that she is not - she is a healthy young woman who just needs some medical assistance to kick start her pregnancy !

However, old habits die hard, and there are still lots of old wife's tales about the need for bed rest after IVF. In fact, some mothers will even insist that their daughter lie in bed during the entire 9 months of their pregnancy ! This is sure to drive anyone crazy - and this is why so many women find IVF to be an emotionally draining experience . It's not the IVF per se which is difficult - it's all the artificial restrictions which are imposed on them by well-meaning but mis-guided doctors and family members which add to their stress levels.

One major harm bed rest causes is that if the cycle fails, then the woman ends up blaming herself for the failure.  To add insult to injury, so do her relatives - and so does the IVF doctor , who has now found an excuse to get off the hook . He holds the poor patient responsible for the the failure by saying that she did not rest properly !

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

Poor Egg Quality- Is IVF the Only Treatment Option?

When patients come in for a consultation and want to know why they can’t have a baby despite trying so hard, I typically start with explaining the basics of making babies . Of course, some of my patients are well-informed and have an arsenal full of information and a barrage of pointed questions, that I’m more than happy to answer. But there are a number of patients who know how babies are to be made in the bedroom , but aren’t too well-versed about what the reasons not being able to conceive are.

The Basic Tests

And so, it’s back to the basics for them; it takes 3 things to get pregnant- good sperm, open fallopian tubes and ovaries that produce good eggs working. When a couple goes in for IVF treatment, some basic tests will be carried out.  However, for some women , even though the ovarian reserve tests are normal( normal antral follicle count, normal AMH, normal Day 3 E2 and FSH levels ), when the IVF cycle fails, her doctor tells her that the reason for the failure was poor egg quality – and this is the reason for her infertility.


Poor Egg Quality Facts

Now this can come as a shocker –especially for a young woman with regular cycles? The first thing you need to do is to get photos of your eggs and embryos. One of the commonest reasons for poor quality eggs is a poor quality clinic. For example, the doctor may not have superovulated you properly; or the IVF lab may have damaged your eggs while handling them in vitro. It’s important to get a second opinion, and repeat your IVF treatment in a better IVF clinic.

What happens if your worst nightmare comes true, and your eggs are of poor quality again ? What exactly is poor egg quality and what can be done about it? Here are some things you should be aware about:

•    Most women who are told that they have poor egg quality feel that it is the end of the road and that they won’t ever be able to get pregnant; but this is not the case. Based on your individual situation, all it means is that it will be more difficult for you to get pregnant. In certain situations, it may mean that these women may have to consider using donor eggs. It’s important to understand that poor egg quality doesn’t necessarily equate to can’t get pregnant.

•    Women are born with all the eggs they will ever have and each month, there are a set number of eggs that try to win the race to reach the fallopian tube. Only one will emerge the winner and will ovulate; the rest of them simply die and can never be used again. Regardless of how old you were when you first started your menstrual period, the number of times you have been pregnant or the length of time you have been on the pill, it is a cruel fact of nature that your ovaries will run out of eggs as you get older.

Every woman loses eggs at a different pace, and you just can’t compare how many eggs could have been retrieved in your egg retrieval process compared to someone else who was doing IVF. The other factors which can have a negative impact on egg quality include history of prior ovarian surgery, endometriosis, cancer treatment, and smoking as well as some genetic conditions such as FragileX.
•    It’s possible for you to try to improve the quality of your eggs, but it’s not possible for any doctor to guarantee that he will be able to make you  get pregnant as there really is no concept of “controlling your fertility”. It’s important that you lead a healthy lifestyle and consult the best IVF specialist; however it’s also important to view the fact that no one can guarantee you will get pregnant with your own eggs (no matter how many different treatments and techniques you try), if you have been told  that the quality of your eggs might be poor.

The Treatments

The simplest way to think about it is that if the quality of your eggs is poor, it means they just don’t have what it takes to actually turn into a normal pregnancy.
IVF is a treatment option where poor egg quality is the cause for infertility in the couple. If the quality of eggs is too poor, donor eggs can also be used. The treatment course and its effectiveness will be determined by your specific condition and will differ from one patient to the next.

Has your doctor told you that you have poor egg quality ? Need a second opinion ? 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!

Embryo Transfer vs Embryo Implantation- What is the Difference?

A number of patients aren’t too sure about the medical details involved in their IVF cycle. At times, this also means they end up using medical terms incorrectly. Most patients tend to use the terms embryo transfer and embryo implantation interchangeably and aren’t sure whether there is any difference between the two.

Embryo transfer is a very simple clinical procedure in which the IVF doctor transfers your embryo/s into your uterus with the use of an embryo transfer catheter. This is essentially a mechanical step; it involves transferring the embryo from the Petri dish, into your uterus. Implantation , on the other hand, is a complex biological process that takes place in the uterus.

The Connection

When the doctor transfers the embryos on Day 3, they have around 8 cells; If all goes well, these cells will continue to divide in utero, until the time they form blastocysts. Once these hatch, the embryo cells then embed themselves in the uterus’ walls. Typically, this occurs on Day 6 or Day 7 post egg collection. Implantation is a silent biological in utero process and we have no control over it; it has 3 phases:

•    Apposition, when the embryo moves towards the endometrium
•    Adhesion , when the blastocyst sticks to the endometrium
•    Invasion, when the blastocyst buries into the endometrium

All these phases are dependent on a perfectly synchronized exchange of molecular signals that takes place between the embryo and the endometrium – what is called molecular cross-talk. Each one of these stages is crucial and they have to take place in a sequential manner. There is no magic “Cinderalla hour”  at which time implantation occurs – it’s a continual process. Also, patients need to remember that we aren’t able to either track or monitor implantation , and there is no way we can influence it either .

Unpredictable Embryo Behavior

Of course, as part of the procedure , we give you progesterone and estrogen to prepare the lining of your uterus for the implantation. However, when it comes to the matter of whether your embryos will implant or not and how many of them will implant, it’s something we can neither predict nor control. If you stop to think about it, this isn’t surprising at all. The embryo is a microscopic ball of cells and there is no way we are able to track what these cells do once they have been transferred into the uterus.

The Genetic Abnormality Factor

So, why then does it happen that all the transferred embryos don’t implant?  This may sound  like a very “un-medical” explanation, but the fact is  that human reproduction can be quite inefficient. Isn’t it true that not all fertile couples get pregnant every time they have sex in their fertile period?

In most instances, a genetic abnormality is the cause of failed implantation. This is actually a natural defense mechanism of our bodies to prevent the birth of an abnormal baby. Of course, these defects don’t really follow any set pattern and are quite random, but they are more common in older women. This occurs because the eggs of older women tend to have a greater number of genetic abnormalities, as they have aged . We still cannot screen for most of these genetic defects . PGS/NGS/CCS only allow us to check for gross chromosomal anomalies.

Need help in making sense of your 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!

Open Letter to ICMR, Ministry of Health,Govt of India regarding the ART Bill

Congratulations on drafting the ART Bill ! This has been created with good intentions. A lot of IVF clinics in India are of poor quality, and substandard IVF medical care means that infertile couples  are often taken for a ride. This is not good for anyone, and because the medical profession hasn't done a very good job at regulating itself, it seems quite logical to introduce a law in order to regulate IVF clinics.

However, your requirement that donor eggs be sourced through ART Banks is a retrogressive measure, and a bill which is actually meant to protect and help infertile couples, may end up hurting them.

Today, all over the world , modern egg donation programs have started using frozen eggs. The egg donor is superovulated, her eggs collected and then frozen in liquid nitrogen , so that they can be used whenever an infertile couple needs donor eggs. This is exactly the same model we use for frozen sperm.   Using frozen eggs and sperm is much more convenient and also much safer. It allows us to match the donor and recipient better; and we can make sure that the donors are free of HIV.  Thanks to vitrification technology , it's now finally become possible to freeze eggs as reliably as we freeze sperm. However, if it's only the ART Banks which are allowed to provide egg donors, then who will freeze the egg donor's eggs? ART Banks are not allowed to do egg collections, and IVF Clinics are not allowed to do recruit egg donors for egg collections !  These outdated rules have created a Catch 22 situation .

By crafting a rule based on obsolete technology, we're actually doing a major disservice to infertile couples by forcing them to use fresh donor eggs. We're actually moving the IVF profession one decade backwards because of poorly crafted rules, which have not been able to keep up with the times. This is a very dangerous and unhappy trend. By trying to create " ART Banks " ( a concept which does not exist anywhere  else in the world !) in order to fulfill arbitrary regulatory requirements, we're doing a disservice to doctors as well as to patients.

All over the world, IVF clinics provide donor egg services to their patients. They will usually source their own egg donors and match the donor and recipient. Keeping this in house helps to ensure a high quality of control. Now, if you can trust an IVF Clinic to take good care of its IVF patients, then why can't you trust it to take good care of its IVF donors as well? After all, aren't you regulating the clinics to make sure that they're not taking any shortcuts ?

The Tech Take on Making Babies

Only couples who face infertility know exactly how much pain they go through to gain the baby they want. Most will have tried every possible treatment under the sun just to hear those three little words- “You are Pregnant”. Most people don’t even give a second thought to whether they will be able to have a baby or not, because they assume it’s something that will happen automatically, once they stop using contraceptives and have regular sex.

Most people don’t know that there is a wide spectrum of methods to get pregnant and that sometimes just having unprotected sex doesn’t make the cut. This post is for all those couples out there who are trying to have a baby and need to know the different ways in which they can have one; and how baby making options can go from the natural end of the scale to the high-tech end.

•    Have Unprotected Sex- Discard the contraceptives and have lots of baby making sex. Most couples don’t have any trouble conceiving naturally; but don’t get too ambitious or complacent- you need to set a time limit, which is typically a year if the woman is under 35 years; and 6 months if she is over 35 years.  Anyone over 35 should be seeing an IVF specialist if they haven’t got pregnant in 6 months of trying.

•    Use an Ovulation Monitor- If after a few months of unprotected sex, you are still not pregnant, but still don’t think you want to consult a specialist, try  to use an ovulation monitor to time sex for the most fertile times. Most chemists will have these monitors and they are available over-the-counter. Ovulation test sticks are the most common and these detect high LH levels (luteinizing hormone, that triggers the egg release from the ovary), in urine.

Even as you do this, don’t rule out the possibility of male infertility. If you feel that you have been trying for too long and are still not pregnant, consult an IVF specialist without delay. The doctor will carry out tests and will be able to determine whether there is a male factor infertility issue or whether it’s related to the woman.

•    Medication- Clomiphene citrate or Clomid is a relatively inexpensive medication that is typically used for patients who have irregular cycles because of anovulation.
In most instances, this medication is used in combination with Intrauterine Insemination with sperm which has been washed in the lab to enhance its fertilizing potential.

•    High-tech Drugs- There are a number of injectable hormonal drugs which can boost ovulation. These are typically used in an IVF cycle; however they are also very effective for women who do not ovulate as well as for ones who have unexplained infertility. These contain the hormones , FSH & LH.


•    IVF- Today, In Vitro Fertilization is the ultimate high-tech infertility treatment, which allows us to bypass all fertility hurdles. We stimulate the follicles with superovulating drugs; the eggs are then retrieved from the woman’s ovaries before ovulation and they will be fertilized with the sperm in a Petri dish. The resulting embryo/s are then transferred in the uterus.

Taking IVF Tech One Step Further

There are some adjuncts that are used in IVF:

•    ICSI (Intracytoplasmic sperm injection)- This is used when the man has an extremely low sperm count or zero sperm count. A single sperm is retrieved from the semen or the testes or the epididymis. It is then injected into the egg using a micromanipulator.

•    IVM (In vitro maturation)- This is still quite a new technique and is used in patients who have polycystic ovaries (they produce multiple immature eggs in one cycle). In this technique, we remove the eggs from the ovaries, they are then “ripened” in the IVF lab before they are fertilized.

•    PGD- Preimplantation genetic diagnosis)-  In this technique it is possible to test the embryos for genetic problems even before we transfer them in IVF. This procedure is typically used in couples who are aware that they carry a gene for genetic disorders such as sickle cell disease or  cystic fibrosis.


As you can see, when we treat infertility, we have a wide variety of different tools and options we can use to help our patients get pregnant.

Need more information? 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 patients ignore good advice

As an IVF specialist , I'm happy to share my knowledge with patients , so that they can improve their odds of getting pregnant. Many patients will do IVF treatment at other clinics , and then send me the medical record so I can guide them as to whether they're on the right track , or whether they need to think of alternative options.

I'm happy to provide this information but it sometimes upsets me that in spite of the fact that I'm educating the patient with reliable information which is in black and white they ignore the advice which I send them and continue following the poor quality advice which their doctor has given them.

I can understand why some of them do this. After all, they have a personal relationship with their doctor. He's sitting in front of them. They're talking to him. I'm a faceless entity who just provides information on the website. Why would they necessarily trust me as compared to their personal doctor?

However, the very fact that they're asking me a question means they're not sure about their doctor's advice, which is why they are checking on it. Once I've provided them with an alternative perspective, the least they can do is some more homework , which will help them to ask their doctor more intelligent questions before deciding on their next plan of action.

It frustrates me when patients ask for advice and then ignore this. Not only is this a waste of my time , it's obviously a waste of their time as well. Why bother to ask questions if you're not going to do anything based on this ?

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

How we make IVF patient's lives easier !

Being infertile can be hell , and going through an IVF cycle just adds to this stress. You have to make multiple visits to the clinic, you have to take daily injections, you have to wait to see the doctor, you have to wait for your scans, you have to wait for your blood test results to come back, you have to wait to find out how your follicles are going , you have to wait to find out how many eggs they got , you have to wait to see how good your embryos are - and finally you have to endure the 2ww to find out if you are pregnant or not. Because it's such a complicated, intricate process and there's so much uncertainty, going through an IVF cycle can add a lot of misery to the poor infertile couple's life.

One of the things we're trying to do to reduce the stress in IVF treatment is to use technology cleverly. Thus, we do a lot of our consultations online using email. This might not seem very
intuitive , because most patients feel that the only way of doing a consultation is a face-to-face consultation, but times have changed and so has technology. The reality is that most IVF treatment plans are based on medical test reports, such as the sperm count, the ultrasound scan reports, the antral follicle count, and the hormonal blood tests, such as AMH , FSH, LH, prolactin and TSH. A clinical examination provides very little additional value to an IVF specialist.

I can review all of these results efficiently and effectively by email , so I can pretty much chart out the treatment plan for the patient based on her medical test results , without actually ever having to  see her. This makes the patient's life much easier  as she does not need to make multiple visits to the clinic . We create lots of free tools such as IVF calendars and we have a really well-organized process, which is transparent and open . We share this with the patient so they know exactly what's going to happen and when it's going to happen. There are no unexpected surprises and this allows them to organize their life.

We don't change the treatment plan on an ad hoc basis , and having this clear structure in place help the patient to trust us. They can see that we know what we're doing , and this increase their confidence levels. I make it a point to answer all my emails myself and I answer them quickly, efficiently, and promptly so that patients know that their queries are being answered by the IVF doctor himself , and that they will get a reply ( usually within 24 hours). This way , patients don't have to play telephone tag, and I can review all their records before replying. The signal to noise ratio of our communication is very high , and because everything is documented it's much easier for patients to follow the right process. This way they don't have to waste time commuting to see me; or waiting in my clinic , because I can answer their questions efficiently .

We encourage our patients to ask as many questions as possible - and I tell them, "The better the quality of your question, the better will be the quality of my answer." Quite honestly, most of these questions have already been asked by some other patients , and they'll be able to find these answers on our website, which now has over a thousand pages of information on IVF, which we think every patient needs to know.

We continue exploring technological advances and have now created the world's first IVF treatment app called 'My Fertility Diary'. After downloading this app , patients know exactly what's going to happen when during their IVF cycle so they can schedule their appointments and carry on with their life, without adding to their stress levels.

We think being a good IVF clinic doesn't just mean providing high quality medical care. It also means taking a holistic picture , and trying to make the patient's life as easy and comfortable as possible , and we pride ourselves on being able to skillfully and compassionately hold our patient's hands during their journey to becoming a parent.

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

Why the ART bill is bad for IVF doctors - and even worse for patients

However, a big problem with this ART bill is that it's not been crafted very well. Perhaps part of the reason is that it's taken over ten years to be actually formulated. IVF technology has progressed dramatically during this time, as a result of which some of its recommendations are now obsolete. They can actually cause harm, so that a bill which is actually meant to protect and help infertile couples, may end up hurting them.

http://health.economictimes.indiatimes.com/health-files/Why-the-ART-bill-is-bad-for-IVF-doctors-and-even-worse-for-patients/965

Why an online opinion can be so helpful for IVF patients

I receive lots of requests for second opinions on our website , and I'm happy to provide inputs to help infertile couples to complete their families. A lot of patients worry about the quality of my opinion , and for many people , the concept of  an online second opinion, which comes from someone whom you've never seen or met can be a bit challenging. Most traditional medical consultations are done face to face, which is how trust is created. Why would anyone be willing to trust an online opinion from someone who's faceless, someone whom they've never met?

I actually think an online second opinion could perhaps be better than one which your personal doctor provides you face to face. For one thing, my opinion is in black and white, which means I need to be careful . I make sure that I've reviewed all your reports carefully and given you a balanced opinion. After all, if I don't do so , I'll look like a fool when you share my opinion with your present doctor, and that's one thing I definitely don't want to allow to happen. In a consultation, on the other hand, the doctor will often take shortcuts because he is rushed, and you are never sure whether he has evaluated you properly or not.  Also, I cannot overpromise or say something incorrect, because I am writing stuff down. However, in the four walls of a clinic, your doctor may make all kinds of tall promises  whichyou have no way of verifying because you're forced to trust him.

Also, because there is no way of your knowing how good or bad I am , you're very likely to counter check whatever I tell you . This will increase your ability to become a smarter, more educated patient ! If you verify everything I say independently of what I tell you your trust in me will actually increase if it all checks out. A second opinion also provides you with a different perspective, which perhaps may help you think of alternative options which your doctor may have overlooked , or may not be able to offer you.

I have no axe to grind. I have no vested interest. You're not my patient. I'm not treating you which means I can tell you what I think is right for you. I can offer you non-medical options and less expensive alternative options, whereas your doctor may have a hidden agenda when he's guiding you. Most importantly, I can provide you with links to information which you can read, so that you can learn to ask your own doctor more intelligent questions . This will ensure you are in a better position to make a decision which is right for you, and you can combine my inputs with your doctor's, so you can craft a plan that works well for you.

Finally, my second opinion is free. How could there possibly be a downside to getting a free second opinion from an IVF specialist who's happy to help you complete your family because this is my professional mission in life? I'm not saying that my opinion is always right or that it's necessarily better. All I'm saying is it's usually carefully thought out because I have so many years of experience , and I can have an intelligent conversation with you by email.

While this is not a face to face conversation , often a continuing conversation by email is far better , because everything is documented. You are forced to think about your questions carefully, and I formulate my answers carefully . This helps you to make sure that you're on the right path.

What do I get out of this? One, of course, is the satisfaction that I'm helping someone with no vested interest . However, it also helps me to become sharper, better informed and better read because I now have patients who are providing me copies of their medical records from all over the world.  This allows me to " see " an extremely wide variety of patients - far more than I could ever do in real life , face to face. This means the cumulative experience which I have acquired because of these free online second opinions I offer is far more than lots of other busy IVF  doctors who restrict their practice to only seeing patients in their clinic. Patients who ask me for an opinion are obviously web savvy, technologically proficient and well educated, which means that I also learn a lot from them. This is a great win-win situation.

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

When to Bend the Rules in IVF

As a junior doctor you are taught all the standard medical rules.  You know exactly what to do , because this is what your text books teach you , and you follow this.  These are the answers you need to give to the questions on your exam and this is what your seniors expect from you.

However, as you become more senior and experienced, you understand that there are exceptions to all rules,  and that you need to bend the rules for certain patients . It's only when you acquire clinical experience over time do you know when it’s appropriate to bend which rule for which patient.

I recently saw a patient who had a mucinous cystadenoma, which is a benign tumour of the ovary.  She’d had had a laparoscopic cystectomy in the past to remove it.  It recurred again, and she changed the surgeon, who did another laparoscopic cystectomy . It recurred again ( as many of these tumours are wont to do ) and then she wasn’t sure what to do next.  She was worried that the repeat surgery would damage her ovaries, and she was scared that if she underwent another surgery, there would be no normal ovarian tissue left on that side.  The other ovary was normal at present, but she was scared that she could get a mucinous cystadenoma in that ovary as well, and she really wasn’t sure what her next step was.  She’d had multiple consultations, so I sat down and explained to her what the standard treatment approach would be.

A mucinous cystadenoma is a tumour which is benign. It usually requires surgical treatment , when the doctor removes it. This is exactly what she’d done in the past, but hadn’t worked very well for
her , because it had kept on recurring so quickly. This was unusual , which meant she was an outlier, so we had to think of some non standard way of managing her.

This is why I wasn’t keen on her repeating a laparoscopic cystectomy . This wouldn't prevent it from recurring again, and it would damage her ovarian reserve even more. Since hadn’t had any babies as yet , and for her the priority was to have kid right now.  One of the options I offered her was that we do an IVF cycle for her , and before starting her superovulation, we’d go ahead and aspirate the mucinous cystadenoma, so it wouldn’t interfere with the treatment.  Now this is not standard practice by a long shot.  Mucinous cystadenomas are not meant to be aspirated because all we do is we remove the content but we leave the cyst wall behind , so it will collect again.

I knew this, but I also knew that the standard surgical approach had the risk of causing  her more harm than good . For her , the priority was to have a baby and the cyst aspiration would be a temporising measure , which would allow her to get pregnant quickly.  Of course, after she’d had a baby we could then resort to definitive treatment, for example another  laparoscopic cystectomy,  or perhaps even a removal of the ovary which was causing her so much grief.  This meant I had to spend a long time talking to her, explaining to her what the standard practice was; why I was advising something which was unusual; and why I thought that she was the outlier patient who, because of her unusual individual circumstances, needed a solution which was not the standard solution and why we needed to think out of the box in order to craft something which would fit her needs.  Fortunately, she was educated and well informed and her father was a doctor, so she understood the pros and cons of the options and is now in a better position to make the right decision for herself.

I still don’t know what the final outcome will be. I also understand that I am taking a calculated risk in giving her this advice. After all, no one can criticise you if you follow the standard treatment protocol. However, if she agrees with my advice to aspirate the cyst and she then has a problem, she’s likely to be unhappy , and that other doctors will criticise my approach.  But this is one of those risks which I think is worth taking because I’m doing it in the patient’s best interest to maximise her personal goal of being able to have a baby.

This is one of the advantages of being a senior experienced IVF expert  ! Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !

How to Find the Best IVF Centre in India

When you decide to do IVF, it’s  natural to want to find the best IVF center for your treatment. IVF is expensive and you want to maximise your chances of success. How can you maximise your ROI and make sure you get the biggest bang for your buck ?

Let's assume you don't have any financial constraints, and can travel. You need to select a IVF center with the best success rate -  this is indicative of the doctor’s competency at making babies. Suppose  you have to pick between two  clinics that have similar success rates?

If you want a clinic which will treat you as an individual and offer you personalised  hands-on care, then you should select a boutique IVF clinic, such as Malpani IVF Clinic. Yes, I am biased, but I honestly believe that we offer far  better care than much larger clinics, who treat you as a widget on an assembly line !

IVF is very different from a majority of medical treatments. The people we treat aren’t patients - they are healthy infertile couples, who happen to need medical help to make a baby.

Not happy with the attention you are getting from your IVF clinic? Need more information? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you!

What went wrong with my IVF Treatment ?

What went wrong with my IVF treatment ? This is one of the commonest questions I get asked.

" Hello Dr. Malpani, please give me your opinion about my treatment .  I was very positive with IVF-ICSI with laser hatching technique , but unfortunately what went wrong ?"

The reality is that often nothing "went wrong". Even in a perfect IVF cycle, the pregnancy rate is not 100%. Human reproduction is not a very efficient enterprise, and most embryos don't become babies. This is as true in the clinic as it is in the bedroom, and there is little doctors can do to control implantation, which is a biological process.

This is why it's very important for patients to have realistic expectations before they start their IVF treatment.

The trouble is that IVF doctors often aren't very forthcoming about IVF failure rates.  When they want to sign up a patient for IVF treatment, they are happy to promise them the earth and the moon . They are always very optimistic - after all, no one wants to lose a patient to another clinic by bringing them down to earth, which is why doctors will often sugarcoat what they say, and inflate their success rates. It's fairly easy to fool a patient who is emotionally vulnerable and is desperate to have a baby ! IVF doctors  offer all sorts of "modern" technology, such as IMSI, embryoscope and PGS/CCS, and patients feel that if they use all these expensive new techniques, success is guaranteed.

Even at the time of the transfer, many doctors wax eloquent about how beautiful the embryos are;  they try to infuse the patient with hope by describing how well the treatment has gone and how perfect the IVF cycle was. Many doctors believe that being positive helps to improve success rates, so they conveniently gloss over the fact that most IVF  cycles will fail, no matter what we do in the lab.

This is why counselling is so important, so that patients don't go to pieces in the case the cycle fails. This is also why patients mush insist on the clinic providing them with photos of their embryos, so they can learn from the cycle . A failed IVF cycle is not the end of the road - it's just the beginning to a more intelligent personalised treatment !

Want a free analysis of your IVF treatment 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 !

Egg Freezing- Your Insurance Policy for Having a Future Family

Having a family is important to many women and they don’t want to lose that opportunity. Today, there are a number of career-oriented women who find themselves at a crossroads when it comes to choosing between diving headlong into the career dream and “settling down” and raising a family. Till not very long ago, there wasn’t really a choice and they would have to compromise on one or the other. However, now with egg freezing technology in the picture it gives women a chance to focus on their lives in the present, without having to be stressed about their future fertility .

I have always found the field of reproductive medicine to be filled with a sense of purpose. Most couples who deal with prolonged infertility and then have a child, are positioned to be great parents; the fact that I am able to help them achieve this goal makes me feel privileged.

The Vitrification Technique

The IVF field is constantly in evolve mode and a number of  technological advancements are taking place in this space. In addition  to treating infertility, we as IVF specialists are also in a unique position  to empower women via the egg freezing technology. Though  the technology itself has been around for a number of years, it was only in the year 2009, that there was a major scientific breakthrough in  the egg freezing technique- vitrification!

Today, the success rates achieved via vitrification are in line with  fresh  IVF cycles in which fresh eggs are used. This advance is what helped egg freezing shrug off its cloak of being an “experimental treatment” and it is now making its way into the mainstream.

Many large global corporations including Facebook and  Google are now  giving their female employees the option to freeze  their eggs. This is a great way for them to retain talent and  it acts as an incentive  for women  to  further their career without worrying about the possibility of them having to remain childless in the future.

The Best of Both Worlds

Egg freezing  gives women the choice  to have a baby when they want to versus when it’s best  to. It helps them plan their present and their future and they can make a more thoughtful decision of when  to have a baby , instead  of rushing into a relationship or marriage when they are  younger, only because  they want to have a family. In simple words, they  can have their cake and eat it too. In effect, it’s an insurance policy for having a future family.

Ovarian Reserve Testing

As women age, there is a drop in ovarian reserves and this makes it important for women above 30 years  to get  ovarian testing done. If it is found that a woman has low ovarian reserve, she  has  the ability  to do something about  it at that point of time; regardless  of whether she is ready to have a family or not. I agree that egg freezing isn’t the right option  for every woman. However , just the fact that this option exists can be very empowering.

The recommendation is that women who are considering egg freezing should  do so when they are in their early to mid-30’s. It’s also a good idea for women in their late 20’s or even their early-30’s  to consider ovarian testing. All it takes is a few weeks to complete the freezing process, but the result can take  the stress off your mind for years. If you have any questions about  the egg freezing process and want  to know how it works and whether it’s right  for you, I would me more than happy  to guide you in this matter.

Need more information? 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!

Follicular Studies (Ovulation Tracking) Can Be Nerve Wracking

When gynecologists are dealing with infertile couples, many of them advise ovulation tracking as the first line of "treatment". At a cursory glance, this seems to be quite sensible advice. The only thing you are required to do is go for regular ultrasound scans; these help you precisely time when you ovulate. You are told to have sex at this time and it’s the perfect formula to get pregnant: eggs + sperm= baby and you will get pregnant in the very first cycle.

Now one would ask- How can this possibly fail? especially if you are young and there is nothing abnormal in your test results! The main problem is that patients have very unrealistic expectations from follicle tracking; even in a perfect cycle, the success rate is only around 10%.

A Tedious Exercise

It’s important  to keep in mind that human reproduction isn’t efficient and just getting the timing right for sex, doesn’t help (unless of course , you haven’t ever had sex at  the right time earlier). Doctors tend to forget the downside of ordering ovulation tracking tests. You obviously have to take time out from work and go to the clinic for the ultrasound scans and after a while, this can get stressful and nerve wracking. What’s probably worse is that it also plays havoc with your sex life.

Crazy About Babies

When you are dealing with infertility, it can seem like you and your partner may be poles apart when it comes to the matter of having a baby. Most men are complacent in this respect and just feel that nature should take its course; and of course who can refute the fact that having frequent sex is a fun way of having a baby. What they can’t seem to fathom is why their wives are going all crazy about having a baby ; why they want  to  time sex ; and why they are obsessing over  things like eggs and ovulation.

From a doctors perspective, by ordering scans, he may be doing what he thinks is right; but he doesn’t realize the stress he is adding to the couple’s life and marriage. Husbands detest being made to have sex on demand and they feel that they are no more than sperm donors who have to produce sperm when they are ordered to do so.

Regimented Sex can be a Spoiler

Not only does it take the fun quotient out of sex, but it fuels marital disharmony. This is because the wife is reluctant to have sex on any other days apart from those she ovulates on, as she wants her husband to "hoard" the good sperm! Any couple that is dealing with infertility is already under a lot of stress and, in most cases this regimented sex becomes the last straw.

The Better Option

Also, doctors forget that  it’s undignified to have to lie with your legs akimbo for the scan and have a doctor carry out the ultrasound by inserting a probe into your vagina, on a daily basis- this can prove to be a major dampener and the woman just ends up losing her appetite  for sex.

My advice is that no more than one cycle of ovulation tracking is necessary. This has its merits because it teaches you to correlate the scan findings with your body's signals, including cervical mucus and ovulation pain. Scanning also allows you to make better use of OPKs and the free online fertility calculator in future cycles.

Because you understand what's happening to your body, you do not have to medicalise baby-making sex in future cycles, and track ovulation discreetly at home! However, if your doctor advises repeated follicular studies, please get a second opinion; or else you risk getting frustrated!

Need help in getting pregnant ? 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!

IVF pseudopregnancy - why do all the patients in some IVF clinics get pregnant ?

Some IVF clinics in India seem to have very high pregnancy rates,  and this makes me a little suspicious.

Their patients come and tell me - I was part of a batch of 20 patients, and except for me, everyone got pregnant !

Now I know it's biologically impossible to have such high IVF success rates, which is why I'd suspect there was some hanky-panky going on.

The first question I ask is - How do you know everyone else got pregnant ? If the answer is - " The IVF clinic told me", which is when  I know that they are most probably taking the patient for a
ride . They must be saying the same lie to every patient, and patients have no way of verifying the truth as to who else did not get pregnant. This way , they get fooled into believing that the IVF clinic was very good, but that they were unlucky.

Others say - Because the pregnancy tests for all the other patients was positive - and so was mine, but then my HCG level  dropped . The doctor told me that  I miscarried and that I should do IVF again because my chances are very good.

This is what I call the IVF pseudopregnancy, and is a cruel trick played on unsuspecting patients by unethical IVF doctors. They give the patient multiple HCG injections after the embryo transfer. This externally administered HCG will cause  the pregnancy test positive, and thus fool the patient.

Some doctors  continue giving the HCG injection to "support the pregnancy" , as a result of which the patient does not get her period, and is deluded into thinking she is pregnant as a result of the successful IVF treatment. However, when they do an ultrasound after 6 weeks, they find there is no pregnancy at all. The doctor tells them that they miscarried - and that they should just repeat the IVF cycle again . He warns that this time they should take strict bed rest , to make sure that they don't miscarry again !

It's easy to fool some of the people some of the time, but I don't think it's possible to fool all of the people all of the time !

Not sure if you are really pregnant or not ? 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 !

Is your IVF doctor fooling you ?

I get lots of requests for a second opinion from patients from all over India.  For example, one patient wrote -

Hi Dr My wife had a 3 day transfer on July 3 2015.Her pregnancy continued for 22 days, but then there was a bleeding on 22nd day...followed by decrease in B HCG after significant rise from 17th day till 22nd day. We have visited our IVF specialist team they told they will do it in next cycle...but they have not done any  IVF transfers till now...They say that endometrium is not thick...optimum thickness should be 8...and it is 6 now, this happened on 30th September, now they have given medicines for withdrawal bleeding and they are saying that they will plan it in next cycle with frozen embryos ... Are they going in right direction ...or are they fooling me ?

This is the kind of email which raises lots of red flags about the quality  of IVF treatment which this patient has received. There are lots of holes in the story, and it's very hard to fill in the gaps.

Was this truly a pregnancy ?  Or was this a IVF pseudo-pregnancy created by giving the patient a  HCG injection, to make the pregnancy test come out positive ?

Was the lining fine in the earlier cycle ? If so, what has happened to it now ? and why ?
I am also not happy that they have not shared a treatment plan with the patient. They seem to be providing information in dribbles, in a very disorganised fashion, and this is going to create trust issues for the patient !

I always assume positive intent, and my first request is to ask the patient to provide me with more details. I need only two things - photos of the embryos ; and a printed treatment summary from the IVF clinic ?

If these are not available, this means the quality of care was poor ( until proven otherwise). This is because every good IVF clinic routinely and proactively provides embryo photos  and a treatment summary, whether or not the patient asks for it. Any clinic which does not is not following standard medical treatment guidelines, and maybe cutting corners.

Want to confirm you are getting good quality IVF care ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !

Why the diagnosis often does not matter when you are infertile

Infertile couples want to know what their diagnosis is. " Why am I not getting pregnant ? What's the reason for my infertility, doctor ?"
This is perfectly logical. After all, before the doctor can find a solution, doesn't he need to first identify what the problem is ? How can he select the right treatment without making the right diagnosis ?
While this is true of most medical illnesses, surprisingly, the diagnosis is usually of little importance in treating infertile women.
The reason is that fertility specialists  are not researchers. Their ability to bypass problems is far better than their tools to identify them. This is because there is a wide range of "abnormalities" seen even in fertile couples, and a lot of the fertility tests give rise to red herrings. "Treating " these just wastes the patient's time and money.
Infertile couples don't come to a doctor and say - "Are my tubes blocked ? " Their need is much more basic - " Doctor, give me a baby !"
The beauty about IVF technology today is that it allows us to bypass problems ,even without being able to identify them.
One way of thinking of this is to imagine a road with multiple potholes which you need to drive on in the middle of the night. One option is to put on headlights, and crawl forward slowly, hoping that you will be able to miss all of them. The much easier option is to take a detour ! This is what IVF allows us to do , so we can substitute the lab for the bedroom. Sure, it's not as much fun, and it's a lot more expensive, but it gets you to your destination much faster !
Is your doctor at a dead-end ? Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you  !

The Mogul Angels of Impact Investing

In contrast to the press that mainstream angel investors and philanthropists have received, very little has been written about angel investors that are focussing on for-profit social enterprises in India.

I am very honoured to be in such august company !

Will I be able to love a baby if I use donor eggs ?

While lots of older women know that donor egg IVF would give them the best chance of having a baby, many are very worried as to whether they will be able to love a child born using donor eggs ? After all, we are all hard-wired into wanting to perpetuate our genes, and this is a perfectly valid doubt.

I remind my patients - It's not the DNA in a baby which makes a baby yours - it's the love you give your baby !

The answer has to come from your own heart - and it's usually the parents who worry about their ability to love a donor egg baby who end up making the best parents .

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



 

Why it's always better to transfer embryos on Day 5 rather than Day 3

Lots of IVF clinics will transfer embryos on day 3 but we  prefer doing transfers on day 5.
Now, if there are lots of eggs and lots of embryos, it's quite obvious why day 5 is a better option. After all, you can allow the embryos to compete amongst themselves and then select the best embryo, so that this is the embryo which then has the best chance of becoming a baby. On day 3, on the other hand, you will have lots of embryos which look exactly the same, so then you have to play eenie-meenie-miney-mo when you decide to pick which ones to transfer. Whereas with day 5, since the embryos have competed amongst themselves, there are fewer embryos left , so it's easier to pick the best ones. The advantage is that we are not wasting any embryos because even on day 5, if there are more than the required number to transfer, we can always freeze the extra embryos, so this way, the patient has her cake and can eat it too !

    So why don't all clinics do day 5 transfers? And I think the reason is that they're concerned about their technical ability to be able to grow embryos to blastocysts . The problem is that for lots of IVF clinics, their success endpoint is an embryo transfer. This means that once they've transferred Day 3 embryos into the patient, the patient is happy , because the doctor has successfully completed the IVF treatment, irrespective of whether that embryo becomes a baby or not. On the other hand, if they continue to grow the embryos to day 5 and the embryos arrest in the lab and they don't have any blastocyst to transfer, the patient is likely to get upset and angry , and blame the doctor, and this is not something which an IVF clinic wants to risk.

    However, our perspective is very different , and even for patients with few eggs ( even 1 or 2) we still prefer a day 5 transfer, and here's the reason why. Of course with every IVF cycle, the primary goal is to have a baby, but there's also a secondary goal of acquiring useful diagnostic information which can help the patient decide what to do for the second cycle, in case the first cycle fails.

If we transfer embryos routinely on day 3, we actually lose a lot of valuable information. For example, if we transfer embryos and the patient doesn't get pregnant, this is "diagnosed" as failed implantation. We can never figure out why the patient didn't get pregnant . Was this because the embryos arrested on day 4 or 5 inside the uterus and did not develop into blastocysts, because they were not genetically competent ?  Or  were there were some other factors which affected embryo implantation ?

    Now, suppose we'd grown these embryos to day 5, and let's assume they did arrest on day 4. Of course this would cause a lot of heartache and angst for the patient who would be extremely upset that we were not able to transfer embryos for her. However, on the other hand, she would acquire extremely valuable information , which she could then use towards crafting her future treatment. The fact that she had few eggs obviously means she has poor ovarian reserve ( DOR) and her egg quality was not great. However, she may not be very keen on using donor eggs so that, even if does get a single day 3 embryo to transfer, and even if that cycle fails, she's quite happy to sign up for a second cycle and a third cycle , in the hope that maybe in the next cycle, one of her day 3 embryos will implant.

Many doctors will often recommend this kind of course of action , because not only can they do more cycles, they can also offer additional options, such as embryo pooling, where they freeze the embryos one at a time, and then transfer multiple embryos at one time. Others will recommend surrogacy , claiming that the reason the embryo failed to implant is because there's something wrong with her uterus or with her immune system or with her Natural Killer ( NK) cells.

    Actually, that's completely flawed thinking. However, because the embryos were transferred on day 3, valuable information was lost. If on the other hand, they had been kept in the lab upto day 5 to grow them to blastocysts, and if they'd arrested, then you would know for sure that the problem lay with the embryo , and not with the uterus, which means there would be no point in wasting so much money on attempting a surrogacy cycle. It would be far more sensible for them to use an alternative option to create better quality embryos ( such as donor eggs) , because the problem obviously was not with the uterus but with the embryos.

For patients with poor quality embryos, especially those as a result of poor ovarian reserve, the chances of success are much better if they use donor eggs , rather than do surrogacy. However, by prematurely transferring the embryos on day 2 or day 3, the valuable ability to extract important information by following the course of the embryo in vitro to day 5, is wasted. The patient is really no wiser as to what to do in her next cycle.

    Doctors will often do Day 3 transfer to minimize the risk, but because our embryologist is so good, and we're so confident about our lab and our ability to grow embryos to blastocysts routinely, that even if we have just one or two eggs, this is the course we would recommend to patients. If they got pregnant, that's obviously great news, but even if they didn't, they would then know what to do differently the next cycle.

    Of course, this requires a very mature patient - someone who understands the pros and cons , and is capable of understanding the rationale for this decision. Equally, it requires a very efficient laboratory and a superb embryologist who understands exactly how to grow embryos routinely to blastocysts in the IVF lab. He needs to be so confident of his ability that he can say, "If the embryo arrested in my lab, this means it would have arrested in the uterus as well, and therefore putting it back in the uterus would not have increased your chances even by 1%."

    Of course, in some labs which are bad, their ability to grow embryos to blastocysts is poor, means that the embryos which would arrest in the lab might have continued to form a baby if they were transferred back into the uterus. In these clinics, perhaps, doing a day 3 transfer makes sense, but in good clinics which have an extremely competent embryologist , growing embryos routinely to blastocysts offers invaluable information. This is information which patients and doctors would never be able to get unless they routinely follow the policy of growing all embryos to blastocysts before transferring them back to the patient.

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

Why don't all IVF clinics give patients photos of their embryos ?

IVF clinics have started getting a bad reputation in India. They seem to be mushrooming left, right and center, and many are of very poor quality. Not only does this harm the poor infertile couple, it also damages the reputation of the good IVF clinics. After all, once  a patient had has a bad experience in one IVF clinic, she is not going to trust any other clinic.

Sadly, patients don't have the technical ability to be able to judge whether an IVF clinic is good or bad.

I feel a simple solution would be to insist that all IVF clinics routinely and proactively give all their patients photos of their embryos. This is a simple, inexpensive action step, and all IVF clinics have the capability of doing so.

Patients should learn to be smart and to insist on photos of their embryos ! This simple step will help to make sure that poor quality IVF clinics will not be able to take their patients for a ride for too
long !

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